Delayed-onset deep mesh infection presenting as discharging sinuses years after lichtenstein hernioplasty: a case report

INTRODUCTION

Globally, inguinal hernia repair is among the most frequently performed general surgeries, with over 20 million procedures conducted annually.¹ The Lichtenstein tension-free mesh repair remains the gold standard for inguinal hernia surgery due to its low recurrence rates, reduced postoperative pain, and faster recovery times.² However, the widespread use of synthetic mesh has introduced mesh-related complications, including chronic groin pain, seroma, foreign body sensation, and mesh infection, the latter being a rare but significant concern.³

Mesh infections are generally classified as early-onset (occurring within 30 days) or delayed-onset (occurring months to years after surgery). While early infections are often due to perioperative contamination, delayed infections are believed to arise from low-grade bacterial colonization, biofilm formation, or late hematogenous seeding, leading to chronic inflammation and abscess or sinus tract formation.⁴ The reported incidence of mesh infection ranges from 0.1% to 1.4% for inguinal hernia repairs, but delayed-onset infections are even rarer, with only sporadic cases documented in the literature.⁵ One of the hallmark clinical features of delayed mesh infection is the development of chronic discharging sinuses, sometimes many years after an otherwise uneventful surgery.⁶ Such infections may resemble other conditions, frequently causing delays in diagnosis. Imaging modalities such as ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI) may aid in delineating sinus tracts and identifying mesh involvement, but definitive diagnosis often requires surgical exploration and histopathological analysis.⁷

The management of deep mesh infection is challenging and often necessitates complete removal of the infected mesh, along with excision of sinus tracts and appropriate antibiotic therapy. Conservative management without mesh explantation often results in persistent or recurrent infection.⁸ Notably, delayed infections may not respond well to conventional antibiotics due to biofilm-associated resistance, and the success of treatment largely depends on timely diagnosis and complete debridement.⁹

Here, we report a rare case of delayed deep mesh infection presenting as discharging sinuses years after Lichtenstein hernioplasty, highlighting the importance of recognizing this uncommon complication, diagnostic vigilance, and the importance of individualized surgical management.

CASE REPORT

A 50-year-old male presented with a history of multiple discharging sinuses along the previous surgical incision line, several years after undergoing Lichtenstein mesh hernioplasty for a right inguinal hernia at our institution. No associated fever or systemic symptoms reported. On examination, the patient was hemodynamically stable. Abdominal examination revealed a soft, non-tender, and uniformly distended contour. A well-healed surgical scar was noted in the right inguinal region, along with multiple actively discharging pus sinuses. No signs of acute inflammation were present.

Radiological investigations were carried out for further evaluation. Ultrasound imaging demonstrated a fluid collection measuring 2.1×1.1×1.9 cm (volume 2.3 ml) at the operative site, accompanied by surrounding inflammatory changes. MRI showed a peripheral enhancing subcutaneous collection that appeared T2 hyperintense and T1 hypointense in the right inguinal region. Multiple sinus tracts were visualized, and a significantly enlarged lymph node measuring 3.2×3.3 cm was detected in the same region as shown in Figure 1.

The patient was taken up for surgical exploration under general anaesthesia. Around 30 ml of purulent discharge encountered. Several interlinked sinus tracts were found involving the mesh and spermatic cord. Mesh was encapsulated in granulomatous tissue. A firm lymph node (3×2 cm) found near inferomedial border of the inguinal canal. The mesh and dense fibrotic tissue had enveloped the spermatic cord. En bloc resection was performed, including the mesh, sinus tracts, fibrotic tissue, and associated lymph node as shown in Figure 2.

Histopathological examination of the excised specimen revealed foreign body-type granulomas, lymphocytic inflammatory infiltration, and follicular hyperplasia of the lymph nodes, confirming a chronic foreign body reaction as shown in Figure 3. The patient was managed postoperatively with incision and drainage, followed by culture-sensitive antibiotic therapy administered for four weeks. Recovery was smooth, with no recurrence noted on follow-up.

DISCUSSION

Chronic mesh infections represent a serious postoperative complication that often demands a multidisciplinary management approach. Infections can remain clinically silent for prolonged periods, later presenting with chronic discharging sinuses, persistent swelling, or inguinal pain unresponsive to analgesics. Systemic symptoms like fever and malaise may also be observed.

In the present case, the patient developed discharging sinuses several years after Lichtenstein hernioplasty, a hallmark feature of delayed mesh infection. Although the reported incidence of mesh infection ranges between 0.1% and 1.4%, the subset presenting with delayed sinus formation is significantly less common and often misdiagnosed due to its insidious presentation and nonspecific symptoms.

