A randomized trial of antibiotic prophylaxis for the prevention of surgical site infection after open mesh-plug hernia repair

Assessing Morinidazole for Surgical Site Infection in Class Ⅲ Wounds Prevention: A Multicenter, Randomized, Single-Blind, Parallel-Controlled Study

INTRODUCTION

Surgical site infections are significant postoperative risks, antibiotic prophylaxis is crucial due to the presence of anaerobic bacteria. This study investigated the efficacy and safety of a novel nitroimidazole, morinidazole, in SSI reduction in class Ⅲ wounds, as there is currently a lack of evidence in the existing literature.

METHODS

A multicenter randomized clinical trial was conducted from December 2020 to October 2022 in the general surgery departments of 12 tertiary hospitals in China. 459 patients in two treatment groups using morinidazole plus ceftriaxone or ceftriaxone alone. Efficacy and safety were evaluated including SSI incidence, adverse events, and compliance. Statistical analysis employed SAS 9.4 software. Data analysis was performed from February to May 2023.

RESULTS

A total of 440 participants (median [IQR] age, 63.0 [54.0, 70.0] years; 282 males [64.09%]; 437 patients were of Han race [99.32%]) were randomized. The experimental group exhibited a significantly lower SSI rate compared with the control group (31 [14.49%] vs 52 [23.01%]; risk difference, 1.76%, 95%CI, 1.08% to 2.88%; P=0.0224). The superficial incisional site infections revealed a marked reduction in the experimental group (12 [5.61%] vs 31 [13.37%]; risk difference,2.68%; 95%CI,1.34%to5.36%; P=0.0042). Non-surgical site infections, severe postoperative complications, and total adverse events showed no statistically significant differences between the groups (P>0.05).

CONCLUSION

The significant decrease in SSI rates and superficial incisional infections demonstrates morinidazole as a valuable prophylactic antibiotic. Our findings provided valuable insights for clinical practice, where this new-generation nitroimidazole can play a crucial role in SSI prevention.

Preventing Surgical Site Infections in the Era of Escalating Antibiotic Resistance and Antibiotic Stewardship

Importance

According to the Centers for Disease Control and Prevention and governing bodies within the American College of Surgeons, the administration of antibiotics as prophylaxis against infection prior to a planned elective procedure is, with rare exception, routinely recommended. The goal of "getting to zero" infections remains a high priority for policymakers, practitioners, and certainly for patients.

Observations

Despite the many advances in surgical technique, skin decontamination, sterile procedure, and enhanced recovery programs, surgical site infections continue to adversely affect procedures as diverse as dental implant surgery, joint arthroplasty, and major abdominal surgery. Although surgical site infection rates are at historically low levels, progress has stalled in recent reporting periods and such infections remain disabling, costly, and occasionally lethal. Stakeholders in the field, including surgeons, infectious diseases specialists, and industry, advocate for strategies emphasizing greater levels of intraoperative sterility or broader-spectrum antibiotic coverage as the most appropriate path forward.

Conclusions and Relevance

The current emphasis on ever-increasing levels of intraoperative sterility and extended-spectrum antibiotic use are not sustainable long-term solutions. Continuing to escalate these approaches may contribute to unintended consequences including antimicrobial resistance. Principles of antimicrobial stewardship and microbiome sciences can be applied to inform a more effective and sustainable approach to infection prevention in the field of surgery.

Outcomes from Early Experience with Laparoscopic Inguinal Hernia Repair Versus Open Technique: Navigating the learning curve

Objectives

This study aimed to evaluate the outcomes of laparoscopic inguinal hernia repair (LIHR) regarding postoperative pain, recurrence rates, duration of hospital stay and other postoperative outcomes within the context of a tertiary care teaching hospital in South India, and the initial experience of laparoscopic repairs. The current consensus in the literature often suggests LIHR as superior to open inguinal hernia repair (OIHR).

