What is the recommended management for a 31-year-old active duty male with abdominal pain surrounding a hernial mesh implant?

Management of Abdominal Pain Surrounding Hernial Mesh Implant

A 31-year-old active duty male with abdominal pain surrounding a hernial mesh implant requires immediate clinical evaluation to distinguish between superficial wound infection, deep mesh infection, mesh reaction, or mesh migration—with management ranging from conservative treatment with antibiotics and observation for superficial infections to complete surgical mesh removal for deep infections or chronic mesh-related pain. 1

Initial Diagnostic Approach

The diagnosis of mesh-related complications requires distinguishing between superficial incisional surgical site infections (SSIs) and deep mesh infections, as they have fundamentally different management strategies 1:

• Superficial wound infections present with localized inflammation and pain at the incision site in the early postoperative period and are not influenced by mesh implantation itself 1
• Deep mesh infections tend to be indolent with chronic signs and symptoms that may initially be underestimated, presenting with signs of local inflammation but often with more subtle findings 1
• Mesh reaction/chronic pain has become an increasingly frequent indication for mesh removal, accounting for up to one-third of mesh removals in recent series, particularly in pelvic mesh 2

Key Clinical Features to Assess

Determine the following specific characteristics 1, 2:

• Timing: Early postoperative (suggests superficial SSI) versus delayed/chronic presentation (suggests deep infection or mesh reaction) 1
• Pain characteristics: Quantify pain score (average pain requiring mesh removal is 5/10), assess for neuropathic features, and evaluate impact on function 2
• Local signs: Erythema, warmth, fluctuance, drainage, or sinus tract formation 1
• Systemic symptoms: Fever, leukocytosis, or signs of sepsis 1
• Functional impairment: Impact on military duties and physical training requirements 2

Imaging and Laboratory Evaluation

• CT scan is the gold standard for evaluating mesh-related complications, assessing for fluid collections, abscess formation, mesh position, and potential migration 1
• Wound cultures should be obtained if drainage is present to guide antibiotic therapy 1
• Consider that mesh infections involve bacterial biofilm formation, which provides an effective barrier against host immune cells and antibiotics 1

Management Algorithm Based on Clinical Presentation

For Superficial Wound Infection (Early, Localized)

Conservative management with antibiotics and local wound care is appropriate 1:

• Initiate culture-guided antibiotic therapy 1
• Perform mechanical scrubbing or irrigation to remove biofilm before it consolidates 1
• Early intervention is critical as biofilm becomes increasingly resistant once established 1
• Monitor closely for progression to deep infection 1

For Deep Mesh Infection

Complete surgical removal of the infected mesh is recommended to reduce the risk of infection recurrence or severe complications such as visceral adhesions and fistulae 1:

• Conservative surgical approaches including abscess drainage, sinus excision, or partial mesh excision frequently fail and result in recurrent mesh infections 1
• Non-operative strategies with conservative management have been successful in certain instances for mesh salvage, but this should only be attempted initially if infection is caught very early 1
• If conservative treatment fails, proceed directly to complete mesh removal 1

For Chronic Mesh-Related Pain or Mesh Reaction

Surgical mesh removal is indicated when conservative measures fail 2:

• Pain is the primary indication for mesh removal in 91% of pelvic mesh cases 2
• Mesh reaction has become increasingly recognized, accounting for one-third of mesh removals by 2017 2
• Pain scores are significantly higher prior to removal of mesh from the pelvis (5.7 vs 4.5 for abdominal mesh, P = 0.047) 2

For Mesh Migration

Immediate surgical removal is required 3:

• Mesh migration into visceral organs (bladder, bowel) has been reported, though rare 3
• CT imaging will identify abnormal mesh position 1
• Surgical removal may be technically challenging due to adhesions but is necessary 3

Surgical Approach for Mesh Removal

The surgical technique for mesh removal has evolved significantly 2:

• Robotic approach has increased dramatically (from 0% to 70% by 2017) and is now preferred when available 2
• Open technique has decreased (from 82% to 17%) 2
• Laparoscopic approach remains an option but has decreased (from 20% to 10%) 2
• Most procedures require general anesthesia (87%) with inpatient stay (53%, typically 1 day) 2

Management After Mesh Removal

Immediate Postoperative Period

• Leave the wound open for drainage if infection was present 1
• Consider negative pressure wound therapy for larger wounds once infection is controlled 1
• Remove any necrotic or devitalized tissue through surgical debridement 1

Hernia Recurrence Risk

Non-mesh tissue repairs have recurrence rates of 19% compared to 0% with mesh repair 4:

• Expect high likelihood of hernia recurrence (15-20%) after mesh removal 4
• Plan for delayed hernia repair with mesh reinforcement after complete infection resolution (typically 3-6 months) 4
• At reoperation, the surgical field will be clean (CDC class I), allowing safe use of synthetic mesh 4

Definitive Repair Options After Infection Resolution

For contaminated fields requiring re-repair 1, 5:

• Biological mesh is preferred for larger defects (≥3 cm) in contaminated/dirty surgical fields when available 5
• Non-cross-linked biological mesh can be used without mesh infection and subsequent need for mesh explantation 1
• Biological mesh sublay repair with primary fascial closure shows lower recurrence rates than bridging repairs 1
• If biological mesh is unavailable, polyglactin mesh or open wound management with delayed repair are alternatives 5

Critical Pitfalls to Avoid

• Do not attempt mesh placement in the presence of active infection, as this will lead to mesh infection requiring removal 4
• Do not close an infected wound primarily, as this traps bacteria and worsens the infection 4
• Do not delay surgical drainage if purulent material is present, as antibiotics alone are insufficient 4
• Do not underestimate chronic, indolent presentations of deep mesh infection 1
• Do not perform partial mesh excision as the primary approach for deep infection, as this frequently fails 1

Special Considerations for Active Duty Military

For this 31-year-old active duty male, additional factors include 2:

• Return to full military duties requires complete resolution of pain and restoration of abdominal wall integrity 2
• Mesh removal may be necessary even without infection if chronic pain prevents military function 2
• Timing of definitive repair should consider deployment schedules and training requirements 4
• Synthetic mesh repair after infection resolution provides the lowest recurrence risk (OR 0.2) for return to demanding physical activity 4