The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 8054-8060

Management of Infected Mesh Following Ventral Repair

Osama Abbas El Kattan, Ahmed Abd El Mawgod Abd El Salam, Ahmed El Sayed Fathy Mohamed Department of General , Faculty of Medicine, Al-Azhar University Corresponding author: Ahmed El Sayed Fathy Mohamed, Mobile: 01142434949, email: [email protected]

ABSTRACT Background: abdominal hernia represents a major health care burden. With over 350,000 repairs performed annually in the United States, millions of dollars are consumed with results that are often far from ideal. The use of the prosthesis in the abdominal wall (AWHR) has introduced new problems. Although mesh has reduced hernia recurrence rates, it has its own set of complications. So, mesh infection is one of the most devastating complications after the implantation of any mesh. Objective: this work aimed to focus on management of infected mesh after ventral hernia repair. Patients and Methods: this study was conducted in the Department of Surgery, Faculty of Medicine, Al-Azhar University Hospitals from September 2016 until March 2018. The study included 40 patients with surgical mesh infections after the repair of the ventral hernia. Results: cases with laparoscopic hernia repair, minor infections and a patient unfit for surgery were excluded for any medical reason. And after taking the history of the disease and clinical examination and the necessary investigations and the most important is to take a sample of infected fluid over the mesh to determine the type of infection caused by this or doing fistulogram if the fistula connected to the intestine small or large. Conclusion: research of best practices in surgical technique, preoperative care and mesh materials is ongoing, and much remains to be learned on prevention and management of this complex and potentially devastating complication. Keywords: abdominal wall hernia repair, partial removal of mesh, Complete mesh removal

INTRODUCTION Abdominal hernia represents a major might reduce the incidence of mesh infection (5). health care burden. With over 350,000 repairs Numerous types of prosthesis have been performed annually in the United States, developed to provide greater strength and lower millions of dollars are consumed with results recurrence rates, and at the same time, the risk that are often far from ideal (1). The use of the of infection and other complications have been prosthesis in the abdominal wall hernia repair decreased (6). Some known risk factors for mesh (AWHR) has introduced new problems. infection have been reported prolonged Although mesh has reduced hernia recurrence operative time or types of mesh are predictive rates, it has its own set of complications. So, factors in heterogeneous series of groin hernia mesh infection is one of the most devastating repairs or AWHR (7). On the other hand, complications after the implantation of any postoperative surgical site infections or mesh (2). The risk of infection in AWHR concomitant intra-abdominal procedures have appeared to be higher than other clean cases, been related to mesh hernia repair (8). Complete but there is a wide range reported from 1% to removal of the infected mesh (CMR) has been 10% depending on the type of mesh, technique, recommended if the infection cannot be and patient population (3). Infection of resolved by conservative measures and/or abdominal wall prostheses can have grave and antibiotic therapy or partial removal of mesh (9). costly consequences and severe impact on the However, this fact generally induces a hernia patient’s life due to prolonged hospitalizations recurrence and needs subsequent surgical and multiple re interventions, as well as very procedures such as autologous flap reconstruction elevated social costs (4). So, these are an or another mesh implantation after the infection incentive to explore any and all means that has been resolved (10). CMR also can lead to a high