Methods

This single-centre, retrospective, observational study was conducted at the Jawaharlal Institute of Postgraduate Education and Research, Puducherry, India, from January 2011 to September 2020. All patients who underwent elective OIHR and LIHR were included. Data on the patients demographics, comorbidities, hernia type, mesh characteristics, surgery duration, hospital stay and immediate postoperative complications were collected and analysed.

Results

A total of 2,690 OIHR and 158 LIHR cases were identified. The demographic profiles, hospital stay and complication rates were similar in both groups. However, surgical site infection was present exclusively in the OIHR group (3.55% versus 0.0%; P <0.05). The timeline for returning to normal activities was statistically shorter for the LIHR group (6 versus 8 days; P <0.05). The most frequent immediate complication in the LIHR group was subcutaneous emphysema (6.54% versus 0.0%; P <0.05). Recurrence (9.23% versus 3.61%; P = 0.09) and chronic pain (41.53% versus 13.55%; P <0.05) were higher in the LIHR group.

Conclusion

Lower recurrence and chronic pain rates were observed with OIHR in the initial experience with LIHR in the hospital. However, LIHR had significant advantages concerning faster patient recovery and lower rates of surgical site infections. While the results contribute an interesting deviation from the standard narrative, they should be interpreted within the context of a learning curve associated with the early experience of the research team with LIHR.

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.

Severe wound infection by MRCNS following bilateral inguinal herniorrhaphy

BACKGROUND

Wound infection after inguinal hernia surgery is not uncommon in the clinical setting. The common microbial aetiology of postoperative inguinal hernia wound infection is Gram-positive bacteria. Staphylococcus aureus is a common pathogen causing wound infection while Staphylococcus epidermidis and Pseudomonas are rare. Staphylococcus epidermidis as a cause of severe wound infection is rarely described in literature. We herein present a case of a 79-year-old man with a rare wound infection after bilateral inguinal herniorrhaphy caused by MRCNS (Methicillin Resistant Coagulase Negative Staphylococcus).

CASE PRESENTATION

We present a case of wound infection accompanied by fever with a temperature of 38.8 °C after bilateral inguinal herniorrhaphy in a 79-year-old man. Bilateral inguinal wounds were marked by redness and swelling, with skin necrosis. In addition, an abscess of approximately 1.5 cm × 1.5 cm was seen on the left wrist. A small amount of gas under the skin in the wound area was observed after pelvic computed tomography (CT) scans. No bacteria were cultured from the inguinal wound discharge, while blood culture detected MRCNS, and Acinetobacter lwoffi was cultured from the pus in the left wrist. We chose appropriate antibiotics based on the results of the bacterial culture and the drug susceptibility results. Vacuum assisted closure (VAC) therapy was used after debridement. The patient was discharged after the wounds improved. He was followed up for ten months and showed no signs of complications. We are sharing our experience along with literature review.

CONCLUSIONS

We are presenting a rare case of MRCNS wound infection following open inguinal hernia surgery. Although a rarity, clinicians performing inguinal hernia surgery must consider this entity in an infected wound and follow up the patient for complications of MRCNS.

HIV patient with prolonged infection after hemicolectomy and repair of complicated hernia. Mini-review of a rare successful surgical outcome

Introduction and importance

Surgical site infection (SSI) is an inevitable occurrence in bowel perforation with faecal soiled hernia wound(s) especially in retroviral patients. Unfortunately, the increased antibiotics and wound care demands do not prevent delayed healing, increased risk of hernia recurrence, or multiple surgeries to control the infection. The standard open or endo-laparoscopic Mesh repairs are either deferred or avoided with alternative tissue-based hernia repairs after bowel surgery. The reported success of open tissue-based repairs remains mixed. Nylon monofilament that have been used in infected wounds was chosen for the patient in anticipation of wound infection.

Case presentation

A 48-year-old man presented with a 7-days complicated hernia at the emergency unit, Margaret Marquart Catholic Hospital. Clinical examination revealed signs of shock, intestinal obstruction, and peritonism, laboratory investigation was remarkable of anaemia, septicaemia, deranged renal function, and positive retroviral test. He had concurrent right hemicolectomy and nylon darn after optimisation. The outcome we evaluated after surgery included postoperative pain, scrotal collection, anastomotic breakdown, postoperative analgesic use, wounds infection, prolonged hospital stays, recurrence, and the need for a second surgery. Though he developed prolonged deep SSI, he has intact hernia repair after 6-years.

