Factors affecting salvage rate of infected prosthetic mesh

The Great Debate: Mesh or No Mesh in Contaminated Hernia Repairs?

Abdominal hernia surgeries are commonly performed with many different approaches, and mesh utilization has become a cornerstone in hernia repair, ensuring durable outcomes with minimal recurrence risk. However, managing contaminated hernia repairs presents unique challenges due to the heightened risks of mesh infection. Recent advancements in lightweight macroporous polypropylene meshes offer promising solutions. Studies have highlighted the superiority of macroporous polypropylene meshes compared to primary suture repair and other mesh types in terms of reduced surgical site infection rates and lower hernia recurrence rates. Moreover, utilizing macroporous polypropylene mesh in the retrorectus plane is associated with a favorable salvage rate, underscoring its efficacy in contaminated hernia repairs. At the same time, contrary evidence suggests higher postoperative complications with mesh use in settings of clean-contaminated or contaminated fields. Most significant complications are increased infection rates and similar recurrence rates compared to mesh-free repairs. New synthetic mesh that is being marketed as having better outcomes than other types of mesh and potentially primary repair need to be carefully assessed as biologic mesh once used to also be touted as the mesh to use in such fields, but more research is showing higher complication rates. The risk of infection and consequent morbidity might outweigh the benefit of less recurrence risk with mesh use. Further research, including prospective studies with long-term follow-up, is warranted to elucidate optimal hernia repair strategies in contaminated fields and inform evidence-based practice guidelines.

Long-term mesh-related complications from minimally invasive intraperitoneal onlay mesh for small to medium-sized ventral hernias

INTRODUCTION

Intraperitoneal onlay mesh (IPOM) placement for small to medium-sized hernias has garnered negative attention due to perceived long-term risk of mesh-related complications. However, sparse data exists supporting such claims after minimally invasive (MIS) IPOM repairs and most is hindered by the lack of long-term follow-up. We sought to report long-term outcomes and mesh-related complications of MIS IPOM ventral hernia repairs.

METHODS AND PROCEDURES

Adult patients who underwent MIS IPOM ventral hernia repair at our institution were identified in the Abdominal Core Health Quality Collaborative database from October 2013 to October 2020. Outcomes included hernia recurrence and mesh-related complications or reoperations up to 6 years postoperatively.

RESULTS

A total of 325 patients were identified. The majority (97.2%) of cases were elective, non-recurrent (74.5%), and CDC class I (99.4%). Mean hernia width was 4.16 ± 3.86 cm. Median follow-up was 3.6 (IQR 2.8-5) years. Surgeon-entered or patient-reported follow-up was available for 253 (77.8%) patients at 3 years or greater postoperatively. One patient experienced an early small bowel obstruction and was reoperated on within 30 days. Two-hundred forty-five radiographic examinations were available up to 6 years postoperatively. Twenty-seven patients had hernia recurrence on radiographic examination up to 6 years postoperatively. During long-term follow-up, two mesh-related complications required reoperations: mesh removed for chronic pain and mesh removal at the time of colon surgery for perforated cancer. Sixteen additional patients required reoperation within 6 years for the following reasons: hernia recurrence (n = 5), unrelated intraabdominal pathology (n = 9), obstructed port site hernia (n = 1), and adhesive bowel obstruction unrelated to the prosthesis (n = 1). The rate of reoperation due to intraperitoneal mesh complications was 0.62% (2/325) with up to 6 year follow-up.

CONCLUSION

Intraperitoneal mesh for repair of small to medium-sized hernias has an extremely low rate of long-term mesh-related complications. It remains a safe and durable option for hernia surgeons.

