The aim of this study was to report our experience on late mesh. ... to report our experience on late mesh infection occ...
Hernia (2007) 11:15–17 DOI 10.1007/s10029-006-0131-1
O RI G I NAL ART I C LE
Late-onset deep mesh infection after inguinal hernia repair S. Delikoukos · G. Tzovaras · P. Liakou · F. Mantzos · C. HatzitheoWlou
Received: 28 March 2006 / Accepted: 24 July 2006 / Published online: 29 August 2006 © Springer-Verlag 2006
Abstract Background Groin sepsis requiring mesh removal is said to be a rare complication of tension-free inguinal hernioplasty. Furthermore, late-onset deep-seated prosthetic infection seems to be an unexpected complication. The aim of this study was to report our experience on late mesh infection occurring years after open hernia repair. Methods Between 1998 and 2005, 1,452 patients (954 men), median age 64 years (range 19–89) underwent groin hernioplasty using a tension-free polypropylene mesh technique. Five patients (0.35%) appeared with late mesh infection (between 2 and 4.5 years postoperatively). The patients’ records were retrospectively reviewed for the purpose of this study. Antibiotic prophylaxis had been given in the Wve patients, while none of them had a prior history of wound infection. Results The patients were re-operated and the meshes were removed. Pus was found in three patients and Staphylococcus aureus was isolated in one. There was no hernia recurrence and none of the patients had chronic groin pain for a period of 6–44 months postoperatively. Conclusion From the results of this study, it appears that late-onset deep-seated prosthetic mesh infection is an important complication which has been rarely reported upon. Its true incidence is yet to be estab-
S. Delikoukos (&) · G. Tzovaras · P. Liakou · F. Mantzos · C. HatzitheoWlou Department of Surgery, Larissa University Hospital, 9 Papakiriazi Street, Larissa 41 223, Greece e-mail: [email protected]
lished. Late graft infection does not seem to correlate to neither the administration or not of antibiotic prophylaxis, nor to the presence or not of previous superWcial wound infection. Furthermore, graft infection does not seem to correlate to neither the type of mesh inserted, nor to the Wxation material. With the increasing use of synthetic materials for primary and recurrent hernia repair, the number of patients presenting with late mesh infections is likely to increase. Keywords Late mesh infection · Inguinal hernioplasty
Introduction Open tension-free hernioplasty using a prosthetic mesh is a common operation for inguinal hernia repair because of the relative ease of the procedure and low recurrence rate . Wound infection, a potential complication of hernia repair, if it happens, is usually encountered early postoperatively. On the other hand, deep-seated mesh infection is quite unusual and may result in groin sepsis . Mesh infection is usually encountered in the early postoperative period and may occur even if antibiotic prophylaxis has been given properly . Removal of the infected mesh is usually essential, and it would potentially result in weakness of the groin repair and subsequent hernia recurrence . Late-onset mesh infection, months or years postoperatively, is an extremely rare complication and results in chronic groin sepsis . We reviewed the outcome of Wve cases among 1,452 patients who underwent late mesh removal for sepsis, examining particularly for hernia recurrence and chronic groin pain.
Materials and methods Between 1988 and 2005, 1,452 patients (954 men), median age 64 years (range 19–89) underwent groin hernioplasty using various types of mesh. Five patients (0.35%) appeared with late mesh infection (between 2 and 4.5 years postoperatively). The patients’ records were retrospectively reviewed for the purpose of this study. The Wve patients had been operated under local anaesthesia (superWcial groin block using 10–15 ml of 2% lignocaine with adrenaline hydrochloride). Antibiotic prophylaxis (one dose of amoxicillin and clavulanic acid) had been given intravenously. The median operative time was 35 min (range 24–56 min). The patients were admitted for overnight observation, with the exception of one patient, who was hospitalised for two days due to associated medical disease (chronic heart failure). The postoperative period was uneventful. The Wve patients were in the usual follow-up (1 week and 1 month postoperatively), and they were asked to contact us if any problem concerning their operation occurred. Between 2 and 4.5 years postoperatively, however, three patients were presented with groin mass and two patients with signs of acute inXammation in the inguinal area. None of the patients had a prior history of wound infection, and no wound seemed to harbour long-term infections. At admission, the swellings were Wrm and painful, and the overlying skin was red in colour. Three patients were Wbril (37.8°–38.6°) and the white blood cell count was raised in four patients (13,000–16,500 l–1). Three of the patients underwent ultrasound and two computed tomography (CT) scan. Ultrasound showed large hypoechoic masses closely adhering to the small bowel. CT scan also showed masses in the inguinal areas.
Results The patients were re-operated through the same groin incision. The masses were opened and the meshes, which had become sequestered in necrotic tissue, were removed. Pus was found in three patients and was taken for microbiologic examinations, which were negative in two patients. Staphylococcus aureus was found in one patient. The immediate postoperative period was uneventful, except for serous discharge through the wound in one patient, which continued for 3 weeks. Samples of the meshes were processed for microbiologic examinations, which were negative. Late-onset mesh infection did not seem to correlate to neither to the type of mesh
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inserted, nor to the Wxation material used, (stitches or metallic clips). The patients were followed up for a median of 22 months (range 6–44 months) postoperatively. No hernia recurrence and/or chronic groin pain occurred.
