The American Journal of Surgery (2017) 213, 50-57

Clinical Science

Predictors of mesh infection and explantation

after abdominal wall hernia repair
José Bueno-Lledó, Ph.D.*, Antonio Torregrosa-Gallud, Ph.D.,
Angela Sala-Hernandez, M.D., Fernando Carbonell-Tatay, Ph.D.,
Providencia G. Pastor, M.D., Santiago B. Diana, M.D.,
José I. Hernández, M.D.

Surgical Unit of Abdominal Wall, Department of Digestive Surgery, Politecnic ‘‘La Fe’’ Hospital,
University of Valencia, Valencia, 46008, Spain

KEYWORDS: Abstract
Mesh infection; BACKGROUND: The main objective was to identify predictive factors associated with prosthesis
Mesh explantation; infection and mesh explantation after abdominal wall hernia repair (AWHR).
Biofilm; METHODS: This is a retrospective review of all patients who underwent AWHR from January 2004
Abdominal wall to May 2014 at a tertiary center. Multivariate analysis identified predictors of mesh infection and
hernia; explantation after AWHR.
Hernia repair; RESULTS: From 3,470 cases of AWHR, we reported 66 cases (1.9%) of mesh infection, and 48
Prosthesis infection repairs (72.7%) required mesh explantation. Steroid or immunosuppressive drugs use (odds ratio
[OR] 2.22; confidence interval [CI] 1.16 to 3.95), urgent repair (OR 5.06; CI 2.21 to 8.60), and post-
operative surgical site infection (OR 2.9; CI 1.55 to 4.10) were predictive of mesh infection. Predictors
of mesh explantation were type of mesh (OR 3.13; CI 1.71 to 5.21), onlay position (OR 3.51; CI 1.23 to
6.12), and associated enterotomy in the same procedure (OR 5.17; CI 2.05 to 7.12).
CONCLUSIONS: Immunosuppressive drugs use, urgent repair, and postoperative surgical site infec-
tion are predictive of mesh infection. Risk factors of prosthesis explantation are polytetrafluoroethylene
mesh, onlay mesh position, and associated enterotomy in the same procedure.
Ó 2016 Elsevier Inc. All rights reserved.

The use of the prosthesis in the abdominal wall hernia
repair (AWHR) has introduced new problems. Although
mesh has reduced hernia recurrence rates, it has its own
set of complications. So, infection is one of the most
devastating complications after the implantation of any
mesh.1
The authors declare no conflicts of interest.
* Corresponding author. Tel.: 134-651-525-437; fax: 963-425-301.
E-mail address: buenolledo@hotmail.com
Manuscript received November 19, 2015; revised manuscript March
16, 2016
The risk of infection in AWHR appears to be higher than
other clean cases, but there is a wide range reported from
1% to 10%2 depending on the type of mesh, technique, and
patient population. Infection of abdominal wall prostheses
can have grave and costly consequences and severe impact
on the patient’s life because of prolonged hospitalizations
and multiple reinterventions and very elevated social costs.3
So, these are an incentive to explore any and all means that
might reduce the incidence of mesh infection.
Over the years, numerous types of prosthesis have been
developed to provide greater strength and lower recurrence
rates, and at the same time, the risk of infection and other