Are Surgeons Going to Be Left Holding the Bag? Incisional Hernia Repair and Intra-Peritoneal Non-Absorbable Mesh Implant Complications

Ventral incisional hernias are common indications for elective repair and frequently complicated by recurrence. Surgical meshes, which may be synthetic, bio-synthetic, or biological, decrease recurrence and, resultingly, their use has become standard. While most patients are greatly benefited, mesh represents a permanently implanted foreign body. Mesh may be implanted within the intra-peritoneal, preperitoneal, retrorectus, inlay, or onlay anatomic positions. Meshes may be associated with complications that may be early or late and range from minor to severe. Long-term complications with intra-peritoneal synthetic mesh (IPSM) in apposition to the viscera are particularly at risk for adhesions and potential enteric fistula formation. The overall rate of such complications is difficult to appreciate due to poor long-term follow-up data, although it behooves surgeons to understand these risks as they are the ones who implant these devices. All surgeons need to be aware that meshes are commercial devices that are delivered into their operating room without scientific evidence of efficacy or even safety due to the unique regulatory practices that distinguish medical devices from medications. Thus, surgeons must continue to advocate for more stringent oversight and improved scientific evaluation to serve our patients properly and protect the patient-surgeon relationship as the only rationale long-term strategy to avoid ongoing complications.

Outcomes of subsequent abdominal operations after an initial ventral hernia repair

INTRODUCTION

Nearly 20% of ventral hernia repair (VHR) patients require a subsequent abdominal operation (SAO), and mesh position may impact the complexity and outcome of the SAO.

METHODS

Retrospective review of VHR with mesh from 2006 to 2020 from an internal database and the ACHQC. Primary outcomes measured incidence, complexity, and complications of SAO relative to mesh position.

RESULTS

SAO was required in 433 of 2539 (17.1%) patients, totaling 671 operations; 197/893 (22.1%) with intraperitoneal mesh (IPM) and 236/1646 (14.3%) with extraperitoneal mesh (EPM; p ​< ​0.001). SAO was directly related to VHR in 180 (232 total SAOs) and unrelated in 253 (439 total SAOs). There were no significant differences in complications after SAO between IPM and EPM, nor any difference in adhesion complexity.

CONCLUSION

Incidence of SAO is higher with IPM, but surgical outcomes are similar. Due to the risk of secondary mesh infection with IPM, significantly more of these were removed at the time of SAO.

Hernia Mesh Complications: Management of Mesh Infections and Enteroprosthetic Fistula

The potential consequences of mesh infection mandate careful consideration of surgical approach, mesh selection, and preoperative patient optimization when planning for ventral hernia repair. Intraperitoneal mesh, microporous or laminar mesh, and multifilament mesh typically require explantation, whereas macroporous, monofilament mesh in an extraperitoneal position is often salvageable. Delayed presentation of mesh infection should raise the suspicion for enteroprosthetic fistula when intraperitoneal mesh is present. When mesh excision is necessary, the surgeon must carefully consider both the risk of recurrent infection as well as hernia recurrence when deciding on single-stage definitive reconstruction versus primary closure with delayed reconstruction.

Ventral Hernia Repair: Does Mesh Position Matter?

Mesh positioning is a commonly discussed detail in ventral hernia repair and is often cited as a major contributor to the outcome of the operation. However, there is a paucity of data that establishes one plane as superior to others. In this article, we will provide an overview of all potential planes to place prosthetic material and review the relevant literature supporting each option and the complications associated with accessing each anatomic plane.

Evaluation of Long-term Performance of the GORE SYNECOR Intraperitoneal Biomaterial in the Treatment of Inguinal Hernias

BACKGROUND

The objective of this study was to analyze device safety and clinical outcomes of inguinal hernia repair with the GORE SYNECOR Intraperitoneal Biomaterial device, a hybrid composite mesh.

METHODS

This retrospective case review analyzed device/procedure endpoints beyond 1 year in patients treated for inguinal hernia repair with the device. Three objectives were evaluated: procedural endpoint-incidence through 30 days of surgical site infection, surgical site occurrence (SSO), ileus, readmission, reoperation, and death; device endpoint-serious device incidence of mesh erosion, infection, excision/removal, exposure, migration, shrinkage, device-related bowel obstruction and fistula, and hernia recurrence through 12 months; and patient-reported outcomes of the bulge, physical symptoms, and pain.

