Fate of the inguinal hernia following removal of infected prosthetic mesh

Quality of life assessment of patients after removal of late-onset infected mesh following open tension-free inguinal hernioplasty: 3-year follow-up

PURPOSE

Open tension-free inguinal hernioplasty is one of the common surgical methods used today to treat inguinal hernias due to its simplicity and low recurrence rate. With the widespread use of tension-free inguinal hernia repair, the number of patients with mesh infections is gradually increasing. However, there is a lack of studies assessing the quality of life of patients after the removal of late-onset infected meshes in open inguinal hernias. The aim of this study was to analyse and assess the quality of life, pain severity and anxiety of patients after late-onset infection mesh removal following open inguinal hernioplasty.

METHODS

Data from 105 patients admitted to our hospital from January 2014 to January 2019 who developed delayed mesh infection after open tension-free inguinal hernia repair were retrospectively analysed. 507 patients without mesh infection after open inguinal hernioplasty were included as cross-sectional controls. The baseline data of the two groups were matched for propensity score matching (PSM) with a caliper value of 0.05 and a matching ratio of 1:1. Patients are followed up by telephone or outpatient consultations for 3 years to assess quality of life, pain and anxiety after removal of the infected mesh.

RESULTS

The 105 patients who developed late-onset mesh infection after inguinal hernia repair had a mean age of 64.07 ± 12.90 years and a mean body mass index (BMI) of 24.64 ± 2.67 (kg/m2). The mean follow-up time was 58 months and 10.5% (10/105) of the patients were lost to follow-up. At the 3-year follow-up there was one case of hernia recurrence and five cases of mesh reinfection. The patients' quality of life scores, pain scores and anxiety scores improved after surgery compared to the preoperative scores (all p < 0.01).

CONCLUSION

Patients with late-onset mesh infection after inguinal hernioplasty showed an improvement in quality of life, pain and anxiety compared to preoperative after removal of the infected mesh. Mesh-plug have a higher risk of mesh infection due to their poor histocompatibility and tendency to crumple and shift.

The role of prophylactic antibiotics in elective inguinal tension-free hernia repair: A systematic review and meta-analysis

Whether to use antibiotics to prevent surgical site infection in elective inguinal tension-free hernia repair has been controversial. To systematically evaluate the effect of prophylactic antibiotic application in elective inguinal tension-free hernia repair, we identified all published randomised controlled trials of the effect of prophylactic antibiotic application on elective inguinal tension-free hernia repair were collected by computer retrieval from the China National Knowledge Infrastructure; VIP Database; Wanfang Database; China Biomedical Literature Database; and PubMed, EMBASE and Cochrane Library databases. Meta-analysis was performed by RevMan 5.3 software. The meta-analysis showed that the total incidence of surgical site infections [P = 0.003] and the incidence of superficial surgical site infections [P = 0.004] in the antibiotic group (AG) were lower than those in the non-antibiotic group (NAG). There was no significant difference in the total incidence of postoperative infections [P = 0.06], deep surgical site infections [P = 0.26] and seroma [P = 0.52] between the AG and the NAG. Based on current evidence, the application of prophylactic antibiotics in elective inguinal tension-free hernia repair can prevent the total incidence of surgical site infections and that of superficial surgical site infections but cannot prevent the total incidence of postoperative infection events, incidence of deep surgical site infections and incidence of seroma.

Treatment of mesh infection after inguinal hernia repair: 3-year experience with 120 patients

PURPOSE

Mesh infection is a devastating complication of sterile hernia repair surgery. This study was performed to assess the short- and long-term outcomes following treatment for mesh infection after inguinal hernia repair.

METHODS

This single-center retrospective study included all patients who developed mesh infection after inguinal hernia repair from January 2018 to December 2020. Patient demographics, mesh infection characteristics, microbiology, features of surgery, short- and long-term outcomes, and follow-up data were analyzed.

RESULTS

In total, 120 patients (8 women, 112 men; mean age, 54.4 years; mean body mass index, 24.8 kg/m²) were treated for mesh infection. The cultures were positive in 88 patients; 62.5% of these were positive for Staphylococcus aureus. Laparoscopic exploration was performed in 108 patients. Seventy patients underwent complete removal of infected mesh, and 50 underwent partial removal. During the short-term follow-up, 11 patients developed a minor wound infection and were treated with dressings and antibiotics, 1 developed a wound infection requiring debridement, 30 developed seromas, and 3 developed hematomas that did not require surgical intervention. During the mean follow-up of 39.1 months, 4 patients developed hernia recurrence, 2 experienced chronic pain, and 23 developed recurrent infection requiring reoperation in the partial mesh removal group (in contrast, only 4 patients in the complete mesh removal group developed recurrent infection, with a statistically significant difference).

CONCLUSION

The outcome of mesh infection after inguinal hernia repair treated by mesh removal is satisfactory. Systematic individualized treatment by experienced experts based on the patient's previous repair technique, implanted mesh, and physical condition is recommended.

What is the outcome of late-onset infected mesh removal after open tension-free inguinal hernioplasty: 3-year follow-up

PURPOSE

Reports of mesh infections following open tension-free inguinal hernioplasty are gradually increasing. Recent research has focused on identifying and managing mesh infections. However, studies examining the long-term outcomes and quality of life following mesh removal for late-onset infections are few. This study aimed to analyze the short and long-term outcomes after maximal removal of the implanted mesh in patients with late-onset mesh infection after open tension-free inguinal hernioplasty.

METHODS

Data of 105 patients who developed late-onset mesh infection after open tension-free inguinal hernioplasty and were admitted to our hospital from January 2014 to January 2019 were retrospectively analyzed. Patients were followed up by telephone or outpatient consultation for 3 years, focusing on hernia recurrence and mesh infection recurrence. Quality of life was assessed preoperatively and postoperatively using our developed scale; postoperative inguinal area pain was assessed using the visual analog score, and postoperative anxiety was assessed using the anxiety self-assessment scale.

