Mesh Infection and Migration after Umbilical Hernia Repair

doi:10.4236/ss.2013.410082

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Surgical Science, 2013, 4, 421-425

http://dx.doi.org/10.4236/ss.2013.410082 Published Online October 2013 (http://www.scirp.org/journal/ss)

Mesh Infection and Migration after Umbilical

Hernia Repair

Valter Ripetti*, Vincenzo La Vaccara, Eleonora Angelini, Giovan Battista Giorgio, Rossana Alloni

Department of General Surgery, Campus Bio-Medico University, Rome, Italy.

Email: *[email protected], [email protected], e.angelini@unicampus.it, [email protected], [email protected]

Received August 16, 2013; revised September 14, 2013; accepted September 21, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Mesh infection and migration are dangerous and common complications after hernia repair. Many factors cause mesh

migration, which may or may not be associated to infection. Before performing hernia repair using a mesh, it is impor-

tant to choose the right device to avoid this kind of complication, above all in the presence of contaminated wounds or

fields. We describe two cases of mesh infection and migration after umbilical hernia repair which were treated, in ac-

cordance with recommendatio ns in the literatu re, by removing the infected mesh and replacing it with a biological mesh.

Our experience confirms the feasibility of using biological mesh to perform umbilical hernia repair after infection, with

consequent migration, of the previously placed mesh. Our cases are the first to be reported in which mesh migration is

associated with infection after umbilical hernia repair, and they demonstrate the advantages of biologic implants in ab-

dominal wall reconstruction.

Keywords: Umbilical; Infection; Migration Hernia; Mesh

1. Introduction

Migration of a surgical mesh, and consequent infection,

are dangerous and common complications in patients

who have undergone hernia repair. Many reports of plug

and mesh migration or dislocation after open or laparo-

scopic inguinal hernia repair can be found in literature.

This kind of complication can cause recurrence of ingui-

nal hernia, intestinal occlusion, chronic neuralgia, and

intestinal erosions, and thus peritonitis and enteric fistula

[1].

In literature, cases of mesh migration after umbilical

hernia repair are extremely rare. There is only one paper,

by Di Muria et al., describing a case of polypropylene

mesh migrating and completely penetrating an ileal loop,

with adhesion to the abdominal wall. Resection of the

ileal loop together with the surrounding abdominal wall

was performed, and the parietal defect was repaired with

single polypropylene stitches, avoiding the use of pros-

thetic material [2]. We describe 2 cases regarding mesh

migration and infection after umbilical hern ia repair, and

provide a review of the literature.

2. Case Presentation 1

The patient was a 60-year-old female whose medical

history included au toimmune thyroditis and hypertension.

She was a smoker, and her BMI was 30.

The patient underwent direct umbilical hernia repair at

the age of 36 years, and 20 years later developed a re-

currence which was treated by intra-peritonium repair

using a Composite® mesh (Bard In c., USA).

After 4 more years she was admitted to another hosp i-

tal for recurrent fever and abdominal swelling. Abdomi-

nal X-ray was negative. A subsequent abdominal CT

scan demonstrated the presence of fluid collection with

gas bubbles near the mesh. Both fever and local swelling

disappeared in response to non-specific an tibio tic th erapy,

and she was discharged after 10 days. Four months later,

she presented with periumbilical swelling with presence

of cutaneous fistula, so a new CT scan was performed.

This revealed persistence of fluid collection with gas

bubbles near the mesh (Figure 1).

Bacterial culture was positive for Streptococcus con-

stellatus. The patient was therefore admitted to our de-

partment and underwent surgical treatment. Intraopera-

tive findings revealed the presence of a subcutaneous

purulent collection and migration of the mesh into an

ileal loop (Figure 2). An intraoperative sampling con-

firmed the growth of Streptococcus constellatus. After

removing the prosthesis en bloc with surrounding skin

structures, we first performed resection of the involved

*Corresponding a uthor.

V. RIPETTI ET AL.

422

Figure 1. Fluid collection with gas bubbles near the mesh.

