What are the management options for a patient with mesh placement recurrence?

Management of Mesh Placement Recurrence

For patients with hernia recurrence after mesh placement, the optimal management strategy depends on whether infection is present: if no infection exists, proceed with re-repair using synthetic mesh in clean fields or biological mesh in contaminated fields; if infection is present, complete mesh explantation is mandatory followed by delayed definitive repair after infection resolution. 1

Initial Assessment: Distinguish Infection from Recurrence

The first critical step is determining whether the recurrence involves mesh infection, as this fundamentally alters management:

• Deep mesh infections present with indolent, chronic signs and symptoms that are frequently underestimated, including local inflammation, drainage, or sinus tract formation 1, 2
• Superficial wound infections occur early postoperatively with localized inflammation and pain at the incision site, and do not necessarily indicate deep mesh involvement 1, 2
• CT imaging is the gold standard for evaluating mesh-related complications, assessing for fluid collections, abscess formation, and mesh position 2
• Wound cultures should be obtained if drainage is present to guide antibiotic therapy 2

Management Algorithm for Infected Mesh with Recurrence

Conservative Management (Limited Role)

• Conservative non-surgical management with antibiotics and mechanical scrubbing/irrigation to remove biofilm can be attempted in select cases of early infection 1
• Early antibiotics and mechanical irrigation are important before biofilm consolidates, as biofilm provides bacteria an effective barrier against host immune cells and antibiotics 1

Surgical Management (Definitive Treatment)

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, 2:

• Conservative surgical approaches including abscess drainage, sinus excision, or partial mesh excision frequently fail and result in recurrent mesh infections 1
• 72.7% of mesh infections ultimately require mesh explantation 1
• Predictors of mesh explantation include type of mesh (OR 3.13), onlay position (OR 3.51), and associated enterotomy (OR 5.17) 1

Post-Explantation Wound Management

• Leave the wound open for drainage if infection was present 2
• Negative pressure wound therapy should be considered for larger wounds once infection is controlled 2
• Surgical debridement must remove all necrotic or devitalized tissue 2

Delayed Definitive Repair Options

After complete infection resolution (typically 3-6 months), plan delayed hernia repair 2:

For clean/clean-contaminated fields (CDC class I-II):

• Synthetic mesh is preferred as it provides superior long-term outcomes with significantly lower recurrence rates (9%) compared to tissue repair (19%) 3, 2, 4
• Laparoscopic approaches (TAPP or TEP) offer advantages including lower wound infection rates 3

For contaminated/dirty fields (CDC class III-IV):

• Small defects (<3 cm): Primary repair without mesh 3, 4
• Larger defects (≥3 cm): Biological mesh is preferred when available 3, 2, 4
• Non-cross-linked biological mesh can be used without subsequent mesh infection and need for explantation 1, 2
• If biological mesh unavailable: Consider polyglactin mesh or open wound management with delayed repair 3

Management Algorithm for Non-Infected Recurrence

Assess Surgical Field Classification

Clean or clean-contaminated fields:

• Synthetic mesh repair should be performed regardless of defect size, as this provides significantly lower recurrence rates 3, 4
• No increased 30-day wound-related morbidity has been observed with mesh use in clean-contaminated fields 3, 4

Contaminated or dirty fields:

• Defects <3 cm: Primary repair without mesh 3, 4
• Defects ≥3 cm: Biological mesh preferred 3, 4

Optimal Mesh Positioning

Underlay or retrorectus mesh placement is associated with lower recurrence rates compared to onlay or interposition positioning 5:

• Onlay position has highest recurrence rates (17%) and is an independent predictor of mesh explantation (OR 3.51) 1, 5
• Retrorectus repair has lowest seroma rates (4%) 5
• Underlay positioning demonstrates superior outcomes with lower recurrence rates 5

Critical Pitfalls to Avoid

• Never attempt mesh placement in the presence of active infection, as this will lead to mesh infection requiring removal 2
• Never perform partial mesh excision as the primary approach for deep infection, as this frequently fails and results in recurrent infections 1, 2
• Never close infected wounds primarily, as this traps bacteria and worsens the infection 2
• Never delay surgical drainage if purulent material is present, as antibiotics alone are insufficient 2
• Never underestimate chronic, indolent presentations of deep mesh infection 1, 2
• Do not avoid mesh in clean/clean-contaminated fields due to fear of infection, as evidence shows it is safe and significantly reduces recurrence 4

Expected Outcomes

• High likelihood of hernia recurrence (15-20%) is expected after mesh removal without re-repair 2
• Recurrence rates with appropriate mesh repair: 9% for synthetic mesh in clean/clean-contaminated fields, 30% for biological mesh in contaminated fields 1
• Recurrence rates depend on achieving primary fascial closure: Biological mesh sublay repair with primary fascial closure shows lower recurrence rates than bridging repairs 1