8054 Received: 15/9/2018 Accepted: 30/9/2018 Osama El Kattan et al. complications rate, until 36-50%, due to Ministry of Health (Clinical/surgical methods, adhesions and high complexity during its removal biological samples/laboratory tests, etc…). (11). Therefore, salvage of the infected mesh All patients were subjected to without surgical removal would be desirable. An preoperative full history taking and included alternative to CMR is the partial removal of mesh personal history such as name, age, sex, (PMR). PMR means the excision of the non- residence, occupation, marital status, special habits of medical importance and menstrual integrated mesh; although less frequently leads to history for females, analysis of the main failures and complications, some patients still complaint chronic infections with fistulas require many reoperations for healing to take chronically secreting a pus-like liquid. A detailed (12) place . present history was taken regarding the onset, duration and course of symptoms and past history AIM of the WORK of previous operations and its postoperative This work aimed to focus on events (wound infection, ileus, distention, wound management of infected mesh after ventral dehiscence and respiratory complications), hernia repair. chronic diseases (as cardiac diseases, Diabetes Mellitus…etc.), drug allergy and intake and blood PATIENTS and METHODS transfusion. Study population: this study was Microbiology data were collected on conducted in the general surgery Department, all patients. Additional variables of interest Al-Azhar University Hospitals (Sayed Galal included postoperative surgical site infection and Al-Hussein Hospitals) in the period from (SSI) and history of previous surgical September 2016 to March 2018. This debridement.Our patients were subjected to prospective study included forty patients preoperative clinical examination including general presented by infected mesh post ventral hernia examination for vital signs and other systems to repair. The study was approved by the Ethics assess fitness for surgery and anesthesia. Local Board of Al-Azhar University. examination (Abdominal examination) was done. In most cases clinical presentation was a cutaneous Inclusion criteria: patients with fistula and if there is any other signs of hernia infected mesh after ventral hernia repair, complications(obstruction, strangulation,…etc.). In patients who agreed the procedure and addition, the abdomen was examined for any understand its risks, fit for surgery prosthetic organomegaly or other intra-abdominal co infection was diagnosed when pathogenic pathology to deal with it during hernia repair. organisms were found in the per prosthetic fluid Laboratory (Routine) investigations were obtained by surgical drainage or percutaneous done for all patients including complete blood puncture using ultrasound. count (CBC),PC, PT, INR, ALT, AST, Urea, Exclusion criteria: patients with Creatinine, blood sugar, and serum albumin, laparoscopic hernia repair, patients with Culture and sensitivity for aspirated fluid from inguinal and femoral hernia, minor infections collection. also radiological investigations such as such as cellulitis that could be treated with abdominal ultrasonography to exclude any intra- antibiotics alone, medically unfit for surgery, abdominal co-pathology, CT Fistulogram, patients who didn't agree to the procedure and sinogram and Chest plain x-ray study in cases of its risks, patients will be included if they agreed previous history of smoking, bronchial asthma, or to be included in the study and an informed clinical signs of chest troubles, Cardiological consent was taken. examination and electrocardiogram and Preoperative evaluation: echocardiography if needed. Ethical considerations were covered by Patients were admitted the day before standard pre-operative consent following surgery except for diabetic patients who were proper instructions/guidelines from the admitted 2 days before operation for control of

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blood sugar. Patients were asked to fast for at . History taking: for any postoperative pain, least 8 hours prior to surgery. Colonic postoperative complications, seroma preparation if large bowel fistula was formation, types and duration of the detected.The night before surgery, preparation patient's activities after surgery and any of the site of the operation then hair shaving just complain related to the surgery. before operation at the morning. A single dose . Clinical assessment: for any signs of of broad spectrum antibiotic was given with recurrence, any seroma collected, and induction of anesthesia. tenderness at the site of the mesh. Post-operative: . Laboratory and radiological assessment in 1- All patients received postoperative selected cases. antibiotics, most of the patients received Statistical Analysis pre and post-operative antibiotics. The statistical analysis was done using 2- All of the patients with known MRSA the statistical package of services solutions infection were treated with vancomycin. (SPSS; SPSS Inc., Chicago, IL, USA) software, 3- The antibiotics were adjusted in the post- version 21.0. Exploratory analysis and testing operative period, according to the results of of continuous data for normality of distribution the bacterial cultures obtained from mesh is done using Kolmogorov–Smirnov statistic samples or fluids taken during the and Shapiro– Wilk statistic. Continuous data operation, or according to the patient’s with normal distribution are expressed in terms clinical progression. of (mean ± standard deviation) while non- 4- Patients were encouraged for immediate parametric data are expressed as median and ambulation, prophylactic antibiotics, post- range, categorical data presented in the form of operative analgesics were administered. proportion and number. P value considered to Post-operative photographs were taken. be important < 0.05. 5- Patients were usually discharged on the 2nd RESULTS or 3rd day post-operative, viability of the Table 1: patient’s demographics flaps and umbilicus was checked before Mean±SD / Variable discharged, they were discharged on frequency (%) prophylactic antibiotics, analgesics with Age 57,2±12,7 advice to Avoid straining; strenuous Sex(male/female) 16/24 Smoking 14 (35 %) physical activity, minimize their physical Diabetes mellitus 4 (10 %) effort and daily dressing for the wounds. BMI 29,3±6,2 6- Abdominal binder was used for 1 month Table 2: microbiology of mesh infection day and night,but in the second month Bacterial agent Frequency Abdominal binder was used during daytime (%) only. MRSA only 26 (65 %) MRSA / MSSA / K pneumoniae / P 4 (10 %) Follow up and assessments mirabilis Follow up was done in the outpatient Non MRSA infection 10 (25 %) clinic, Drain were usually removed within a Table 3: pre-operative antibiotics usage period of one week or when it drains less than N Period Antibiotic regimen 30mL per day and there is no evidence of patients (days) collection. Sutures were usually removed after Vancomycin 18 10 2 or 3 weeks according to condition of the Vancomycin/Meropenem 2 6 Methicillin 2 5 wound. All patients were followed for up to 6 None 18 months. The follow up sessions were at two Table 4: onset of symptoms weeks, one month, two months, four months, six 1-3 month Seroma months after discharge from hospital. 3 -20months Sinus Small bowel Each follow up session included: 1-2 years Large bowel

