Surgical Site Infection: The Scourge of Abdominal Wall Reconstruction

Abstract

Background:

Surgical site infection (SSI) is a well-recognized and potentially catastrophic complication of abdominal wall reconstruction (AWR). The authors present a review of the literature surrounding SSI in AWR, exploring prevention and treatment strategies as well as risk factors.

Methods:

A comprehensive review of the current literature was undertaken. Evidence was reviewed and summarized with particular focus on prevention and treatment strategies available to hernia surgeons.

Results:

Patient risk factors for SSI are well described in the literature and include obesity, smoking, and other comorbidities. Contaminated hernias and cases involving enterocutaneous fistulae are also at higher risk of SSI. Surgical decisions such as type of mesh, plane of mesh placement, and fascial release may all contribute to SSI risk. To treat established mesh infection, conservative management with antibiotic agents and negative pressure therapy is a reasonable option in some cases. Removal of prosthesis appears to provide favorable results, however, repeat surgery can be problematic

Conclusions:

Surgical site infection remains an important pathology in the world of AWR. Surgeons have a wealth of tools in their arsenal to prevent and treat SSI and should be aware of the emerging evidence in the fast-moving specialty of hernia surgery. Complex cases should be handled by surgeons and centers with expertise in treating such patients.

Abdominal wall reconstruction (AWR) is an exciting and rapidly expanding specialty filled with new techniques designed to solve the challenges of modern hernia surgery. Despite the progress that has been made over past decades, the obstacle of surgical site infection (SSI) remains as relevant as ever—and a thorn in our side.

In 1992 the US Centers for Disease Control and Prevention (CDC) developed its own modified classification for SSI [1]. It described SSI as a post-operative infection that can be either superficial incisional, deep incisional, or organ/space infection. This definition is particularly relevant in the field of hernia surgery, highlighting the depth of tissue involvement. The CDC states that superficial incisional infections must be identified within 30 days of the procedure and must not involve the deeper muscle or fascial layers. Deep incisional infections must also be identified within 30 days, unless there is a prosthesis involved, in which case diagnosis can be made within one year. Organ/space infection includes any other site opened during surgery, such as an intra-abdominal collection. As discussed, SSI in AWR does not always adhere strictly to these definitions.

Surgical site infection affects AWR with varying frequency depending on the complexity of the repair. Whereas the literature describes SSI rates of 1%–3% [2] for elective inguinal hernia repairs, higher rates are reported for incisional hernias. One retrospective study looking at 169 complex incisional hernias (grade 1 and 2) found an overall SSI rate of 12% [3]. As procedures become more complex and contaminated, we see SSI rates increase. A retrospective series by Cobb et al. [4] assessed 255 cases of incisional hernia repair. In this series with a mean defect size of 181 cm² and 17% contaminated or dirty cases, they recorded an SSI rate of 19.6%. In an even more complex population, a series of 37 cases of AWR with component separation and closure of enterocutaneous fistula produced an SSI rate of 65% [5]. Incidence of SSI can therefore change drastically dependent upon the complexity and contamination involved.

When considering deep incisional SSI and mesh infection specifically, different numbers may apply. Some have described an incidence of between 6% and 10% for open ventral hernia repairs, and 0% and 0.36% for laparoscopic repair [6]. In a meta-analysis of six cohort studies, Mavros et al. [7] found that mesh infection occurred at a rate of 7.2% in ventral hernias (varying types) compared with only 0.3% in groin hernias.

Impact on Patients with Hernias

Once established, SSI can be catastrophic for patients, and can place substantial burden on healthcare institutions. Surgical site infection leads not only to unnecessary exposure to antibiotic agents, but prolonged length of stay, and a protracted treatment course in the community or outpatient setting.

In the first instance, simple cellulitis can be treated with antibiotic agents, and infected collections will require formal drainage, leaving the patient to endure several weeks of wound packings. However unpleasant this may be, it is the event of deeper incisional infections, and moreover, mesh infections, that bear the most substantial morbidity.

Although the diagnosis of superficial SSI is usually straightforward, this is not always the case with mesh infection. Deep infections can be slow developing, delaying diagnosis and treatment for months. Although the CDC suggests that SSI after AWR should be diagnosed within the first 12 months, others have reported that many patients (up to 34.7%) can present after more than one year post-operatively [8]. In fact, one large mesh explantation study by Klosterhafen and Klinge [9] noted a median period to manifestation of infection was two years. The longest time between implantation and infection in their study was a startling 88 months. These studies highlight how certain mesh infections can lie dormant for months before requiring treatment. Although difficult to study, this indicates that patients may be suffering in silence for a long period before seeking help.

