Events, care, and outcomes after hernia mesh explantation for infection.

BACKGROUND: Mesh explantation for infection after hernia surgery sets a cascade of events that has not been previously described. The purpose of this study is to review the care of these patients and outcomes. METHODS: We obtained data on all Veterans Health Administration enrollees undergoing hernia repair during 2008-2015. All mesh explantation cases were identified and manually reviewed through December 2020 to identify surgical site occurrences, re-repairs, and subsequent explantations. RESULTS: We identified 332 index explantations due to infection. A first subsequent repair was performed in 82.5% (274/332); a second repair in 18.2% (50/274); a third repair in 16.0% (8/50); and a fourth repair in 25% (2/8). Overall recurrence rate over a 12 year-period was 160/332 (48.1%). CONCLUSIONS: Mesh explantation due to infection sets a cascade of complications and hernia recurrences necessitating re-operation. Complications resulting from mesh explantation suggest that resolution of the initial abdominal wall infection is crucial to prevent future mesh infections.

Risk of Hernia Mesh Explantation following Early Versus Late Onset Skin and Soft Tissue Infection.

To estimate the relative risk of explantation in patients with skin and soft tissue infection onset within 90 days of hernia surgery, compared with days 91-365 and after 1 year. BACKGROUND: Infectious complications occurring after hernia repair with synthetic mesh require prolonged treatment, and eventual mesh explantation. Little is known whether early versus late onset infection is associated with differential risk of mesh removal, and whether treatment with long-term antibiotics or debridement are associated with mesh salvage. METHODS: This was a retrospective observational cohort study. We obtained data on all inguinal, umbilical, and ventral hernia repairs with implanted synthetic mesh performed in Veterans Affairs hospitals during 2008-2015. Participants without a 5-year infection after hernia surgery were excluded. Logistic regression estimated the association of mesh explantation with exposure to mesh-related infection during postoperative days 0-90, versus days 91-365 versus after 1 year. Additional covariates included any subsequent abdominal operation, antibiotic administration, and incision and drainage (I&D) or debridement procedures. RESULTS: One thousand eight hundred eighty-five patients underwent index hernia repair and developed a skin and soft tissue infection within 5 years. Infection onset during days 91-365 was associated with increased explantation risk (OR, 1.62; 95% CI, 1.04-2.48), as was increased antibiotic use (OR, 1.04; 95% CI, 1.03-1.05) and surgical treatments (OR, 3.74; 95% CI, 3.02-4.67). Subsequent abdominal operation was associated with lower explantation risk (OR, 0.46; 95% CI, 0.33-0.61). CONCLUSIONS: Early infections may be more suitable for conservative management. Later-onset infections have lower probability of mesh salvage and should be considered for earlier explantation to save the patients prolonged courses of antibiotics and surgical interventions.

Re-Infection after Explantation of Infected Hernia Mesh: Are the Same Micro-Organisms Involved?

Background: It is unclear if a history of mesh explantation for infection is predictive of future microbiology after subsequent hernia operations. We investigated how often the same causative organism is cultured in the initial explantation and subsequent repairs. Patients and Methods: We obtained data on patients undergoing ventral/incisional, umbilical, and inguinal hernia repairs from the Veterans Affairs Surgical Quality Improvement Program during 2008-2015. Manual review was performed for all patients with an administrative code indicative of mesh explantation and those with explantation for infection were retained. We then obtained data on cultured organisms from the mesh site at the time of index explantation and at any re-repair or subsequent explantation during a follow-up period ending in December 2020. Results: We identified 332 patients undergoing mesh explantation because of infection (64.8% ventral, 18.7% umbilical, 16.6% inguinal). Mean age was 60.3 years (standard deviation [SD], 9.7) and 93.9% were male. The same organism was cultured at re-infection in 23 of 59 (39%) cases. Gram-positive micro-organisms were the most prevalent in 20 of 23 (87%). Among the gram-positive, Staphylococcus aureus was the most common pathogen and was cultured in 18 of 20 (90%) cases, of which 14 of 18 (77.8%) were methicillin-susceptible Staphylococcus aureus (MSSA) and 4 of 18 (22.2%) were methicillin-resistant Staphylococcus aureus (MRSA). Three of 23 (13%) gram-negative organisms were the same at both re-infection and index explantation consisting of Escherichia coli in 2 of 3 (66.7%), and Pseudomonas aeruginosa in one of three (33.3%). Conclusions: Identification of organisms at time of prosthetic infection is helpful not only in treating the initial infection, but also in prevention of infection with the same organisms after subsequent repairs. Same organism re-infection should not be underestimated, particularly when Staphylococcus aureus is isolated.

Incidence and Risk Factors for Long-Term Mesh Explantation Due to Infection in More than 100,000 Hernia Operation Patients.

BACKGROUND: Infectious complications after hernia operation are potentially disastrous, often requiring long-term antibiotic administration, debridement, and mesh explantation. Our objective was to describe the long-term incidence and risk factors for synthetic mesh explantation due to infection after hernia operation in a large cohort. STUDY DESIGN: Retrospective database study using Veterans Affairs Surgical Quality Improvement Program and chart review of veterans undergoing abdominal or groin hernia repair with synthetic mesh implantation during 2008-2015. The main outcome was mesh explantation due to infection within 5 years. RESULTS: The study population consisted of 103,869 hernia operations, of which 74.3% were inguinal, 10.7% umbilical, and 15.0% ventral. Explantation incidence was highest among ventral (1.5%). Median explantation interval overall was 208 days. In multivariable logistic regression, all obesity levels from pre-obesity to obesity class III were associated with higher explantation risk. American Society of Anesthesiology physical status classification of 3 to 5 was associated with odds ratio (OR) of 1.7 (95% CI, 1.28 to 2.26), as was longer operative duration (OR 1.83; 95% CI, 1.51 to 2.21), and contaminated or dirty surgical wound classification (OR 2.27; 95% CI, 1.11 to 4.64). Umbilical repair (OR 6.11; 95% CI, 4.14 to 9.02) and ventral repair (OR 14.35; 95% CI, 10.39 to 19.82) were associated with higher risk compared with inguinal. Open repair was associated with a higher risk compared with laparoscopic (OR 3.57; 95% CI, 2.52 to 5.05). Deep incisional surgical site infection within 30 days of operation was more likely to result in long-term mesh explantation (29.2%) than either superficial (6.4%) or organ space infection (22.4%). CONCLUSIONS: Mesh explantation for infection is most common after ventral hernia repair. Risk factor optimization is crucial to minimize such an end point.