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Table 5: characteristics of mesh infection several key issues remain unanswered. A well- Variable Frequency(%) defined hernia in a clean setting can be Presentation addressed effectively with a retro rectus or Chronic sinus 30 (75 %) underlay synthetic mesh. How to repair a hernia Infected Seroma 8 (20 %) in a contaminated or infected setting with LB 1 (2.5 %) Entericfistula significant loss of domain, however, remains a SB 1 (2.5 %) challenge (13). Mesh infection is a serious Table 6: surgical management of infected postoperative complication after prosthetic mesh hernia surgery and removal of the mesh is still Partial Total Deroofing the usual treatment. However, mesh removal mesh mesh and removal removal generally results in hernia recurrence, drainage (PMR) (TMR) necessitating subsequent surgical procedures Sinus 0 30 0 such as autologous tissue repair or biological Seroma 8 0 0 mesh placement. Enteric 0 0 2 fistula The rate of infectious complications is influenced considerably by both surgery-

related factors such as operation time, size of Table 7: possible causes for persistence of the defect and the type of prosthesis used, as infection well as by underlying medical co-morbidities Variable Frequency(%) such as chronic obstructive pulmonary disease, Unincorporated 18 (45 %) (14) Polypropylene sutures 10 (25 %) steroid use, diabetes, smoking and obesity . Multifilament sutures 4 (10 %) Patients with infected mesh represent a Multifilament and polypropylene 4 (10 %) particularly difficult group to treat due to sutures multiple prior operations, obliterated Mesh over mesh and 2 (5 %) polypropylene sutures anatomical planes, loss of domain, and presence Bowel erosion by mesh 2 (5 %) of infected foreign object that frequently (15) Table 8: post-operative antibiotics usage necessitates urgent intervention . Antibiotic regimen N Period Seroma appeared within one to three patients (days) months, whilst sinus appeared within three to Vancomycin 15 4- twenty months, moreover, within one to two 21(mean10) years small bowel (SB) and large bowel (LB) Vancomycin/Piperacillin- 5 15 appeared. In compliance with our results, Tazobactam Vancomycin/Ciprofloxacin 2 11 Patient-related factors, including diabetes, Vancomycin/Meropenem 2 14 morbid obesity, nutritional deficit, smoking, Methicillin/Ciprofloxacin 2 7 steroid therapy and renal disease, have been Cefazolin/Cephalexin 2 7 associated with increased risk of developing a Table 9: short and long-term outcomes mesh-related. This is as a result of reduced Variable Frequency(%) perfusion of the skin and subcutaneous tissue No complication 32 (80 %) and immunosuppression linked to these co- Major wound infection 5 (12.5 %) morbidities (16).The obese population is known Minor wound infection 2 (5 %) to have diminished blood supply to the tissue Mortality 1 (2.5 %) involved with hernia repairs and thus have Table 10: explanted mesh location impaired , putting them at particularly high risk of infection. The reduced Variable Frequency(%) Onlay 30(68,2) oxygen tension inherent to the obese patient Pre-peritoneal 6(13,6) decreases the ability of polymorphonuclear Retro-muscular 4 (9.1) leukocytes to kill bacteria and thus Weight of (17) surgery-related infections . In hernia repairs, these obese patients often require more DISCUSSION extensive incisions to adequately repair their Abdominal wall hernia represents a defects, thus creating larger areas of “dead major clinical burden to the workforce of space” that can also lead to infection. Adipose general and plastic surgeons. Although cells in the obese patient have been documented outcomes of surgical repair have improved, to be in an inflammatory state. This

