Postoperative Mesh Infection—Still a Concern in Laparoscopic Era

Abstract

Introduction of synthetic mesh was a landmark breakthrough in the management of hernia repair and has significantly reduced recurrence rates. But in addition to the benefits, some more problems have come in picture major being 'mesh infection'. Prolene mesh has shown promise when used in abdominal and inguinal hernia repair, especially when used in planned surgeries. This material, derived from monofilament polypropelene, is found to be biologically inert in almost every person. Being a foreign material, a slightest breach in asepsis can lead to favourable environment for bacterial proliferation and form a 'biofilm'. This phenomenon especially after laparoscopic surgeries gives rise to chronic discharging sinus at the port site, abscess formation around mesh and even sepsis. It appears that laparoscopic hernia repair is a promising method but having chances of mesh infection owing to difficult approach and lack of uniformity in sterilization of laparoscopic instruments. Slightest breach in sterility or protocols might lead to such a large ventral wall sinus, increasing morbidity and cost of treatment. Treatment of infected mesh is possible by local debridement, irrigation, mesh removal and systemic antibiotics culminating in increased morbidity over duration of disease, but still it would be worth emphasizing-'Prevention is better than cure'.

Prevention of patch infection after abdominal external hernia repair

“…The specific mechanism underlying patch infection remains unclear to date because of its complex origin. Factors that increase the risk for patch infection include patients, chronic obstructive pneumonia, diabetes, morbid obesity, malnutrition, history of coronary heart disease, smoking history, immunodeficiencies, and American Society of Anesthesiologists score ≥3 [3][4][5][6]. In addition, recent studies have discovered other factors related to the occurrence of patch infection.…”

“…Compared with the patch of a single fiber structure (polypropylene patch), the patch of multiple fiber structures (polytef patch) has a higher rate of infection because of its larger surface area for bacterial adhesion [3]. The gaps between the woven fibers not only provide a hiding area for bacteria but also serve as a deterrent to immune cells [7].…”

“…By theory, repeated disinfection of the contaminated hernia patch after adequate disinfection will not increase the risk of infection. However, the resterilized patch may inhibit the growth of fibroblasts and affect the binding of the patch to host tissue [3], which can result in complications, such as local effusion, and increase the risks for patch infection.…”

“…Liu et al reviewed 22 cases of patch infection after external abdominal hernia repair and found that the disease course lasts 3-14 months [1]. Clinical manifestations are mostly caused by local inflammatory reactions, including surgical incision purulent discharge, local swelling, sinus tract formation, and chronic pain in the surgical site [3]. The formation of a honeycomb abscess at a distant site may also result from the shedding of bacterial clumps and cause serious complications, such as bacteremia [9].…”

“…As a foreign matter, the patch lowers the threshold of the bacteria needed for infection. Biofilm is formed through the proliferation after the bacteria are adhered to the patch, which can enhance the resistance of the bacteria to antibiotics, evade host immunity, and lead to negative results of common bacterial culture [3]. Through confocal microscopy, Kathju et al [9] directly discovered the bacterial biofilm from the patch removed from surgery and confirmed that the formed bacteria biofilm is heterologous and is a combination of microorganisms.…”