Mesh Explantation Research Articles

Mesh infection in cases of polypropylene mesh hernioplasty.

Mesh hernioplasty is the most common surgery for hernia repair with Polypropylene mesh as the preferred one. But the use of synthetic prosthesis is associated with the inherited risk of developing a prosthetic infection that may manifest even after a very long time as subtle symptoms in the form of fever, myalgia, erythema of overlying skin and in some cases as chronic discharging sinus. With this in view a systematic prospective observational study has been carried out to estimate the incidence of mesh infections, to identify the type of associated organism and to study the outcome of the cases with hernioplasty using Propylene mesh. Mesh hernioplasty performed in all adult patients using propylene mesh exclusively on 161 males and 20 females were considered in this prospective observational study carried out for 3years (2016-2019) at tertiary care centre and teaching hospital in India. A standard size of the propylene mesh and well laid procedures were used for surgery as well as post operative care, identification and culture of microorganism. The patients were followed up to identify any symptoms of SSI or mesh infection. The entire data was statistically analyzed using Statistical Package for Social Sciences (SPSS ver 21.0, IBM Corporation, USA) for MS Windows. Out of 181 cases, the mesh contamination was observed in 59 cases while total cases of mesh infection were nine (09), which include 07 males and 02 females. The cases that developed infection were of mostly groin hernias. The cases commonly presenting with erythema, seroma and surgical wound dehiscence with identification of methicillin sensitive Staphylococcus aureus (MSSA) in the few samples of the wound discharge were managed conservatively and none of the cases had to undergo mesh explantation. Of the numerous factors viz. age, sex, associated co-morbidities, educational status, socio-economic status, duration of surgery and expertise of the operating surgeon, the two factors viz. duration of surgery and the mesh contamination were found to be associated with mesh infection in a statistically significant way. The incidence of mesh infection was observed in 4.97% of total 181 cases. To the best of knowledge, this seems to be the first prospective observational carried out in this country. Of the numerous factors studied, the duration of surgery and mesh contamination were the factors found to have statistical significance on the incidence of mesh infection. Although a clear picture to differentiate surgical site infection from acute mesh infection is yet to be obtained, the study provided better understanding of the management as no mesh explantation was required in either of the cases.

Effectiveness and Safety of Mesh Repair for Incarcerated or Strangulated Hernias: A Systematic Review and Meta-Analysis.

Hernia repair with mesh in patients with incarcerated or strangulated hernias is controversial. Moreover, the use of mesh for hernia repair with concomitant bowel resection poses a great dilemma. This study compared the outcomes of mesh and anatomic repairs in patients with acutely incarcerated or strangulated hernias. PubMed, Embase, and Cochrane databases were searched for studies published before November 2019. Randomized controlled trials (RCTs) and prospective studies were included. We conducted meta-analyses using a random-effects model. The treatment outcome was measured by the incidence of surgical site infection (SSI), seroma formation, and hernia recurrence postoperatively. Two RCTs and six prospective studies with 978 patients were included. No significant difference in SSI incidence was observed between patients with incarcerated hernia from the mesh and anatomic repair groups. Recurrence was significantly lower in mesh repair group than in anatomic repair group (odds ratio, 0.08; 95% confidence interval, 0.01-0.45). Only two patients needed to have mesh explantation due to mesh infection. In the setting of hernia repair with concomitant bowel resection, the SSI rate with mesh repair was slightly higher, but most cases of infections were well controlled with conservative antibiotic therapy. Mesh repair for incarcerated or strangulated hernias was feasible with a great benefit of lower recurrence rates. However, due to limited data, drawing conclusions regarding the use of mesh for hernia repair with concomitant bowel resection was difficult. Further studies with preset criteria for evaluating patients undergoing concomitant bowel resection may help elucidate this issue.