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Management of Infected Mesh Following Ventral Hernia Repair

inflammatory state has been linked to many mesh in the presence of methicillin resistant S. comorbid illnesses and may also explain the aureus (MRSA). In the case of a documented increased infection rate in the obese population MRSA infection, usually longer courses of (18). A review of the literature on mesh infection antibiotics are warranted, as this particular reveals that at least an attempt at mesh salvage infection can be more difficult to eradicate with conservative treatment was made in each (21).The management of infected mesh might case initially, and some were in fact successful differ according to the type of mesh used. (14). No group comments that they immediately Specifically, it is suggested that infection of explanted the mesh upon diagnosis of infection. polyester or polypropylene mesh might be Most ultimately came to the realization that the managed with drainage and antimicrobial infected/exposed mesh was not salvageable. agents only, whereas the infected mesh should Prosthetic mesh is most commonly be surgically removed in cases of infection used as part of abdominal wall hernia repairs involving expanded due to its success in reducing hernia recurrence. mesh (22). This may be attributed to the fact that However, it is associated with a greater risk of a PP mesh becomes incorporated into the infection which traditionally would have anterior abdominal wall with necessitated a return trip to the operating theatre neovascularization within 2 weeks of for the patient, removal of the infected mesh implantation, allowing leukocytes and and probable recurrence of the hernia. Due to macrophages to gain access to the local the potential difficulty in mesh removal and the microenvironment. Local management associated potential for hernia recurrence(19). In includes removal of skin sutures, opening of accordance with our study, Berrevoet et al. (20) wound and drainage of pus, irrigation with reported that on early mesh infection only, saline/povidone-iodine and gentle debridement within the first few weeks after surgery. It of the wound (23). Moreover, Surgical appears that mesh infection occurs during management includes mesh explanation which integration of the mesh, which is confirmed by consists of opening the prior incision and a lack of integration signs in infected meshes. extirpating the mesh, sutures and tacks, with Although it is possible that the number of blood closure of the fascia, if possible. More recently, vessels in fibrotic tissue decreases, thereby there has been a trend toward mesh salvage, as reducing blood supply to the mesh and explanation is plagued by hernia recurrence, obstructing granulocyte access, this hypothesis loss of domain and risk of enterotomy or cannot be confirmed by our series, as large pore enterocutaneous fistula formation to solve this meshes did not lower the overall infection rate. problem. Rectus abdominis myofascial flap Moreover, Klinge et al. reported that, it was closure, known as ‘separation of parts’ hernia striking that the only meshes that had to be repair, can be done to reduce the hernia completely or partially removed because of recurrence rates (24). ongoing infection and the lack of granulation Limitations of this study tissue covering the mesh were multifilament The observational nature and the small polyester meshes. It is known that study size are important limitations of this multifilament meshes are more prone to work. Another limitation of this study was the persistent infection than monofilament meshes. lack of the data concerning the type of mesh and Subsequently, biologic mesh has been their position employed during initial surgery. identified as being of value in certain However, the results of this study may provide abdominal wall hernia repairs due to their the foundation for the understanding, care, and ability to resist infection, but because of the management of these patients. Moreover, our high cost of these meshes, surgeons need to be analysis is weakened by biased recollections. selective in their use(16).Parallel with our results, However, this study recognizes the importance antibiotics are an important component of this of clinical examination and the surgeon’s mesh salvage plan. The duration of antibiotics judgments regarding treatment options for these is not clearly defined. However, the often-complex patients. antimicrobial agent selected should be directed Each patient must be evaluated and at the more commonly encountered bacteria, treated on a case by- case basis, rather than Staphylococcus aureus and Streptococcus receive therapy based on generalizations. epidermiditis. Another study have even Patience, watchful waiting, and attention to described successful salvage of composite

