A patient presents with bilateral lower abdominal pain five weeks after right inguinal hernia repair, with a brief episode of rectal bleeding for two days immediately post‑operatively that has resolved; what is the likely diagnosis and recommended management?

Bilateral Lower Abdominal Pain 5 Weeks Post-Hernia Repair: Likely Diagnosis and Management

This patient most likely has a postoperative complication requiring urgent imaging with contrast-enhanced CT scan to rule out internal hernia, bowel obstruction, or mesh-related complications, with strong consideration for diagnostic laparoscopy if symptoms persist or imaging is concerning.

Clinical Context and Differential Diagnosis

The presentation of bilateral lower abdominal pain 5 weeks after right inguinal hernia repair, particularly with a history of early postoperative rectal bleeding, raises several important diagnostic possibilities:

Most Likely Diagnoses

1. Internal Hernia or Small Bowel Volvulus

• The bilateral nature of pain extending beyond the surgical site is concerning for intra-abdominal pathology
• Small bowel volvulus has been reported after transabdominal preperitoneal (TAPP) hernioplasty, presenting with recurrent abdominal pain as the primary symptom 1
• In the reported case, intestinal volvulus occurred 3 months post-TAPP when a barbed suture penetrated the peritoneum, causing small bowel adhesion and volvulus without closed-loop obstruction 1

2. Mesh-Related Complications

• Mesh migration, folding, or adhesion formation can cause persistent pain
• Barbed sutures (V-Loc™) used for peritoneal closure can penetrate through and create adhesion points 1

3. Pubic Symphysis Stress Reaction with Myositis

• Recent literature describes pubic symphysis stress reaction with adjacent pelvic girdle myositis following robotic-assisted inguinal hernia repair 2
• Presents with bilateral lower abdominal and groin pain exacerbated by movement, bending, and physical activity
• CT may be unremarkable; MRI shows edema and capsular hypertrophy at pubic symphysis with multifocal myositis 2

4. Postoperative Abscess or Infection

• Less likely given the 5-week timeframe and resolution of bleeding, but must be excluded

Immediate Diagnostic Approach

Step 1: Clinical Assessment

Look specifically for:

• Tachycardia (most important alarming sign in postoperative complications) 3
• Fever, hemodynamic instability
• Signs of bowel obstruction (distension, absent bowel sounds, vomiting)
• Focal tenderness, rebound, guarding
• Pain characteristics: cramping/colicky suggests internal hernia; constant dull ache with sharp episodes suggests musculoskeletal 1, 2

Step 2: Laboratory Investigations

Order immediately:

• Complete blood count
• Serum creatinine, lactate, CPK, D-dimer (predictive of bowel strangulation) 4
• C-reactive protein, procalcitonin 5

Step 3: Imaging Strategy

Contrast-Enhanced CT Abdomen/Pelvis is the First-Line Investigation

• Perform urgently without delay if patient has tachycardia, fever, or signs of peritonitis 4, 6
• Look specifically for:
  • Whirlpool sign of mesenteric volvulus 1
  • Internal hernia defects
  • Bowel obstruction or ischemia
  • Intra-abdominal fluid collections or abscesses
  • Mesh position and complications

Important Caveat: CT may be unremarkable in musculoskeletal complications 2

If CT is Non-Diagnostic but Symptoms Persist:

• Consider MRI pelvis to evaluate for:
  • Pubic symphysis edema and capsular hypertrophy
  • Pelvic girdle myositis
  • Soft tissue inflammation not visible on CT 2

Management Algorithm

If Imaging Shows Bowel Volvulus, Internal Hernia, or Obstruction:

Proceed to urgent laparoscopic exploration 1

• Laparoscopy allows both diagnosis and treatment
• Perform adhesiolysis, reduce volvulus, remove penetrating sutures if present
• Assess bowel viability
• Do not delay surgical intervention when intestinal complications are suspected 4

If Imaging Shows Localized Abscess Without Peritonitis:

• Percutaneous drainage plus antibiotics 7
• Empiric antimicrobial therapy based on clinical severity 5

If CT is Unremarkable but Pain Persists:

1. Obtain MRI pelvis to evaluate musculoskeletal causes 2

2. If MRI shows pubic symphysis stress reaction/myositis:

   • Structured physical therapy (NOT general exercise)
   • NSAIDs for inflammation
   • Activity modification
   • Critical point: General fitness does not substitute for targeted postoperative rehabilitation 2

3. If all imaging is negative, consider diagnostic laparoscopy

   • Active laparoscopic exploration can confirm diagnosis and prevent serious complications 1
   • Particularly important given the early postoperative bleeding episode suggesting possible intra-abdominal pathology

Critical Pitfalls to Avoid

1. Do not dismiss bilateral pain as "normal postoperative pain" at 5 weeks post-surgery
2. Do not rely solely on CT if clinical suspicion remains high—MRI may be necessary 2
3. Do not delay surgical exploration if patient has tachycardia, fever, or progressive symptoms 4, 3
4. Do not assume physical fitness eliminates need for structured rehabilitation 2
5. Remember that volvulus can present with recurrent pain alone without complete obstruction 1

Specific to This Case

The early postoperative rectal bleeding is particularly concerning and suggests:

• Possible intra-abdominal injury or complication at time of surgery
• Potential for adhesion formation leading to current symptoms
• This history mandates aggressive investigation rather than conservative management

The bilateral nature of pain (beyond the right-sided surgical site) strongly suggests either:

• Intra-abdominal pathology (volvulus, internal hernia) requiring laparoscopy 1
• OR musculoskeletal inflammation (pubic symphysis/myositis) requiring MRI 2

Bottom line: Obtain contrast-enhanced CT immediately. If negative but symptoms persist, proceed to MRI pelvis. Maintain low threshold for diagnostic laparoscopy given the concerning presentation and early bleeding history.