What is the treatment for hardening post herniorrhaphy (hernia repair) without mesh repair accompanied by purulent discharge?

Management of Infected Non-Mesh Hernia Repair with Purulent Discharge

This represents a surgical site infection requiring immediate wound drainage, culture-guided antibiotic therapy, and consideration for surgical debridement if there is deep tissue involvement or abscess formation. 1

Immediate Management Algorithm

Initial Assessment and Classification

• This is a CDC wound class IV (dirty/infected) surgical field requiring aggressive infection control measures 1
• The presence of purulent discharge with induration indicates established surgical site infection (SSI), likely superficial but potentially deep 2
• Assess for signs of deep infection: fluctuance, fascial involvement, systemic sepsis, or necrotizing soft tissue infection 1

Acute Infection Management

Wound drainage and debridement:

• Open and drain the wound immediately if purulent discharge is present 2, 3
• Remove any necrotic or devitalized tissue through surgical debridement 1
• Obtain wound cultures before initiating antibiotics to guide subsequent therapy 3
• Leave the wound open for drainage and healing by secondary intention 1

Antibiotic therapy:

• Initiate empiric broad-spectrum antibiotics covering skin flora, particularly Staphylococcus aureus which is the most common pathogen in hernia repair infections 3
• A first-generation cephalosporin (cefazolin 1-2g IV) or equivalent is appropriate initial coverage 3, 4
• Adjust antibiotics based on culture results and clinical response 2
• Continue antibiotics until clinical signs of infection resolve (typically 7-14 days depending on severity) 3

Local wound care:

• Perform daily dressing changes with normal saline irrigation 2
• Consider negative pressure wound therapy for larger wounds once infection is controlled 1
• Monitor for signs of hernia recurrence as the repair may fail without mesh reinforcement 1

Risk of Recurrence

The absence of mesh in the original repair significantly increases recurrence risk:

• Non-mesh tissue repairs have recurrence rates of 19% compared to 0% with mesh repair in acute settings 1
• Expect high likelihood of hernia recurrence (15-20%) after the infection resolves given the combination of tissue-only repair and subsequent infection 1

Definitive Management After Infection Resolution

Once the infection has completely cleared (typically 3-6 months):

• Plan for delayed hernia repair with mesh reinforcement to prevent recurrence 1, 5
• At reoperation, the surgical field will be clean (CDC class I), allowing safe use of synthetic mesh 1, 5
• Synthetic mesh repair reduces recurrence risk significantly (OR 0.2) compared to repeat tissue repair 6

Key Clinical Pitfalls to Avoid

• Do not attempt mesh placement in the presence of active infection - this will lead to mesh infection requiring removal 1, 6
• Do not close an infected wound primarily - this traps bacteria and worsens the infection 1
• Do not delay surgical drainage if purulent material is present - antibiotics alone are insufficient 2, 3
• Do not assume superficial infection - examine carefully for deep space involvement or fascial dehiscence 1, 2

Monitoring and Follow-up

• Examine wound every 2-3 days initially until granulation tissue forms 2
• Watch for signs of hernia recurrence: bulge, pain with Valsalva, or palpable fascial defect 1
• Plan definitive repair only after complete wound healing and resolution of inflammation (minimum 3 months) 1, 5