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Osama El Kattan et al. detail can save these patients considerable 6. Majumder A and Novitsky YW (2015): potential pain, morbidity, and delay in their Antibiotic Coating of Hernia Meshes: The recovery. Next Step Toward Preventing Mesh Infection. Surg. Technol. Int.,7:27-41. CONCLUSION 7. Wiegering A, Sinha B, Spor L et al. Management of Infected Mesh (2014): Gentamicin for prevention of Following Ventral Hernia Repair presents a intraoperative mesh contamination: number of unique challenges for the treating demonstration of high bactericide effect (in surgeon. With little clear evidence in the vitro) and low systemic bioavailability (in literature to support a single optimal approach, vivo). Hernia,18:691-700. clinical judgment is important. Mesh salvage is 8. Reslinski A, Dąbrowiecki S and possible in a variety of settings and mesh types, Głowacka K (2015): The impact of usually requiring a multimodal approach, and diclofenac and ibuprofen on biofilm should be attempted in most cases. As with formation on the surface of polypropylene many surgical complications, prevention is mesh. Hernia,19: 179-185. crucial. Optimization of patient comorbidities, 9. Jezupors A and Mihelsons M (2006): The patient selection, preoperative management, analysis of infection after polypropylene operative approach, and meticulous technique mesh repair of abdominal wall hernia. all play an important role in the development of, World J. Surg., 30:2270–2278. and therefore the prevention of, mesh infection. 10. Fawole AS, Chaparala RPC and Research of best practices in the surgical Ambrose NS (2006): Fate of the inguinal technique, preoperative care, and mesh hernia following removal of infected materials is ongoing, and much remains to be prosthetic mesh. Hernia,10:58–61. learned on prevention and management of this complex and potentially devastating 11. Sabbagh C, Verhaeghe P, Brehant O et complication. al. (2012): Partial removal of infected parietal meshes is a safe procedure. REFERENCES Hernia,16: 445–449. 1. Poulose BK, Shelton J, Phillips S et al. 12. Tolino MJ, Tripoloni DE, Ratto R et al. (2012): Epidemiology and cost of ventral (2009): Infections associated with hernia repair: making the case for hernia prosthetic repairs of abdominal wall research. Hernia, 16:179–183. : pathology, management and results. Hernia,13:631–637. 2. Chung L, Tse GH and O’Dwyer PJ (2014): Outcome of patients with chronic 13. Clay L, Stark B, Gunnarsson U et al. mesh infection following abdominal wall (2018): Full-thickness skin graft vs. hernia repair. Hernia, 18:701–704. synthetic mesh in the repair of giant incisional hernia: a randomized controlled 3. Ousley J, Baucom RB, Stewart MK et al. (2015): Previous methicillin-resistant multicenter study. Hernia, 22(2):325-332. Staphylococcus aureus infection 14. Munegato G and Brandolese R (2001): independent of body site increases odds of Respiratory physiopathology in surgical surgical site infection after ventral hernia repair for large incisional hernia of the repair. J. Am. Coll. Surg.,221:470-477. abdominal wall. J. Am. Coll. Surg., 192: 298-304. 4. Liang MK, Li LT, Nguyen MT et al. (2014): Abdominal reoperation and mesh 15. Elfaki A, Gkorila A, Khatib M et al. explantation following open ventral hernia (2017): Infection of PTFE mesh 15 years repair with mesh. Am.J. Surg.,208: 670- following pedicled TRAM flap breast 676. reconstruction: mechanism and aetiology. The Annals of the Royal College of 5. Mazaki T, Mado K, Masuda H et al. (2014): A randomized trial of antibiotic Surgeons of England, 100(1):18-21. prophylaxis for the prevention of surgical 16. Meagher H, Moloney MC and Grace PA site infection after open mesh-plug hernia (2015): Conservative management of repair. Am. J. Surg.,207:476-484. mesh-site infection in hernia repair surgery: a case series. Hernia, 19(2):231-237.

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