Management of Synthetic Mesh Infection With Open Resection and Laparoscopic Ventral Hernia Repair Using Biosynthetic Prosthetic Material

Ventral hernia repair (VHR) is a common surgical operation with the prevailing complication of hernia recurrence. The development of diverse mesh materials has led to a lower hernia recurrence rate but poses concern for mesh infection. Featured is the case study of a patient who underwent laparoscopic recurrent VHR with utilization of biosynthetic mesh and removal of prior permanent synthetic mesh. During the post-operative course, the patient developed a seroma, cellulitis, and wound dehiscence. Despite these complications, the biosynthetic mesh was salvaged using conservative measures. The patient has been followed over the course of 3 years without hernia recurrence or other complications to date.

One of the most common surgical complications in the United States is recurrent incisional hernias. The emergence of permanent mesh materials has led to less hernia recurrence but poses complications of chronic inflammation and infection. ¹ Biologic meshes contribute to lower infection rates but increased laxity and recurrent herniation. Biosynthetic hybrid mesh capitalizes on the advantages of both biologic and synthetic meshes, while reducing the disadvantages. ² Mesh infection remains one of the most concerning complications after abdominal reconstruction and often requires mesh removal. ¹ Highlighted is the case study of a patient who underwent laparoscopic recurrent ventral hernia repair (VHR) with utilization of biosynthetic mesh (Synecor Intraperitoneal Biomaterial, Gore) and removal of a prior permanent synthetic mesh (Ventralex, Bard.) This case features successful complication resolution without the need for additional surgery and a hernia non-recurrence timeline of nearly 3 years, to date.

A 57-year-old man with a history of prior open umbilical hernia repair with mesh, cholecystectomy, body mass index (BMI) of 34.0, and current smoker presents in the outpatient clinic due to a chronic draining wound at his umbilicus. Six years prior, he had an open umbilical hernia repair with permanent synthetic mesh. Physical exam revealed a chronic sinus at the umbilicus consistent with a suture granuloma and a small recurrent hernia defect at the umbilicus.

A horizontal incision overlying the umbilicus and chronic suture granuloma site was created and skin, soft tissue, scar tissue, prior mesh, and prior suture material were excised. The fascia was subsequently closed with 2-0 polydioxanone (PDS) absorbable suture and the incision site was closed with a 3-0 Vicryl suture followed by a 4-0 Monocryl subcuticular suture. Pneumoperitoneum was established and a 15 × 20 cm Synecor Gore mesh was selected. Transabdominal absorbable 0 Vicryl sutures and absorbable tacks were utilized for positioning the mesh with an intraperitoneal onlay of mesh (IPOM) technique. The patient was discharged home on 5 days of oral antibiotics.

Nine days post-operation, the patient presented to the emergency department with reports of blood and pus oozing from his surgical site with constant erythema and edema peri-umbilically. Contrast tomography of the abdomen and pelvis with intravenous (IV) contrast indicated fluid collections superficial and deep to the anterior wall and mottled gas in the soft tissues. The patient was started on IV antibiotics and interventional radiology (IR) placed a percutaneous drain secondary to the seroma. The patient was subsequently discharged on oral antibiotics. Three-week follow-up demonstrated resolution of the seroma and cellulitis, but with dehiscence of the wound. Wound vacuum-assisted closure (vac) was initiated along with oral Bactrim. Eleven weeks of continued wound vac changes and antibiotics resulted in closure of the wound.

Mesh infection remains one of the most detrimental complications of VHR and often puts patients at risk for hernia recurrence. A multisite cohort study from 1998 to 2002 reported that of the prosthetic mesh repairs performed, (5.1%) had mesh explantation after incisional hernia repair (IHR) with nearly 70% due to mesh infection. This study indicated that patients with a history of recurrent VHR with prior mesh implant demonstrated increased risk of mesh explantation and infection.^1,3

Current recommendations for infection of mesh are complete foreign body removal and antibiotics. Conservative treatment to salvage mesh includes percutaneous wound drainage, wound therapy, and antibiotics. ¹ In a retrospective study done by Stremitzer et al, 476 patients with history of IHR were addressed with conservative management, with 100% success in those patients with a partially absorbable mesh with large pores. Additionally, they comment on the utility of vacuum-assisted therapy benefit in mesh salvage. ⁴

As the third leading cause of reoperation, mesh infection leads to increased patient morbidity, increased duration of hospital stay, and increased cost to the patient and health care system. ¹ According to the COBRA Study, biosynthetic absorbable mesh displayed efficacy in mitigating hernia re-recurrence and infection in single-staged contaminated ventral hernias. Because biosynthetic meshes are broken down via hydrolysis within 6-7 months, the body’s immune cells can infiltrate the mesh to protect against bacteria. ² As highlighted in our patient’s clinical course, his biosynthetic mesh was salvaged using conservative measures despite seroma formation, cellulitis, and dehiscence. This patient is now 3 years post-operation without hernia recurrence or other complications.

VHR is a commonly occurring surgery. The most prevalent problem that arises with VHR is hernia recurrence. Infection of the mesh is a deleterious problem that can present, with surgical removal of the foreign body being the mainstay of treatment. Emergence of biosynthetic hybrid mesh offers improved clinical outcomes with mesh salvage in mesh infections. Our clinical case presentation supports the utilization of biosynthetic mesh in hernia repairs with optimum results regarding mesh salvage resolution, hernia non-recurrence, and a positive patient outcome.