Clinical discussion

The postoperative critical clinical events presented in this case were unexpected but might have been precipitated by his retroviral status. Thus, a weight loss of over 13 kg within 2 weeks was highly unusual. Furthermore, the positive retroviral status couple with the perforated caecum and soiled peritoneum was the cause of the surgical site infection.

Conclusion

Nylon darning in a retro-positive patient developing prolonged SSI appeared beneficial. It should be considered in patients with anticipated long period wound infection.

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Surgical site infection is a challenge in hernias with perforated viscus after repair.

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Current standard modalities of hernia repairs are used in such patient's infection are not anticipated.

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Patient with retroviral infection and wound contamination requires a different approach to ensure the intact repair.

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Nylon darn, one of the methods was used with success.

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Our patient with a prolonged infection after surgery and a 5-year post-repair success are a first of the kind reported.

Antibiotic Prophylaxis against Surgical Site Infection after Open Hernia Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The role of antibiotic prophylaxis (AP) in the prevention of surgical site infection (SSI) after hernia repair is debated. We conducted this systematic review and meta-analysis to assess the evidence on the value of prophylactic antibiotics in reducing the risks of SSI after open hernia surgery.

METHODS

We ran an online and manual search to identify relevant randomized controlled trials that compared prophylactic antibiotics to nonantibiotic controls in patients undergoing open surgical hernia repair. Data on SSI risk were extracted and pooled as risk ratios (RRs) with 95% confidence intervals (95% CIs), using RevMan software. We further used the Cochrane risk of bias tool and GRADE assessment to evaluate the quality of generated evidence.

RESULTS

Twenty-nine studies (N = 8,616 patients) were included in the current analysis. Antibiotic prophylaxis reduced the risk of SSI in open hernia repair patients (RR = 0.65, 95% CI = 0.53, 0.79). Subgroup analysis showed a significant benefit for antibiotics in mesh repair patients (RR = 0.60, 95% CI = 0.48, 0.76) yet no significant difference in SSI risk after herniorrhaphy (RR = 0.86, 95% CI = 0.54, 1.36). In addition, AP was associated with a significant reduction in superficial SSI risk (RR = 0.56, 95% CI = 0.43, 0.72) but not deep SSI (RR = 0.70, 95% CI = 0.30, 1.62). Further analysis showed a significant reduction in SSI risk with amoxicillin/clavulanic acid and cefazolin but not with cefuroxime.

CONCLUSION

The present meta-analysis suggests that AP is beneficial prior to open mesh hernia repair. However, the quality of evidence was low, and further well-designed trials are needed.

Surgical Antimicrobial Prophylaxis—Where Do We Stand?

Introduction Surgical site infection (SSI) is the commonest preventable health care–associated infection among postoperative cases. Several guidelines are available for surgical antimicrobial prophylaxis (SAP) and other measures which prevent SSI. National Center for Disease Control (NCDC), India, has also provided a guideline for prevention of SSI in 2016. In this study we have compared the NCDC, India, guideline with WHO (World health organization) and American Society of Health System Pharmacists (ASHP) guidelines. The timing of antimicrobial agent administration is the only parameter which is included in all the three guidelines. As per NCDC and ASHP it should be within 60 minutes of incision while as per WHO it is within 120 minutes of incision.

Materials and Methods This was a prospective observational study—104 patients undergoing surgery in general surgical ward between January 2016 and June 2017 were included in this study. The NCDC guideline was compared with WHO and ASHP guidelines. Real data comparison was done for those parameters which were included in all the three guidelines.

Statistical Analysis Data were analyzed using descriptive methods and chi-square test.

Results None of the patients in our study received SAP within 60 minutes of incision. In 70% cases it was administered within 2 hours of incision and in the remaining 30% it was administered after more than 2 hours. There was no significant difference in the incidence of SSI among these two groups.

