Mesh infection after abdominal hernia repair: assessment of risk factors and strategy for maintaining infected mesh

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• general surgery
• Postoperative hernias
• Laparoscopic treatment using mesh implants

My personal experience of using mesh implants in the treatment of postoperative ventral hernias includes more than 450 operations performed using open and laparoscopic approaches since 1994. During this time, many scientific works and original inventions were published on the above topic. Features of our own methods of surgical treatment of ventral hernias are presented in this section. Currently, the majority of patients (more than 80%) are operated on by me using laparoscopic access.

You can watch a video of operations for ventral incisional hernias performed by me on the website “Video of operations of the best surgeons in the world.”

results

Thirty-one of 476 (6.5%) patients developed deep wound infection involving the implanted mesh. Multivariate analysis showed that only operative time was a significant risk factor associated with mesh infection (p = 0.0038). In 17 (55%) cases out of 31, the infected mesh was saved thanks to conservative measures. A significant relationship was observed between the type of mesh used and its ability to survive infection. Conservative therapy allowed saving 100% of infected polyglactin/polypropylene meshes, only 20% of polypropylene and 23% of PTFE/polypropylene meshes (p < 0.0001). None of the patients with preserved mesh had a recurrence of hernia at the surgical site.

Introduction

Deep surgical wound infection (SSI) after mesh implantation for an incisional hernia is a serious challenge for both the patient and the surgeon. Many authors recommend removal of the infected mesh if the infection cannot be completely eradicated by conservative measures and/or antibiotic therapy [1-3]. However, removal of the mesh usually leads to recurrence of the hernia, which will require autoplasty or re-installation of the mesh, if you are brave enough [1, 4, 5]. Therefore, saving the infected mesh without removing it is highly desirable. The number of observations where it was possible to save an infected mesh is small [6-8]. The purpose of this study is to identify risk factors associated with mesh infection and evaluate the effectiveness of conservative wound therapy in implant preservation.

Preparing for surgery

At the preliminary consultation, the surgeon will set a date for the planned hernioplasty and a number of necessary studies - ECG, blood tests, urine tests, fluorography. You can undergo all the necessary tests and examinations at GMS Hospital within one day. If you regularly take medications, you should tell your doctor about this during your consultation; they may need to be temporarily discontinued.

Two weeks before the procedure, you must avoid alcohol and do not smoke on the day of surgery. Some operations require preliminary bowel preparation. The surgeon will tell you more about the preparatory stage during the consultation.

You have questions? We will be happy to answer any questions Coordinator Tatyana

Methods

We conducted a retrospective study of all p/o abdominal hernias operated on from February 1, 2000 to February 28, 2005 in the Department of Surgery of the Medical University of Vienna, Austria. In patients who had a mesh prosthesis installed, their medical history, age, body mass index, type and size of hernia, diabetes, steroid use, and smoking were studied. Details of the operation itself included the year it was performed, duration, skill of the surgeon, surgical technique, additional intraoperative procedures, type and size of mesh, type of suture, intra- and postoperative antimicrobial therapy, intraoperative irrigation of 250-500 ml of solution before wound closure, and drainage. In addition, serum creatinine and albumin levels were studied. All these data were compared between patients with infected and non-infected mesh in terms of identifying potential risk factors for wound suppuration.

Operation

Performed under general anesthesia. The size of the hernia was measured by the operating surgeon during the intervention. Intraoperative status was determined by category according to the criteria of the National Academy of Sciences [9], 465 operations were considered clean (98%) and 11 (2%) were considered clean-contaminated. The first dressing was carried out, as expected, on the 2nd day. The stitches were removed at 10-14.