Internal herniation as a complication of tension-free vaginal tape implantation: A report of two cases

Tension-free vaginal tape (TVT) is often placed for stress urinary incontinence. A number of gastrointestinal complications following TVT placement have been previously described. Internal herniation through this pelvic mesh, however, has not yet been documented. Herein, we describe the presenting symptoms and operative management strategies of this rare complication. Two patients who presented to our institution were ultimately found to have internal herniation through TVT mesh and managed differently. Both patients presented complaining of unilateral sharp flank pain and were initially worked up for renal colic; computed tomography of the kidney, ureters, and bladder raised suspicion for small bowel obstruction. Both were taken to the theater. In one case, exploratory laparotomy revealed necrotic strangulated small bowel herniating through a defect in the TVT mesh. We performed small bowel resection and mesh explantation with postoperative return of urinary incontinence. In the other case, the hernia was reduced laparoscopically revealing noninfracted small bowel. The mesh defect was obliterated with interrupted sutures. Flank pain and symptoms of bowel obstruction with a history of TVT placement should prompt surgeons to consider internal herniation. The extent of ischemia and the need for small bowel resection are factors that should be considered when deciding whether to manage open or laparoscopically and whether to preserve or remove the mesh.

Hernia recurrence and infection rate in elective complex abdominal wall repair using biologic mesh

BackgroundElective complex ventral hernia repairs, done using synthetic mesh in patients with comorbidities, can result in mesh related complications such as hernia recurrence or infection. We studied hernia recurrence and surgical site occurrences after elective complex repairs in predominately clean cases using biologic mesh and examined the impact of several comorbidities.MethodsA retrospective chart review was completed on patients who underwent elective repair with biologic mesh in clean/clean-contaminated settings between 2012 and 2015 with a minimum of 1-year follow-up. Multiple comorbid conditions, including diabetes, chronic obstructive pulmonary disease, steroid use, smoking history and previous hernia repairs were identified. Post-operative complications including recurrence and infections were ruled out by computed tomography, clinical exam, and/or by telephone survey.Results40 patients were identified. 85% (n = 34) had class 1 wounds. 25% (n = 10) experienced a hernia recurrence. 10% (n = 4) of patients developed postoperative infection, none required mesh explantation or re-operation. No statistically significant association was found between the comorbidities assessed and recurrence/infection rates.ConclusionsWe present the first study analyzing clinical outcomes of complex ventral hernia repairs using biologic mesh in predominately clean settings. This study being non-comparative limits definitive conclusions, but our aim is to add to the growing literature on biologic mesh to help future researchers performing comparative trials of synthetic versus biologic meshes.

Laparoscopic ventral hernia repair with intraperitoneal onlay mesh-results from a general surgical unit.

Symptomatic ventral herniation is a common clinical presentation. The treatment, whether elective or as an emergency, can be difficult and a variety of surgical repairs are utilised. Intraperitoneal onlay mesh (IPOM) involves the placement of a reinforcing prosthesis, usually supported by primary closure of the defect. Intra-abdominal adhesions have been highlighted as a potential complication in utilising this form of mesh placement. Several methods of laparoscopic mesh placement outside of the peritoneal cavity are gaining prominence as potential alternatives to IPOM. This study reviews our experience with IPOM in the repair of ventral hernia by a single surgical team. A prospectively maintained electronic database of all laparoscopic ventral hernia repair (LVHR) performed within the study period was analysed and reported. Follow-up questionnaires were sent to patients to follow long-term outcomes. One hundred eight patients underwent LVHR over a 7-year period. Demographics demonstrated an obese patient group (BMI 30.89 ± 4.9kg/m2), with a variety of hernia sizes and morphologies. Hernia recurrence was found in two patients (1.8%). Twenty-nine (26.8%) patients suffered a complication, but only eight (7.4%) of those required intervention beyond pharmacotherapy. Two patients required mesh explantation. IPOM for the general surgeon is a relatively safe and effective method of repairing ventral hernias, with a low recurrence rate.

Indications and Outcomes of a Cross-Linked Porcine Dermal Collagen Mesh (Permacol) for Complex Abdominal Wall Reconstruction: A Multicenter Audit.