Figure 2. Prosthesis penetrated in ileal loop.

ileal loop. After primary suture, repair of the posterior

rectus sheath was performed using vicryl 2, and an

overlay mesh of PermacolTM (10 × 15 cm) was secured

with a series of sutures (2/0 prolene; ethicon). The

external rectus sheath was re-approximated at midline

with a series of 2 vicryl sutures. Additionally, a Jackson-

Pratt drain was placed in the subcutaneous plane, and

was left in place for four days. The patient was treated

with antibiotic therapy (Cefazolina Teva) until her dis-

charge. The postoperative course was uneventful and the

patient was discharged on postoperative day 6. The pa-

tient was also instructed to wear an abdominal binder for

at least two months. At 24 months follow-up, there was

no evidence of recurrence or other symptoms.

3. Case Presentation 2

A 56-year-old female, also a smoker, who had a history

of umbilical hernia repair with a Goretex® (Japan Gore-

Tex, Inc., Japan) mesh six years previously, was admit-

ted to our department with pus ou tput from a periumbili-

cal swelling, and external mesh migration (Figure 3).

BMI was 31. Bacterial culture, done before admission,

was positive for Escherichia coli, Streptococcus agalac-

tiae and Streptococcus dysgalactiae.

The patient underwent surgical treatment, and intraop-

Figure 3. External mesh migration.

erative findings revealed the presence of a subcutaneous

purulent collection confirming the multiple infections

mentioned above. We performed complete removal of

the mesh, together with surrounding skin structures, and

an underlay abdominal wall repair using a mesh of

PermacolTM (10 × 15 cm ) which was secured with a

series of sutures (2/0 prolene; ethicon) to the posterior

rectus sheath. Primary suture repair of the posterior and

external rectus sheath was performed using vicryl 2.

Additionally, a tubular suction drain was placed in the

subcutaneous plane. the drain was left in place for two

days until it expressed less than 50 ml/24h. The patient

was treated with antibiotic therapy (Cefazolina Teva)

until her discharge. The postoperative course was un-

eventful and the patient was discharged on postoperative

day 3. The patient was also instructed to wear an ab-

dominal binder for at least two months. At 24 months

follow-up, there was no evidence of recurrence or other

symptoms.

4. Discussion

Umbilical hernia is relatively common in adults, but ac-

counts for only 3% - 8.5% of abdominal hernias, third in

incidence after inguinal (70% - 75%) and femoral (6% -

17%) hernias [3]. Meshes have significantly reduced the

incidence of recurrence after umbilical hernia repair,

from 54% to less than 10% [4]. On the other hand,

Arroyo et al. did not report a significant relationship be-

tween recurrence rate and size of the hernia, comparing

suture and mesh repair of umbilical defects in a random-

ized clinical trial [5]. Although open primary repair still

remains the operation of choice for some surgeons faced

with defects of less than 2 cm in diameter [6], others

prefer the use of a mesh plug for defects of up to 3 cm in

diameter, and a mesh sheet for larger lesions [5].

Regardless of the technique used, the risk of mesh in-

V. RIPETTI ET AL. 423

fection remains a serious problem. The incidence of

mesh infection in op en su rgery ( 6% - 10%) [7,8 ] drop s to

0% - 3.6% with laparoscopic procedure [9], thanks to

mesh introduction through trocars, which avoids skin

contact, and placement far from the trocar incisions [10].

In literature, most prosthetic infections are reported to be

due to skin pathogens [11], although in our experience

the pathogens involved were not part of the cutaneous

flora.

In 2001, an experts’ meeting about the classification

and treatment of incisional hernia reported a higher mesh

removal rate after infection in laparoscopic repair (0% -

7%) than after open repair (0% - 4%) [12]. This was

probably due to a more prevalent use of ePTFE mesh in

laparoscopic repair: this type of mesh produces less

bowel adhesion than polypropylene or polyester mesh

but, once infected, must more often be removed [13]. In

fact, infection of polypropylene mesh can be managed

locally with surgical drainage and excision of exposed

unincorporated segments, whereas infection of ePTFE

mesh requires removal of the prosthetic material because

its microporous (10 µm) surface allows fluid retention

and bacterial contamination, but not leukocyte diapedesis

[8]. The removal of infected ePTFE mesh becomes nec-

essary because of its intraperitoneal placement, in contact

with the intestinal loops, which leads to the involvement

of adjacent organs.