Treating and Documenting Mesh Infection

In all patients, the diagnosis of SSI was based on clinical symptoms such as redness, swelling, local hyperthermia, and discharge of pus. Suppuration was classified according to the Center for Disease Control and Prevention: SSI 1 (superficial), SSI 2 (deep wound), SSI 3 (interorgan and cavitary) [10]. In case of infection, the sutures were removed, the pus was sent for culture, and antimicrobial therapy was prescribed. Patients were treated according to the recommendations of the European Association for Wound Care, using periodic changes of dressings, washing wounds with disinfectants, absorbents, leaving dressings containing silver [11]. When the wound diameter was more than 2 cm, vacuum therapy was used. Secondary wound closure was not used, adhering to the concept of open wound treatment and fear of reactivation of the infection. Antibiotics were used routinely based on culture results.

results

Characteristics of patients

In total, 1188 patients with abdominal hernias were operated on during this period. 478 (40.2%) received a prosthesis, the rest underwent autoplasty. Indications for alloplasty were hernias larger than 4 cm or recurrent hernias. The method of mesh placement was chosen by the surgeon himself. Of the 478, 369 (77.2%) had a median hernia. In 107 (22.4%) the hernia was localized in another part of the abdomen. In 161 (33.7%) we placed a mesh for recurrent hernia. Two patients (0.4%) were excluded from the study due to insufficient data. A total of 96% of patients were followed for an average of 44 months (range, 1 to 116 months).

Mesh infection

Seroma was observed in 10 (2.1%) of 476 patients, while 31 (6.5%) developed deep wound suppuration (SSI 2) involving the mesh. There were no patients with intra-abdominal or interorgan suppuration (SSI 3). In patients with infected mesh, wound sizes were ≤2 cm in 47.1%, 2–10 cm in 23.5%, 10–20 cm in 17.6%, and >20 cm in 11.8% of patients. The average time to clinical infection after surgery was 12 days (2-42 days). From the moment of wound suppuration, broad-spectrum antibiotics were prescribed for 7-14 days, which were adjusted according to the antibiogram (Table 1).

Table 1. Bacterial spectrum.

Risk factors for mesh infection

The duration of the operation is the only factor influencing the risk of infection. It increases statistically significantly every 15 minutes. Factors such as the size of the hernia, surgery for recurrence, additional interventions during hernia repair, type of suture, drainage, wound irrigation, antibiotic prophylaxis, and surgeon qualifications did not differ statistically significantly between patients with and without mesh infection. In addition, there was no significant difference in patients with suppuration compared with patients with clean wounds (6.5% or 30 of 465) or clean-contaminated wounds (9.1% or 1 of 11). Regarding surgical technique, open surgery was more prone to infection than the laparoscopic approach (7 vs. 0%), however, this difference was not statistically significant.

The effect of conservative therapy to preserve the infected mesh

Since it became clear that removal of an infected mesh is accompanied by an increase in the duration of the disease and the likelihood of relapse, we began to wonder whether it is possible to preserve the mesh with conservative measures? The key point was the use of a vacuum system for wounds larger than 2cm. The mesh was preserved in 17 of 31 patients (55%), and had to be removed in the remaining 14 (45%). The average duration of conservative therapy was 81 days (range = 24-213).

Factors on which mesh preservation depends

Of course, these factors need to be assessed in patients who are candidates for retaining infected mesh, identifying those from whom it should be removed early. Therefore, we analyzed demographic and surgical factors in these patients.

All 13 infected polyglactin-polypropylene meshes were saved by conservative treatment (100%). And only 3 out of 13 polytetrafluoroethylene/polypropylene meshes (23%) and 1 out of 5 polypropylene (20%) (p < 0.0001). Patients who received po antibiotic prophylaxis were significantly more likely to have mesh removed due to infection. Among primary hernia repairs, 71% of meshes were saved, and only 20% among recurrent ones (p < 0.019).

Impact of the learning curve on mesh preservation

Conservative treatment of infected mesh depends on special techniques established in our clinic. Among the patients who suffered from mesh infection, 4 were operated on in 2000, 3 in 2001, 8 in 2002, 4 in 2003, 12 in 2004, respectively. The number of retained meshes was 0% in the first two years and increased to 38, 75, 92% in subsequent years (p < 0.0001). This suggests that as experience increases, the number of meshes stored increases.