RESULTS

Of the 105 patients who experienced late-onset mesh infection following open inguinal hernioplasty, 100 underwent mesh plug repair. The mean follow-up time was 58 months, and 10.5% (95/105) of the patients were lost to follow-up. Recurrence of infection was observed in 28.6% of patients (2/7) who underwent partial mesh removal and in 3.4% of patients (3/88) who underwent complete mesh removal. One inguinal hernia recurred 12 months after mesh removal (1.0% recurrence rate). In the third year following surgery as compared to the preoperative period, there were significant improvements in quality of life.

CONCLUSIONS

Hernia plugs may not be a good choice in tension-free inguinal hernia repair in view of the risk of late infections and fistulas. Remove all mesh at the time of the first operation for mesh infection. Hernia recurrence after late-onset infected mesh removal following open inguinal tension-free hernioplasty is rare. The post-operative quality of life, pain, and anxiety are gradually steadily improving.

Delayed mesh infection after inguinal hernia repair: a case report

Delayed deep mesh infection is a rare complication and the precise mechanism of its development is unknown. We report a case of delayed deep mesh infection after inguinal hernia repair. A 65-year-old man was admitted for treatment of colon cancer. He had a history of bilateral hernioplasty repaired with mesh-plugs 6 years previously. Fluorine-18 fluorodeoxyglucose positron emission tomographic scan showed positive findings in the right inguinal region similar to cancer. He had no complaints or findings to suspect mesh infection. Postoperative computed tomography scan over time revealed a fluid collection with inflammation. Eleven years after hernia repair, the patient presented with inflammation in the right inguinal region and emergency operation was performed. An abscess cavity was found and the mesh-plug covered with granulation tissue was removed. The patient remains free of recurrence of inguinal hernia or inflammatory changes after 3 years of follow-up.

Non-mesh Desarda Technique Versus Standard Mesh-Based Lichtenstein Technique for Inguinal Hernia Repair: A Systematic Review and Meta-analysis

BACKGROUND

The aims of the present systematic review and meta-analysis were to compare non-mesh Desarda technique with standard mesh-based Lichtenstein technique for inguinal hernia repair.

METHODS

A systematic literature search for RCTs comparing between DT and LT was conducted using electronic databases and Google scholar service. Studies were evaluated for recurrence and post-operative complications. We pooled the data using fixed effects model and random effects model after assessing the heterogeneity among the included studies.

RESULTS

A total number of 8 RCTs studies were included in this meta-analysis with total number of 3177 patients divided between Desarda group and Lichtenstein group as follows: 1551 patients and 1,626 patients, respectively. There was no difference in terms of recurrence between the Desarda repair and Lichtenstein repair groups [P = 0.44]. There was a lower rate of overall post-operative complications [P = 0.003], seroma [P = 0.0004] and surgical site infections (SSIs) [P = 0.04] in the Desarda group.

CONCLUSION

DT and LT were found to have comparable results in terms of recurrence rate, haematoma formation, testicular atrophy and time to return to normal daily activity/work. DT is superior to LT in terms of reducing post-operative mesh-attributed complications, such as SSI and Seroma formation.

Engineering multifunctional bactericidal nanofibers for abdominal hernia repair

The engineering of multifunctional surgical bactericidal nanofibers with inherent suitable mechanical and biological properties, through facile and cheap fabrication technology, is a great challenge. Moreover, hernia, which is when organ is pushed through an opening in the muscle or adjacent tissue due to damage of tissue structure or function, is a dire clinical challenge that currently needs surgery for recovery. Nevertheless, post-surgical hernia complications, like infection, fibrosis, tissue adhesions, scaffold rejection, inflammation, and recurrence still remain important clinical problems. Herein, through an integrated electrospinning, plasma treatment and direct surface modification strategy, multifunctional bactericidal nanofibers were engineered showing optimal properties for hernia repair. The nanofibers displayed good bactericidal activity, low inflammatory response, good biodegradation, as well as optimal collagen-, stress fiber- and blood vessel formation and associated tissue ingrowth in vivo. The disclosed engineering strategy serves as a prominent platform for the design of other multifunctional materials for various biomedical challenges.

Maximal Infected Mesh Removal with Methylene Blue Injection for Mesh Infection after Inguinal Hernia Repair

Background: Mesh infection is a serious complication of inguinal hernia repair, but surgeons have not reached a consensus on the method of treatment. The aim of this study was to assess the outcomes of maximal mesh removal therapy with methylene blue injection for mesh infection after inguinal hernia repair. Patients and Methods: The study was a monocentric retrospective analysis following STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statements of all patients with mesh infection undergoing maximal mesh removal operation with methylene blue injection. Demographics, mesh infection characteristics, microbiology, early post-operative data, and follow-up data were recorded. Results: Sixteen patients underwent complete removal of infected mesh and 13 had partial removal. The operation time was 76.3 ± 26.0 minutes. In 13 patients the cultures tested positive, five for Staphylococcus aureus. Twelve participants developed surgical site infection post-operatively and eventually healed after 27.4 ± 16.3 days of dressing. In a mean follow-up of 46 months, one patient suffered chronic pain and one had chronic sinus in the partial removal group, although none did in the complete removal group, without a statistically significant difference. No hernia recurrence occurred. Conclusions: Maximal mesh removal therapy with methylene blue injection can be considered as a feasible alternative for the treatment of mesh infection.

Re-do surgery after prosthetic abdominal wall repair: intraoperative findings of mesh-related complications

INTRODUCTION

Mesh repair is one of the most popular technique for the treatment of abdominal wall hernias, resulting in lower recurrence rates. However, it is associated with a high risk of mesh-related complications. The aim of the present study is to assess the impact of biomaterials on the intra-abdominal organs, in terms of adhesions and visceral complications, in a series of patients undergoing re-do surgery at our abdominal wall unit.

MATERIALS AND METHODS

We reviewed the clinical records of 301 patients who undergone laparotomy between June 2008 and May 2018, selecting 67 patients with one or more previous prosthetic abdominal wall repair (AWR).

RESULTS

The average number of previous repairs was 1.6 with a mean time interval of 66 months from the last repair. Clinical presentation included hernia recurrence (69%), mesh infection (26%), infection and recurrence (10%), and fistula (1%). Adhesions were intraoperatively observed in all patients, except for eight cases. Mesh was completely removed in 43 patients, partially in four. Postoperative complications were observed in 39% of cases, including wound dehiscence, hematoma, seroma, and mesh infection.

