Conservative Management of Mesh-Site Infection in Hernia Repair

Abstract

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 × 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 × 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 × 28 cm PTFE mesh. A fluid collection measuring 20 × 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.

Introduction

The placement of prosthetic biomaterials has become a standard procedure during ventral hernia repair surgery. Clinical evidence support lower recurrence rates as they generate “tension-free” closure of hernia defects and provide a permanent replacement for native fascia that frequently has been weakened or removed by previous surgery. Reduction of ventral hernia recurrence by 30%^1–3 has been shown. However, the lower recurrence rates come at the price of mesh-related complications, including seromas, adhesions, chronic severe pain, migration, and mesh-related infections.^4,5 The exact incidence of mesh infections is difficult to obtain due to the variable presentation period after surgery. Infections can arise anywhere from 2 to 39 months⁶ following repair. The incidence has been reported from 0.001 to 8%^7–14 in the literature. While this appears relatively infrequent, when compared with other device-related infections, the clinical significance of this diagnosis portends a complex,^9,10 extended course for both the patient and the surgeon.^8,12 The rate of mesh infection is influenced considerably by underlying comorbidity, immunosuppression, incision size, obesity, history of previous hernia repair or wound infection, and tobacco use.^7–14 Unfortunately, patients with these same risk factors are also likely to have a recurrent hernia, if the prosthetic mesh is not utilized in the repair.⁸

Standard surgical practice has traditionally advocated the removal of contaminated or exposed prosthetics. Unfortunately, the removal of the prosthetic materials is often technically difficult when there is good tissue incorporation and can increase the risk of subsequent enterocutaneous fistula formation.¹⁵ Achieving closure of the fascial defect after mesh removal is not usually possible; therefore, a larger ventral hernia than at the time of original repair may result. These issues have generated interest in a successful, conservative treatment algorithm that does not involve mesh removal.^13,14,16,17 In this article, we describe a novel approach to manage the complex problem of infected prosthetic mesh following laparoscopic ventral hernia repair (LVHR).

Materials and Methods

This study was conducted by the Department of Surgery at Mayo Clinic Hospital (Phoenix, AZ). We report 3 cases of mesh infection after laparoscopic hernia repair with a prosthetic mesh. The infection was diagnosed by clinical evidence of pain, redness, induration, fever, and purulent discharge on aspiration. We attempted to treat these cases with a conservative approach.

After ultrasonografic confirmation of a fluid collection surrounding the prosthetic mesh, a computed tomography (CT)-guided placement of a drain was perform in all cases. The skin overlying the left abdomen was sterilely prepped, then draped to infiltrate 1% lidocaine. An 18-gauge needle was advanced into the fluid collection. Through the needle, an Amplatz wire was placed in the collection, the tract was dilated with a 6.8- and 10-Fr fascial dilator, followed by the placement of a 10-Fr locking loop all-purpose drainage catheter that was then placed into the fluid collection. Repeat CT was performed, confirming appropriate placement. A specimen was sent to the lab for microbiology analysis. The tube was secured with the skin by using a 2-0 Prolene suture. The catheter was left to external bulb suction. The patients and their relatives were instructed to irrigate the catheter with gentamicin (80 mg) in 20 mL of normal saline, leaving the solution in the cavity for 30 minutes and then returning the drain to bulb suction. This was performed 3 times per day.

We chose gentamicin as the primary antibiotic for the irrigation therapy for its properties as a bactericidal agent at low concentrations and its known activity against Staphylococcus spp. as well as gram-negative cocci. Local use of gentamicin provides much higher concentrations at wound sites, so blood concentrations remain low, thus preventing toxicity. Special recognition has been given to the use of gentamicin for the treatment of infected skin cysts and other skin abscesses, when preceded by incision and drainage to permit adequate contact between the drug and the infecting bacteria.⁷

Case 1

A 50-year-old female underwent a robotic bilateral ovarian cystectomy, at which time she had an abdominal wall mesh place for an umbilical hernia. This mesh became infected and was removed. Six months following removal, an LVHR was performed with a 20 × 18 cm polytetrafluoroethylene (PTFE) Gore DualMesh^® (Creative Technologies Worldwide, Flagstaff, AZ) for a recurrent hernia. One month later, the patient was found to have erythema over her abdominal wall as well as an elevated white blood cell count. A CT scan demonstrated a complex fluid collection in the anterior abdominal wall overlying the patient's mesh. Percutaneous drainage of the abscess was then undertaken, where approximately 100 mL of purulent material was aspirated. A drain was left in place. The cultures revealed Staphylococcus aureus sensitive to ampicillin and sulbactam. Drain irrigation with gentamicin (80 mg) in 20 mL of normal saline (NS) 3 times a day as well as 1 month of intravenous (i.v.) antibiotics was initiated. The drain and central line were then removed. There has been no clinical evidence of recurrent infection at 18 months of follow-up.