Recurrence of hernia with preserved mesh

After an average of 30 months, not a single patient with a preserved infected mesh experienced a recurrence of the hernia. None of them had a second attack of infection.

List of published works on the topic of ventral hernias

1. Puchkov K.V., Seliverstov D.V., Gausman B.Ya., Polit G.G., Strangulated supravesical internal median hernia // Clinical surgery. - 1993. - No. 4. — P.68.
2. Puchkov K.V., Filimonov V.B., Tilov Kh.I. Surgical treatment of inguinal hernias using a mesh implant // Ros. magazine gastroenterology, hepatology, coloproctology. - 2002. - T.12, No. 5. — P.10.
3. Puchkov K.V., Filimonov V.B., Tilov Kh.I. The use of a mesh implant for the surgical treatment of inguinal hernias // Current issues of herniology: materials of the conference. - M., 2003. - P.48.
4. Puchkov K.V., Filimonov V.B., Bekk A.V., Tilov Kh.I., Shvalb A.P., Osipov V.V. Alloplasty of inguinal hernias with a polypropylene implant: experimental and clinical study // Pacific Med. magazine - 2003. - No. 1 (11). — P.81 — 83.

Laparoscopic hernioplasty in 3D endoscopy (Professor K.V. Puchkov, April 2013 (Moscow). Laparoscopic repair of postoperative ventral hernia (Professor K.V. Puchkov, November 2012 (Moscow).

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5. Puchkov K.V., Filimonov V.B., Osipov V.V., Shvalb A.P., Ivanov V.V. Alloplasty of inguinal hernias using a polyprolene implant // Herniology. - 2004. - No. 1. — P.36 — 40.
6. Puchkov K.V., Ivanov V.V., Bakov V.S., Usachev I.A. The use of polypropylene implants in herniology // 9th Moscow. international congr. in endoscopic surgery, Moscow, April 6 - 8. 2005: abstract. report / ed. Yu.I. Galingera. - M., 2005. - P.293 - 294.
7. Puchkov K.V., Filimonov V.B. The use of modern implants in the surgical treatment of inguinal hernias: experimental data and clinical application // Current issues in specialized surgery: scientific and practical materials. conf. - Tashkent, 2007. - P.86 - 87.
8. Puchkov K.V., Puchkov D.K. Evaluation of the results of using composite meshes in the treatment of postoperative ventral hernias // Materials of the International Scientific and Practical Conference “Endovideosurgery in a Multidisciplinary Hospital”, St. Petersburg: Publishing House “Man and His Health”, 2014 – pp. – 94 – 96. ISBN 978-5-9905495-4-8
9. Puchkov K.V., Puchkov D.K. Results of the use of composite meshes in the treatment of postoperative ventral hernias // Almanac of the Institute of Surgery named after. A.V. Vishnevsky. T.10, No. 1 - 2015. “Materials of the XVIII Congress of the Society of Endoscopic Surgeons of Russia.” – Moscow, 2015. – P. 343-344.

Discussion

In this post we discuss the problem of preserving an infected mesh. In a retrospective analysis of 476 hernia repairs, we were able to preserve the implant in 55% (17/31) of cases of infection. All 100% of infected polyglactin-polypropylene meshes were saved by conservative treatment. Most polytetrafluoroethylene/polypropylene meshes and pure polypropylene meshes had to be removed due to the ineffectiveness of conservative therapy. This difference can be explained by the relatively large pore sizes of absorbable meshes (2-5mm) compared to polypropylene meshes (1-2mm). Large pores facilitate better ingrowth into the partially absorbable mesh of surrounding tissues [12], better migration of leukocytes into the mesh and cleansing in case of infection. When using PTFE, the prosthesis is encapsulated by fibrous tissues, which make it less accessible to immune cells, preserving infection [13]. Improvement of leukocyte migration can also be facilitated by 50% dissolution of the galactin component of the network, which occurs in 60-70 days. It is for such meshes that vacuum therapy (VAC) is effective, even for large wounds. It is a routine component for the treatment of large or deep wounds. VAC is extremely valuable for removing purulent wound contents from wound crevices and compressing the wound during its treatment and stimulation of regeneration [14-19]. Today it is the leading method of treating purulent wounds, especially in the presence of mesh. In addition, VAC is an extremely valuable technique for outpatients with complex wounds that require long-term treatment.