RESULTS

A total of 157 patients (mean age: 67±13 y) with 201 inguinal hernias (mean size: 5.1±5 cm 2 ) were included. Laparoscopic approach and bridging repair were performed in 99.4% of patients. All device location was preperitoneal. No procedure-related adverse events within 30 days were reported. No surgical site infection or SSO events or device-related hernia recurrence occurred through 12 months. Procedure-related serious adverse events occurred in 6 patients; 5 recurrent inguinal hernias (at 1 and 2 y) and 1 scrotal hematoma (at 6 mo). Through 24 months, no SSO events requiring procedural intervention occurred. Through 50 months, 6 (2.98%) patients had confirmed hernia recurrence and 4 (1.99%) patients had hernia reoperation. The patient-reported outcome for pain was reported by 7.9% (10/126) of patients who completed the questionnaire.

CONCLUSIONS

In this study, inguinal hernia repair with the hybrid composite mesh was successful in most patients and the rate of recurrence was low, further supporting the long-term safety and device performance.

Biologic versus synthetic mesh in open ventral hernia repair: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Ventral hernia repair is one of the most common operations performed worldwide, and using mesh is standard of care to decrease recurrence. Biologic meshes are increasingly used to minimize complications associated with synthetic mesh, but with significantly higher cost and unclear efficacy. Until recently, most of the evidence supporting the use of biologic meshes was from retrospective cohorts with high heterogeneity and risk of bias. We aimed to report a meta-analysis of randomized controlled trials comparing the outcomes of synthetic and biologic mesh in elective open ventral hernia repair.

METHODS

A literature search of PubMed, Embase, and Cochrane Library databases was performed to identify randomized controlled trials comparing biologic and synthetic mesh in elective open ventral hernia repairs. The postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I² statistics.

RESULTS

A total of 1,090 studies were screened, and 22 were fully reviewed. Four randomized controlled trials and 632 patients were included in the meta-analysis. Fifty-eight percent of patients had contaminated wounds (Wound Classification II-IV). Hernia recurrence (odds ratio 2.75; 95% confidence interval 1.76-4.31; P < .00001; I² = 0%) and surgical site infections (odds ratio 1.53; 95% confidence interval 1.02-2.29; P = .04; I² = 0%) were significantly more common in patients with biologic mesh. The rates of seroma, hematoma, and mesh removal were similar in both groups.

CONCLUSION

As compared to synthetic mesh, biologic meshes resulted in increased hernia recurrences and surgical site infections. Current evidence supports macroporous, uncoated synthetic mesh as the implant of choice for elective open ventral hernia repair, and its use should be considered even in contaminated cases.

Short-term outcomes of robotic inguinal hernia repair during robotic prostatectomy - An analysis of the Abdominal Core Health Quality Collaborative

BACKGROUND

Concomitant robotic-assisted laparoscopic prostatectomy (RALP) and robotic inguinal hernia repair (RIHR) has been reported. Nevertheless, data on its safety is lacking and some surgeons avoid performing both operations concurrently due to the potential risk of mesh related complications in the setting of a fresh vesicourethral anastomosis. We aimed to investigate differences in 30-day outcomes between patients undergoing RALP+RIHR and those undergoing RIHR alone.

METHODS

Patients who have undergone concomitant RALP and RIHR with 30-day follow-up available were identified within the Abdominal Core Health Quality Collaborative. Using a propensity score algorithm, they were matched with a cohort of patients undergoing RIHR alone based on confounders such as body mass index, age, ASA class, smoking, hernia size and recurrent status and prior pelvic operation. The groups were compared for 30-day rates of surgical site infection (SSI), surgical site occurrences (SSO), surgical site occurrences requiring operative intervention (SSOPI) and hernia recurrence.