To reduce the occurrence of complications in the setting of high-risk patients with contaminated operative field, a wide range of biologic meshes has been developed. Yet, few series have reported outcomes after abdominal wall repair (AWR) using such meshes. Permacol is an acellular porcine dermal collagen matrix with a cross-linked pattern. This study reports short- and long-term outcomes after AWR for incisional hernia using Permacol. All consecutive patients undergoing single-stage open AWR using Permacol mesh at eight university hospitals were included. Mortality, complication and hernia recurrence rates were assessed. Independent risk factors for complications and hernia recurrence were identified with logistic regression and Fine and Gray analysis, respectively. Overall, 250 patients underwent single-stage AWR with Permacol. Nearly 80% had a VHWG grade 3 or 4 defect. In-hospital mortality and complication rates were 4.8% (n = 12) and 61.6% (n = 154), respectively. Reintervention for complications was required for 74 patients (29.6%). Mesh explantation rate was 4% (n = 10). Independent risk factors for complications were smoking, defect size and VHWG grade. After a mean follow-up time of 16.8months (± 18.1months), 63 (25.2%) experienced hernia recurrence. One-, 2- and 3-year RFS were 90%, 74% and 57%, respectively. Previous AWR, mesh location and the need for reintervention were independent predictors of hernia recurrence. Single-stage AWR is feasible using Permacol. Mortality and complication rates are high due to patients' comorbidities and the degree of contamination of the operative field. Given the observed recurrence rate, the benefit of biologics remains to be ascertained.

Infection and recurrence rates of the C-QUR V-Patch™ in ventral hernia repairs.

Ventral hernias are a common surgical issue and a myriad of surgical mesh designs has been developed for their treatment. Many of these new mesh designs have not been extensively tested and their complications rates are largely unknown. The C-QUR V-Patch Mesh™ combines a unique knit construction polypropylene mesh with an omega-3 fatty acid coating. There has only previously been one reported study investigating this mesh. A multicentre cohort study, with a single surgeon, of 168 consecutive patients with ventral hernias underwent repair using a standardized open pre-peritoneal approach with the novel C-QUR V-Patch Mesh™ between January 2013 and June 2015. A median follow-up of 37 months was completed to assess the patients for hernia infection and recurrence rates. Mesh infections were further classified into early and late infections for further subgroup analysis. Infection and recurrence rates of the C-QUR V-Patch® were compared with similar published results of alternate mesh designs. Surgical site infection rates were 7.7% and recurrence rates were 2.4%. The infection rate rose dramatically to 19.0% when the mesh was placed intra-peritoneally. The rate of mesh explantation was 2.4% and usually occurred between 4 and 12months post-operatively. Smoking was the only factor that appeared to be associated with recurrence. This series finds that recurrence rates associated with the novel C-QUR V-Patch Mesh™ is acceptably low; however, infection rates appear to be higher when compared to comparable products for use in ventral hernia repairs.

Survey of Surgeons Regarding Prophylactic Antibiotic Use in Inguinal Hernia Repair.

The use of prophylactic antibiotics in the mesh repair of inguinal hernias remains controversial. The aim of this study was to determine the perception of surgeons about surgical site infection and how this affects their clinical practice. A SurveyMonkey of general surgeons and senior surgical trainees was conducted via the local trust network and the questionnaire was displayed on the website of the Association of Surgeons of Great Britain and Ireland and Association of Surgeons in Training. Eighty-one responses were received from surgeons who perform an average of 75 hernia repairs per year - the majority by open technique. Thirty-six (44.4%) used routine antibiotic prophylaxis, 40 (49.4%) selectively, and five (6.2%) not at all as the five surgeons who did not use antibiotics perceived their surgical site infection rate to be <1% and have never removed an infected mesh from a hernia wound. There was no clear difference between those who use prophylactic antibiotics routinely or selectively as the experience of mesh explantation is similar (56% versus 55% had 2-10 meshes removed respectively). Seventy-seven (95%) of surgeons felt a new specific set of guidelines was required. This study highlights the fact that in the absence of clear guidelines, most surgeons base their use of prophylactic antibiotics on their perceived risk or experience of surgical site infection. There is a strong need for a new set of guidelines to address the use of prophylactic antibiotics in groin hernia surgery.

Patterns of Recurrence and Mechanisms of Failure after Open Ventral Hernia Repair with Mesh

