Excision of Infected Onlay Mesh

CHAPTER 1

My name is Eric Pauli. I'm an abdominal wall reconstructive and hernia surgeon at Penn State Hershey Medical Center in Hershey, Pennsylvania. The operation we're going to do today is actually a removal of some infected mesh. This is a 73-year-old patient who has a history of multiple previous operations. She has a history of an abdominoplasty that utilized mesh to reinforce the abdominal wall in an onlay fashion. Earlier this year, about four months ago or so, she had a problem related to some erosion of some vaginal mesh. And she developed a fistula that required an extensive operation by my urology team and our gynecology team to do a partial cystectomy, remove the mesh, and that was done through a midline laparotomy incision. The laparotomy incision that she had exposed the onlay mesh, and unfortunately, she developed a postoperative wound infection that exposed the onlay mesh, and that onlay mesh became infected and she required several debridements in the operating room, also in the emergency room, and ultimately, she came to my clinic. When I met her in clinic, she had a fair bit of mesh that was exposed and I actually removed most of it in clinic, but she was a bit uncomfortable for me to remove the mesh, the rest of the mesh, because it was heavily embedded and a bit deep in the abdominal wall. And so we're taking her to the operating room today so that under anesthesia, we can more widely explore. When I meet somebody and they have exposed mesh, obviously, the goal is that they get rid of their wound infection. We know from literature about mesh removal in the setting of an infection that generally, a complete extirpation of the mesh is gonna be what is best for the patient, and so our goal today is complete mesh removal. My concerns in doing the case are that the mesh is in an onlay fashion, that it does bridge the midline a bit, and that below it are enteral contents. And so our goal is to remove the mesh carefully off the abdominal wall without creating a full-thickness injury, without getting back into the abdominal cavity, or really having to deal with any intraabdominal processes. After the removal, I suspect we'll have a big tissue defect, soft tissue defect, and my plan is to use a wound vac to manage that and for her to go home with wound vac therapy.