RESULTS

24 patients underwent RALP + RIHR and were matched to 72 patients who underwent RIHR alone (3:1). Median age was 64 years, 33% were obese and 17% smokers. No significant differences were found on 30-day rates of overall complications (21% RALP + RIHR vs. 15% RIHR, p = 0.53) and surgical site occurrences (12% RALP + RIHR vs.11% RIHR, p = 0.85). No patient in the RALP + RIHR group had a 30-day SSI, SSOPI or early recurrence.

CONCLUSION

RALP+RIHR appears not to result in increased rates of wound complications, overall complications or early recurrence when compared to patient undergoing RIHR alone. Prospective, controlled studies with larger number of patients are needed to confirm our findings.

Intestinal erosion caused by meshoma displacement: A case report

BACKGROUND

A meshoma formation and erosion to the small intestine is rare. Herein, we report one case of a meshoma that was not treated early; causing it to displace and erode the small intestine, with infection, complete control of symptoms was achieved after removal of the infected patch mass, no recurrence of hernia after 2 years of follow-up.

CASE SUMMARY

A 62-year-old male patient presented with recurrent abdominal pain repeatedly for 1 wk, which has worsened 2 d before admition, accompanied by fever. Five years before presentation he underwent right inguinal hernia Plug and patch repair approach. Two years ago, a computed tomography scan revealed a right lower abdominal mass with soft tissue density, measuring approximately 30 mm × 17 mm, which was diagnosed as meshoma that was not treated. The patient had poorly controlled diabetes in the past year.

CONCLUSION

The formation of meshoma is rare, and that if not treated in time it might erode and require resection of the involved organ.

State-of-the-art abdominal wall reconstruction and closure

Open ventral hernia repair is one of the most common operations performed by general surgeons. Appropriate patient selection and preoperative optimization are important to ensure high-quality outcomes and prevent hernia recurrence. Preoperative adjuncts such as the injection of botulinum toxin and progressive preoperative pneumoperitoneum are proven to help achieve fascial closure in patients with hernia defects and/or loss of domain. Operatively, component separation techniques are performed on complex hernias in order to medialize the rectus fascia and achieve a tension-free closure. Other important principles of hernia repair include complete reduction of the hernia sac, wide mesh overlap, and techniques to control seroma and other wound complications. In the setting of contamination, a delayed primary closure of the skin and subcutaneous tissues should be considered to minimize the chance of postoperative wound complications. Ultimately, the aim for hernia surgeons is to mitigate complications and provide a durable repair while improving patient quality of life.

Evaluation of long-term performance of an intraperitoneal biomaterial in the treatment of ventral hernias

BACKGROUND

One-year device safety and clinical outcomes of ventral hernia repair with the GORE® SYNECOR Intraperitoneal Biomaterial, a hybrid composite mesh was evaluated.

METHODS

This retrospective, multicenter, case review analyzed device/procedure endpoints and patient-reported outcomes in patients treated for hernia repair ≥ 1 year from study enrollment.

RESULTS

Included were 459 patients (with 469 ventral hernias) with a mean age of 58 ± 15 years; 77.1% met Ventral Hernia Working Group 2 (VHWG2) classification. Mean hernia size was 18.9 cm² and 57.3% of hernias were incisional. Laparoscopic or robotic approach was utilized in 95.4% of patients. Mesh location was intraperitoneal for 75.6% and bridging repair was performed in 57.3%. Procedure-related adverse events within 30-days occurred in 5.0% of patients and included surgical site infection (SSI), surgical site occurrence (SSO), ileus, readmission, and re-operation. Procedure-related SSI or SSO events were 3.8% through 12 months. SSO events requiring procedural intervention (SSOPI) were 2.6% through 24 months. Four patients (0.9%) had confirmed hernia recurrence through the study (the mean follow-up was 32-months, range 14-53 months). Subgroup comparisons were conducted for all type recurrence; only diabetes was found to be statistically significant (p = .0506).

CONCLUSION

In this analysis, ventral hernia repair with hybrid, composite mesh results in successful outcomes in most patients. This study represents a heterogeneous patient population undergoing repair using various approaches, mesh fixation, and mesh placement locations. These data appear to confirm long-term acceptable safety and device performance with a low rate of recurrence in a predominantly VHWG2 population.