Recurrence after ventral hernia repair (VHR) remains a significant complication. We sought to identify the technical aspects of VHR associated with recurrence. Patients who underwent open midline VHR between 2006 and 2013 (n = 261) were retrospectively evaluated. Patients with recurrence (Group 1, n = 48) were compared with those without recurrence (Group 2, n = 213). Smoking, diabetes, and body mass index were not different between groups. More patients in Group 1 underwent clean-contaminated, contaminated, or dirty procedures (43.8 vs 27.7%; P = 0.021). Group 1 had a higher incidence of surgical site occurrence (52.1 vs 32.9%; P = 0.020) and surgical site infection (43.8 vs 15.5%; P < 0.001). Recurrences were due to central mesh failure (CMF) (39.6%), midline recurrence after biologic or bioabsorbable mesh repair (18.8%), superior midline (16.7%), lateral (16.7%), and after mesh explantation (12.5%). Most CMF (78.9%) occurred with light-weight polypropylene (LWPP). Recurrence was higher if the midline fascia was unable to be closed. Recurrence with midweight polypropylene (MWPP) was lower than biologic (P < 0.001), bioabsorbable (P = 0.006), and light-weight polypropylene (P = 0.046) mesh. Fixation, component separation technique, and mesh position were not different between groups. Wound complications are associated with subsequent recurrence, whereas midweight polypropylene is associated with a lower overall risk of recurrence and, specifically, CMF.

Budget Impact Analysis Of P4HB VS Permanent Synthetic Meshes In Complex Abdominal Wall Repair In Spain

Despite advances in surgical technique and prosthetic technologies, the risks for recurrence and infection are high following the repair of incisional ventral hernias. The current standard for reinforced hernia repair is synthetic mesh, which may reduce the risk for recurrence in many patients. Patients with comorbidities, contaminated wounds or previous wound infections experience higher rates of surgical site occurrences/infections (SSO/SSI). Mesh choice in Complex Abdominal Wall Repair (CAWR) may have an impact on short and long-term patient outcomes. The aim of this study was to analyze the economic consequences of P4HB Mesh use versus Permanent Synthetic Meshes in CAWR, under the perspective of the Spanish National Health System A dynamic excel-based decision-analytic model was developed to assess the Budget Impact of P4HB Mesh in Complex Abdominal Wall Repair. For each comparator, variables of efficiency were set as Hernia Recurrence, Infected Mesh Explantation, Surgical Site Infection and Seroma. The analysis covered a 12 month time horizon and assumed 100% use for each technology. Public databases, as well as published and grey literature were used to estimate model input data. In the base case, a price difference of +1,500€ for P4HB mesh was considered. A tornado analysis was conducted for verification Compared to Permanent Synthetic meshes, use of P4HB mesh in CAWR resulted in cost savings of 364€ per procedure in Spain. The sensitivity analysis showed robust results for P4HB mesh, even in the most complex scenarios. Compared to Permanent Synthetic meshes, use of P4HB mesh may lead to potential cost savings in CAWR, under the perspective of the Spanish Health System. Further research is needed in order to better assess rates of clinical complications, as well as the appropriate patient groups where P4HB technology would be most beneficial for patients and health systems

Partial titanium mesh explantation cured post-cranioplasty implant-associated scalp infection

Titanium mesh cranioplasty is routinely used worldwide for skull defect patients given its advantages, such as stability and biocompatibility. However, there are very few reports concerning the treatment of implant-associated scalp infection, which is one of the most common complications. The aim of the study is to retrospectively evaluate a novel operation technique for the treatment of titanium mesh-associated scalp infection post-cranioplasty, namely partial titanium mesh explantation (PTME). A retrospective study was conducted in all patients who underwent surgical treatment for implant-associated scalp infection from January 2012 to September 2016 in our hospital. In total, 17 patients were selected for study analysis among 231 patients who underwent cranioplasty. The treatment success rate of PTME was 85.7%. There was no statistically significant difference in demographics and characteristics except for follow-up length of time between the PTME group and TTME (total titanium mesh explantation) group (Non-paired Student’s t-test, P=0.037). While, The PTME group exhibited a significantly reduced skull defect area post-operation compared with the TTME group (Non-paired Student’s t-test, P=0.002). Moreover, post-PTME skull area also exhibited a significantly reduced skull defect area compared with the pre-cranioplasty area in the same patient (Non-paired Student’s t-test, P=0.006). Compared with traditional surgical treatment of implant-associated scalp infection, PTME combined with strict debridement and antibiotic therapy can cure implant-associated scalp infection. Moreover, PTME could preserve sufficient titanium mesh for brain protection and cosmesis.