Imaging modalities such as ultrasonography, CT, and MRI play a supportive role in diagnosis. In our case, MRI was particularly useful in identifying T2 hyperintense collections and sinus tracts tracking to the mesh, along with an enlarged lymph node—features consistent with chronic mesh infection. However, imaging findings must be interpreted alongside clinical suspicion, as definitive diagnosis often requires surgical exploration and histopathological confirmation.¹⁰ Histopathological examination confirmed the presence of granulomatous inflammation, foreign body-type granulomas, and follicular hyperplasia of lymph nodes—findings characteristic of chronic inflammatory responses to synthetic material.¹¹

Management of delayed mesh infection remains surgical in most cases. Conservative treatment with antibiotics alone often fails due to biofilm resistance and does not address the nidus of infection. Several reports have indicated that partial removal or simple drainage often results in recurrence or persistence of infection. In our case, en bloc resection of the infected mesh, associated sinuses, and involved lymph node resulted in complete resolution of symptoms, supporting the effectiveness of aggressive surgical management.

This case underscores the importance of long-term vigilance in patients with mesh implants and highlights that deep mesh infections may present years after surgery, often in the form of persistent or recurrent sinus tracts. Early recognition, appropriate imaging, and definitive surgical management are essential to prevent further complications and ensure complete recovery.

CONCLUSION

This case highlights the rare but clinically significant occurrence of delayed-onset deep mesh infection following Lichtenstein hernioplasty, manifesting as multiple discharging sinuses years after the initial surgery. Despite the procedure’s widespread acceptance as the gold standard for inguinal hernia repair, clinicians should remain aware of potential late complications, including chronic mesh infections. Such infections are often underrecognized due to their indolent presentation and long latency, leading to diagnostic delays.

Our case reinforces the importance of maintaining a high index of suspicion in patients presenting with chronic discharging sinuses along previous surgical sites, even in the absence of systemic symptoms. Imaging modalities such as MRI are valuable adjuncts in delineating sinus tracts and identifying associated mesh involvement. However, surgical exploration remains both diagnostic and therapeutic, especially in cases complicated by biofilm-associated infections unresponsive to conservative management.

Definitive management involves complete mesh explanation along with resection of involved tissues, including fibrotic adhesions and lymph nodes, followed by culture-directed antibiotic therapy. Histopathological confirmation of a chronic foreign body reaction further corroborates the diagnosis.

This case underscores the need for individualized management strategies, careful long-term surveillance of hernia repair patients, and multidisciplinary involvement to optimize outcomes. Awareness of this delayed complication can facilitate timely intervention and prevent recurrence, enhancing overall surgical care quality.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. The Lancet. 2003;362(9395):1561-71.
2. 2. Amid PK. Lichtenstein tension-free hernioplasty: its inception, evolution, and principles. Hernia. 2004;8(1):1-7.
3. 3. Sajid MS, Craciunas L, Sains P, Singh KK, Baig MK. Open versus laparoscopic repair of incisional/ventral hernia: a meta-analysis. AJS. 2012;204(1):98-104.
4. 4. Gachabayov M, Latifi R. Different etiopathogeneses in early-onset and late-onset inguinal hernia mesh infections in a prospectively evaluated cohort. Acta Chirurgica Belgica. 2021;121(3):164-9.
5. 5. Falagas ME, Kasiakou SK. Mesh-related infections after hernia repair surgery. Clin Microbiol Infect. 2005;11(1):3-8.
6. 6. Delikoukos S, Tzovaras G, Liakou P, Mantzos F, Hatzitheofilou C. Late-onset deep mesh infection after inguinal hernia repair. Hernia. 2007;11(1):15-7.
7. 7. Kitagawa Y, Hirasaki S, Bando M. Difficult differential diagnosis of delayed mesh infection following inguinal hernia surgery involving appendiceal cancer: A case report. IJS. 2023;113:109057.
8. 8. Gachabayov M, Gogna S, George G, Samson D, Latifi R. Recurrence of infection and hernia following partial versus complete removal of infected hernia mesh: a systematic review and cohort meta-analysis. Hernia. 2020;24(3):433-9.
9. 9. Kathju S, Nistico L, Hall-Stoodley L, Post JC, Ehrlich GD, Stoodley P. Chronic surgical site infection due to suture-associated polymicrobial biofilm. Surg Infect. 2009;10(5):457-61.
10. 10. Martínez R, Morales-Conde S. Diagnosis and treatment of mesh infections in abdominal wall hernia surgery. Cir Esp. 2013;91(4):219-25.
11. 11. Klinge U, Klosterhalfen B, Müller M, Schumpelick V. Foreign body reaction to meshes used for the repair of abdominal wall hernias. Euro J Surg. 1999;165(7):665-73.