CONCLUSIONS

Long-term implant results in abdominal wall repair and are not completely known, and literature is still lacking on this topic. Re-do surgery for subsequent pathological events may represent a way to increase our knowledge.

Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia repair

BACKGROUND

Inguinal or femoral hernia is a tissue protrusion in the groin region and has a cumulative incidence of 27% in adult men and of 3% in adult women. As most hernias become symptomatic over time, groin hernia repair is one of the most frequently performed surgical procedures worldwide. This type of surgery is considered 'clean' surgery with wound infection rates expected to be lower than 5%. For clean surgical procedures, antibiotic prophylaxis is not generally recommended. However after the introduction of mesh-based hernia repair and the publication of studies that have high wound infection rates the debate as to whether antibiotic prophylaxis is required to prevent postoperative wound infections started again.

OBJECTIVES

To determine the effectiveness of antibiotic prophylaxis in reducing postoperative (superficial and deep) wound infections in elective open inguinal and femoral hernia repair.

SEARCH METHODS

We searched several electronic databases: Cochrane Registry of Studies Online, MEDLINE Ovid, Embase Ovid, Scopus and Science Citation Index (search performed on 12 November 2019). We also searched two trial registers and the reference list of included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing any type of antibiotic prophylaxis versus placebo or no treatment for preventing postoperative wound infections in adults undergoing inguinal or femoral open hernia repair surgery (tissue repair and mesh repair).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed risk of bias. We separately analysed results for two different surgical methods (herniorrhaphy and hernioplasty). Several studies revealed infection rates that were higher than the expected 5% for clean surgery and we therefore divided studies into two subgroups: high infection risk environments (≥ 5% infection rate); and low infection risk environments (< 5% infection rate). We performed meta-analyses with random-effects models. We analysed three outcomes: superficial surgical site infections (SSSI); deep surgical site infections (DSSI); and all postoperative wound infections (SSSI + DSSI).

MAIN RESULTS

In this review update we identified and included 10 new studies. In total, we included 27 studies with 8308 participants in this review. It is uncertain whether antibiotic prophylaxis as compared to placebo (or no treatment) prevents all types of postoperative wound infections after herniorrhaphy surgery (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.56 to 1.33; 5 studies, 1865 participants; very low quality evidence). Subgroup analysis did not change these results. We could not perform meta-analyses for SSSI or DSSI as these outcomes were not reported separately. Twenty-two studies related to hernioplasty surgery (total of 6443 participants) and we analysed three outcomes: SSSI; DSSI; SSSI + DSSI. Within the low infection risk environment subgroup, antibiotic prophylaxis as compared to placebo probably makes little or no difference for the outcomes 'prevention of all wound infections' (RR 0.71, 95% CI 0.44 to 1.14; moderate-quality evidence) and 'prevention of SSSI' (RR 0.71, 95% CI 0.44 to 1.17, moderate-quality evidence). Within the high infection risk environment subgroup it is uncertain whether antibiotic prophylaxis reduces all types of wound infections (RR 0.58, 95% CI 0.43 to 0.77, very low quality evidence) or SSSI (RR 0.56, 95% CI 0.41 to 0.77, very low quality evidence). When combining participants from both subgroups, antibiotic prophylaxis as compared to placebo probably reduces the risk of all types of wound infections (RR 0.61, 95% CI 0.48 to 0.78) and SSSI (RR 0.60, 95% CI 0.46 to 0.78; moderate-quality evidence). Antibiotic prophylaxis as compared to placebo probably makes little or no difference in reducing the risk of postoperative DSSI (RR 0.65, 95% CI 0.26 to 1.65; moderate-quality evidence), both in a low infection risk environment (RR 0.67, 95% CI 0.11 to 4.13; moderate-quality evidence) and in the high infection risk environment (RR 0.64, 95% CI 0.22 to 1.89; low-quality evidence).

AUTHORS' CONCLUSIONS

Evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces the risk of postoperative wound infections after herniorrhaphy surgery. Evidence of moderate quality shows that antibiotic prophylaxis probably makes little or no difference in preventing wound infections (i.e. all wound infections, SSSI or DSSI) after hernioplasty surgery in a low infection risk environment. Evidence of low quality shows that antibiotic prophylaxis in a high-risk environment may reduce the risk of all wound infections and SSSI, while evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces DSSI after hernioplasty surgery.

Chronic mesh infection complicated by an enterocutaneous fistula successfully treated by infected mesh removal and negative pressure wound therapy: A case report

RATIONALE

Tension-free repair of inguinal hernia with prosthetic materials in adults has become a routine surgical procedure. However, serious complications may arise such as mesh displacement, infection, and even enterocutaneous fistula (EF). The management of chronic mesh infection (CMI) complicated by an EF is very challenging. A simple treatment of infected mesh removal and negative pressure wound therapy (NPWT) may cure the patients with EF with CMI.

PATIENT CONCERNS

A 75-year-old male patient underwent tension-free treatment for a bilateral inguinal hernia at a county hospital 10 years ago. Three months before admission, the right groin gradually formed a skin sinus with outflow of fetid thin pus, and it could not heal.

DIAGNOSES

The patient was diagnosed preoperatively with mesh plug adhesion to the intestine, which resulted in low-flow EF combined with CMI.

INTERVENTIONS

The patient received a simple treatment mode consisting of an incision made from the original incision, but the new incision did not penetrate the abdominal cavity; treatment included resection of the fistula, removal of the mesh, repair of the intestine and local tissue, and continuous irrigation of vacuum sealing drainage (VSD) devices for NPWT.

OUTCOMES

The infected mesh was completely removed. Five VSD devices were utilized to treat the EF and wound. The time from intervention to wound healing was 35 days, and follow-up for 6 months revealed no infection and no hernia recurrence in the right groin.

LESSONS

The NPWT is effective in treating CMI concomitant with EF and does not increase the risk of hernia recurrence.