Hybrid fascial closure with laparoscopic mesh placement for ventral hernias: a single surgeon experience

Background: Incisional hernia and primary ventral hernia are among the most common surgical problems that general surgeons face annually in the United States (U.S.). Over 2 million laparotomies are performed in the US and the subsequent incisional hernia rate is 3–20%. At our institution, over the last several years, one surgeon has been performing a unique repair of intermediate-sized hernias by combining open and laparoscopic approaches. We hypothesized that, through a minimal incision, lysis of adhesions and primary repair can be performed, which can then be buttressed with a laparoscopically placed mesh that provides a generous underlay reinforcement that cannot be achieved in open repair. Furthermore, this technique provides the additional benefit of apposition of the rectus muscles and decreased seroma formation compared to laparoscopic hernia repair. Methods: Patients that underwent ventral hernia repair with laparoscopic assistance at NYU Lutheran Medical Center between October of 2012 and January 2015 form this study population. Each patient’s demographic, intra-operative, and postoperative data were collected and analyzed. Patient demographics included gender, age, BMI, prior abdominal surgery, co morbidities, and anticoagulation use. Intra-operative data included defect size, mesh size, and operative time. Postoperative data included complications, length of hospitalization, re-currences, seroma formation, surgical site infections (SSI), and mesh explantation. The surgical technique was as follows: a minimal incision was used over the defect which was only big enough to allow dissection down to the hernia borders. The hernia was reduced and lysis of adhesions of surrounding tissue performed. The hernia was sized and a mesh chosen to provide at least 3 to 5 cm of underlay around the defect. A series of one to four stay sutures were placed in the midline of the mesh and the mesh was placed intra-corporeally. The defect was closed primarily using the Smead-Jones technique (in 17 of 19 patients) to provide a tension-free double layer closure. The abdomen was in-sufflated, the mesh visualized, fixed to the midline via the stay sutures, and tacked circumferentially. The subcutaneous tissue and the skin were closed with absorbable suture. Results: A total of 19 patients (12 females, 7 males) underwent the hybrid hernia repair from October 2012 through January 2015. Only 1 (5%) was admitted postoperatively due to severe underlying co morbidities. The average size of the hernia defect was 5.94 cm 2 (2.5–15 cm 2 ) with an average mesh size of 16×16 cm 2 (9×9–25×20 cm 2 ) being used. Average operative time was 153 minutes with a range of 69–281 minutes. One (5%) had an early (within the first three months post-surgery) recurrence of the hernia. One patient (5%) had an early superficial SSI noticed during the 1 week follow-up appointment and was treated with oral antibiotics. None of the patients required re-hospitalization. None of the patients developed any seroma or any deep tissue infections requiring mesh explantation. Fourteen (74%) of the 19 patients were reached via telephone for further follow-up. All 14 patients were satisfied with the results of their surgery with only 1 complaint of pre-existing gastritis unrelated to the surgery. All of the patients that were employed prior to the surgery were able to return to work post-operatively. None of the patients reported any residual incisional or back pain. Conclusions: Hybrid ventral hernia repair has the physiological benefit of fascial continuity by re-approximating the hernia edges. This technique also maximizes the benefit of laparoscopic repair while mini-mizing associated complications. Patients had no severe wound complications. This surgical technique resulted in a low recurrence rate, and minimal pain after the procedure, making the hybrid technique a safe alternative method when repairing intermediate sized ventral hernias.

Negative Pressure Wound Therapy for Treatment of Mesh Infection After Abdominal Surgery: Long-Term Results and Patient-Reported Outcome.

Treatment of synthetic mesh infections has previously often resulted in mesh explantation. Negative pressure wound therapy has been used in these situations with encouraging results. The aims of this study were to evaluate wound healing, mesh preservation, and patient-reported outcome after negative pressure wound therapy of mesh infections. Medical records of patients treated with negative pressure wound therapy for mesh infection and age-matched mesh-operated controls without postoperative complications were scrutinized in a retrospective study. An abdominal wall complaints questionnaire was used to evaluate patient-reported outcome. Of 722 mesh operations performed 2005-2012, negative pressure wound therapy was used for treating postoperative mesh infections in 48 patients. A total of 48 age-matched controls were recruited from patients without wound complications. No differences were found between groups regarding preoperative characteristics. The following peroperative characteristics were significantly more frequent in the negative pressure wound therapy group: emergency operation, dirty/infected surgical field, surgical techniques other than laparoscopic intraperitoneal onlay mesh repair, implantation of more than one mesh, larger mesh size, longer duration of surgery, and mesh not completely covered with anterior rectus fascia. The entire mesh was salvaged in 92%, while four meshes were partly excised. Wounds healed in 88% after a median of 110 (range 3-649) days. In total, 85% in the negative pressure wound therapy group and 75% in the control group answered the questionnaire. There were no significant differences regarding pain, other abdominal wall symptoms, and satisfaction with the final result in favor of the controls. No mesh had to be explanted and wound healing was achieved in the majority of patients when negative pressure wound therapy was used for treatment of mesh infections. However, time to healing was long, and numerous procedures were sometimes needed. Positive long-term outcome was more frequently reported among controls.

