Overview
Definition:
Infected mesh explant refers to the surgical removal of a prosthetic mesh that has become infected, often following procedures like hernia repair, abdominal wall reconstruction, or breast reconstruction
Reconstruction may be necessary to restore structural integrity and function.
Epidemiology:
Mesh infections are a significant complication, with reported rates varying from 1% to 5% for inguinal hernia repairs and higher for complex abdominal wall reconstructions
Factors like mesh type, surgical technique, patient comorbidities, and perioperative antibiotic use influence incidence.
Clinical Significance:
Mesh infections can lead to significant morbidity, including chronic pain, recurrent hernias, enterocutaneous fistulas, sepsis, and abdominal wall defects requiring complex reconstruction
Early diagnosis and management are crucial to prevent severe outcomes and optimize patient recovery.
Clinical Presentation
Symptoms:
Increasing incisional pain and tenderness at the mesh site
Redness, warmth, and swelling of the overlying skin
Purulent wound discharge
Fever and chills
Possible systemic signs of infection such as malaise and anorexia
Development of a palpable fluctuant collection
In late stages, recurrent hernia symptoms or bowel obstruction may occur.
Signs:
Erythema and edema of the surgical wound
Tenderness to palpation over the mesh area
Purulent drainage from the incision
Boggy or fluctuant mass in the operative site
Palpable mesh remnants
Signs of sepsis: tachycardia, hypotension, tachypnea, fever.
Diagnostic Criteria:
Diagnosis is primarily clinical, supported by imaging and laboratory findings
Criteria often include: 1
Presence of local signs of infection (erythema, warmth, tenderness, discharge) at the mesh site
2
Systemic signs of infection (fever, elevated WBC)
3
Imaging evidence of mesh infection or fluid collection
4
Positive microbiological culture from wound drainage or explanted mesh.
Diagnostic Approach
History Taking:
Detailed history of the index surgery (type of mesh, procedure, complications)
Onset and progression of symptoms
Presence of fever, chills, or systemic illness
Previous antibiotic use
Comorbidities such as diabetes, immunosuppression, obesity, or smoking
History of recurrent infections or wound healing issues.
Physical Examination:
Thorough examination of the abdominal wall or surgical site
Assess for erythema, warmth, edema, induration, and tenderness
Palpate for any fluctuant collections or sinus tracts
Evaluate the integrity of the abdominal wall and check for signs of hernia recurrence
Examine for signs of sepsis.
Investigations:
Complete Blood Count (CBC) with differential to assess for leukocytosis
C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR) for inflammatory markers
Blood cultures if sepsis is suspected
Wound culture and sensitivity of any purulent drainage
Imaging: Ultrasound can detect fluid collections
CT scan of the abdomen/pelvis is essential to delineate the extent of infection, identify abscesses, assess mesh involvement, and detect potential fistulas or bowel complications
MRI may provide more detailed soft tissue characterization.
Differential Diagnosis:
Seroma formation without infection
Wound dehiscence without infection
Abscess unrelated to mesh
Cellulitis of the abdominal wall
Recurrent hernia
Enterocutaneous fistula from other causes
Postoperative hematoma.
Management
Initial Management:
Prompt broad-spectrum intravenous antibiotics covering common Gram-positive and Gram-negative organisms, and anaerobes
Analgesia and antipyretics
Wound care: sterile dressing changes
Consultation with surgery department for urgent assessment.
Medical Management:
Antibiotic therapy should be guided by culture and sensitivity results
For established infection, parenteral antibiotics are typically required for at least 2-6 weeks, potentially longer based on clinical response and extent of infection
Long-term oral suppressive antibiotics may be considered in select cases or while awaiting definitive reconstruction.
Surgical Management:
Surgical explantation of the infected mesh is the definitive treatment
This involves debridement of all necrotic tissue, pus, and infected mesh material
The approach can be open or laparoscopic, depending on the extent of infection and surgeon expertise
Once the mesh is removed, thorough irrigation and drainage of the wound are critical
Reconstruction of the abdominal wall defect is often required, using autologous tissue (e.g., rectus abdominis flaps) or synthetic grafts in a non-infected field at a later stage
Primary closure of the defect or staged reconstruction may be performed.
Supportive Care:
Nutritional support to promote healing
Close monitoring of vital signs and laboratory parameters
Strict wound care and dressing protocols
Management of comorbidities
Pain management
Patient education regarding wound care and signs of recurrence.
Complications
Early Complications:
Wound dehiscence
Abscess recurrence
Sepsis
Hemorrhage
Injury to adjacent organs (bowel, bladder, major vessels) during explantation
Pneumothorax if laparoscopic approach used without proper precautions.
Late Complications:
Chronic wound drainage
Enterocutaneous fistula formation
Incisional hernia recurrence
Chronic pain syndrome
Adhesion formation
Formation of enterocutaneous fistula
Scarring and cosmetic deformities
Need for further reconstructive surgeries.
Prevention Strategies:
Meticulous aseptic technique during mesh implantation
Judicious use of mesh, especially in contaminated fields
Appropriate perioperative antibiotic prophylaxis
Patient optimization (smoking cessation, diabetes control)
Early recognition and management of wound complications
Use of biologic meshes or alternative techniques in high-risk patients
Minimizing mesh surface area and ensuring adequate tissue coverage.
Prognosis
Factors Affecting Prognosis:
Extent of infection
Presence of systemic sepsis
Comorbidities of the patient
The ability to achieve complete debridement of infected material
The success of subsequent reconstruction
Timing of intervention
Virulence of the infecting organism.
Outcomes:
With timely and aggressive management (explantation and antibiotics), outcomes can be favorable, leading to resolution of infection
However, recurrence of hernia is common if reconstruction is inadequate or delayed
Chronic pain and functional deficits can persist
Complete recovery may require multiple surgical interventions
Morbidity and mortality are significantly higher in patients with sepsis or delayed treatment.
Follow Up:
Regular follow-up is essential, typically for several months to a year or more
This involves serial clinical examinations to monitor for signs of recurrent infection, hernia recurrence, or wound healing issues
Imaging (ultrasound, CT) may be performed periodically to assess the reconstructed area and rule out complications
Patients should be educated on self-monitoring for warning signs.
Key Points
Exam Focus:
Infected mesh explantation is a common complication after hernia repair and abdominal wall reconstruction
CT scan is the gold standard for diagnosis
The mainstay of treatment is surgical removal of the mesh and antibiotics
Reconstruction is often staged and uses autologous tissue
Early recognition and management are key to reducing morbidity.
Clinical Pearls:
Always consider mesh infection in patients with persistent or worsening wound pain, discharge, or fever post-mesh implantation
Thorough debridement is paramount during explantation
leave no residual foreign material
Consider a staged approach for reconstruction, allowing the infected field to fully resolve before reimplanting synthetic material
Autologous tissue reconstruction is preferred for definitive closure in infected fields.
Common Mistakes:
Delaying surgical explantation in favor of prolonged antibiotics alone
Inadequate debridement of all infected mesh and tissue
Attempting primary reconstruction with synthetic material in a recently infected field
Underestimating the extent of infection
Not considering bowel involvement or fistula formation.