Conclusion NCDC SAP guideline helps in rational use of antimicrobials. Increasing the duration for SAP may be added in the NCDC guidelines. Inclusion of certain additional parameters like weight-based doses and consideration for other comorbidities will help in patient- and procedure-specific SAP. Antimicrobial stewardship should be encouraged in all the hospitals and should follow local antimicrobial resistance pattern. This will assist in therapy decision, policy making, and evidence-based treatment.

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.

Chitosan Cross-Linked Bio-based Antimicrobial Polypropylene Meshes for Hernia Repair Loaded with Levofloxacin HCl via Cold Oxygen Plasma

Polypropylene (PP) large pore size nets have been most widely used implants for hernia repair. Nevertheless, the growth of bacteria within PP mesh pores after operation is a major reason of hernia recurrence. Secondly, pre-operative prophylaxis during mesh implantation has failed due to the hydrophobic nature of PP meshes. Herein, chitosan cross-linked and levofloxacin HCl incorporated, antimicrobial PP mesh devices were prepared using citric acid as a bio-based and green cross-linking agent. The inert PP mesh fibers were surface activated using O2 plasma treatment at low pressure. Then, chitosan of different molecular weights (low and medium weight) were cross-linked with O2 plasma activated surfaces using citric acid. Scanning electron microscopy (SEM), energy dispersive X-ray (EDX) spectroscopy, and Fourier transform infrared (FTIR) spectroscopy confirmed that chitosan was cross-linked with O2 plasma-treated PP mesh surfaces and formed a thin layer of chitosan and levofloxacin HCl on the PP mesh surfaces. Moreover, antimicrobial properties of chitosan and levofloxacin HCl-coated PP meshes were investigated using an agar plate release method. The coated PP meshes demonstrated excellent antimicrobial inhibition zone up to 10 mm. Thus, modified PP meshes demonstrated sustained antimicrobial properties for six continuous days against Staphylococcus aureus (SA) and Escherichia coli (EC) bacteria.

Polydopamine-Inspired Surface Modification of Polypropylene Hernia Mesh Devices via Cold Oxygen Plasma: Antibacterial and Drug Release Properties

Mesh infection is a major complication of hernia surgery after polypropylene (PP) mesh implantation. Modifying the PP mesh with antibacterial drugs is an effective way to reduce the chance of infection, but the hydrophobic characteristic of PP fibers has obstructed the drug adhesion. Therefore, to prepare antimicrobial PP mesh with a stable drug coating layer and to slow the drug release property during the hernia repair process has a great practical meaning. In this work, PP meshes were coated by bio-inspired polydopamine (PDA), which can load and release levofloxacin. PP meshes were activated with cold oxygen plasma and then plasma activated PP fibers were coated with PDA. The PDA coated meshes were further soaked in levofloxacin. The levofloxacin loaded PP meshes demonstrate excellent antimicrobial properties for 6 days and the drug release has lasted for at least 24 h. Moreover, a control PP mesh sample without plasma treatment was also prepared, after coating with PDA and loading levofloxacin. The antimicrobial property was sustained only for two days. The maximum inhibition zone of PDA coated meshes with and without plasma treatment was 12.5 and 9 mm, respectively. On all accounts, the modification strategy can facilely lead to long-term property of infection prevention.

One-Step Surface Functionalized Hydrophilic Polypropylene Meshes for Hernia Repair Using Bio-Inspired Polydopamine

An ideal hernia mesh is one that absorbs drugs and withstands muscle forces after mesh implantation. Polypropylene (PP) mesh devices have been accepted as a standard material to repair abdominal hernia, but the hydrophobicity of PP fibers makes them unsuitable to carry drugs during the pre-implantation of PP meshes. In this study, for the first time, one-step functionalization of PP mesh surfaces was performed to incorporate bio-inspired polydopamine (PDA) onto PP surfaces. All PP mesh samples were dipped in the same concentration of dopamine solution. The surface functionalization of PP meshes was performed for 24 h at 37 °C and 80 rpm. It was proved by scanning electron microscopic (SEM) images and Fourier Transform Infrared Spectroscopy (FTIR) results that a thin layer of PDA was connected with PP surfaces. Moreover, water contact angle results proved that surface functionalized PP meshes were highly hydrophilic (73.1°) in comparison to untreated PP mesh surfaces (138.5°). Thus, hydrophilic PP meshes with bio-inspired poly-dopamine functionalization could be a good choice for hernia mesh implantation.