Hybrid fascial closure with laparoscopic mesh placement for ventral hernias: a single surgeon experience

Background: Incisional hernia and primary ventral hernia are among the most common surgical problems that general surgeons face annually in the United States (U.S.). Over 2 million laparotomies are performed in the US and the subsequent incisional hernia rate is 3–20%. At our institution, over the last several years, one surgeon has been performing a unique repair of intermediate-sized hernias by combining open and laparoscopic approaches. We hypothesized that, through a minimal incision, lysis of adhesions and primary repair can be performed, which can then be buttressed with a laparoscopically placed mesh that provides a generous underlay reinforcement that cannot be achieved in open repair. Furthermore, this technique provides the additional benefit of apposition of the rectus muscles and decreased seroma formation compared to laparoscopic hernia repair. Methods: Patients that underwent ventral hernia repair with laparoscopic assistance at NYU Lutheran Medical Center between October of 2012 and January 2015 form this study population. Each patient’s demographic, intra-operative, and postoperative data were collected and analyzed. Patient demographics included gender, age, BMI, prior abdominal surgery, co morbidities, and anticoagulation use. Intra-operative data included defect size, mesh size, and operative time. Postoperative data included complications, length of hospitalization, re-currences, seroma formation, surgical site infections (SSI), and mesh explantation. The surgical technique was as follows: a minimal incision was used over the defect which was only big enough to allow dissection down to the hernia borders. The hernia was reduced and lysis of adhesions of surrounding tissue performed. The hernia was sized and a mesh chosen to provide at least 3 to 5 cm of underlay around the defect. A series of one to four stay sutures were placed in the midline of the mesh and the mesh was placed intra-corporeally. The defect was closed primarily using the Smead-Jones technique (in 17 of 19 patients) to provide a tension-free double layer closure. The abdomen was in-sufflated, the mesh visualized, fixed to the midline via the stay sutures, and tacked circumferentially. The subcutaneous tissue and the skin were closed with absorbable suture. Results: A total of 19 patients (12 females, 7 males) underwent the hybrid hernia repair from October 2012 through January 2015. Only 1 (5%) was admitted postoperatively due to severe underlying co morbidities. The average size of the hernia defect was 5.94 cm 2 (2.5–15 cm 2 ) with an average mesh size of 16×16 cm 2 (9×9–25×20 cm 2 ) being used. Average operative time was 153 minutes with a range of 69–281 minutes. One (5%) had an early (within the first three months post-surgery) recurrence of the hernia. One patient (5%) had an early superficial SSI noticed during the 1 week follow-up appointment and was treated with oral antibiotics. None of the patients required re-hospitalization. None of the patients developed any seroma or any deep tissue infections requiring mesh explantation. Fourteen (74%) of the 19 patients were reached via telephone for further follow-up. All 14 patients were satisfied with the results of their surgery with only 1 complaint of pre-existing gastritis unrelated to the surgery. All of the patients that were employed prior to the surgery were able to return to work post-operatively. None of the patients reported any residual incisional or back pain. Conclusions: Hybrid ventral hernia repair has the physiological benefit of fascial continuity by re-approximating the hernia edges. This technique also maximizes the benefit of laparoscopic repair while mini-mizing associated complications. Patients had no severe wound complications. This surgical technique resulted in a low recurrence rate, and minimal pain after the procedure, making the hybrid technique a safe alternative method when repairing intermediate sized ventral hernias.

