Management of Postoperative Mesh Infection with Visible Mesh and Purulent Drainage
Remove the infected mesh and perform open wound management with daily dressing, as mesh infections with visible mesh and purulent discharge require complete mesh explantation to prevent severe complications including visceral adhesions and fistulae. 1
Rationale for Mesh Removal
The presence of visible mesh with purulent discharge represents a deep mesh infection (CDC wound class IV - dirty/infected), which fundamentally alters management:
Conservative management with antibiotics alone fails in most cases - mesh infections with established purulent drainage and exposed mesh cannot be salvaged with antibiotics alone, as bacterial biofilm formation on the prosthetic material creates an effective barrier against both host immune cells and antibiotics 1
Partial mesh excision or drainage alone has high failure rates - conservative surgical approaches including abscess drainage, sinus excision, or partial mesh excision frequently fail and result in recurrent mesh infections 1
Complete mesh removal is necessary - when conservative treatment fails (as evidenced by visible mesh with purulent discharge), complete surgical removal of the mesh is required to reduce the risk of infection recurrence and prevent severe complications such as visceral adhesions and fistulae 1
Immediate Surgical Management Algorithm
Step 1: Urgent mesh explantation with wound debridement
- Remove the entire infected mesh 1
- Perform thorough debridement of infected tissue 1
- Obtain aerobic and anaerobic cultures 2
Step 2: Broad-spectrum IV antibiotics
- Start immediately at the time of mesh removal 2
- Modify based on culture results and sensitivities 2
- Include anaerobic coverage (such as metronidazole) given the polymicrobial nature of mesh infections 1
Step 3: Open wound management
- Leave the wound open with daily dressing changes 1
- This represents the safest approach for a contaminated/dirty field 1
Delayed Reconstruction Options
After wound healing and infection clearance:
- For defects <3 cm: Primary repair without mesh 1
- For defects ≥3 cm: Consider biological mesh or delayed synthetic mesh repair once the wound is completely healed and infection cleared 1
- Timing: Attempt definitive closure only after patient stabilization and complete resolution of infection 1
Why Other Options Are Inadequate
Option A (Open wound with daily dressing alone) is insufficient because it leaves the infected mesh in place - the mesh itself perpetuates infection through biofilm formation and must be removed 1
Option C (Observation with IV antibiotics alone) will fail because antibiotics cannot penetrate bacterial biofilm on prosthetic material, and the exposed mesh with purulent drainage indicates established deep infection requiring surgical intervention 1
Critical Risk Factors Present
This patient has multiple predictors of mesh infection requiring explantation:
- Postoperative surgical site infection (OR 2.9) - the purulent discharge confirms SSI 1
- Visible mesh in wound - indicates deep infection rather than superficial SSI 1
- Early postoperative timing (couple of days) - suggests high bacterial burden 1
Important Caveats
Do not delay mesh removal - prolonged conservative therapy with infected mesh in place risks suture line disruption, hemorrhage, and progression to visceral complications 2
Mesh salvage is not appropriate here - while some indolent mesh infections can occasionally be managed conservatively, visible mesh with purulent discharge represents established deep infection beyond salvage 1
Monitor for systemic sepsis - though currently stable, the patient requires close monitoring as mesh infections can progress 1