Case 2

A 63-year-old male with end-stage liver disease secondary to primary sclerosing cholangitis underwent an orthotopic liver transplant and Roux-en-Y choledochojejunostomy performed in 2005. He subsequently developed a large ventral hernia, which was repaired laparoscopically with a 30 × 20 cm PTFE Gore DualMesh in September 2007. In January 2009, the patient underwent a routine colonoscopy and developed Enterococcus faecalis and Escherichia coli bacteremia. An abdominal CT scan demonstrated a fluid collection posterior to the abdominal mesh. At that time, an external drain was placed to treat the infection with gentamicin flushes (80 mg in 20 mL of NS 3 times a day), as well as i.v. antibiotics through a peripherally inserted central catheter (PICC line), including ceftriaxone (2 g once-daily) and ampicillin (2 g 3 times a day). After 1 month of treatment, there were no clinical signs of infection. The drain and antibiotics were then discontinued. He continues to have no sign of infection currently at 11 months of follow-up.

Case 3

A 41-year-old female underwent multiple cesarean sections, followed by the development of a ventral hernia. This was repaired 8 times with mesh placement, in most cases. On one occasion, the mesh had to be removed secondary to infection. We performed an LVHR with a 22 × 28 cm PTFE Gore DualMesh.

The patient presented the following month with generalized body aches, chills, and fever. An abdominal CT scan was performed that demonstrated a large fluid collection in the anterior abdominal wall measuring 20 × 10 cm. It was drained, producing 450 mL of fluid. A percutaneous drain and a PICC line were placed. Cultures grew 1+ S. lugdunensis. I.v. amipicillin and sulbactam as well as gentamicin irrigation (80 mg in 20 mL of NS) through the drain 3 times a day was initiated.

At the end of treatment, a follow-up CT scan performed on her abdomen and pelvis demonstrated improvement of the anterior fluid collection previously drained. There remained a seroma posterior to the mesh that was 9 cm in size without evidence of abscess features. An attempt to aspirate the seroma was unsuccessful due to its depth. The patient was placed on amoxicillin/clavulanate (875 mg) by mouth twice-daily for an additional 3 weeks of antibiotic therapy. The anterior drain remained in place during this time and was removed after it produced less than 10 mL of serous fluid daily. At 13 months of follow-up, she has done well with no signs of infection.

Discussion

Surgical-site infections continue to be a major source of morbidity throughout the world, accounting for almost 40–60%^10,18 of all postoperative infectious complications. This concern, along with the increased costs associated with extended hospitalization and reparative treatment, justifies efforts to identify patient populations at risk and optimize preoperative preparation and perioperative care. In the past few years, the hernia repair with alloplastic prothesis has become the standard treatment due to lower rates of recurrence, when compared with simple suture closure. However, the implantation of synthetic materials are related with wound-associated complications in up to one third of cases.⁵ Mesh-related infectious complications occur in up to 13.6% and usually require recurrent surgical intervention.¹² The more common agents associated with mesh infection are Staphylococcus species (spp.) (especially S. aureus), Streptococcus spp. (including group B streptococci), gram-negative bacteria (mainly Enterobacteriaceae), and anaerobic bacteria (including Peptostreptococcus spp.).^18–21 In a study of mesh-related infections following ventral herniorrhaphies, 63% of the microorganisms isolated were methicillin-resistant S. aureus (MRSA). Rarely, mesh infections are caused by Candida spp. or Mycobacterium spp.²¹

Various factors are predictive of prosthetic infections, such as patient-related illness, including diabetes mellitus, malnutrition, chronic obstructive pulmonary disease, tobacco and/or alcohol use, medical therapy with steroids, renal failure, and morbid obesity.^{5–10,12,17,18,21} These medical comorbidities are associated with decreased perfusion of the skin and subcutaneous (s.c.) tissues as well as immunosuppressive attributes. Factors directly to the operation, such as the choice of mesh material and type of surgical procedure, are still the subject of critical debate. In a meta-analysis of 20 trials (5016 participants) of open versus open nonmesh repair of groin hernias, it was shown that the rate of postoperative complications, including infections, was similar in both procedures.⁴ A similar clinical trial with 200 adult umbilical hernia repairs with or without mesh showed no differences in results between techniques, including infection rate.²¹ Korenkov et al.,²² in a clinical, randomized trial of 160 patients with simple or complex hernias that underwent either suture repair, autodermal skin graft, or onlay polypropylene mesh repair, found fewer infectious complications after suture repair (9%) than after skin graft or mesh repair (18%) for simple hernias and 23–35% for complex hernias. White et al.²³ reported that the use of a mesh and hernia defect > 10 cm were associated with significantly more wound complications (44 versus 26%; P < 0.05), especially a increased incidence of seroma (21 versus 7%). They also reported that patients undergoing mesh repair were more likely to receive antibiotics (91 versus 71%) and have s.c. drains placed (57 versus 25%), compared to simple primary repair.