Laparoscopic transabdominal preperitoneal technique versus open surgery with the ULTRAPRO Hernia System for the repair of female primary femoral hernias-an observational retrospective study

Femoral hernias (FHs), predominantly seen in females, require surgery for cure. To date, surgical repair of primary FHs in female patients with either open surgery or laparoscopic operation has been poorly documented. We retrospectively investigated the treatment of female primary FHs with open surgery using the ULTRAPRO Hernia System (UHS procedure) or the laparoscopic procedure, namely, the transabdominal preperitoneal (TAPP) technique. A total of 41 female patients with primary FHs who had undergone UHS or TAPP were included in this study. The procedural parameters, post-surgical complications, treatment expense, and follow-up results were analyzed. The vast majority of patients (39/41) underwent elective operations: 15 received UHS (including 2 emergency cases) and 26 had TAPP (P = .08). The UHS group had a greater average age, due to the fact that FHs occur often in people with advanced age who tend to have systemic disease, limiting the use of general anesthesia required for TAPP. Compared with UHS, TAPP took a significantly shorter time to complete and patients undergoing TAPP had a dramatically shorter hospital stay. While no recurrence was observed in both groups, post-procedure pain and foreign body sensation were reported by significantly more patients in UHS group. The cost was greater with TAPP. Taken together, we concluded that both UHS and TAPP are effective in the management of female FHs. In view of the advantages and disadvantages between the open and the laparoscopic operation, surgeons can select a procedure according to their skills and patients' situation.

Comparison of Lichtenstein Repair and Mesh Plug Repair Methods in The Treatment of Indirect Inguinal Hernia

Objective: The lifetime risk to develop an inguinal hernia is 27%-43% for men and 3%-6% for women. Methods of hernia repair currently involve prosthetic mesh applications. The aim of this study is to compare the Lichtenstein repair and Mesh-plug repair methods in the surgical treatment of indirect inguinal hernias and to identify which of these two techniques is superior regarding its conferred advantages.

Materials and Methods: In this study, a total of 102 patients who were diagnosed with indirect inguinal hernia between the years 2014 and 2015 without a previous operation were analyzed. Patients undergoing Lichtenstein repair and Mesh-plug repair were compared, especially during operation time, hospital stay, postoperative pain and other aspects.

Results: The mean age of patients was 28.7 years (19-73). The mean duration of operations and hospitalizations was significantly shorter in patients who had undergone mesh-plug repair. Inguinal pain in the operation area on postoperative day one, two weeks and six months was significantly less in patients who had undergone mesh-plug repair. Patients were followed-up for two years.

Conclusion: We concluded that mesh-plug repair was superior to Lichtenstein repair regarding postoperative pain, quality of life of the patient, shorter duration of operation, and duration of hospital stay although the two methods were similar regarding both recurrence and complication rates. Considering this information, we suggest that mesh-plug repair can be used safely for the treatment of indirect inguinal hernias.

Late Ps. aeruginosa Inguinal Mesh Infection 12 Years after the Initial Operation: Report of the Case and Short Review of the Literature

Inguinal hernia mesh repair is one of the most frequent operations performed worldwide. The Lichtenstein technique and its various modifications are the most popular operations for groin hernia repair. The rate of surgical site infection (SSI) following inguinal hernia repair ranges between 0 and 14% in various series. Most of these infections developed early postoperatively. The incidence of late mesh infection following open inguinal hernia repair still remains unclear and highly variable. Late deep mesh infections are relatively rare specially after more than 10 years. The most common pathogens reported in the literature are E. coli and St. aureus. The infection is treated by conservative means initially but in case of failure then the mesh should be removed surgically. A unique case of a patient with very late (chronic) mesh infection is presented. The infection was due to Pseudomonas aeruginosa, which occurred 14 years after the initial operation and presented as subcutaneous fistula.