Once deeper SSI has become symptomatic, treatment will include not only antibiotic agents, but also intervention to ensure source control. Often the infection will require explantation of the mesh, either on a partial or complete basis [10], with some patients having to endure more than a year of conservative therapy, involving repeated courses of antibiotic agents, serial wash-outs, and debridement before explantation is finally considered [11]. In cases of chronic infection with failed explantation, this step may have to be undertaken more than once.

Salvage of infected mesh is certainly a laudable challenge, and many would advocate it as a reasonable option in certain cases. There is literature on the successful use of negative pressure dressings in an attempt to clean a cavity and salvage an infected mesh but with substantial impact on patient quality of life [12]. Meagher et al. [12] reviewed 13 patients with mesh infection, 10 of whom received negative pressure therapy (NPT) to salvage mesh. Although treatment was eventually successful, time to healing was an average of 199 days, during which patients had to undergo dressing changes every three days, and presumably manage their lives handling suction cannisters. Costs were approximately €6,500 per patient. If patients do eventually undergo complete mesh removal, they are often destined for recurrence regardless [10].

Notwithstanding mesh infection, SSI has been proven as an independent risk factor for hernia recurrence [13,14]. It is postulated that the presence of infection and inflammation interrupts the host tissue integration, leading to poor healing [2]. When Burger et al. [15] followed 181 patients in a randomized control trial for between 75 and 81 months they identified SSI as an independent risk factor for recurrence. The review by Cobb et al. [4] of 255 retromuscular mesh repairs and the COBRA study examining 104 patients had similar findings [16]. The impact of SSI on patients’ lives and outcomes should be seen as a blight on AWR, and our priority should be prevention at all costs.

Risk Factors and Their Prevention

Risk factors for SSI are reported extensively in the literature, and are best described in terms of patient factors, hernia factors, and technical factors [6]. This review examines briefly these groups but mainly focuses technical factors to reduce SSI.

Patient factors

Unfortunately for hernia surgeons, many risk factors for SSI are inherent in the population that develops large complex hernias. Elimination of these preventable comorbidities may see lower rates of SSI and lower costs to healthcare providers [17]. One such factor, obesity, is well established as a risk factor, however different studies describe differing relations between high body mass index (BMI) and SSI. Docimo et al. [18] recently examined more than 4,000 patients who had undergone AWR with open component separation. They identified a BMI of >35 as an independent risk factor for SSI with an odds ratio of 1.47 (95% confidence interval [CI], 1.21–1.78). A BMI >35 was also associated with an increase in overall minor complications, major complications, re-admissions, and re-operations [18]. As with all surgery, smokers are more susceptible to SSI after AWR [7] which is likely secondary to poor oxygenation to tissues [19]. Many other patient factors including COPD, American Society of Anesthesiologists (ASA) score, peripheral vascular disease, and coronary artery disease have all been identified in the literature [20,21].

Hernia factors

Contaminated hernias are clearly a risk factor for SSI. Aside from active infection, more subtle elements of hernia repair have been associated with SSI. Ten Broek et al. [22] found a relation between adhesiolysis time and SSI, as well as adhesiolysis time and enterotomy rates. Inadvertent enterotomies will increase the risk of SSI, with rates of 18% in some series [8]. Enterocutaneous fistulae provide wound contamination, leading to an SSI rate of 65% in some series [5]. The management of such complex hernias is clearly beyond the scope of this short review. Suffice it to say that they represent such a substantial challenge that they are probably best managed in specialist centers with an appropriate level of experience and expertise [23].

Technical factors

As we develop new surgical approaches to AWR and new materials to support those approaches, technical or operative factors will become increasingly important in the fight against SSI. Perhaps the most surgeon-dependant risk factors for SSI in AWR remain surgical technique and the use and choice of mesh to support that repair. The efficacy of mesh in avoiding hernia recurrence in incisional hernia repair is well established, but recent controversies in the media have led to challenges to our surgical teaching and perhaps surgical dogma.

Mesh

What remains clear is that synthetic mesh, although strong and durable in terms of strength for repair, acts as a foreign body and provides a surface upon which bacteria can form biofilms and propagate. These biofilms act as a barrier to the penetration of antibiotic agents, giving bacteria protection and the ability to colonize [9].

Many have examined which mesh characteristics present a higher risk of infection. Engelsman et al. [2] looked in detail at mesh choice, discussing how the microstructure may influence mesh infection. They suggest that risk factors may include multi-filament and hydrophilic meshes as well as those that integrate poorly with host tissue [2]. They suggest that meshes made of expanded polytetrafluoroethylene (ePTFE) have a microporous structure making it more difficult for antimicrobial drugs to penetrate through to any bacteria colonizing the mesh [2]. They go on to discuss various potential ways of lowering the risk of mesh infection, including adding silver to the mesh and even investigating mesh polarity.