Deep SSI after mesh-mediated groin hernia repair: management and outcome in an Emergency Surgery Department

AIM

Mesh-mediated groin hernia repair is considered the goldstandard procedure. It has low recurrence rate. Rarely a deep Surgical Site Infection (SSI) is seen when a synthetic prosthesis is used.

CASE REPORT

We describe a rare case of bilateral deep SSI after mesh-mediated groin hernia repair. Diagnosis was performed through the physical examination and radiological exams. Microbiological samples identified a methicillin-resistant Staphylococcus aureus responsible of the infection. Target therapy was performed and re-operation performed in order to remove the infected prosthesis and to apply a biological one to create the fibrous scaffold. During follow-up time, right side recurrence was observed. Tru-cut biopsy of fascia was obtained in order to identify the responsible of the recurrence.

CONCLUSION

Combination of antibiotic therapy and surgical reoperation seems to be the correct way to approach the deep SSI after mesh-mediated groin hernia repair. The use of biological mesh after synthetic removal seems to improve the final outcome.

Study of mesh infection management following inguinal hernioplasty with an analysis of risk factors: a 10-year experience

PURPOSE

We present a review of our 10-year experience in managing patients with mesh infection following hernioplasty and analyze the occurrence of known predisposing factors.

METHODS

We analyzed 392 cases of mesh infection treated at our center between 2007 and 2018 after a preoperative work-up. (Thirty-one patients underwent the primary hernia repair procedure at our hospital, whereas the others underwent the primary surgery at other local centers and were referred to our center.) The method of infected mesh removal (open or laparoscopic) was selected depending on the primary surgical approach. Open repair involved the excision of the mesh, infected tissue, and sinus (if present). The laparoscopic approach was used to identify the abscess, excise the mesh, and allow drainage into the preperitoneal space.

RESULTS

The operative course in all patients was uneventful. A second surgery to extract the residual mesh around the pubic bone was performed in 7 patients. Hernia recurred in 29 patients after mesh removal. The discharge culture results were positive in 193 patients. Of these, Staphylococcus spp. was identified as the causative organism in 126 patients. Risk factors for mesh infection, including obesity, smoking, and diabetes, were identified in 182 (46.5%), 154 (39.3%), and 35 (8.9%) patients, respectively.

CONCLUSIONS

It is recommended the approach of mesh removal is tailored as per the primary hernioplasty method. We analyzed the occurrence of risk factors for mesh infection in this study, but further studies are needed to develop a predictive model that is both internally and externally validated to evaluate the probability of mesh infection.

The Management of Mesh Infection After Laparoscopic Inguinal Hernia Repair

We present our experience in managing mesh infection after laparoscopic inguinal hernia repair. We analyzed 19 patients with extensive mesh infection treated between 2012 and 2017 via laparoscopic mesh excision after preoperative workup. After mesh removal and insertion of a drain into the preperitoneal space, the peritoneal flap was closed with 3/0 absorbable consecutive suture. The operative course in all patients was uneventful. Sigmoidectomy for a fistula was required in 1 patient. Two patients required a second laparoscopic surgery for infection on the contralateral side and residual mesh around the pubic bone. In total, 3 cases of recurrence were identified during follow-up. Laparoscopic mesh excision is an effective and minimally invasive method for the management of infection that also avoids unnecessary disruption of healthy layers of the abdominal wall.

Totally Extraperitoneal (TEP) Removal of an Infected Mesh by Laparoscopy after Open Preperitoneal Repair: Initial Case Report

Prosthetic mesh infection after open or laparoscopic hernia repair is a rare complication. Superficial wound infection can be resolved by treatment with a combination of antibiotics and wound drainage, whereas deep-seated mesh infection, which can lead to chronic groin sepsis, usually requires removal of the mesh. A 56-year-old Japanese man was admitted to our hospital for the treatment of deep-seated mesh infection. The patient had undergone inguinal hernia repair at another hospital 18 months earlier. The operation was prosthetic mesh repair via an anterior approach. The patient developed deep-seated mesh infection despite conservative treatment for infection, such as abscess drainage and antibiotic therapy. Since the patient eventually developed chronic groin sepsis, he was referred to our hospital, and infected mesh was removed successfully by laparoscopic surgery via a totally extraperitoneal approach. The laparoscopic approach provides several advantages, including less postoperative pain, a shorter hospital stay, and earlier rehabilitation. Furthermore, seeding of the abdominal cavity with pus never occurs with this approach unlike the laparoscopic transabdominal preperitoneal approach.

Partial versus complete removal of the infected mesh after abdominal wall hernia repair

BACKGROUND

To compare the results with complete mesh removal (CMR) versus partial mesh removal (PMR) in the treatment of mesh infection after abdominal wall hernia repair (AWHR).

METHODS

Retrospective review of all patients who underwent surgery for mesh infection between January 2004 and May 2014 at a tertiary center.

RESULTS

Of 3470 cases of AWHR, we reported 66 cases (1.9%) of mesh infection, and 48 repairs (72.7%) required mesh explantation. CMR was achieved on 38 occasions, while PMR was undertaken ten times. We observed more postoperative complications in CMR than PMR group (p = 0.04). Three patients with intestinal fistula were reoperated in postoperative period after a difficult mesh removal; one of them died due to multiple organ failure. The overall recurrence rate after explantation was 47.9%: recurrence was more frequent in CMR group (p = 0.001), although persistent or new mesh infection was observed more frequently with PMR (p = 0.001).

CONCLUSIONS

Although PMR has less postoperative morbidity, shorter duration of hospitalization and lower rate of recurrence than CMR, prosthetic infection persists in up to 50% of cases.

Self-gripping mesh versus fibrin glue fixation in laparoscopic inguinal hernia repair: a randomized prospective clinical trial in young and elderly patients

Laparoscopic transabdominal preperitoneal inguinal hernia repair is a safe and effective technique. In this study we tested the hypothesis that self-gripping mesh used with the laparoscopic approach is comparable to polypropylene mesh in terms of perioperative complications, against a lower overall cost of the procedure. We carried out a prospective randomized trial comparing a group of 30 patients who underwent laparoscopic inguinal hernia repair with self-gripping mesh versus a group of 30 patients who received polypropylene mesh with fibrin glue fixation. There were no statistically significant differences between the two groups with regard to intraoperative variables, early or late intraoperative complications, chronic pain or recurrence. Self-gripping mesh in transabdominal hernia repair was found to be a valid alternative to polypropylene mesh in terms of complications, recurrence and postoperative pain. The cost analysis and comparability of outcomes support the preferential use of self-gripping mesh.