0002-9610/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2016.03.007
J. Bueno-Lledó et al. Mesh infection and explantation after hernia repair
complications have been decreased.4 Some known risk
factors for mesh infection have been reported: prolonged
operative time and type of mesh are the predictive factors
in heterogeneous series of groin hernia repairs or
AWHR.5–7 On the other hand, postoperative surgical site
infections (SSIs) or concomitant intra-abdominal proce-
dures have been related to mesh explantation in hernia
repair.8 But no previous study has been conducted consid-
ering factors relating the mesh infection and explantation
following AWHR together.
The main purpose of this retrospective study was to
identify the incidence, etiologies, and independent predictors
associated with prosthesis infection and mesh explantation
after AWHR.
Methods
A retrospective review was performed of all patients
who underwent AWHR from January 2004 to May 2014 at
a tertiary center. Only patients admitted for hernia repair
with prosthesis were considered. Patients with laparoscopic
hernia repair were excluded.
Prosthetic infection was diagnosed when pathogenic
organisms were found in the periprosthetic fluid obtained
by surgical drainage or percutaneous puncture using ultra-
sound. Minor infections, such as cellulites, that could be
treated with antibiotics alone were not included in the mesh
infection group. Patients who underwent subsequent mesh-
related infection were compared with patients without
infection: all factors related to mesh infection were
collected by retrospective revision of clinical data.
The treatment of prosthetic infection consisted on
antibiotics according to antibiogram, percutaneous drainage,
or standard wound debridement under general or local
anesthesia. If the infection remained, despite these measures,
the prosthesis was removed. Mesh explantation was defined
as any surgery where the prosthesis was partially or
completely removed in a subsequent procedure. Reasons
for abdominal reoperation and mesh explantation were
documented. Further analysis of patients who required
complete or partial mesh removal after the index surgery
was compared with patients who did not require it. All
patients maintained prophylactic antithrombotic (subcu-
taneous enoxaparin) and prophylactic dose of antibiotic at
the moment of mesh implantation. Patients who needed
surgery of mesh explantation received antibiotic therapy
according to previous antibiogram.
Demographic variables including patient’s age and sex
were collected. The following medical comorbidities were
reported: body mass index (BMI), chronic obstructive pul-
monary disease, steroid use, immunosuppression, diabetes
mellitus, smoking history, and American Society of Anes-
thesiologist score. Types and sizes of mesh were identified
using physician-abstracted operative notes and we further
classified into onlay, underlay, or inlay. Microbiology data
were collected on all patients. Additional variables of interest
51
included postoperative SSI and history of previous surgical
debridement. Hernia characteristics collected included emer-
gency repair, number of previous hernia repairs, type of
repair, drain use, concomitant repair (where another proce-
dure was performed at the same time, such as enterotomy
and ventral hernia repair), recurrent hernia, and hernia
location. In addition, the type of removed mesh and any
related intraoperative or postoperative complications were
also noted.
Patients were followed up at 1 month, 3 months, and
1 year after surgery (and subsequent annual reviews). Long-
term readmission or referral to another hospital was
checked through the hospital database.
In the statistical analysis, a commercial software pro-
gram (SPSS, version 20.0) was used. Univariate analysis
was performed using Student t test to explore quantitative
variables and ‘‘chi square’’ (or Fisher test) if they were
dichotomous. Univariate variables with significance values
P less than .05 were included in a logistic regression anal-
ysis, identifying independent predictors of mesh infection
and explantation, expressed in terms of ‘‘odds ratio’’
(OR) and 95% confidence interval (CI). The significance
level was P less than .05.
Results
Over the 10-year study period (January 2004 to May
2014), 3,470 AWHR were performed at our hospital. At a
median of 50.6 months (range 14 to 85 months) of
postoperative follow-up, we reported 66 cases of mesh
infection and 48 repairs (72.7%) required mesh explanta-
tion. The overall infection rate in AWHR was 1.9%.
Mesh infection
Characteristics were distributed equally in the subgroups
with and without prosthetic infection (Table 1). The average
age of the mesh infection group was 55.3 6 21.6 years, and
the population was predominantly women (53.1%). Sixteen
patients were diabetic, 50.5% had hypertension, and 13.5%
had chronic obstructive pulmonary disease. Approximately,
9% (307 of 3,404) of repairs were performed in patients
with immunosuppressive therapy, mainly hepatic and kidney
transplantation; of them, 5.4% (16 of 307) of patients devel-
oped mesh infection. BMI superior to 30 was observed in 49
cases (74.2%). Almost half of patients smoked at the
moment or had a history of using tobacco (46.9%).
According to the type of hernia repair, we found mesh
infection in 6 patients with Lichtenstein repair (9% of
repairs with prosthesis infection), 2 patients with Rutkow–
Robbins technique (3%), 5 cases in Rives–Stoppa technique
(7.5%), 11 patients in component separation technique
(16.6%), 15 cases in preperitoneal repair (22.7%), and 27
cases with Chevrel technique (40.9%).
In 22 patients, intestinal resection was planned in a
concomitant procedure with the ventral hernia repair
52 The American Journal of Surgery, Vol 213, No 1, January 2017