[Management of late onset septic complications after IPOM implantation: case series from a hernia center]

BACKGROUND

The intraperitoneal onlay mesh (IPOM) is for many surgeons a pragmatic solution for the operative treatment of extensive and complex abdominal wall hernias. A few years after mesh implantation we are now faced with a number of late complications of the IPOM procedure. Chronic septic complications, such as mesh infections and fistula formation have an outstanding position.

OBJECTIVE

With this case series we would like to share our experiences with the operative treatment of severe late onset septic complications after abdominal wall augmentation with IPOM. Furthermore, the current indications for the IPOM procedure are discussed.

MATERIAL AND METHODS

For the period February 2016-July 2019 a total of 10 patients with late septic complications after IPOM implantation were treated in our clinic. The index interventions took place between 2010 and 2017. The clinical picture varied from mesh infections with only minor symptoms to formation of multiple intestinal fistulas.

RESULTS

Multiple stage procedures were required in 9 out of the 10 patients in order to achieve sufficient decontamination of the surgical field. Due to enterocutaneous fistulas, bowel resection was performed in 5 patients. The mesh could be preserved in situ in only one patient. For the reconstruction of the abdominal wall, both plastic surgical methods and implantation of absorbable and non-absorbable meshes were used.

CONCLUSION

A consistent treatment with great effort is required for septic complications of the IPOM procedure. The interventions are often associated with extensive adhesiolysis and intestinal resection. Therefore, the indications for intraperitoneal mesh implantation should be handled with caution and an alternative surgical procedure should be considered. There are still special cases, such as hernias with very large abdominal wall defects in which the IPOM method is a suitable treatment option for tension-free reconstruction.

Ventral Hernia Management in Obese Patients

Ventral and incisional hernias in obese patients are particularly challenging. Suboptimal outcomes are reported for elective repair in this population. Preoperative weight loss is ideal but is not achievable in all patients for a variety of reasons, including access to bariatric surgery, poor quality of life, and risk of incarceration. Surgeons must carefully weigh the risk of complications from ventral hernia repair with patient symptoms, the ability to achieve adequate weight loss, and the risks of emergency hernia repair in obese patients.

The negative pressure wound therapy may salvage the infected mesh following open incisional hernia repair

Background

s: Incisional hernias may occur in 10–25% of patients undergoing laparotomy. In cases of a surgical site infection (SSI) after incisional hernia repair (IHR) secondary operative intervention with mesh removal are often needed. There is only minimal data available in the literature regarding the treatment of a wound infection with negative pressure wound therapy (NPWT). Conducting the study at hand, we aimed to provide more evidence on this topic.

Methods

From April to June 2020 a monocentric retrospective study has been performed. Patients who underwent NPWT due to a SSI with mesh involvement following open IHR from 2007 to 2020 were included. The primary endpoint was the mesh removal rate in the end of NPWT. Main secondary endpoints were the duration of NPWT and the amount of NPWT procedures.

Results

The data of 30 patients were extracted. The average age was 65.9 years (9.9). A total of 13 individuals were male and 17 females. The BMI was on average 31.1 kg/m² (4.9). All patients received a polypropylene mesh. The average duration of NPWT was 31.3 days (22.1). The first wound revision with initiation of a NPWT was conducted on average 31.1 days (34.0) after IHR. The average amount of NPWT procedures was 8.3 (7.2). In 5 of 30 patients (16.6%) the mesh was removed (Open sublay group n = 4 (36.34%) vs. open onlay group n = 1 (5.26%), p = 0.047).

Conclusion

In cases of SSI following IHR the NPWT may facilitate mesh selvage. Further trials with a larger sample size are mandatory to confirm our hypothesis.

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As one of a main complication SSI may occur in up to 30% of cases following incisional hernia repair.

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The mesh is often removed in cases of a SSI.

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NPWT may salvage mesh removal in cases of mesh infection.