62: Complete midurethral sling removal: An analysis of mesh explantation by length

Mesh removal is an option for the management of complications arising from synthetic mesh placement for stress urinary incontinence (SUI). Definitions of “complete” versus “partial” removal of midurethral sling mesh vary. Using an objective measurement to define these terms could help physicians to better study mesh removal. To date, it has not yet been described how much mesh by length is explanted during complete retropubic (RP) and transobturator (TO) sling removals. The objective of this study was to determine the median length of midurethral slings, both RP and TO, that is explanted during complete removal of sling mesh. Following IRB approval, a retrospective chart review of a referral urogynecology practice was performed from January 2015 to December 2015 by CPT code 57287 (sling revision/removal). Complete removal of a RP sling was defined as excision of the vaginal portion as well as the retropubic arms coursing through the retropubic space, rectus abdominus, and subcutaneous tissues. Complete removal of a TO sling was defined as excision of the vaginal portion as well as the lateral arms coursing through the obturator/adductor muscles. Inclusion criteria included patients who had a prior RP or TO sling and underwent a complete sling removal with no prior history of sling excision. Single-incision slings and those with incomplete or unclear pathology reports were excluded. Mesh length in centimeters (cm) was collected and analyzed descriptively. A subanalysis was also performed comparing patient body mass index (BMI) by World Health Organization classification to explant length using a Mann-Whitney U test. Of the 114 patients undergoing complete sling removal, there were 55 sling explants included in the analysis. The median length of the complete RP mesh explants (n = 23) was 25.5 cm (15.4-35.2 cm). The median length of the complete TO mesh explants (n = 32) was 18.4 cm (12.8-29.2 cm). Patients with a normal BMI had a significantly smaller RP explant length (median = 23.3 cm) than obese patients (median = 29.0 cm), U = 13, p = 0.049. However, TO explant length was similar in patients with a normal BMI and those classified as obese (median: 18.2 cm vs 18.8 cm, respectively), U = 26, p = 0.98. This is the first series to describe the length of mesh explant based upon pathology after complete sling removal. Our study identified a wide range of mesh lengths in both RP and TO explantation. The lack of uniformity of sling length between patients complicates the preoperative prediction of an individual patient's suspected mesh length. Furthermore, for patients presenting with a history of sling revision, simply knowing the length of mesh previously excised does not provide the surgeon with enough information to estimate the amount of mesh remaining in vivo. Therefore, surgeons need to obtain both pathologic reports and detailed operative report description of previous mesh excisions to make an accurate prediction of the amount of mesh remaining in the patient. While our findings indicate a relationship between BMI and length of RP sling explanted, further study into other specific patient characteristics, which could affect mesh length, may be helpful.

Complex abdominal wall defect repair using biologic porcine matrix.

The management of patients with complex abdominal wall defect (CAWD) is challenging, and requires appropriate surgical planning, and intensive patient preparation in order to minimize postoperative complications. The aim of this work was to review the management of CAWD using one-stage repair with biologic mesh. We retrospectively reviewed patients with CAWD having undergone repair with biologic mesh between January 2013 and October 2014. Demographics, preoperative assessment, intraoperative management and postoperative outcomes were assessed. A total of 15 patients were included. Biologic mesh was used for hernia repair with primary fascial closure (N.=12) or for bridging of the abdominal wall defect (N.=3). Seven patients presented postoperative complications Clavien-Dindo grade ≥3, and among them six required reoperation but no one required the mesh explantation. After a follow-up period of 12 months, four patients presented hernia recurrence and two required a later surgery. The use of biologic mesh allows single-stage repair of complex abdominal wall defects. The procedure involves significant postoperative morbidity, and requires intensive preoperative multidisciplinary preparation.

Partial versus complete removal of the infected mesh after abdominal wall hernia repair

BackgroundTo compare the results with complete mesh removal (CMR) versus partial mesh removal (PMR) in the treatment of mesh infection after abdominal wall hernia repair (AWHR). MethodsRetrospective review of all patients who underwent surgery for mesh infection between January 2004 and May 2014 at a tertiary center. ResultsOf 3470 cases of AWHR, we reported 66 cases (1.9%) of mesh infection, and 48 repairs (72.7%) required mesh explantation. CMR was achieved on 38 occasions, while PMR was undertaken ten times. We observed more postoperative complications in CMR than PMR group (p = 0.04). Three patients with intestinal fistula were reoperated in postoperative period after a difficult mesh removal; one of them died due to multiple organ failure. The overall recurrence rate after explantation was 47.9%: recurrence was more frequent in CMR group (p = 0.001), although persistent or new mesh infection was observed more frequently with PMR (p = 0.001). ConclusionsAlthough PMR has less postoperative morbidity, shorter duration of hospitalization and lower rate of recurrence than CMR, prosthetic infection persists in up to 50% of cases.

