What is the best course of action for a patient with a hernia laparotomy who develops a 3x4cm wound with discharging pus and visible mesh a couple of days post-op, but remains stable?

Management of Postoperative Mesh Infection with Visible Mesh and Purulent Drainage

Remove the mesh completely and perform open wound management with daily dressing changes (Option B modified with open wound management), as the presence of visible mesh with purulent discharge represents a deep mesh infection requiring complete mesh explantation to prevent severe complications including visceral adhesions and fistulae. 1

Immediate Surgical Management

Complete mesh removal is mandatory in this scenario. The visible mesh with purulent drainage indicates established deep infection with bacterial biofilm formation on the prosthetic material, which creates an effective barrier against both host immune cells and antibiotics, making conservative management futile. 2, 1

Why Conservative Management Fails

• Conservative treatment with antibiotics alone (Option C) fails in most cases of mesh infections with established purulent drainage and exposed mesh 1
• Partial mesh excision or drainage alone (Option A) has high failure rates, resulting in recurrent mesh infections 2, 1
• Mesh salvage is not appropriate for established deep infections with visible mesh and purulent discharge 1
• Only 34.5% of percutaneous drainage attempts and 34.8% of negative pressure wound therapy attempts successfully salvage infected mesh, and these successes are limited to macroporous polypropylene in extraperitoneal positions 3

Surgical Approach

Perform complete mesh explantation with the following steps:

• Remove all mesh material completely, as any retained mesh will perpetuate infection 2, 1
• Start broad-spectrum IV antibiotics with anaerobic coverage immediately at the time of mesh removal, given the polymicrobial nature of mesh infections (Staphylococcus spp., Enterococcus spp., and Gram-negative bacteria are commonly isolated) 2, 1
• Debride all necrotic tissue, as it provides an excellent medium for bacterial growth 4
• Perform wound irrigation to remove foreign matter, hematoma, and decrease bacterial contaminants 4
• Leave the wound open for daily dressing changes, as this is the safest approach for a contaminated/dirty field (CDC Class III-IV) 1

Critical Risk Factors Present

This patient has multiple predictors of mesh infection requiring explantation:

• Postoperative surgical site infection with purulent discharge (odds ratio 2.9 for mesh infection) 2
• Visible mesh in the wound indicates deep infection rather than superficial surgical site infection 2
• Early postoperative timing (couple of days) suggests high bacterial burden 1

Delayed Reconstruction Options

After complete wound healing and infection clearance:

• For defects <3 cm: Primary repair without mesh is recommended 2, 1
• For defects ≥3 cm: Consider biological mesh or delayed synthetic mesh repair once the wound is completely healed and infection cleared 2, 1
• Closure of the defect after mesh removal significantly lowers recurrence rate (P < 0.001) 3

Important Caveats

Monitor for systemic sepsis progression, as mesh infections can rapidly deteriorate despite hemodynamic stability. 1

Do not attempt mesh salvage in this scenario. While macroporous polypropylene mesh in extraperitoneal positions can be salvaged in 72.2% of cases, this only applies to early infections without visible mesh and purulent discharge. 3 Once the mesh is visible with established purulent drainage, salvage attempts fail and delay definitive treatment. 2, 1

The high infection rates (21% in emergency hernia repairs with polypropylene mesh in CDC Class III fields) underscore why immediate mesh removal is necessary. 2