CHAPTER 2

So, we were talking earlier about how to approach this, and option one is to just go way above and get in intra-abdominal. Option two is just to say, "Look, the mesh was theoretically an onlay mesh. And so let's see if we can't just lift the plane up over the mesh here, okay?" So I'm just gonna stay... No, you can leave it off for now. Let's just open up this direction, so come through that stuff there. Yep. Yep, don't pass point. Don't go deep. So there's a suture there from them having been here before us, so we're still in the right spot. Keep going, open the midline. Yep, take it layer by layer. Good. That's mesh and suture there. That's the sheath, that's the mesh there. Uh-huh. Can I get a Ray-Tec? Got a Kocher? So that's edge of mesh there. That's mesh there. You can do that, yep. Little buzz buzz buzz. That's fine. That's a capsule, probably. Probably, get the skin. Come up here, get the skin. Yep. You found the blood supply to the mesh infection. That's where all the antibiotics have been going through. It's why it's so distended. The aorta of the skin. Keep going and get it. Your headlight is not looking where we're working. I'm just gonna come beyond it. Great. Yep. Okay. You can open the skin more. Okay, I'll take a Kocher. This is the rind. I'll take another Kocher. That's mesh and rind there. Another Kocher here, mesh and rind there. Okay, all right. So on her scan going up appears to be a safe place. Agreed. Because she doesn't have any bowel stuck up here. There's an intact midline underneath. I don't think that's fascia. But if it is and we're getting intraabdominal, then we're in a safe place. I also think the mesh ends right there. That feel like the end of the mesh to you? It does. Yep. Okay. So the question is, was that... Now where's the fascia? On today's exciting edition of, is that fascia? Let's buzz this corner here. Fine. So I don't know what this is, let's open it. Okay, so it may be fascia. That's fine if it is. It's the problem of two people wearing headlights. You get the headbutting unicorn phenomenon. That's the mesh. Snap. Nevermind, curved Mayo. So that's an individual stitch. It's not a running and it's a permanent. So that may have been a tacking stitch at the top of the mesh, 'cause I don't think that was one of the closure stitches from the midline laparotomy. Okay, so that's edge of mesh there. What's this? This is also mesh here though. So that's edge of mesh there, this is edge of mesh here, that's the mesh there. This is under the mesh. Under the mesh. Under the mesh. Divide it. On the mesh. Heavy scissors. This is a heavyweight piece of what looks like probably some polypropylene. That's mesh. That's mesh. Go ahead and just cut it. All right, that's the top of the mesh there. All right, so if our understanding is that this was an onlay mesh, this is rind, that's mesh, that's gonna be fascia underneath. So again, we know that lower down, it definitely becomes much more problematic. So let's try to get this exposed here a little bit, as best we can. I'm gonna stay right against the mesh and just kind of carve. Lots of cutting current, lots of spasticity. My hands are gonna kind of shake around here a lot, and I would normally say, don't do that, when you use a Bovie, we kind of wanna stick and move. Stick and move, stick and move, stick and move, okay? Surprising how little there was there. She had previously had some of this resected. Her understanding was, she had no mesh in situ. They just happened to find it when they were doing her most recent operation. So I didn't really want to come down through there, what I wanted to do is kind of keep opening this up. So this is the mesh here. Again, if it's an onlay mesh, this should be just kind of above the fascia. Get that little thing on your side that's bleeding right there. Sorry. Hold on. Pause. It's under your finger, it's up in there. Right there, okay. Let's come down to here and let's work on this little section. Let's go back to our toothy pickups. I'll take a just a... Yeah, just an Adson there. All right, so here's the cut edge on my side. I don't see the edge on your side, but I do see some scar plate here, and that's all nonsense, and so this is gonna lift right up and there'll be some mesh probably under there somewhere. Everything we give you can be labeled abdominal wall debridement and mesh for gross evaluation only. Let's get a handle on that, going your way, and let's lift the skin up off of this, okay? I'll take a toothed pickup. Yep, get your Bovie. Use the side of the blade, like this. Got it. So that there's... At no point will you cut through the mesh with the blade, okay? I'll take that right angle. Again, you're gonna come across, gonna be some sutures and stuff here too, right? Remember that, you know, it was held in place, so... Oh, he's holding one. I'll take another one. Yep, there's a stitch there. So is it aProlene that was used to hold the mesh in place? It sure looks like it. It's a solitary, sort of a 3-0 Prolene. Yep, just keep working this way. Just raise the skin up off the mesh. We just wanna get past where the mesh was. Yep, don't dig a hole. Let's go this way. So yeah, that's the edge of the fascia there or the edge of the rind, around... That's the mesh there. Yeah. So just kind of get in there. Don't cut into the mesh. Always stay parallel to it. Okay. Okay, let's keep going here. So that's the mesh there. I think the mesh may end in this little corner here. I don't feel any mesh up there. Okay fine, so that might be the piece we're dealing with. Let's keep working our way inferior. Heavy scissors. Again, these are all like 3-0 Prolene, like interrupteds. So these must have been what they used to tack the mesh in, previously. Kocher, I don't think that these are the urology team's closure stitches here. Everything I give you will be a specimen labeled, "Infected mesh and abdominal wall debridement for gross evaluation only." Remember our