Discussion Open tension-free hernioplasty using a prosthetic mesh is a common operation for inguinal hernia repair because of the relative ease of the operation and the low recurrence rate. Wound infection is a potential complication of hernia repair. It is usually encountered in the early postoperative period and is treated by a combination of antibiotics and wound drainage. On the other hand, deep-seated infection involving an inserted mesh may result in groin sepsis, which usually necessitates complete removal of the mesh to produce resolution . Fortunately, chronic groin sepsis requiring mesh removal is said to be a rare complication of tension-free inguinal hernioplasty . The use of antibiotic prophylaxis for the ‘clean’ operation of herniorrhaphy is currently a controversial issue, and its eVectiveness in reducing postoperative wound infection rates has not been proved. SanchezManuel et al.  presented a review of eight randomized clinical trials. In patients with antibiotic prophylaxis, the overall infection rates were 2.88% in hernioplasties using prosthetic materials, compared to 3.78% in patients with herniorrhaphies. In patients without antibiotic prophylaxis, the infection rates were 4.3% and 4.87%, respectively. Based on the results of this meta-analysis, there was no clear evidence that routine administration of antibiotic prophylaxis for elective inguinal hernia repair reduced the infection rate, even in patients with mesh insertion. Furthermore, the use of a foreign body for hernia repair does not appear to alter the incidence of superWcial wound infection, regardless of the administration of antibiotic prophylaxis or not . The biological response to surgically implanted prosthetic mesh materials has been extensively studied . The initial reaction, characterized by acute inXammatory cell inWltration, is gradually replaced by Wbroblasts and a variable number of giant cells [7, 8]. As with all inXammatory tissue, it is prone to the attachment of bacteria more frequently and rejection of the mesh is more likely . When considering bacterial invasion however, a distinction must be made between superWcial wound infection and deep graft infection. The former tend to occur in the early postoperative period it has been
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usually reported, and do not seem to be inXuenced by the use of a mesh . In fact, treatment of superWcial wound infection may be eVective using some combination of antibiotics and wound drainage. In these circumstances, removal of the prosthesis may not be necessary for complete healing . In contrast, deep graft infection has not been commonly reported in the literature. The presentation of deep-seated infection of the prosthesis is usually encountered early postoperatively. However, this complication may be delayed, occurring months or even years after operation . It seems that, usually, the only way to ensure the eradication of infection is to remove the mesh, although some meshes can be saved by judicious surgical treatment. In our patients however, it was impossible to save the meshes because infection plus local necrosis was present. Removal of the mesh may not necessarily result in recurring herniation if suYcient Wbrous scarring remains. In our study, the Wve patients were followed-up for a median of 22 months (range 6– 44 months) postoperatively. No recurrent herniation was found. Whether any relationship exists between early superWcial wound infection and late-onset deep graft infection is unclear. The time course of these rather diVerent infective complications suggests that, while early superWcial infection relates to operative contamination, late prosthetic infection may arise as a complication of a persisting Xuid collection . However, other factors, such as visceral injury, may alter the infection rate at the time of operation, or when the mesh is folded after the operation . In our series, mesh infection was presented between 1.5 and 4.5 years postoperatively. None of our patients had a prior history of wound infection. Staphylococcus aureus is the usual infecting organism in wound and graft infection, although enteric organisms may also be cultured [10, 11]. Staphylococcus aureus was found in one of our patients. In the other four patients, the cultures were negative. We suppose that aseptic local infection was present in these patients. A question arises as to whether mesh infection correlates with the choice of mesh inserted or the kind of Wxation material used. In our series, we used four diVerent types of mesh and we Wxed them either with
stitches or with metallic clips. It seems that mesh infection does not correlate with any special type of mesh or Wxation material as well. In conclusion, late-onset deep-seated graft infection is an important but, fortunately, rare complication following mesh repair for inguinal hernia. It does not appear to correlate to neither the administration or not of antibiotic prophylaxis, nor to the presence or not of previous superWcial wound infection. Furthermore, graft infection does not seem to correlate with the type of mesh or Wxation material. However, with the more widespread use of synthetic materials for primary and recurrent hernia repair, the number of patients presenting with such infections may become increasingly evident.
References 1. Fawole AS, Chaparala RP, Ambrose NS (2005) Fate of the inguinal hernia following removal of infected prosthetic mesh. Hernia 10(1):58–61 2. Taylor SG, O’Dwyer PJ (1999) Chronic groin sepsis following tension-free inguinal hernioplasty. Br J Surg 86(4):562–565 3. Sanchez-Manuel FJ, Seco-Gil JL (2004) Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev 18(4):CD003769 4. Stephenson BM (2003) Complications of open groin hernia repair. Surg Clin North Am 83(5):1255–1278 5. Mann DV, Prout J, Havranek E, Gould S, Darzi A (1998) Late-onset deep prosthetic infection following mesh repair of inguinal hernia. Am J Surg 176(1):12–14 6. Usher FC (1963) Hernia repair with knitted polypropylene mesh. Surg Gynecol Obstet 117:139–140 7. Arnaud JP, Eloy R, AdloV M, Grenier JF (1977) Critical evaluation of prosthetic materials in repair of abdominal wall hernias. Am J Surg 133(3):338–345 8. Bellon JM, Bujan I, Contreras L, Juranto F (1994) Macrophage response to experimental implantation of polypropylene prostheses. Eur Surg Res 26(1):46–53 9. Dougherty SH (1986) Implant infection. In: von Recum AF (ed) Handbook of biomaterials evaluation. Macmillan, New York, pp 276–289 10. Gilbert AI, Felton LL (1993) Infection of inguinal hernia repair considering biomaterials and antibiotics. Surg Gynecol Obstet 177(2):126–130 11. Bauer JJ, Salky BA, Gelernt IM, Kreel I (1987) Repair of large abdominal wall defects with expanded polytetraXuoroethylene (PTFE). Ann Surg 206(6):765–769 12. Foschi D, Corsi F, Cellerino P, Trabucchi A, Trabucchi E (1998) Late rejection of the mesh after laparoscopic hernia repair. Surg Endosc 12(5):455–457