1. Unusual Cause of
Chronic Abdominal Pain
Case Presentation
Dr. Majd AlHaddadin, MBChB, MS, MRCS, FACS
Consultant General & Laparoscopic Surgery
Al Hammadi Hospital – Riyadh- Saudi Arabia

2. Introduction
• Chronic abdominal pain is a challenging complaint for both primary care providers
and specialists, due to a broad differential diagnosis and sometimes extensive and
negative workup.
• In the absence of red flag features that herald more acute conditions, the majority
of patients with chronic abdominal pain have a benign cause or a functional
disorder (e.g., irritable bowel syndrome).
• Undiagnosed abdominal pain should be investigated starting with a detailed history
and physical examination. Diagnostic investigations should be limited and adapted
according to the clinical features, the alarm symptoms, and the symptom severity.

3. Introduction
• The primary role of the general practitioner is to differentiate an organic
disease from a functional one, to refer to a specialist, or to provide treatment
for the underlying cause of pain. The functional disorders should be considered
after the organic pathology has been confidently excluded.
• Unfortunately , many of those patients with chronic abdominal pain reach a
level in which they are ignored by the physicians, due to the inability to establish
a clear diagnosis and provide the proper treatment.

4. Case Presentation
• A 43 year — old, medically free.
• Complaining of :
- chronic right lower abdominal pain since many years.
- Recurrent attacks of abdominal distention and vomiting.( intestinal obstruction??)
- Multiple OPD visits at different specialties ( Internal Medicine, Gastroenterology,
Rheumatology and surgery)
- Multiple ER visits for his recurrent pain and vomiting. ( admitted for lap appendectomy few
years ago as the pain was attributed to the appendicitis.)

5.  The patient had multiple diagnosis:
• irritable bowel disease.
• Inflammatory bowel disease ( a large number of investigations)
• Liver disorders.
• Psychological issues.
• Muscular pain.
 Multiple hospital admissions due to his abdominal pain and signs of partial bowel obstruction
( last one on June 2022).
 Positive past surgical history of:
- Laparoscopic bilateral inguinal hernias mesh repair ( at the beginning of laparoscopic hernia repair).
- Laparoscopic appendectomy for the same pain.

6. June 2022
• Chronic abdominal pain ( RIF)
• Feature of small bowel obstruction.
• Examination: distended, tympanic abdomen without signs of peritonitis,
hyperactive bowel sounds.
• Investigation confirmed the diagnosis of small bowel obstruction.
• CT scan : partial small bowel obstruction but no definitive transition point.
• Rest of investigations were within normal limits.

9. Management :
During this admission the patient was successfully managed by conservative treatment:
- NPO
- IV Fluids
- Correction of electrolyte imbalance
- Strict input output
- Contrast Ct scan : Osmotic pressure of the gastrografin
- Discharged in good general condition and advised OPD follow up.

10. Re-visit OPD (23/ July/2022)
• No signs of obstruction
• Same chronic lower abdominal pain
• Definitive decision is a must.
• Plan : diagnostic laparoscopy and act according to the findings
• Possible findings: adhesions, thick bands, meckel’s diverticulum, chron’s
disease, mesenteric lymphadenitis, internal hernia, lymphoma, small bowel
tumor….or even normal diagnostic laparoscopy.

11. Preoperative preparation
• Proper consent obtained, including laparotomy and bowel resection.
• All preoperative investigations were within normal limits.
• Anesthesia, fit for surgery.
On the day of the surgery:
Complete scrubbing and draping of the abdomen, Foley's catheter…etc.

12. Diagnostic laparoscopy Findings:
photos

13. plane

14. MESH
GONADAL
VESSLES
EXTERNA
L ILIAC
ARTERY
ILEAL LOOP
KINK

15. EXT. ILIAC
ARTERY

16. Mesh eroding
into the wall of
the ileal loop

17. Procedure
• Resection of the affected ileal loop ( the mesh was eroding into the muscular
layer).
• Side to side anastomosis
• Peritoneal flap created and the exposed mesh was covered.
• Omentum interposition between the inguinal area and the bowel loos.

18. Postoperative course
• The patient discharged on Day 4.
• Good general condition.
• No complications.
• OPD follow up until 6 months after the surgery showed no symptoms
recurrence.

19. Discussion
Laparoscopic repair is the gold standard treatment of inguinal hernia. It involves placement of mesh in pre-
peritoneal space. However, mesh is a foreign body which can migrate as well as erode into surrounding
visceral organs including urinary bladder and bowel. Such an occurrence is rare and need high index of
suspicion.
Factors :
• Peritoneal damage and infection of the mesh are important factors leading to mesh erosion.
• A peritoneal defect leads to direct contact between mesh and intra-abdominal organs resulting in adhesions,
mechanical bowel obstruction, and fistula formation.
This may also explain the higher number of cases being reported after TAPP than TEP.

20. Some authors postulated that primary mesh migration occurs along the paths of low
resistance either due to inadequate fixation or external displacing forces.
Failure to fix the mesh may result in mesh displacement. Similarly, strenuous activity
including bending and hip flexion in the immediate post-operative period (during
which mesh and staples have the greatest likelihood of dislodging) may be a causative
factor.
On the other hand, secondary migration occurs as a consequence of foreign body
reaction leading to erosion through the anatomic planes. Weakening of wall and
erosion of viscus can also occur due to sharp cut edges of mesh leading to
inflammatory reaction.

21. CONCLUSION
My recommendations in laparoscopic hernia repair:
- Fix the mesh as long as it is possible. However, avoid excessive unnecessary tacker
fixation.
- A proper mesh the to use in the (light weight, macroporous ).
- 3D mesh is an excellent one to do laparoscopic repair of the inguinal hernias.
- Closure of the peritoneal flap to guarantee complete mesh coverage.
- Peritoneal tears can be closed with clips ,stiches, tacker. If not possible, omentum
interposition between the mesh and the intestine.

22. Thank You…