goals here, our goals are that her wound heals and she doesn't have a recurrence of this annoying mesh infection. Let's see what's happening in this corner pocket here. Lift up the skin edge, I'll take a Debakey please. Is there any mesh in here? We know the bottom part of this, which healed with a VAC, where they have pictures of the thing healing the entire time and I looked at them, and there's no obvious mesh in that area on the images. So again, it's possible that somebody... Let's grab that skin edge there, that somebody resected most of the mesh. Pause for one second. DeBakey? Watch right there. That's probably posterior sheath. Could be. Okay. Grab that edge there, yep. We're just gonna feel down. Is there any mesh in there? No, I don't feel any mesh in there. So that comes down to there, this is definitely mesh here. That's mesh. This is mesh. Now your side is... This is mostly free, man. I think so. I'll take a toothed pickup and a right angle. A Bonney for me. We'll wind up taking off that skin edge at the very end, okay? Yeah. There's nothing in here. There's no mesh. It's just stuff that healed by secondary intention. It's all okay. Easy buzzing the floor. We don't know where the abdominal contents are yet. Okay, so this is edge of mesh. That's all edge of mesh. This we said we didn't think was mesh. Let's grab this, which is above the mesh. I'm gonna try and work from this corner out to there. You're lifting rind above off of mesh. I need to find a plane under you. Flatten that out, go that way with it. There's some more. That's normal fat. That's back to normal fat. That's the whole rind cavity that kind of healed by secondary intention there. Okay, so that's mesh there. This is mesh edge here. Let's get your right angle on that. I'll take a DeBakey. Can you hold a little less of it? I need just a little bit, so I got a corner here that I can kind of start working under. Very slowly here, very slowly. The battery pack, we'll need a new... Headlight, we need a new battery pack please. Yep. Leave it, leave it, leave it. Clean the tips of those. There's no mesh there. It's just this little piece, stops right here. Right angle. All right, so that's all just rind now. This side, that's just rind. That's a little fiber of a little mesh there. So grab that. I think the overwhelming majority of this mesh has previously been removed, and I think they just had some islands left in the middle, which were stuck with Prolenes, and they just got exposed at the last, you know, operation. What do you got in the way of... Give him two Bonneys. Let's hold the skin edge up here, let that down for a second. Skin edge there and skin edge roughly there. So that's the edge of the mesh there, 'cause there's a stitch in it. Another stitch Snap. Got a Kocher? Yep. Heavy curved Mayos. Snap. Okay. So that's an edge of the mesh there, and that edge goes to this edge here. There's just a little strip of it here. Yep. Do you have any peanuts available? Yeah, I do. Nice. This is mostly incorporated into the abdominal wall here. So we kind of just want to get the loose edges up and out. DeBakey? Prolene right there. Edge of the mesh right there. Snap Kocher. Cut one of those. Just cut one of these right here. That's a running stitch going somewhere. Snap. Almost seems like two separate ones. Could be. Just lift that up for me. There's a layer of scum here underneath it as well. So there's some little abscess or rind or something in this rough of vicinity. Do you want cultures for it? Nope, it's all infected and we cultured it sometime previous. Okay. Hold that. Another sponge. Yeah, I think the mesh ends. I don't feel any mesh at that level. I think the mesh is just this strip here in the middle now. Like that looks like native tissue to me. Yeah. Do you think like this to this? Or even narrower than that. I think it's just a tiny little strip. Her native tissue is so inflammatory, it's hard to tell. Yep. Can I see that right angle? Got it. I'll take one of the Bonneys that you have. Grab this here. Right there, there's no mesh there. Feel there and tell me what you think. I don't feel any mesh in that midline. It's inflamed, but I don't feel any... I mean, I think there's just a tiny little strip of stuff here, okay? I'm gonna do it from this side. I'm gonna just try and peel everything off of it going that direction, now that we got it on the run. That's the bottom of it right there, that's it. There's the edge of it there. Yep. Regrab up here? We got it on the run. Get ready. It's time for something bad to happen. Just hold the edge of the mesh, don't hold too close to the base. There you go, move that... This is that little abscess space where that suture was located, the infected Prolene. Okay. Now we're talking. Let's go back to the very bottom again. Go back a little bit lower on it. Get right to the very bottom there. Yep. I'm gonna come under this now, we're gonna take this out. No mesh, I'm feeling as I go through that what I'm cutting is not mesh. You can see it peeling out now 'cause we cut the sutures already. It's the middle colic right there, I got it. If you were this mesh, where would you stop? Do this and you'll feel click, click, click, and then it... And native tissue. Yeah. It turns to native tissue somewhere in there. So I do that, you know, that little kind of dividing rod maneuver. I do that in clinic as well with a little... Like a wooden Q-tip can help you do that as well. Yep, let the... Yep. Okie-dokie, there's more. Snap. A couple little fibrils there, just grab those little fibrils. Let's look and see if we opened any fascia, and if we did, we're gonna close it. Again, I think it's just rind to rind. Down here, this looks like a little opening in the fascia. See, there to there? Yeah. Yeah, so that we're gonna close. With a 2-0 Vicryl? I would normally use a PDS on it. I don't mind using a Vicryl. I mean, I think it's 6 of 1, half a dozen of another. We can just do a PDS.

