Clinical Management of Hernia Mesh Infections: Treatment Strategies and Considerations

Understanding Mesh Infection Risk Factors

• ⚠️ Patient risk factors for mesh infection include immunosuppression, BMI over 35, active smoking, uncontrolled diabetes, and a history of prior surgical site infections.
• ⚙️ Operative risk factors encompass urgent repairs, prolonged operative times, intraoperative contamination, wound class, and the creation of large dead spaces, particularly in the onlay position.
• ⏳ It's crucial to distinguish between definitive and temporizing hernia repairs, especially in non-optimized patients or urgent settings, to minimize infection risks.

Initial Management and Source Control

• 🎯 Source control is the primary principle, involving drainage of fluid collections via percutaneous or operative methods to manage abscesses or deep space infections.
• ⚖️ The decision between mesh salvage and explantation depends on the mesh type, its position, the infection's extent, and the presence of fistulas or gross contamination.
• 🧪 Obtaining cultures from deep wounds or drains is essential for tailoring antibiotic therapy, with empiric broad-spectrum coverage initially, narrowing based on results.
• 🦠 Enteric bacteria isolation suggests a mesh-enteric fistula requiring surgical intervention, while MRSA growth raises concerns for biofilm formation necessitating explantation.

Mesh Properties and Salvageability

• 🔬 Multifilament meshes and sutures harbor bacteria in small interstices, hindering clearance by the body's immune response and often requiring excision.
• 🌟 Monofilament meshes, particularly macroporous ones, offer fewer hiding spots for bacteria and allow for better neovascularization, increasing salvage potential.
• 🚫 PTFE meshes and solid laminar sheets are generally not salvageable due to their structure, which prevents bacterial clearance and ingrowth.
• 📍 Mesh location is critical; extraperitoneal repairs against well-vascularized muscle promote healing and infection defense, unlike onlay positions closer to the skin or intraperitoneal underlay meshes with reduced perfusion.

Mesh Explantation and Reconstruction

• ✂️ Complete mesh excision is generally preferred over partial excision to adequately clear infection, as partial removal is often inadequate and leads to recurrence.
• 🔗 All foreign bodies, including suture material like multifilament polyester, should be removed to prevent harboring bacteria.
• 🏥 Reconstruction of the abdominal wall is typically performed in a staged fashion after the infection is cleared, aiming for a durable repair with extraperitoneal macroporous polypropylene in a clean field.

Prevention and Optimization

• 💪 Pre-operative optimization is crucial, including weight loss, diabetes control, and smoking cessation, especially for patients requiring abdominal wall reconstruction.
• ⏳ In urgent situations, temporizing repairs with primary suture or bioresorbable mesh can manage acute issues, with definitive reconstruction planned for a later, optimized stage.
• 🎯 The ultimate goal is to select the right patient, at the right time, for the right operation, ensuring optimal long-term outcomes.