Network meta-analysis of antibiotic prophylaxis for prevention of surgical-site infection after groin hernia surgery

BACKGROUND

First-generation cephalosporins (such as cefazolin) are recommended as antibiotic prophylaxis in groin hernia repair, but other broad-spectrum antibiotics have also been prescribed in clinical practice. This was a systematic review and network meta-analysis to compare the efficacy of different antibiotic classes for prevention of surgical-site infection (SSI) after hernia repair.

METHODS

RCTs were identified that compared efficacy of antibiotic prophylaxis on SSI after inguinal or femoral hernia repair from PubMed and Scopus databases up to March 2016. Data were extracted independently by two reviewers. Network meta-analysis was applied to assess treatment efficacy. The probability of being the best antibiotic prophylaxis was estimated using surface under the cumulative ranking curve (SUCRA) analysis.

RESULTS

Fifteen RCTs (5159 patients) met the inclusion criteria. Interventions were first-generation (7 RCTs, 1237 patients) and second-generation (2 RCTs, 532) cephalosporins, β-lactam/β-lactamase inhibitors (6 RCTs, 619) and fluoroquinolones (2 RCTs, 581), with placebo as the most common comparator (14 RCTs, 2190). A network meta-analysis showed that β-lactam/β-lactamase inhibitors and first-generation cephalosporins were significantly superior to placebo, with a pooled risk ratio of 0·44 (95 per cent c.i. 0·25 to 0·75) and 0·62 (0·42 to 0·92) respectively. However, none of the antibiotic classes was significantly different from the others. SUCRA results indicated that β-lactam/β-lactamase inhibitors and first-generation cephalosporins were ranked first and second respectively for best prophylaxis.

CONCLUSION

β-Lactam/β-lactamase inhibitors followed by first-generation cephalosporins ranked as the most effective SSI prophylaxis for adult patients undergoing groin hernia repair.

Antibiotic prophylaxis in open inguinal hernia repair: a literature review and summary of current knowledge

More than 1 million inguinal hernia repairs are performed in Europe and the US annually. Although antibiotic prophylaxis is not required in clean, elective procedures, the routine use of implants (90% of inguinal hernia repairs are performed with mesh) makes the topic controversial. The European Hernia Society does not recommend routine antibiotic prophylaxis for elective inguinal hernia repairs. However, the latest randomized controlled trial, published by Mazaki et al., indicates that the use of prophylaxis is effective for the prevention of surgical site infection. Unnecessary prophylaxis contributes to the development of bacterial resistance and significantly increases healthcare costs. This review documents clinical trials on inguinal hernia repairs with mesh and summarizes the current knowledge. It also tries to solve certain problems, namely: what constitutes a real risk factor, late-onset infection, and how the "surgical environment" impacts on the need to use antibiotic prophylaxis.

The effectiveness of i.v. cefuroxime prophylaxis of surgical site infection after elective inguinal hernia repair with mesh: A retrospective observational study

PURPOSE

The efficacy of routine antibiotic prophylaxis for prevention of surgical site infection (SSI) after elective inguinal hernia repair with a mesh patch remains uncertain. The authors of a recent Cochrane meta-analysis based on 17 randomized trials were unable to draw a definitive conclusion on this subject. The purpose of this study was to determine the effectiveness of prophylactic antibiotics for prevention of SSI after elective inguinal hernia repair with mesh and the risk factors for SSI.

METHODS

All low-risk patients who underwent elective inguinal hernia repair with mesh at our institution between 2010 and 2015 were enrolled in this study, with the exception of patients with recurrent hernias or immunosuppressive diseases. All patients received a single intravenous (i.v.) injection of cefuroxime (1.5 g) within 2 h prior to surgery at the discretion of the surgeon. SSI was defined using criteria of the Centers for Disease Control and Prevention. The variables which could influence the rate of SSI were analyzed by multivariate analysis to determine the independent risk factors for SSI.