Table 1 Predictors of mesh infectiondunivariate and multivariate analyses

No mesh infection Mesh infection
group (%) group (%) Multivariate
Variables N 5 3,404 n 5 66 Univariate P OR (95% CI) Multivariate P
Age (mean 6 SD) 53.6 6 25.5 55.3 6 21.6 .116 1.21 (.91–1.49) .121
Sex
Male 1,528 (44.8) 31 (46.9) .241 2.14 (.97–4.69) .072
Female 1,976 (55.2) 35 (53.1)
BMI
.30 1,290 (37.8) 49 (74.2) .002 1.56 (.68–2.75) .093
%30 2,114 (62.2) 17 (25.8)
Smoking
Yes 851 (25) 31 (46.9) .001 1.06 (.38–2.67) .930
No 2,553 (75) 35 (53.1)
Diabetes
Yes 667 (19.6) 16 (24.2) .089 1.82 (.96–3.46) .067
No 1,737 (80.4) 50 (75.8)
Steroid or immunosuppressive drugs use
Yes 291 (8.5) 16 (24.2) .020 2.22 (1.16–3.95) .016
No 3,113 (91.5) 50 (75.8)
ASA class
I–II 2,561 (75.2) 47 (71.2) .420 .55 (.19–1.57) .254
III–IV 843 (24.8) 19 (28.8)
Previous abdominal wall hernia repair
Yes 786 (23.1) 17 (25.7) .272 1.06 (.42–2.45) .098
No 2,218 (76.9) 49 (74.3)
Hernia defect location (EHS class.)
Groin hernia 1,801 (52.9) 8 (12.1) .060 1.12 (.74–2.33) .059
Midline hernia/umbilical hernia 1,358 (39.9) 54 (81.8)
(M1, M2, M3, M4, M5)
Lateral hernia (L1, L2, L3, L4) 245 (7.2) 4 (6.1)
Case status
Urgent 177 (5.1) 9 (13.6) .001 5.06 (2.21–8.6) .001
Elective 3,227 (94.9) 57 (86.4)
Type of repair
Lichtenstein 1,399 (41) 6 (9) .234 1.66 (.32–2.89) .088
Rutkow–Robbins 502 (14.7) 2 (3)
Rives–Stoppa 258 (7.5) 5 (7.5)
Preperitoneal technique 295 (8.6) 15 (22.7)
Component separation 298 (8.7) 11 (16.6)
Chevrel technique 652 (19.2) 27 (40.9)
Operative time in previous repair
,90 min 1,913 (56.1) 10 (15.1) .003 2.11 (.89–4.32) .056
91–179 min 1,036 (30.4) 22 (33.3)
.180 min 455 (13.5) 34 (51.6)
Mesh position
Overlay 2,025 (59.4) 55 (83.4) .017 2.01 (.55–3.89) .062
Underlay (preperitoneal/retromuscular) 1,335 (39.2) 11 (16.6)
Intraperitoneal 44 (1.4) 0
Type of prosthesis
PPL 2,408 (70.7) 42 (63.6) .231 .90 (.31–1.99) .122
PTFE/dual mesh 483 (14.1) 18 (27.2)
PVDF 319 (9.3) 3 (4.5)
Polyester 169 (4.9) 1 (1.5)
Biologic 25 (.8) 2 (3)
Prosthesis size
Standard (6 ! 11 cm; 7 ! 15 cm) 2,175 (63.8) 14 (21.2) .001 1.23 (.55–2.35) .099
Large (15 ! 15 cm: 20 ! 15 cm) 568 (16.6) 23 (34.8)
(continued on next page)
J. Bueno-Lledó et al. Mesh infection and explantation after hernia repair 53

Table 1 (continued )

No mesh infection Mesh infection

group (%) group (%) Multivariate
Variables N 5 3,404 n 5 66 Univariate P OR (95% CI) Multivariate P
Very large (20 ! 30 cm; 661 (19.6) 29 (44.0)
30 ! 30 cm or more)
Enterotomy (concomitant procedure)
Planned (intestinal resection 20 (.6) 2 (3) .002 1.41 (.45–3.20) .058
and hernia repair)
Unplanned 28 (.7) 4 (6.1)
no 3,356 (98.6) 60 (90.9)
Drain use
Yes 1,505 (44.2) 25 (37.8) .342 .69 (.23–1.43) .721
No 1,899 (55.8) 41 (62.2)
(Postoperative) Surgical wound infection
Yes 349 (10.2) 26 (39.3) .001 2.9 (1.55–4.10) .002
No 3,055 (89.8) 40 (60.7)
Statistically significant results are indicated in bold.
ASA 5 American Society of Anesthesiologist; BMI 5 body mass index; CI 5 confidence interval; EHS class. 5 European Hernia Society classification;
OR 5 odds ratio; PPL 5 polypropylene; PTFE 5 polytetrafluoroethylene; PVDF 5 polyvinylidene difluoride; SD 5 standard deviation.