Two-center Analysis of Long-term Outcomes after High Ligation Inguinal Hernia Repair in Adolescents

High ligation of the inguinal hernia sac is standard practice for many pediatric surgeons in post-pubertal adolescents. Most adult surgeons do not use this technique to repair indirect inguinal hernias because of concerns for higher recurrence rates compared with mesh repairs. Therefore, we examined long-term outcomes of adolescent high ligation hernia repair performed by pediatric surgeons. Telephone surveys were conducted on children over 12 years old at the time of repair, and patients and/or their parents were contacted 18 months postrepair. Patients were identified from two institutions between 1998 and 2010. The incidences of reoperation, recurrence, presence of bulge, chronic pain, or numbness were determined. A total of 210 patients (40.7% response rate) were available for phone interviews at 18.6 to 159.5 months postrepair. Mean age was 14.6 ± 1.8 (range: 12.0–19.0 years). Fourteen patients had pain (6.7%) and five had numbness (2.4%). There were four (1.9%) patients with a second operation, two of which confirmed a recurrent hernia. Three patients expressed concern about possible recurrence. Two report a bulge, but have not been evaluated. Pediatric hernia repair with high sac ligation appears effective in patients anatomically similar to adults with low recurrence rate and low incidence of chronic symptoms. These data suggest that prospective trials on the adequacy of high ligation in adults are warranted.

A case report on management of synergistic gangrene following an incisional abdominal hernia repair in an immunocompromised obese patient

•

Synergistic gangrene is generated from bacterial colonies present in necrotic tissues. Within our case, continual removal of the necrotic burden was essential in wound bed preparation, reducing contamination and tissue destruction.

•

In surgery, wide necrotic wound debridement, early and repetitive wound drainages with the use of a large pore polypropylene mesh with a detailed surgical follow up is recommended.

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This case has demonstrated how a planned multidisciplinary action can produce prosperous results in a severely obese immunocompromised patient with an SSI, following an incisional hernia repair.

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Our selective case is unique within current literature, being the first to illustrate mesh salvage in a morbid obese patient with chronic lymphoblastic leukaemia.

Introduction

We present a case on conservative management of salvaging the mesh in an immunocompromised morbidly obese patient, who developed a synergistic gangrene infection following a primary open mesh repair of an incisional hernia.

Presentation of case

Our patient presented with a surgical wound infection, comorbidities were Chronic Lymphoblastic Leukemia (CLL), Body Mass Index (BMI) of 50, hypertension and diet controlled type-2 diabetes. In surgery, wide necrotic wound debridement, early and repetitive wound drainages with the use of a large pore polypropylene mesh and a detailed surgical follow up was required. High dose intravenous broad-spectrum antibiotic treatment and Negative Pressure Wound Therapy (NPWT) was administrated in combination with adopting a multidisciplinary approach was key to our success.

Discussion

Stoppa Re et al. complied a series of 360 ventral hernia mesh repairs reporting an infection rate of 12% that were managed conservatively. However, our selective case is unique within current literature, being the first to illustrate mesh salvage in a morbid obese patient with CLL. Recent modifications in mesh morphology, such as lower density, wide pores, and lighter weight has led to considerable improvements regarding infection avoidance.

Conclusion

This case has demonstrated how a planned multidisciplinary action can produce prosperous results in a severely obese immunocompromised patient with an SSI, following an incisional hernia repair.

Blood vessel matrix seeded with cells: a better alternative for abdominal wall reconstruction-a long-term study

PURPOSE

The aim of this study was to present abdominal wall reconstruction using a porcine vascular graft seeded with MSC (mesenchymal stem cells) on rat model.

MATERIAL AND METHODS

Abdominal wall defect was prepared in 21 Wistar rats. Acellular porcine-vascular grafts taken from aorta and prepared with Triton X were used. 14 aortic grafts were implanted in place, of which 7 grafts were seeded with rat MSC cells (Group I), and 7 were acellular grafts (Group II). As a control, 7 standard polypropylene meshes were used for defect augmentation (Group III). The assessment method was performed by HE and CD31 staining after 6 months. The mechanical properties have been investigated by Zwick&Roell Z0.5.

RESULTS

The strongest angiogenesis and lowest inflammatory response were observed in Group I. Average capillaries density was 2.75, 0.75, and 1.53 and inflammatory effect was 0.29, 1.39, and 2.72 for Groups I, II, and III, respectively. The means of mechanical properties were 12.74 ± 1.48, 7.27 ± 1.56, and 14.4 ± 3.7 N/cm in Groups I and II and control, respectively.

CONCLUSIONS

Cell-seeded grafts have better mechanical properties than acellular grafts but worse than polypropylene mesh. Cells improved mechanical and physiological properties of decellularized natural scaffolds.

Outcome of the patients with chronic mesh infection following open inguinal hernia repair

Purpose

Hernia repairs are the most common elective abdominal wall procedures performed by general surgeons. The use of a mesh has become the standard for hernia repair surgery. Herein, we discuss a management strategy for chronic mesh infections following open inguinal hernia repair with onlay prosthetic mesh.

Methods

In this study, 15 patients with chronic mesh infections following open inguinal hernia repairs were included. The medical records of these patients were retrospectively reviewed and information regarding presentation, type of previous hernia repair, type of mesh, operative findings and bacteriological examination results were obtained. In all cases, the infected mesh was removed completely and the patients were treated with antibiotic regimens and local wound care.

Results

Fifteen mesh removals due to chronic infection were performed between January 2000 and March 2012. The mean interval of hernia repair to mesh removal was 49 months. All patients were followed up for a median period of 62 months (range, 16 to 115 months). In all patients, the infections were resolved successfully and none were persistent or recurrent. However, one patient developed recurrent hernia and one developed nerve injury.