CHAPTER 3

Let's debride this abdominal wall. Yeah, you wanna do a 2-0? Yeah, I think so. Something small. Let's lift this skin edge up, I'll take a Bonney. Small wound VAC is gonna be fine, actually. I'm sorry if you brought anything bigger after I asked you. Say again? Lots of local. You got that? She won't feel any of this. That's a muscle. I see muscle jumping. There's something there. What are you? Is that a stitch? That's a stitch. Okay. Can I have a Kocher? This is all gonna go. It's pretty normal and healthy looking fat right there. Agreed. More stuff for you. Oh my gosh. Thank you. You're welcome. That's all I've ever wanted. Has a 10-day return policy. If you wear it, we will not take it back. Okay. Snap, and then... What is it? Heavy scissors. Is that the... What was it called? Hero? Halo? The echo positioning system? Echo. Oh I sure hope not. That's a piece of Ethibond. It's multi-filament permanent suture made outta polyester. Fine, so now we know where we are. I'll take a right angle. Can I get another pack of Rays? Yeah. Thanks. This is some old rind cavity here, and I'd like to kind of connect from there to there if we can, without getting intra-abdominal. So let's just start. Gimme like a little nick right there, from there to there. Connecting the fat. Stay up here, up here. There to there. Slow and steady, okay great. And if we see normal fat then that's kind of... I kind of wanna work around the normal fat. We're just lifting up this edge of rind that we're gonna debride with the skin. That looks like rind to me. Take it right there, a little... Yep, that's good. Uh-huh. So the rind extends this way? Do it, next layer right there, I think it's rind. Stay up, stay up, stay up. Good, stop. That's all just rind. Is that like the scar tissue or an edge of infected abscess? Yes. All of it. If you leave this stuff in, it doesn't have good blood supply. It's old scar, it probably has some infected material still in it. Without injuring stuff, we're trying to get back to now healthy abdominal wall that we can actually... I dunno what it used to be, but I think it can stay. It looks alive. Right there, on the bottom jaw. Yep, bottom jaw. Right on it. Yep. Don't dig deep, go parallel. Kind of the junction between the skin and the fat. Roughly like you're making a skin flap. There you go, good. Your goal is just to get enough, that this trash can come off, and you're back to sort of normal looking fat back there. That looks pretty good. Yep. That's good. I wouldn't go too far. I'm okay with this. That looks alive and healthy and usable. Okay? Yep. Same thing. We're not closing, we don't need to, you know? So let's just take this off now, okay? Yep. Do it. Great. Yep. Good. Awesome. Lop it off. There we go. All right, dry it up. Right there. You got that 2-0? We'll take some irrigation first, you got some warm irrigation? Somewhere In there. Got a ruler? Would you write some numbers down and put 'em on a card for me? Yes. Would you write eight by five by two as the wound size? Look at that thing. We found it. Eight by five by two. That's it, it's the mesh blood supply right there. You got it. The artery of mesha. And now you'll see the mesh will become ischemic now that we've taken its blood supply. That's interesting. Yep. It demarcates really well, but if you use ICG, then it really lights up. Yeah, I can see that. Okay, let's irrigate it. Got the suction turned on? Irrigation. Irrigation. Oh, irrigation. Yes, irrigation, the finest. Sorry. You're good. It's French. Vintage saline. Bespoke saline. What time is it? 4:20. Okay. Okay. Let's see what we can do here with the fascia now, okay? You've got that 2-0, PDS? I'll take a small Richardson. I'll take the PDS, I'll take a Richardson.

CHAPTER 4

Okay. That. Yep. Rind. No, you're gonna close it. It doesn't matter what it is. You're not gonna be able to tell. You gotta skive the whole thing, okay? So no deep bites. Yep, just like that. Good. I'm gonna have you tie a self-locking anchor knot. You know how to do that? To start a small bite closure? You're using a 2-0 suture on the fascia, right? So if you're gonna use 2-0, you gotta do the self-locking anchor knot. - [Surgeon] You explained this to me last time. I can't remember how to... Scroll under. Yep, there you go. Beautiful. Okay. Unlock that. That's up here in the corner. That's just there. Okay fine. Yep, you got that Richardson. We are not intra-abdominal. We have some small nicks in the fascia from peeling the mesh off, but we are not in the abdominal cavity, okay? It's very short now. I have one, two Ray-Tecs out. Right, okay, so this has to run parallel to your tail. Wrap it around three times. You gotta go around both the driver and that thing. Yep, one, two, three. This needs to get brought up through. Put tension on that. It's forming, right? There it goes. It should slide forward. Sometimes when you're sliding them off, if the second loop goes above the first loop, they just get tangled and it doesn't slide forward. So it's a self-locking knot. So instead of locking, you know, most knots when they lock, they lock this way around the suture, which reduces the bursting strength by up to 30%. That knot that we just tied locks this way around the suture and actually lets it slide inside the formed knot, and oh by the way, the tail... I mean, this is actually a long tail, but the tail is relatively short, okay? Normally we would do this when we're doing a four to one suture length to wound length ratio, sort of small bite closure. The main reason to do it here is, we're using 2-0 suture, which doesn't have a lot of burst strength. And so if we're gonna do that, you wanna make sure you're not reducing the burst strength anymore, yep. Skiving bites. Yep. We're gonna close some rind and some stuff to stuff since we don't know exactly where the fascia is. You just kinda wanna get some stuff closed over the top so that if you did open the fascia, she doesn't herniate it out tomorrow, okay? She's gonna get a hernia here. She had an infected wound, it was already open, she had mesh there. Like there's not a whole lot you can do to prevent that, but if we can prevent it from happening in the next six months or I mean even, you know, overnight, you just don't want her to herniate out ASAP. Yep, that's fine. That stuff is okay. Yep. Uh-huh. Yep, skive, take it, yep. My god. What's wrong? She doesn't have a single platelet or something, like... Every raw surface. Yep, good, skiving bites, I like it. It really explains why this mesh has been so viable for so many years. It had excellent perfusion. Good ingrowth. Okay, after this point, I'm not too concerned about anything below this being opened, 'cause we didn't even... Like, we didn't even open it. That all healed by secondary intention, yeah. So once we find this little corner guy here where that... That was where that stitch... I'll take a DeBakey. Where's that little stitch abscess guy? Little stitch abscess guy was kind of down there. I'd do one more sort of there to there, and we're gonna leave it, so we can VAC on the rest of that, okay? Yep. Yep. Do it. Yep, do it. Fine. All right, so you gotta do the Aberdeen, that's also a self-locking knot. You know that one from doing skin closures, you just don't know the first one. The first knot we tied is called a half blood knot. It's a knot that people use to tie up all sorts of important things. It's a knot that people who climb use, it's a knot that fishermen might use. People tie up their yachts and boats with those sorts of things. Thank you. Okay. That's where that little abscess was coming from. So that's gonna be VACed on. Anything that's underneath there, theoretically, if there's anything that's gonna come out right there, it'll come out, okay?