(partial or complete colectomy in 18 cases and small bowel interval between mesh infection and reoperation to mesh
surgery in 4 cases). In 32 patients, enterotomy was removal was 7.3 months (range 1 to 16 months). The most
unplanned: 20 cases with intestinal perforation during common reasons for mesh explantation on univariate
adhesiolysis of the hernia sac and 12 urgent cases that analysis were BMI greater than 30 (P 5 .002), steroid
needed intestinal resection and prosthetic hernia repair. and immunosuppressive drugs use (P 5 .002), hernia defect
On univariate analysis, risk factors associated to mesh location (P 5 .047), operative time in previous repair
infection were BMI greater than 30 (P , .002), smoking greater than 180 minutes (P 5 .019), urgent repair (P 5
(P , .001), steroid or immunosuppressive drugs use .001), polytetrafluoroethylene mesh (P 5 .002), onlay posi-
(P , .020), urgent repair (P , .001), operative time in pre- tion (P 5 .001), and concomitant enterotomy (P 5 .002;
vious repair greater than 180 minutes (P , .003), onlay mesh Table 3).
position (P , .017), very large prosthesis size (P , .001), On multivariate analysis, the independent predictors of
concomitant enterotomy with hernia repair (P , .002), and mesh explantation because of infection were type of mesh
postoperative surgical wound infection (P , .001). (OR 3.13; CI 1.71 to 5.21, P 5 .001), onlay position
On multivariate analysis, immunosuppressive drugs (OR 3.51; CI 1.23 to 6.12, P 5 .003), and associated enterot-
use (OR 2.22; CI 1.16 to 3.95, P 5 .016), urgent repair omy in the surgical procedure (OR 5.17; CI 2.05 to 7.12, P 5
(OR 5.06; CI 2.21 to 8.60, P 5 .001), and development .001). So, adjusting for covariates, AWHR with expanded
of a postoperative SSI (OR 2.9; CI 1.55 to 4.10, P 5 polytetrafluoroethylene (ePTFE) placed during an open
.002) were predictive of mesh infection. There was no repair were associated with a 3-fold increase in the hazard
difference in the infection rate among repairs of primary of mesh explantation compared with other variables. Patients
and recurrent hernias, prosthesis type, operative time, undergoing a concomitant enterotomy with prosthetic repair
type of repair, drain use, hernia defect location, obesity, were 5 times more likely to undergo subsequent mesh
or other comorbidities.
The types of contaminating organisms identified on
the infected mesh are listed in Table 2. Overall, gram- Table 2 Contaminating organisms identified on the infected
mesh
positive organisms were found in 78.6% and gram-
negative organisms in 21.4%. Eight of the 66 patients Microbiology Number of patients (%)
had polymicrobial infections. Staphylococcus aureus and Staphylococcus aureus 29 (43.3)
methicillin-resistant Staphylococcus aureus (MRSA) MRSA 12 (18.2)
were the most common organisms, which were found in Staphylococcus epidermidis 10 (15.1)
61.5%. Escherichia coli 6 (9.1)
Anaerobic/Enterococcus 9 (13.6)
Pseudomona 4 (6)
Mesh explantation Proteus 4 (6)
Klebsiella 2 (3)
From 66 patients with mesh infection, we identified 48
MRSA 5 Methicillin-resistant Staphylococcus aureus.
(72.7%) who required subsequent mesh explantation. The
54 The American Journal of Surgery, Vol 213, No 1, January 2017