The traditional surgical management for infection after hernia repair with prosthetic materials advocates that all infected prosthetic materials must be removed, but this leads to a high risk of hernia recurrence. Innovative studies aim to provide evidence that a conservative approach may be a suitable alternative. Carbonell et al.²⁶ studied hernia repairs by using seven prosthetic mesh biomaterials innoculated with bacteria in a live animal and concluded that ePTFE was the least susceptible to infection, and with silver/chlorhexidine coating, the prosthesis was able to kill all the inoculated bacteria. Silver-chlorhexidine-impregnated meshes may be the prosthetics of choice to prevent the occurrence of mesh infection in LVHR. The literature would support that the debridement of all purulent material and necrotic tissue is essential, but it remains debatable whether to remove the prostheses. Irrigation with antimicrobial solutions has been attempted in a few trials. Trunzo et al.¹³ reported 2 cases of infected seroma after laparoscopic ventral repair: A 20 × 23 cm Parietex^™ composite polyester mesh was used in 1 patient, and a 32 × 33 cm piece of expanded PTFE was used in the other. After the infections were diagnosed, the patients were treated by abscess drainage, parenteral antibiotics, and 4 weeks of gentamicin irrigation (80 mg in 30 mL of solution) via a drain 3 times per day. Both patients remained free of clinical signs of infection at 12 and 16 months, respectively. Ahmad et al.¹⁴ described 13 cases of open ventral hernia repair with using polypropylene mesh resulting in infection. They treated their patients with local management, including incision, drainage, and debridement of the wound, followed by irrigation with saline/povidone iodine. Eight patients (62%) required daily dressing changes and five to seven debridements. Three patients (23%) developed severe sepsis and complete dehiscence of the wound. These patients averaged 10–12 debridements during recovery. Two patients (15%) with cellulitis were discharged after 10–12 days with full recovery. All the patients were followed for 3 months and did not have recurrence of infection.

Some researchers believe that an individualized approach is necessary to treat patients with mesh infections, and special considerations must be taken regarding the type of mesh.²⁷ The use of a multifilament polyester mesh is related to a higher incidence of infection, small-bowel obstruction, and enterocutaneous fistula formation than the use of other types of mesh (e.g., knitted monofilament polypropylene, PTFE, or woven polypropylene).^2,12,19,17 Further, experimental studies in animals relate the use of microporous mesh to a higher rate of infections and development of seromas, whereas macroporous material was shown to be associated with a higher incidence of adhesive and erosive events.^23–25 The ePTFE mesh has generated conflicting theories as to its ability to be salvaged in the face of infection. Paton et al.²⁷ concluded that patients with limited ePTFE mesh infections could be treated with abscess drainage, antibiotics, and local wound care, but more extensive infections require mesh removal. Petersen et al.¹² concluded that in their experience with 8 mesh-infected cases, adequate drainage seemed to be sufficient for polypropylene or polyester meshes; however, infected ePTFE patches should be removed early. The researchers explained that the structural matrix of ePTFE permits fluid retention and bacterial growth due to inadecuate leucocyte invasion through the 10-mm pores. Bellon et al.^29,30 demonstrated that S. aureus colonies produce alterations in the structure of ePTFE. From using electron microscopy, they demonstrated the deformation of internodal filaments and the creation of fissures in the ePTFE microstructure, and that alteration of the biomaterial facilitated the attachment and invasion of bacteria. Despite these findings, we have had success with the salvage of ePTFE after laparoscopic ventral hernia repair. In our experience, infection of ePTFE does not always mandate removal. Our 3 cases were successfully managed with drainage, parenteral antibiotics, and gentamicin irrigation through a drain, with no recurrence of infection.

Conclusions

For patients with an infected mesh in the absence of systemic sepsis, a conservative approach that includes percutaneous drainage, followed by antibiotic irrigation, is a potential alternative to prosthetic removal. Further evaluation of this technique is warranted to define the most appropriate management strategies for these patients.

Footnotes

Disclosure Statement

No competing financial interests exist.

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