Conclusion

Chronic mesh infection following hernia repair mandates removal of the infected mesh, which rarely results in hernia recurrence.

Risk factors for mesh-related infections after hernia repair surgery: a meta-analysis of cohort studies

Mesh infection, although infrequent, is a devastating complication of mesh hernioplasties. The aim of this study was to systematically review and synthesize the available evidence on risk factors for synthetic mesh infection after hernioplasty. A systematic search was performed in PubMed and Scopus databases. The extracted data were synthesized with the methodology of meta-analysis. We identified six eligible studies that reported on 2,418 mesh hernioplasties. The crude mesh infection rate was 5%. Statistically significant risk factors were smoking (risk ratio [RR] = 1.36 [95% confidence interval (CI): 1.07, 1.73]; 1,171 hernioplasties), American Society of Anesthesiologists (ASA) score ≥3 (RR = 1.40 [1.15, 1.70]; 1,682 hernioplasties), and emergency operation (RR = 2.46 [1.56, 3.91]; 1,561 hernioplasties). Also, mesh infections were significantly correlated with patient age (weighted mean difference [WMD] = 2.63 [0.22, 5.04]; 2,364 hernioplasties), ASA score (WMD = 0.23 [0.08, 0.38]; 1,682 hernioplasties), and the duration of the hernioplasty (WMD = 44.92 [25.66, 64.18]; 833 hernioplasties). A trend toward higher mesh infection rates was observed in obese patients (RR = 1.41 [0.94, 2.11]; 2,243 hernioplasties) and in patients operated on by a resident (in contrast to a consultant; RR = 1.18 [0.99, 1.40]; 982 hernioplasties). Mesh infections usually resulted in mesh removal, and common pathogens included Staphylococcus spp., Enterococcus spp., and gram-negative bacteria. Patient age, ASA score, smoking, and the duration and emergency setting of the operation were found to be associated with the development of synthetic mesh infection. The heterogeneity of the available evidence should be taken under consideration. Prospective studies with a meticulous follow-up are warranted to further investigate mesh-related infections.

Desarda versus Lichtenstein technique for primary inguinal hernia treatment: 3-year results of a randomized clinical trial

BACKGROUND

The Shouldice method and other tissue-based techniques are still acknowledged to be acceptable for primary inguinal hernia repair according to the European Hernia Society guidelines. Desarda's technique, presented in 2001, is an original hernia repair method using an undetached strip of external oblique aponeurosis. This randomized trial compared outcomes after hernia repair with Desarda (D) and mesh-based Lichtenstein (L) techniques.

METHODS

A total of 208 male patients were randomly assigned to the D or L group (105 vs. 103, respectively). The primary outcomes measured were recurrence and chronic pain. Additionally, early and late complications, foreign body sensation, and return to everyday activity were examined in hospital and at 7, 30 days, and 6, 12, 24, and 36 months after surgery.

RESULTS

During the follow-up, two recurrences were observed in each group (p = 1.000). Chronic pain was experienced by 4.8 and 2.9% of patients from groups D and L, respectively (p = 0.464). Foreign body sensation and return to activity were not different between the groups. There was significantly less seroma production in the D group (p = 0.004).

CONCLUSIONS

The results of primary inguinal hernia repair with the Desarda and Lichtenstein techniques are comparable at the 3-year follow-up. The technique may potentially increase the number of tissue-based methods available for treating groin hernias.

Mesh infection after inguinal hernia mesh repair

INTRODUCTION

Infection after repair of groin hernia is rare, even since the advent of mesh repair. The debate remains open about antibiotic prophylaxis.

AIM OF THE STUDY

Assess incidence of this kind of complication, determine criteria of diagnosis and strategy of therapy by examining the collective experience of 32 surgeons.

METHOD

Fifty surgeons were asked to report their experience with mesh repair of inguinal hernias and specifically mesh infection. Diagnosis and therapy for each mesh infection were detailed.

RESULTS

Forty-five cases were reported in 38 patients who had undergone open or laparoscopic mesh repair. Diagnosis was straightforward and established at a variable delay after mesh insertion: 51% during the first postoperative month; 26% more than one year after the procedure. Infection cured in 33 patients after mesh removal, in one step in 14 cases, but after many attempts for conservative therapy in 19 cases; the mean delay to cure was 12.5 months. Visceral resections had to be associated with mesh removal in 13% of cases.

CONCLUSIONS

This is the largest series of mesh infections after inguinal hernia repair reported in the literature. According to the evidence provided here, mesh removal appears to be the most appropriate treatment of this rare and serious complication.

Late polypropylene mesh susceptibility to infection during intra-abdominal sepsis

PURPOSE

To evaluate the susceptibility of high-density polypropylene mesh to contamination, 1 year after experimental hernia repair.

METHODS

Wistar rats were randomized into two groups: one experimental group (n = 20) and another control group (n = 10). Mesh hernia repair was performed with intra-abdominal (group I, n = 10) or subcutaneous (group II, n = 10) implantation of grafts. The three groups were exposed to an intra-abdominal E. coli administration after 1 year of operation. After 24 hr, the meshes and peritoneum were sampled from the experimental and control groups, respectively, in order to assess bacterial inoculation. Immunoreaction to E. coli inoculation was also evaluated after 24 hr by measuring serum interleukin-6 (IL-6) and C-reactive protein (CRP) levels.

RESULTS

Bacteriological analysis revealed increased contamination in groups I and II when compared with the control group (p = .001 and .007, respectively). IL-6 levels were increased in both groups I and II compared with the control group, 24 hr after E. coli injection (p = .034 and .022, respectively), while there was no statistically significant difference between groups concerning the concentration of CRP.

CONCLUSIONS

Polypropylene mesh is vulnerable to bacterial inoculation during intra-abdominal sepsis 1 year after mesh placement.

Infections associated with prosthetic repairs of abdominal wall hernias: pathology, management and results

PURPOSE

To analyse clinical and demographic factors of patients who suffered infection of the surgical site requiring mesh removal as a complication of prosthetic repairs, details of the hernioplasties in which meshes were implanted and their management and outcomes.