Table 3 Predictors of mesh explantationdunivariate and multivariate analyses

Mesh No mesh
explantation explantation Multivariate
Variables n 5 48 n 5 18 Univariate P OR (95% CI) Multivariate P
Age (mean 6 SD) 56.9 6 22.8 53.1 6 19.4 .135 .51 (.11–1.03) .876
Gender
Male 20 (41.6) 7 (38.8) .252 2.01 (.77–3.61) .092
Female 28 (58.4) 11 (61.2)
BMI
.30 40 (83.3) 9 (50) .002 1.2 (.28–2.76) .343
%30 8 (16.7) 9 (50)
Smoking
Yes 23 (48) 8 (44.4) .123 1.11 (.38–2.31) .076
No 25 (52) 10 (55.6)
Diabetes
Yes 11 (22.9) 5 (27.7) .091 1.48 (.76–3.21) .322
No 37 (72.1) 13 (72.8)
Steroid or immunosuppressive drugs use
Yes 15 (31.2) 1 (5.5) .022 2.22 (.36–4.91) .066
No 33 (68.8) 17 (94.5)
Average time of mesh infection in months 11.1 6 8.3 10.2 6 7.9 .320 .55 (.19–1.57) .688
since the previous mesh implantation (SD)
Previous abdominal wall hernia repair
Yes 3 (6.2) 5 (27.7) .061 1.11 (.32–2.11) .087
No 43 (89.5) 11 (61.1)
Hernia defect location (EHS class.)
Groin hernia 2 (4.2) 6 (33.3) .047 1.12 (.74–2.33) .434
Midline hernia/umbilical hernia 44 (91.6) 10 (55.6)
(M1, M2, M3, M4, M5)
Lateral hernia (L1, L2, L3, L4) 2 (4.2) 2 (11)
Symptoms
Wound infection 30 (62.5) 11 (61.1) .123 1.96 (.88–3.32) .909
Chronic sinus 16 (33.3) 6 (33.3)
Mesh extrusion 2 (4.2) 1 (5.5)
Operative time in previous repair (min)
,90 5 (10.4) 5 (27.7) .019 2.01 (.55–3.89) .104
91–179 12 (25) 10 (55.6)
.180 31 (64.5) 3 (16.6)
Case status
Urgent 8 (16.6) 1 (5.5) .001 .55 (.23–1.1) .072
Elective 40 (83.4) 17 (94.5)
Type of mesh
PPL 27 (56.2) 15 (83.3) .004 3.13 (1.71–5.21) .001
PTFE/Dualmesh 17 (35.4) 1 (5.5)
PVDF 2 (4.2) 1 (5.5)
Polyester 0 1 (5.5)
Biologic 2 (4.2) 0
Mesh position in hernia repair
Onlay 44 (91.6) 11 (61.1) .001 3.51 (1.23–6.12) .003
Sublay 4 (8.4) 7 (38.9)
Intraperitoneal 0 0
Prosthesis size
Standard (6 ! 11 cm; 7 ! 15 cm) 4 (8.4) 10 (55.6) .061 1.9 (.55–3.33) .089
Large (15 ! 15 cm: 20 ! 15 cm) 19 (39.5) 4 (22.3)
Very large (20 ! 30 cm; 30 ! 30 cm or more) 25 (52.1) 4 (22.3)
Enterotomy (concomitant procedure)
Planned (intestinal resection and hernia repair) 3 (6.2) 0 .001 5.32 (2.1–7.43) .001
Unplanned 3 (6.2) 0
(continued on next page)
J. Bueno-Lledó et al. Mesh infection and explantation after hernia repair
Table 3 (continued )
Mesh
explantation
Variables n 5 48
No 42 (87.5)
(Postoperative) surgical wound infection
Yes 21 (43.7)
No 27 (56.3)
Drain use
Yes 40 (83.3)
No 8 (16.7)
Statistically significant results are indicated in bold.
BMI 5 body mass index; CI 5 confidence interval; EHS class. 5 European Hernia Society classification; OR 5 odds ratio; PPL 5 polypropylene; PTFE 5
polytetrafluoroethylene; PVDF 5 polyvinylidene difluoride; SD 5 standard deviation.
explantation, in multivariate analysis. There was no associa-
tion among comorbidities, prosthesis size, or postoperative
surgical wound infection and subsequent explantation.
Comments
Infection of a mesh results in increased patient
morbidity because of secondary operations, impaired
wound healing, functional loss of the abdominal wall, and
significantly extended hospital stay.9 With the high use of
synthetic materials for hernia repair, the number of patients
who will suffer such infections is likely to increase. It is
because of this great morbidity that everything must be
done to prevent infection in these patients. Therefore, the
study of risk factors in the mesh infection and explantation
after AWHR is essential to try to minimize its impact.
In our cohort of patients followed for a median of
50.6 months, the overall mesh infection rate was 1.9%, and
of them, 72.7% underwent subsequent abdominal reopera-
tion and mesh explantation after AWHR. The literature
reports a very wide range of infection rates for AWHR from
.5% to 30%,3,10 and mesh explantation in cases of pros-
thetic infection after AWHR is common.11 The time frame
from hernia repair to mesh infection in our series was
10.3 months (range 1 to 29 months) and the interval be-
tween mesh infection and reoperation to mesh removal
was a median of 7.3 months (range 1 to 16 months). This
is in agreement with other authors, who have described
the onset of infection of the mesh with a striking delay of
up to 39 months after implantation, because of the
continuing presence of bacteria from the introduction dur-
ing surgery onward.12,13 In most cases, the bacteria are pro-
tected from the immune response of the host and antibiotics
by a biofilm.14
This biologic response to surgically implanted prosthetic
materials has been extensively studied.15 The initial reac-