Hidden Morbidity of Ventral Hernia Repair with Mesh: As Concerning as Common Bile Duct Injury?

Ventral hernia repair with mesh is increasingly common, but the incidence of long-term complications that necessitate mesh explantation is unknown. We aimed to determine the epidemiology of mesh explantation after ventral hernia repair and to compare this with common bile duct injury, a dreaded complication of laparoscopic cholecystectomy. We evaluated a retrospective cohort of patients undergoing ventral hernia repair by linking the all-payers State Inpatient Databases and State Ambulatory Surgery Databases for New York, California, and Florida. We followed patients longitudinally from 2005 to 2011 for the primary end point of mesh explantation, designated by concurrent procedure codes for ventral hernia repair and foreign body removal. We determined time to mesh explantation and calculated cumulative costs for surgical care, comparing these with historical data for common bile duct injury. During the study period, 619,751 patients underwent at least one ventral hernia repair (91%open, 9% laparoscopic). In a mean follow-up of 3 years, 438 patients (0.07%) had mesh removed at a median of 346 days after repair. Median cumulative cost for patients requiring mesh explantation was $21,889 vs $6,983 without (p < 0.01). Rates of mesh explantation and costs were on par with laparoscopic common bile duct injury, based on published data, but occurred later in the postoperative course. By this conservative estimate, complications of ventral hernia repair with implantable mesh are comparably as frequent as for common bile duct injury, but occur later in a patient's experience. Long-term follow-up is critically necessary to fully understand the ramifications ofimplanted devices.

Predictors of mesh infection and explantation after abdominal wall hernia repair

BackgroundThe main objective was to identify predictive factors associated with prosthesis infection and mesh explantation after abdominal wall hernia repair (AWHR). MethodsThis is a retrospective review of all patients who underwent AWHR from January 2004 to May 2014 at a tertiary center. Multivariate analysis identified predictors of mesh infection and explantation after AWHR. ResultsFrom 3,470 cases of AWHR, we reported 66 cases (1.9%) of mesh infection, and 48 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 postoperative 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). ConclusionsImmunosuppressive drugs use, urgent repair, and postoperative surgical site infection are predictive of mesh infection. Risk factors of prosthesis explantation are polytetrafluoroethylene mesh, onlay mesh position, and associated enterotomy in the same procedure.

Outcomes of Posterior Component Separation With Transversus Abdominis Muscle Release and Synthetic Mesh Sublay Reinforcement.

To evaluate the safety and efficacy of transversus abdominis muscle release (TAR) with retrorectus synthetic mesh reinforcement in a large series of complex hernia patients. Posterior component separation via TAR during abdominal wall reconstruction (AWR) continues to gain popularity. Although our early experience with TAR has been promising, long-term outcomes have not been reported. From December 2006 to December 2014, consecutive patients undergoing open AWR utilizing TAR were identified in our prospectively maintained database and reviewed retrospectively. Main outcome measures included demographics, perioperative details, wound complications, and recurrences. During the study period, 428 consecutive TAR procedures were analyzed. Mean age was 58, with mean body mass index 34.4 kg/m (range 20-65). Major comorbidities included diabetes (21%), chronic obstructive pulmonary disease (12%), and immunosuppression (3%). Mean hernia defect area was 606 cm (range 180-1280) and average mesh size was 1220 cm (range 600-4500). The majority of cases (66%) were clean, 26% were clean-contaminated, and 8% were contaminated. Eighty (18.7%) surgical-site events occurred, of which 39 (9.1%) were surgical-site infections. Three patients required mesh debridement; however, no instances of mesh explantation occurred. Of the 347 (81%) patients with at least 1-year follow-up (mean 31.5 mo), there were 13 (3.7%) recurrences. Complex AWR represents a formidable surgical challenge. In this large series, we demonstrated that posterior component separation via TAR with wide synthetic mesh sublay provides a very durable repair with low morbidity, even in comorbid patients with large defects. We strongly advocate TAR as a robust addition to the armamentarium of reconstructive surgeons.