Although VAC therapy costs approximately €60–70/day, studies comparing the best wound therapy methods find this type of treatment to be the most cost-effective [20]. To prevent unnecessary conservative treatment in cases of infection, we recommend early mesh removal in patients with non-absorbable implants and open wound management. Moreover, we do not recommend delaying conservative treatment when the mesh becomes infected in patients operated on for recurrent hernias, because, in our experience, it is quite difficult to preserve the mesh in this situation. We believe that these patients have a poorer chance of wound healing without mesh removal due to the large amount of fibrous tissue in the surgical site. Also, infected remains from the first operation, such as ligatures that have not been removed.

Our data show that the success of conservative therapy depends on experience - meshes were removed, as a rule, in the first year of the study, when there was no experience with conservative therapy. This is proven by the fact that the number of saved grids was 0% in the first 2 years and 38, 75, and 92%, respectively, in the subsequent ones. In addition, the incidence of polyglactin/polypropylene mesh use increased from 1% in the first year to 4, 12, 51, 61 and 75% in subsequent years. This also, along with increased experience, had an impact on the likelihood of mesh retention during the study period.

It is clear that the best way to combat mesh infections is to prevent them. Traditional risk factors for wound infection in general surgery include duration of surgery, hypoalbuminemia, body mass index, chronic obstructive pulmonary disease, steroids, diabetes, etc. [21-26]. Our analysis showed that the duration of the operation is of paramount importance, and any efforts in this direction are justified. Therefore, we suggest surgery as early as possible, while the hernia is small.

Interestingly, patients with drainage, wound irrigation before suturing, or antimicrobial prophylaxis are more prone to mesh infection. Although this trend is not statistically significant. We do not recommend the routine use of antibiotics for alloplasty - it is pointless.

In conclusion, conservative treatment of infected mesh is possible, although time consuming. Success is likely with the use of partially absorbable mesh.

Translated by Fedorov I.V.

Why are they treated with us?

The clinic employs experienced and qualified medical personnel. The operations are performed by a doctor of medical sciences who has experience of many thousands of similar operations.

The surgical department is equipped with modern equipment: air conditioning and ventilation systems, lighting, operating tables, anesthesia and monitoring devices, an uninterruptible power supply system.

We directly cooperate with large Western companies - manufacturers and suppliers of medical equipment and instruments. In particular, in our work we use three-dimensional polyester meshes Parietex 3D TET (France).

Postoperative wards provide a comfortable stay for patients after surgery (24-hour communication with staff, monitoring equipment, air conditioning and ventilation systems, comfortable multifunctional beds)

At the Phlebology Center clinic, the cost of the operation includes the cost of a mesh implant, anesthesia and hospital stay.

Literature

Translator's comment

The widespread introduction of synthetic materials for abdominal hernia repair has significantly reduced the incidence of disease recurrence, but has led to the emergence of new, previously unknown complications, one of which is associated with infection of the mesh and the formation of fistulas caused by the presence of a foreign body in the wound. Prevention of infection of the implant, tactics for deep suppuration of a wound bearing a mesh is an important task of modern herniology, discussed in an article by Austrian surgeons. And although the concept of the possibility of preserving the mesh, strictly depending on the type of implanted material, seems to me very controversial, the work is based on a large number of observations and contains a number of nuances, important details in the work of a surgeon, which, in fact, make up our profession.

What symptoms to treat

You definitely need to consult a surgeon if you have the following symptoms:

• The appearance of a swelling or protrusion in the groin, abdomen, or scrotum, which increases with physical stress and disappears if you lie down.
• Feeling of heaviness, discomfort or pain in the protrusion area.
• The pain intensifies with lifting weights, walking, coughing and any other activity.

Our specialists treat all types of hernias, both in the initial stage and in the presence of complications.