tion, characterized by acute inflammatory cell infiltration,
is gradually replaced by fibroblasts (which infiltrate
through the interstices of porous meshes) and a variable
number of giant cells. The most important of these reasons
55
No mesh
explantation Multivariate
n 5 18 Univariate P OR (95% CI) Multivariate P
18 (100)
5 (27.7) .023 .09 (.12–1.95) .080
13 (72.3)
14 (77.7) .111 .65 (.23–1.12) .434
4 (22.3)
relates to the fibroblastic response of the organism to the
polymer of the implanted mesh, which results in the devel-
opment of a thick fibrous capsule surrounding the mesh.
Consequently, when an infection is established, this capsule
restricts the penetration of antimicrobial agents into the in-
fected mesh.16
Long-lasting infections on surgical meshes are consid-
ered as consisting of multiple different bacterial strains.6,17
Most of our infections (78.6%) involved gram-positive or-
ganisms, and S. aureus and MRSA were the most common
organism, which were found in 61.5%. This fact can sug-
gest that skin/deeper SSI was the root cause of some of
the mesh infections. This is in agreement with other re-
ported series in the literature that showed these organisms
as the predominant pathogen in incisional hernia mesh
infections.16,17 According to these findings, any patient
who presents a mesh infection after an AWHR should be
placed on an antibiotic with activity against MRSA and
gram positives.18 On the other hand, our data set showed
that 27% of infections were caused by gram-negative
organisms (mainly Enterobacteriaceae) and 24% were
polymicrobial. These data are higher than reported previ-
ously,9 possibly because of the frequent association of
abdominal surgery with enterotomy and AWHR in our
group: of the 54 patients operated jointly, 6 had mesh
infection (11.2%).
In our analysis, treatment with corticosteroids or immu-
nocompromised agents represents a predictor of mesh
infection but not explantation. This factor is important
because of significant incidence of incisional hernia repairs
after kidney, pancreatic, or hepatic transplantation.4 Her-
nias after abdominal organ transplantation are of particular
concern as patients are placed on immunosuppressive med-
ications postoperatively, which may increase the risk of in-
cisional hernia formation because of an associated
impairment in the wound healing process. In fact, to pro-
duce an overall reduction in the immune response, this
medication also facilitates the development of bacterial bio-
film, an essential factor in resistance of micro-organisms to
antibacterial mechanisms; bacteria secrete a sort of polymer
gel within which they become encased and which protects
56
them from antibacterial agents and is a source of persistent
or chronic infection.14
Our findings show that urgent repair and postoperative
SSI predispose mesh infection but not explantation. Other
studies identified that SSI was associated with mesh
infection and removal; however, postoperative outcomes
to predict mesh explantation are not clinically useful.7,19 A
distinction must be made between superficial wound infec-
tion and deep graft infection. In case of superficial infec-
tion, it occurs in the early postoperative period and do
not seem to be influenced by the use of mesh. Combination
of antibiotics (for cellulitis) and drainage (for subcutaneous
collection) may result effective, and in these circumstances,
removal of the prosthesis may not be necessary for com-
plete healing.6
Therefore, we show that mesh explantation after
prosthesis infection is significantly more likely after
repairs involving planned concomitant surgery on the
gastrointestinal tract than those using ePTFE-containing
mesh products or those with onlay repairs. Clinical studies
that have been published on infection rates of abdominal
wall implants demonstrate that the incidence of infection
depends heavily on the type of mesh and surgical
technique applied.6,7 According to our study, the type of
prosthesis does not affect the appearance of prosthetic
infection but influences the need of explantation. So,
ePTFE and dual meshes need complete removal to solve
the chronic infection, whereas 36% of polypropylene
(PPL) meshes does not require reoperation to remove
them.
PPL meshes show infection rates ranging from 2.0% to
4.2%.20,21 In contrast, ePTFE shows more wide-ranging
infection rates ranging from .5% to 9.2% when an open
surgical approach is used,22 and only up to 3% when