CHAPTER 5

Okay, we're gonna put a little VAC dressing on this. You wanna stick a whole bunch of local in? Yeah. Just you know, local around. Yeah, and I think this skin, I don't think we need to revise any further. No, no. I think it looks good. Yeah. Okay. Get some local, we'll take some local. Yep. She can eat. How do you feel about her Bactrim. About what? She was on Bactrim. Oh, I mean, the wound is now opened officially, so I think you can probably stop it. Yeah. Are you closing, or just putting a VAC on? We're gonna put some local in. Okay. Because somebody asked for it. Yes. And then a VAC and then we're done. Okay. Got the local-yocal? Yep, we're just getting a syringe. Are we just gonna sprinkle it in, like topical? Local going in. We got 30 total? Yeah. 15 on your side. Yep. Beautiful. All right, I have one, two Ray-Tec up. They'll need a consult for home care. Her husband said that he is not able to manage this. Well, he had concerns that he wouldn't be able to manage it, so... Hildegard, scoot on up there, put some local in, just like he did. Okay. Go in, aspirate, make sure you're not in a vessel. Go in, aspirate, inject. Inject hard, pull the needle out. Go in, aspirate, inject. Do it. Inject hard. Hard. Very hard. Curling. You ever watch curling? Yeah. Beautiful. Yep, don't go deep. That's just firm there, there's still some scar down there from the old incision. All right, we'll take the last 10 of local. Okay. No, she's on the rental plan. If we don't do 15 each way, I'm gonna feel uneasy. Okay, beautiful. She's gonna love it.

CHAPTER 6

Something wet, something dry, something borrowed, and you got some glue? Something sticky, you got some Mastisol? Can I have Mastisol please? Yep. You said benzoin or? Oh. Yeah, they tried to sabotage us by putting Benzoin in there. It's fine. I would've taken it. You get a Mastisol, you get a Mastisol. You don't need to be near the edge. You need to be where the drapes are gonna go, which is kind of a little farther out. Yeah, up top. I think that's doing great. It's working. Is that still wet? Is it tacky? Yep. Tacky. Tacky? Okay. Yes. Hold on. Scis? Got it. We got our VAC box. Looks pretty good. Continuous 150.

CHAPTER 7

So as you could see, the mesh was pretty heavily embedded in the abdominal wall there and that is definitely not a procedure that we could have done safely or efficiently in clinic. So certainly glad that she was under anesthesia. We started in an area where the mesh was easily accessible, and extended that upward because radiographically, we knew that the upward direction was away from where there were any potential bowel adhesions. Lower down on the scan, there was some bowel nearby. Once we had a leading edge, we just worked that edge around the corner. We can actually see areas where the mesh was fixated to the abdominal wall, and so I think she actually had just a small amount of mesh left after all of the previous debridements. It can be challenging though to assure that you've gotten it all out, and obviously, going deeper, dissecting more, risks injury to content underneath, and so there's a balance point. If you're confident that you got all of it, then fine, then stop operating. If you know that there's mesh left behind, and it's not gonna come out without a larger operation, then you do the larger operation, and we were prepared to do a midline laparotomy, to do a complete enterolysis in the midline, and to do a full-thickness resection of the abdominal wall if we had to. Fortunately for us and for the patient, we were able to get that out without a substantial amount of effort. And then the wound VAC will do a good job taking care of that and she'll be able to go home, hopefully within 24 hours.