METHODS

Factors related to infection (demographic variables and characteristics of the repairs and mesh utilised) and the management before proceeding to mesh removal were obtained from patient charts. Collected specimens (meshes and tissues) from 32 consecutive patients were cultured and observed microscopically. The outcomes after mesh removal were prospectively evaluated.

RESULTS

Twenty-two patients underwent incisional hernioplasties and ten inguinal hernioplasties; most of the procedures took a long time, and 28 patients presented early wound complications (seroma or haematoma). During the “implantation–removal” interval, some conservative treatments, such as drainages or sinus resection, were attempted under local anaesthesia. Twenty-two meshes were totally removed (nine after partial extraction); in the remaining ten cases partially removal was successful. Most of the meshes (24) were made of multi-filament polypropylene; microscopic observation of neighbouring tissues showed leucocyte infiltration, giant cell reaction, disorganisation of the collagen fibres and abscedation. Treatment of 32 patients required 51 operations. Following mesh removal, there were six recurrences and two fistulas of the bowel. The average follow-up was 40 months (30–97).

CONCLUSIONS

Most of the infections requiring mesh removal were related to prolonged repair operations that presented untreated early postoperative wound complications. Partial extraction of meshes frequently leads to failures and complications. Surgical exploration should be performed under general anaesthesia to accomplish complete mesh extraction.

Mesh graft infection following abdominal hernia repair: risk factor evaluation and strategies of mesh graft preservation. A retrospective analysis of 476 operations

BACKGROUND

Mesh graft infection after prosthetic hernia repair is a challenging complication usually treated by mesh removal. The aim of this study was to identify risk factors associated with mesh infection and to assess the efficacy of conservative wound therapy in preserving an infected mesh.

METHODS

We performed a retrospective analysis of 476 consecutive patients with incisional hernia who received mesh graft repair between February 1, 2000 and February 28, 2005 at our institution using chart review and clinical investigation.

RESULTS

Thirty-one of 476 (6.5%) patients developed a deep surgical site infection involving the implanted mesh graft. Upon multivariate analysis, operation time was the only significant risk factor associated with mesh infection (p = 0.0038). Seventeen (55%) of 31 infected mesh grafts were preserved by conservative means. There was a significant association between the type of mesh graft used and the probability of mesh preservation in case of infection: While conservative therapy led to preservation of 100% of infected polyglactin/polypropylene meshes, only 20% of infected polypropylene and 23% of infected PTFE/polypropylene meshes could be salvaged using conservative means (p < 0.0001). In none of the patients with preserved mesh graft was hernia recurrence at the former site of infection observed.

CONCLUSIONS

Operation time is the only significant risk factor associated with mesh graft infection following incisional hernia repair. Conservative treatment should be applied in case of infection of absorbable mesh grafts such as polypropylene/polyglactin, while nonabsorbable meshes such as PTFE/polypropylene or pure polypropylene are much less amenable to conservative treatment, usually requiring early surgical removal.

An abscess mimicking a left incarcerated groin hernia

We present the case of a 79-year-old man with an irreducible and painful left groin mass. Obtaining a detailed history of present illness and assessment of radiological findings revealed an abscess in a groin hernia sac, which was formed secondary to perforation of the descending colon. Various examinations, however, failed to reveal the cause of the bowel perforation. Percutaneous drainage improved his symptoms. He was discharged home 24 days after admission with no further sequelae. An abscess in a groin hernia sac is very rare. Although neither bowel perforation nor hernia is rare, surgeons do not sufficiently consider the possibility of an abscess in a groin hernia sac. Thus, surgeons often encounter unexpected abscesses in the groin hernia sac during operations. Our case points to the necessity of obtaining a detailed history of present illness as well as assessment of radiological findings, and presents a therapeutic option for an abscess in a groin hernia sac.

Conservative management of mesh-site infection in hernia repair

BACKGROUND

Mesh hernioplasty is the preferred surgical procedure for large abdominal wall hernias. Infection remains one of the most challenging complications of this operation. Salvaging infected prosthetic material after ventral hernia repair is rarely successful. Most cases require mesh excision and complex abdominal wall reconstruction, with variable success rates. In this article, we report 3 cases of mesh salvage after laparoscopic ventral herniorrhapy with a novel use of percutaneous drainage and antibiotic irrigation.

RESULTS

Three patients developed infected seromas after laparoscopic ventral hernia repair. The fascial defect of the first patient was repaired with a commercially available 20 x 18 cm polytetrafluoroethylene (PTFE) mesh. A complex fluid collection developed the following month in the anterior abdominal wall overlying the patient's mesh. The cultures grew Staphylococcus aureus. The second patient had a 30 x 20 cm PTFE mesh placed, which developed a fluid collection with Enterococcus faecalis and Escherichia coli. The third case underwent repair, using a another commercially available 22 x 28 cm PTFE mesh. A fluid collection measuring 20 x 10 cm in the anterior abdominal wall developed, growing Staphylococcus lugdunensis. In all 3 cases, a percutaneous drain was placed within the fluid collection and long-term intravenous (i.v.) access was obtained. I.v. antibiotics were initiated. In addition, gentamicin (80 mg) with 20 mL of saline was infused through the drain 3 times a day. All patients have remained free of clinical signs of infection following the completion of therapy.

CONCLUSIONS

Infected mesh after laparoscopic ventral herniorrhapy without systemic sepsis may be amenable to nonoperative treatment. A conservative approach that includes percutaneous drainage followed by antibiotic irrigation is a potential alternative to prosthetic removal in carefully selected patients. Further evaluation of this technique is warranted to define the most appropriate management strategies for these patients.