a laparoscopic approach is used.23,24 In our experience,
all meshes have the potential to become infected.
Although there is still not enough data in the literature
to suggest that one material is far superior to another, it
has reported that conservative treatment (drainage and
antimicrobial agents only) allowed mesh preservation in
most of polyester or PPL meshes but not in infected
ePTFE ones.2,5
The microporous surface of the ePTFE allows bacterial
contamination, but leukocytes cannot invade the 10-mm
pores.25 This fact may explain the pathophysiology of
chronic infections and later presentations that can be seen
with this mesh. An infected ePTFE patch should, therefore,
be removed early and the necessarily developing hernia
recurrence should be closed later.13 Like other series,5,6,26
our data showed that, except in one case, all contaminated
ePTFE patches had to be removed. So, AWHR with ePTFE
placed during an open repair were associated with a 3-fold
increase in the hazard of mesh explantation compared with
other variables.
Onlay mesh position is a predictive factor for mesh
explantation. Some authors have speculated that a reduction
in exposure to skin flora and the thickness of wound
The American Journal of Surgery, Vol 213, No 1, January 2017
coverage by muscle and fatty tissue protects against
infection.27 This is supported by the low infection rate after
hernia repair by the preperitoneal technique or laparoscopic
approach, from 0% to 3%.28 In our study, laparoscopy was
an exclusion criteria because we have no experience in this
procedure. We have made fewer than 30 cases during the
study period, and we believe that the results from this anal-
ysis would not be significant.
Several main approaches to the prevention of mesh
infection have been used; however, no definitive recom-
mendation can be made in favor of the use of prophylactic
antibiotics (systemic or topical) in hernia repair.29 As our
study, clinical routine still uses a single prophylactic dose
of systemic antibiotics at the moment of implantation
to prevent biomaterial-centered infections in the recov-
ering patient. Unfortunately, there is little direct clinical
evidence to base recommendations when implantable
mesh is used.30
Mesh coating has been a subject of research for a long
time. However, human studies on the efficacy of antibiotic-
coated mesh in the prevention of mesh infection would be
difficult to carry out as a large number of participants will
be required to demonstrate a statistically significant
result.31 Although our group did not use these materials,
the wound can be rinsed with an antibiotic-containing solu-
tion, starting immediately after the dissection of the hernia
sac. In randomized trials who underwent inguinal hernia
repair, there were no deep infections after the application
of a single dose of cefamandole directly to the wound32
or gentamicin placed on the mesh in vivo33 or in vitro.34
But at the present time, these measures are best reserved
for patients at high risk of infection, such as diabetic and
obese patients. A more recent study showed that diclofenac
and ibuprofen in the concentration obtained in vitro in the
serum limit the formation of biofilm by S. aureus and E.
coli35: the effect of isolates incubation in the medium
with nonsteroidal anti-inflammatory drugs was the decrease
of the number of bacteria adjacent to the PPL surface.
Finally, more important than the choice of antibacterial
is the observance of strict asepsis during mesh preparation
and implantation.30 In recent years, we have applied
preventive measures such as careful and meticulous surgi-
cal technique, avoiding bruises and dead spaces with suc-
tion drains, manipulating the prosthesis as little as
possible, avoiding direct contact between prosthesis and
the skin, changing gloves when inserting the prosthesis,
preventing foreign bodies, and monitoring the state of
the wound edges. It remains clear that bacterial contami-
nation of the prosthesis happens during its initial
implantation.7
In conclusion, infection has become one of the most
prevalent and challenging complications in AWHR. Steroid
or immunosuppressive drugs use, urgent repair, and devel-
opment of a postoperative SSI are predictive of mesh
infection. Risk factors of explantation are polytetrafluoro-
ethylene mesh, onlay mesh position, and associated enter-
otomy in the same procedure.
J. Bueno-Lledó et al. Mesh infection and explantation after hernia repair
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