The use of biologic mesh to reduce post-operative mesh infection has been adopted widely, and in 2010 the Ventral Hernia Working Group recommended the use of biologic mesh in all grade 3 and grade 4 hernia repairs [23]. Huntington et al. [24] published their review of 223 patients treated with a mixture of different biologic meshes. Despite 31% of patients in their review having active infection at the time of surgery, only 0.9% developed mesh infection that required removal [24]. Darezhereshki et al. [25] looked at eight retrospective studies and found that biologic meshes led to fewer SSIs, but no worse recurrence. In addition, a recent retrospective study of 266 contaminated cases (Modified Ventral Hernia Working Group III) found that the use of biologic mesh reduced the rate of hernia recurrence [26]. Other authors have been less convinced about the use of biologic mesh, and feel that there is more high-level data of these meshes required before we can encourage their use in contaminated fields [27].

Relatively recently, a new selection of absorbable synthetic or biosynthetic meshes have risen to prominence. Being absorbed in six to 18 months, they are considered by some to possess the mechanical strength for good hernia repair, without leaving a permanent foreign body to cultivate biofilms. The COBRA study identified a relatively low SSI rate of 20% in 104 patients who had undergone open ventral hernia repair in a contaminated field [16]. Others have also highlighted the potential financial savings compared with the use of biologic mesh [28]. However, there is not yet consensus and one study revealed a substantial increase in SSI rates using biosynthetic meshes compared with polypropylene mesh in open ventral hernia repair [29]. A consensus review published in 2018 by the expert BioMesh Study Group could not yet recommend routine use of biosynthetics in a contaminated field, and that evidence of greater quantity and quality is needed [30].

Plane of mesh placement

The decision as to where to place mesh also plays a role in preventing SSI. A recent publication by our group has tried to define those planes of placement better, resulting in an expert consensus on the issue [31]. The retro-rectus plane or pocket has become the preferred choice to avoid recurrence, but evidence also suggests it may have beneficial effects upon reducing SSI [32,33]. Onlay mesh placement itself has been found to be an independent risk factor in eventual explantation [34]. Timmermans et al. [32] conducted a meta-analaysis of 10 articles and 1,948 patients. They specifically assessed incisional hernias and discovered a lower rate of SSI in retro-rectus placement (odds ratio [OR] = 2.42; 95% CI, 1.02–5.74). Holihan et al. [33] did similar with all ventral hernias comparing four different locations for mesh placement. They identified retro-rectus mesh placement as ideal to prevent SSI but found less convincing confidence interval (0.12–1.16).

Component Separation

Our surgical approach to fascial release must also be considered carefully. Anterior component separation (ACS) runs the risk of disturbing blood supply to the skin via abdominal wall perforators. Dissection of these skin flaps has been found to be a risk factor for SSI in open ventral hernia repair [20]. Some have looked to optimize ACS technique and reduce wound complications through perforator preservation. One case series of 11 patients with extruded or infected mesh did this successfully, resulting in no wound infections and only one hernia recurrence [35]. Others have found that rather than using an ACS approach, a transversus abdominus release (TAR) can be favorable to avoid wound infection. Rosen et al. ]36] looked at 111 patients who had undergone either TAR and ACS, discovering the TAR group suffered less wound complications, but did not comment specifically on SSI (OR 0.34; p < 0.04).

Infection Prevention in the Operating Room

It is clear that even before scalpel meets skin, there are a number of simple techniques that can reduce the risks of infection. Practice such as using clippers rather than shaving body hair [37], and using an alcohol- based skin preparation for all surgeries [38] are “low-hanging fruit” in the fight against SSI.

Although many surgeons and guidelines would recommend pre-operative antibiotic agents for AWR involving a mesh, the use of post-operative antibiotic agents is a subject of debate. In their 2017 guidelines, the CDC suggests that antibiotic agents should not be given after skin closure for clean and clean contaminated procedures [39] but made no comment on contaminated procedures. Iaonnidis et al. [40] assessed different dosing regimens of antibiotic agents post-hernia repair, but were not able to find evidence that antibiotic dosage affected outcomes. Another retrospective review of 234 patients found a substantial reduction in SSI after ventral hernia repair [41]. Further evidence on post-operative antibiotic agents is required in the form of randomized trials.

