Can polypropylene mesh be used for hernia repair after resection and primary anastomosis of necrotic jejunum?

Polypropylene Mesh Use After Resection and Primary Anastomosis of Necrotic Jejunum

Polypropylene mesh can be safely used for hernia repair after resection and primary anastomosis of necrotic jejunum, as the presence of non-viable intestine is not a contraindication for prosthetic repair. 1, 2

Decision Algorithm Based on Contamination Level and Defect Size

• For small defects (<3 cm) in contaminated fields (CDC wound class III) with bowel necrosis and/or gross enteric spillage, primary repair without mesh is recommended 1, 2
• For larger defects (≥3 cm) in contaminated fields:
  • Biological mesh is the preferred option when available 1, 2
  • If biological mesh is not available, polyglactin mesh or open wound management with delayed repair may be viable alternatives 1
• In clean-contaminated fields (CDC wound class II) or contaminated fields without gross spillage, polypropylene mesh can be safely used 1, 2, 3

Evidence Supporting Polypropylene Mesh Use

• Multiple studies have shown no significant difference in wound or mesh infection rates between hernias with viable versus non-viable intestinal contents 1, 2
• A prospective study by Bessa et al. demonstrated that the presence of non-viable intestine was not associated with increased infection rates in prosthetic repair 1
• Synthetic mesh has shown lower recurrence rates (OR = 0.2) compared to non-mesh repair, with similar surgical site infection rates when comparing cases with and without bowel resection 1
• A 2018 prospective study specifically examining polypropylene mesh in contaminated and dirty strangulated hernias requiring bowel resection found acceptable morbidity (26.67% wound infection rate) with no need for mesh removal and low recurrence (6.7%) 3

Important Considerations and Caveats

• Bowel resection is a risk factor for overall postoperative complications (P < 0.0001) and major complications (P = 0.003), but not necessarily for surgical site infection (P = 0.42) 1, 2
• High infection rates (up to 21%) have been reported after emergency hernia repairs with polypropylene mesh in contaminated fields, so careful patient selection is important 1
• The degree of contamination matters - cases with gross enteric spillage or peritonitis (CDC wound class IV) carry higher risk and may be better suited for biological mesh or primary repair 1, 2
• Absorbable prosthetic materials will eventually dissolve completely, leading to inevitable hernia recurrence, making them less ideal for permanent repair 1

Practical Recommendations

• When using polypropylene mesh after bowel resection:
  • Ensure thorough irrigation of the surgical field 3
  • Consider appropriate antibiotic coverage 3
  • Be vigilant for signs of wound infection postoperatively, though most can be managed with antibiotics and dressing without mesh removal 3
• In cases with gross contamination from perforated gangrenous bowel, consider alternative approaches as outlined in the algorithm above 1, 2
• Monitor for recurrence, especially in high-risk contaminated cases, though recurrence rates remain lower than with primary repair 1, 3