RESULTS

Among the 605 patients who underwent elective inguinal hernia repair with mesh during the study period, 553 were eligible for enrolment in the study. Of these, 331 received a single dose of cefuroxime preoperatively. The overall SSI rate was 5.4 %; 9.4 % of those patients who did not receive preoperative antibiotic prophylaxis developed SSI versus 2.8 % of those who did receive prophylaxis (P = 0.001). All infections were superficial. Factors independently associated with SSI were advanced age, smoking and preoperative stay.

CONCLUSIONS

The incidence of SSI among low-risk patients who did and did not receive preoperative antibiotic prophylaxis after elective inguinal hernia repair with mesh differed significantly, particularly among patients of advanced age, smokers and patients with a prolonged preoperative stay in the hospital.

Predictors of mesh infection and explantation after abdominal wall hernia repair

BACKGROUND

The main objective was to identify predictive factors associated with prosthesis infection and mesh explantation after abdominal wall hernia repair (AWHR).

METHODS

This is a retrospective review of all patients who underwent AWHR from January 2004 to May 2014 at a tertiary center. Multivariate analysis identified predictors of mesh infection and explantation after AWHR.

RESULTS

From 3,470 cases of AWHR, we reported 66 cases (1.9%) of mesh infection, and 48 repairs (72.7%) required mesh explantation. Steroid or immunosuppressive drugs use (odds ratio [OR] 2.22; confidence interval [CI] 1.16 to 3.95), urgent repair (OR 5.06; CI 2.21 to 8.60), and postoperative surgical site infection (OR 2.9; CI 1.55 to 4.10) were predictive of mesh infection. Predictors of mesh explantation were type of mesh (OR 3.13; CI 1.71 to 5.21), onlay position (OR 3.51; CI 1.23 to 6.12), and associated enterotomy in the same procedure (OR 5.17; CI 2.05 to 7.12).

CONCLUSIONS

Immunosuppressive drugs use, urgent repair, and postoperative surgical site infection are predictive of mesh infection. Risk factors of prosthesis explantation are polytetrafluoroethylene mesh, onlay mesh position, and associated enterotomy in the same procedure.

Complications, Pain Control, and Patient Recovery After Local Versus General Anesthesia for Open Inguinal Hernia Repair in Adults—Systematic Review and Meta-analysis

The purpose of this systematic review is to provide an “up-to-date” evidence-based guideline and clarify the possible benefits as well as drawbacks of local anesthesia (LA) and general anesthesia (GA) in open inguinal hernia surgery in adults. Study method comprised randomized controlled trials. Primary outcome measures were complications, pain control, and patient recovery. Secondary outcome measures were patient satisfaction and hernia recurrence. A total of 14 randomized controlled trials contributed to the study. A total of 1677 patients were analyzed, with 953 in the LA group and 724 in the GA group. Complications were statistically less frequent in the LA group compared with the GA group [odds ratio (OR), 0.31; 95% confidence interval (95% CI), 0.15, 0.64). Supplemental intraoperative analgesia had a statistical significance in the LA group, with an OR of 28.93 (95% CI, 7.86, 106.47). Postoperative pain was statistically significantly lower in the LA group [standardized eman difference (SMD), −1.06; 95% CI, −1.64, −0.48)]. Length of stay was shorter for patients who underwent operation under LA compared with those receiving GA (OR, −1.21; 95% CI, −2.08, −0.33]). Time to full mobility was shorter in the LA group, without statistical significance (OR, 3.04; 95% CI, 0.19, 47.90), whereas measuring in SMD showed significance in comparison with GA (SMD, −1.74; 95% CI, −2.34, −1.14). Hernia recurrence was not noted. Patient satisfaction was greater in the LA group (SMD, 0.65; 95% CI, 0.15, 1.15). Compared with GA, LA showed superiority in terms of complications, postoperative pain, length of stay, time to full mobility, and patient satisfaction. Therefore, it appears to be a more appropriate anesthetic technique for open inguinal hernia repair in adults.