Reconstruction of an infected recurrent ventral hernia after a mesh repair using a pedicled tensor fascia lata flap: report of two cases

Recently, the use of prosthetic mesh has revolutionized the repair of ventral hernias. However, the occurrence of infection related with the use of this prosthesis remains an important complication, which may result in occurrence of fistula formation of the skin or intestine, sepsis, or reoccurrence of ventral hernia. This report presents two cases where a pedicled musculocutaneous flap using the tensor fascia lata (pedicled TFL flap) was effective as a treatment for an infectious large abdominal hernia, and reviews the previous literature. Two Japanese men aged 61 and 78 years old underwent a ventral hernia repair using Composix Kugel mesh. They both developed a wound infection with methicillin-resistant Staphylococcus aureus. Conservative therapy was not successful and the defect in the abdominal wall of two patients measured 12 x 21 cm and 7 x 10 cm in length, respectively. Reoperations were performed by removing the infectious mesh and then reconstructing the abdominal wall with the bilateral and left-side pedicled TFL flaps, respectively. No recurrence of the ventral hernia has been recognized for 50 months and 7 months after reoperation, respectively. A review of previous studies showed that no patients treated with a pedicled TFL flap experienced a recurrent hernia. Therefore, the pedicled TFL flap was considered to be effective for infectious large abdominal recurrent hernia.

Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh

OBJECTIVES

Mild pain lasting for a few days is common following mesh inguinal hernia repair. In some patients however, severe groin pain may appear months or even years postoperatively. The aim of this study was to report our experience of late-onset persisting severe postoperative groin pain occurring years after mesh hernioplasty.

METHODS

In a 9-year period, 1,633 patients (1,073 men), median age 63 years (range 19-88), underwent mesh groin hernia repair. Between 1.5 and 4 years postoperatively, six patients (0.35%) presented with severe chronic groin pain unrelieved by conservative measures and surgical exploration was essential. The patients' records were retrospectively reviewed for the purpose of this study.

RESULTS

Ilioinguinal nerve entrapment was detected in four patients. The meshes appeared to be indistinguishable from the nerve and were removed along with the stuck nerve. New meshes were properly inserted. Mesh fixation on the periostium of the pubic tubercle by a staple was found in the other two patients. The staples were removed from the periostium in both patients. Neither hernia recurrence nor chronic groin pain was persisting in all six patients during a follow-up of 6-44 months postoperatively.

CONCLUSION

From the results of this study, it appears that ilioinguinal nerve entrapment and/or mesh fixation on the periostium of the pubic tubercle are the causes of late-onset severe chronic pain after inguinal mesh hernioplasty. Mesh removal, along with the stuck ilioinguinal nerve and staple detachment from the periostium, are the gold-standard techniques if conservative measures fail to reduce pain.

Tension-free repair versus Bassini technique for strangulated inguinal hernia: A controlled randomized study

By Evidence Based Medicine (EBM) principles, several meta-analyses concluded that use of mesh is superior to the non-mesh operations in inguinal hernia surgery. Wound infection is a potential complication of all hernia repairs and deep-seated infection involving an inserted mesh may result in chronic groin sepsis. In the event of incarcerated or strangulated hernias, however; placement of prosthetic material is presumed to increase that risk of infection.

AIM

Aim of the study is to compare the outcome of tension-free mesh repair to Bassini technique used to treat strangulated inguinal hernia.

PATIENTS AND METHODS

In the period from May 2004 to December 2006, 54 patients were submitted to emergency operation because of strangulated inguinal hernia. The patients were randomized into two groups (27 patients in each group). Group A patients underwent open tension-free anterior repair utilizing a monofilament polypropylene mesh according to Lichtenstein "tension-free" technique, whereas group B patients underwent Bassini technique. Mesh hernioplasty was not attempted in patients with preoperative peritonitis, inflammatory hernia and for those in whom bowel resection was perfumed for ischemic necrosis caused by strangulated inguinal hernia and they were excluded from the study. Assessment of the primary outcome included surgical complications and hospital stay and secondary outcome was the recurrence of hernia.

RESULTS

Postoperative complication rate did not differ significantly between the two groups. Postoperative hospital stay was also significantly longer in group B compared to group A (5+/-3.4 days versus 3+/-2.1 days, p<0.01). During the follow-up, (mean 22+/-6months), three patients had recurrence after Bassini operation (group B), but there was no recurrent hernia after mesh herniorrhaphy (group A) (0/27=0% versus 3/27=7, 11.1%, p<0.001).

CONCLUSION

The use of Lichtenstein "tension-free" technique in emergency treatment of strangulated inguinal hernia is safe, effective with an acceptably low rate of postoperative complications and without recurrence.

Mesh repair of common abdominal hernias: a review on experimental and clinical studies

Results on hernia surgery from numerous centers confirm that tensionless repair with various meshes reduces the complication rates and the frequency of recurrences. Some evidence on incisional hernias suggests, however, that the use of mesh seems to transfer the onset of recurrences by several years. Persistent pain and other discomfort is also an unpleasant complication of otherwise successful surgery in a number of patients. Thus, improved, slowly degrading, mesh materials, with strong connective tissue-inducing action, might be more optimal for hernia surgery. Accumulating evidence also suggests that recurrent hernias appear in patients having inherited weakness of connective tissues. Numerous tissue specific collagens, in addition to the classical fibrillar I-III collagens and numerous substrate specific matrix proteinases, have recently been described in biochemical literature, and their roles as possible causes of tissue weakness are discussed.

The analysis of infection after polypropylene mesh repair of abdominal wall hernia

AIM

The aim of the study was to evaluate the frequency of superficial and prosthetic mesh infection following polypropylene mesh repair of different abdominal wall hernia in individual patients and to analyze the manifestation, clinical process and outcomes in patients with prosthetic mesh infection.

METHODS

This was a retrospective analysis of 375 patients with 423 implanted meshes for groin, femoral, umbilical, incisional and epigastric hernias, with a mean follow-up of 15 months (range: 3-73 months).

RESULTS

The total superficial infection rate was 1.65%, and the rate of mesh infection was 0.94%. There were no statistically significant differences in prosthetic mesh infection between monofilament and multifilament meshes as well as between the different repair groups of hernias. The deep incisional surgical site infection after previous operation was established as a significant risk factor for prosthetic mesh infection in incisional hernia repair (P < 0.0001). Five cases of prosthetic mesh infection were presented and analyzed.

CONCLUSIONS

There is no correlation between the superficial and prosthetic mesh infection. There may be difficulties in determining mesh infection and to choose the right tactic. The reconvalescence in all patients with mesh infection was achieved only after removal of the infected mesh.