Negative Pressure Closed Wound Therapy

Another technique used to reduce the rate of SSI is post-operative NPT. A review by Singh et al. [42] reviewed six articles and assessed the role of prophylactic NPT in AWR. They concluded that although there were no controlled trials for the use of NPT, there is evidence in favor of its use. Recently Tran et al. [43] conducted a larger meta-analysis of 11 articles and 1,723 patients. They concluded that in AWR, use of NPT therapy reduces the risk of wound infection (relative risk [RR] 0.5). Zwanenburg et al. [44] had a similar result with a larger meta-analysis across surgical specialties (RR 0.61 and number needed to treat 19). Negative pressure therapy obviously comes with cost implications and must be used selectively, however, it may well be cost effective in the long term when treating higher risk patients [45].

Management

Once a deep SSI has set in and mesh becomes infected, cases can be incredibly difficult to treat. Bacterial biofilms settle on synthetic meshes, making it more difficult for antibiotic agents to penetrate around the prosthetic [2]. The historical consensus among the hernia community has been that synthetic mesh infection usually requires explantation [2 8,10].

Although explantation usually yields better results in terms of infective clearance, consideration must be given to other treatment options. A number of different approaches have been attempted to deal with mesh infection, ranging from conservative therapy with mesh salvage to complete explantation and reconstruction of the abdominal wall.

The idea of mesh salvage through conservative measures is controversial, and some believe it should only be attempted in specific circumstances. Heniford et al. [8] outlined their experience with mesh salvage, advising that only lightweight polypropylene mesh in non-smokers without methicillin-resistant Staphylococcus aureus (MRSA) infection should be treated as salvageable. Rates of successful mesh salvage have been reported as between 24% and 77% in a number of small studies [10,12,46].

Several studies have commented on how the type of mesh influences the success of salvage. Berrevoet et al. [47] noted that infected large-pore monofilament meshes can often be treated conservatively. Others have commented that their rates of salvage with polypropylene and ePTFE meshes have been particularly poor [46]. The idea that infected ePTFE meshes frequently require explantation has been echoed by others. Both Bueno-lledo et al. [34] and Hawn et al. [48] found that the use of ePTFE mesh for open hernia repair was an independent risk factor for explantation, with the latter finding a hazard ratio of 4.04 (CI, 1.99–8.19). So reticent was the first group to treat this infection conservatively, that they made it an exceptional circumstance when considering mesh salvage [10].

If conservative therapy is unsuccessful, or not attempted, mesh explantation should be the next step. This can be done using either a complete or partial technique, with differing rates of success between the two. One larger study showed that whereas partial mesh explantation gives a lower hernia recurrence rate than complete mesh excision, patients suffer repeat infection or sinus formation in half of cases [10]. Others have highlighted the apparent futility of partial mesh removal, revealing that more than half of patients suffer a recurrence of an infected sinus within three months [49]. Documented surgical technique involves the preservation of mesh that is well integrated into tissue and not involved in the infective process. Different groups have written about injecting dyes into infected sinuses, and the subsequent removal of “blue” or infected mesh [10,50].

Although surgically challenging, many would consider complete mesh excision as the gold standard of treatment for post-operative mesh infection. The difficulty is then treating the subsequent defect left by the explantation. Depending on the original plane of mesh placement, the familiar surgical planes that are used for the various component separation techniques and mesh placement are often damaged or destroyed. The surgical choices for repair of the remaining defect are, therefore, limited but may include simple fascial closure, further component separation if possible, or bridging and planned future hernia repair [10,11]. Clearly the literature is limited in this area and patients need to be assessed on a case by case basis. In 2018 Shubinets et al. [51] published their own experience of the management of mesh infection, in which they outlined a useful algorithm for any surgeon dealing with such difficult cases.

Conclusions

Surgical site infection in AWR represents a substantial and regrettable complication, and one that can be a blight upon a patient's life for months and years. Given the inherent poor outcomes, ideal management should always be prevention. Modifiable risk factors cannot be underestimated, and patients should be counselled about their individual risk before proceeding to surgery. The literature suggests that the TAR technique with a retro-rectus mesh placement is a preferable option to reduce infection. Mesh materials can influence explanation rates and surgeons should look to understand the meshes they use as well as their contraindications. Although new meshes such as biosynthetics continue to enter the market, we must proceed with caution and further robust data must be sought before recommendations can be made.

Once established, mesh infection is difficult to treat, and presents a host of challenges. Attempted mesh salvage with negative pressure therapy may be a legitimate conservative option for some, however patients should always be counselled on the length of treatment, and potential failure rates. Mesh explantation is often seen as the only truly definitive option but brings a number of surgical challenges. Complex cases requiring explantation and repeat operation must be carefully thought out, and referral to specialist centers with sufficient expertise should always be considered.

Funding Information

No funding has been granted to the authors for this research. Mr. Whitehead-Clarke is in receipt of a research grant from the British Hernia Society.

Footnotes

Author Disclosure Statement

Mr. Windsor: Speaker bureau: BARD, TelaBio, Medtronic, Cook.

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