Excision of Infected Onlay Mesh

A 73-year-old female has a history of ventral hernia repair with onlay mesh complicated by mesh infection requiring multiple debridement. She later underwent additional laparotomies for other procedures that led to her previous mesh being chronically infected and exposed to air. Multiple office debridement did not successfully remove all of the mesh. She was taken to the operating room where her onlay mesh was completely excised. This case highlights the importance of complete foreign body excision when dealing with infected prostheses of the abdominal wall.

Hernia repair; infected mesh; wound; injuries.

Prosthetic mesh infection after hernia repair remains one of the most dreaded and challenging complications in abdominal wall reconstruction. The incidence of mesh infection is low, typically quoted as 1–2%, but can vary depending on risk factors including wound classification, prior contamination, operative approach (open versus minimally invasive), and patient comorbidities including smoking and diabetes.^1,2 Mesh infection can present early as with cellulitis, seromas or abscesses, and wound breakdown, or late with persistent draining sinuses, fistulas, or exposed mesh. 

The treatment strategies of mesh infection included targeted antibiotics, percutaneous drainage, aggressive local debridement, and negative pressure wound therapy (NPWT).³ However, once bacteria become adherent to mesh, biofilm formation precludes antibiotic penetration, blunts immune clearance, and often complete surgical excision is required in order to achieve source control.⁴ In addition to the immediate clinical morbidity of prolonged antibiotics, repeat hospitalization, and additional surgeries for the patient, mesh infection can compromise abdominal wall integrity, interfere with future reconstructive strategies, and create a substantial economic burden on the healthcare system.⁵ The prevention and effective treatment of mesh infections is critical in abdominal wall reconstruction.

In this video, we demonstrate the diagnosis and management of infected onlay polypropylene mesh. We highlight the risk factors of mesh infection, the consequences of incomplete mesh excision, the strategies to minimize damage to the abdominal wall, and considerations for reconstruction.

The patient is a generally healthy 73-year-old female with a history of an abdominoplasty wherein an onlay polypropylene mesh was placed at the time. She subsequently had issues with recurrent methicillin resistant staphylococcus aureus (MRSA) infections of the mesh and required mesh explanation, placement of a biologic mesh, and NPWT, but the complete details of these surgeries are unavailable. The patient then went on to have a laparotomy for excision of pelvic mesh eroding into the vagina, wherein polypropylene mesh in the abdominal wall was encountered and divided in the midline and closed with absorbable sutures. This led to a chronic non-healing wound with exposed mesh. Cultures demonstrated MRSA. After multiple courses of targeted antibiotics and office debridement of the exposed mesh and suture, the patient continued to have a persistent open wound with exposed mesh. As such, she was consented to undergo a mesh excision in the operating room.

On exam, she has a history of a lower midline incision scar. At the apex of this incision, there is a 4 x 1 cm open chronic wound with exposed mesh.

Infected meshes can present in the early postoperative period with cellulitis, seroma/abscess around the mesh, wound dehiscence, and patients can have fever or malaise. Late presentations of infected mesh present as chronic draining sinuses, recurrent cellulitis, or exposed mesh. While certain mesh infections can be salvaged with weeks to months conservative management, most mesh infections do not resolve until complete excision.

Non-operative treatment options for mesh infections include prolonged targeted antibiotic therapy, percutaneous drainage of associated collections, and application of NPWT. Exposed mesh can be trimmed and debrided in the office. However, most mesh infections require complete excision in the operating room.

The goal of complete excision of infected mesh is to resolve the chronic infection and allow complete wound healing. The native abdominal wall and underlying structures should be preserved and protected to avoid inadvertent injury to the underlying viscera or recurrent hernia.

Care should be taken to preserve the native abdominal wall so as to not create a hernia. Any full-thickness defects should be closed. For patients who have chronically infected mesh and an associated ventral hernia defect, consideration should be given to a staged approach, wherein the infected mesh is excised and the hernia defect is closed primarily. If or when the hernia recurs, a definitive mesh repair can be performed. This staged approach reduces the risk of recurrent mesh infection. 

All chronically infected meshes should be cultured to rule out antibiotic-resistant organisms. If antibiotic therapy is necessary postoperatively after mesh excision for an SSI or an abscess, antibiotic therapy can be targeted appropriately.

In this video, we demonstrate the excision of a chronic infected onlay mesh, primary closure of a fascial defect, and application of an incisional wound vacuum. After 2 weeks of NPWT, the patient was transitioned to traditional dressings and had complete closure of her chronic wound in follow up. She has not had recurrent hernia or recurrent infection after 6 months of follow up.

This study demonstrates an example of a mesh infection that is not amenable to non-operative management therapies and requires complete surgical excision. There are factors that can predict a higher likelihood of mesh salvage with conservative management. Extraperitoneal/preperitoneal meshes, macroporous meshes, light- or medium-weight meshes, and polypropylene mesh are associated with a higher likelihood of mesh salvage with non-operative strategies.⁴ However, onlay or intraperitoneal mesh, composite mesh, heavy-weight mesh, multifilament mesh, expanded polytetrafluoroethylene (ePTFE) or polyester mesh, mesh infections with MRSA, exposed mesh, or mesh infections associated with an enteroprosthetic fistula typically do not resolve with non-operative management and require operative excision.⁶

This case also highlights the importance of complete mesh excision in the setting of a mesh infection. Despite multiple mesh excisions and previous placement of a biologic mesh, this patient continued to have recurrent chronic mesh infections and ultimately required a thorough exploration and removal of all foreign body material including mesh and permanent suture. While there has been debate whether well incorporated mesh can be left in situ during excision of infected mesh, multiple studies have demonstrated that incomplete excision of mesh or foreign body material is associated with a higher likelihood of a surgical site infection requiring procedural intervention (SSOPI) or reoperation for additional mesh excision.^7,8 In general, we advocate for complete excision and foreign body material for patients with infected mesh who have failed non-operative management.

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Dr. Fung has the following disclosures: speaker for Becton-Dickinson.

Dr. Pauli has the following disclosures: speaker for Becton-Dickinson and Medtronic, consultant for Boston Scientific Corp., Actuated Biomedical, Inc., Cook Biotech, Neptune Medical, Surgimatix, Noah Medical, Allergan, Intuitive Surgical, ERBE, Integra, Steris, Vicarious Surgical, Telabio and Mesh Suture Inc. He has royalties in UpToDate, Inc. and Springer and financial interests in IHC, Inc., Cranial Devices Inc, Actuated Medica.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.