According to a meta-analysis of cohort studies based

on 2418 patients, publish ed in 2011 by Mavros et al., our

patients had risk factors significantly associated with the

development of mesh infection after hernioplasty, such as

high BMI score and tobacco smoking [14]. In our two

cases, mesh migration was caused by infection of the

mesh, as suggested by Agrawal and Avill [15], who hy-

pothesized two possible mechanisms of mesh migration.

In the first of these, displacement of the mesh occurs

along a path of low resistance resulting either from in-

adequate fixation or from external displacing forces. In

the second, referred to as secondary migration, the mesh

moves gradually and slowly through the anatomic planes

due to erosion induced by foreign body reaction; the mi-

gration depends on the nature of the mesh biomaterial

and the type of fixation of the mesh, if fixed. On the

other hand, Chowbey et al. suggested that the cut edges

of the mesh become sharp, damaging the surface of the

viscus and evoking an inflammatory reaction, thereby

leading to weakness, erosion, and finally infection [16].

Because of a high morbidity rate due to mesh explan-

tation after mesh infection (hernia recurrence, damage to

surrounding structures, loss of domain, risk of entero-

tomy or enterocutaneous fistula formation), it is essential

to observe rigorous asepsis during surgical placement of

an appropriate mesh, to avoid the formation of intrapa-

rietal haematomas which could cause infection and, in

the end, mesh explantation [13].

At the 30th International Congress of the European

Hernia Society in 2009, different properties of the pros-

thesis (such as pore size, geometry, active surface area,

memory, afﬁnity for water, elasticity, and polymer type)

were taken into account to identify an “ideal” mesh

prosthesis. The po re size of meshes is crucial in defining

the surgical activity profile, which includes handling,

flexibility, memory, ﬁbrosis, and foreign body reaction.

Although lightweight macroporous meshes may lead to a

higher risk of adhesions, the panel agreed that they seem

to be safer to use in a contaminated environment because

of their greater flexibility and lower risk of foreign body

reaction an d fibrosi s [17].

Recently, greater use of biocompatible implants, such

as PermacolTM, has been necessary, because of complica-

tions with infection, and adhesions associated with wide-

spread use of prosthetic materials, such as polypropylene

mesh and ePTFE, to reconstruct abdominal wall defects.

PermacolTM (acellular porcine dermis) is used as a der-

mal scaffold, vascularised and remodelled to reconstruct

the abdominal wall, particularly in the presence of con-

taminated or potentially contaminated wounds [18].

Thanks to its structure, which is similar to human dermis,

PermacolTM is considered to be equally non-allergenic,

nontoxic, and devoid of foreign body reaction. Addi-

tional collagen crosslinking, which allows fibroblast in-

filtration and neovascularisation, incorporating the im-

plant into the surrounding host tissue [19], confers

greater stability, decreasing degradation by collagenase

and resulting in a more long-term prosthesis [20].

Literature report conflicting results with regard to

Permacol’s ability to become vascularized and incorpo-

rated into host tissue [20-23], showing conflicting data

on how chemical crosslinking influences vascular incor-

poration. However, a recent report demonstrated clinical

and histological evidence of vascular incorporation in a

full-thickness [24]. Regardless of whether or not chemi-

cal crosslinking may lead to integration of the mesh and

decreased ability for vascularization, this is offset by its

resistance to degradation and its long-term strength. In

fact it was demonstrated the chemical crosslinking of

collagen in PermacolTM confers more long-term stability

and strength [25].

According to a report on histologic and biomechanical

evaluation of crosslinked and non-crosslinked biologic

meshes in a porcine model of ventral incisional hernia

repair, PermacolTM showed increased cellular infiltration

between 1 and 6 months, with some scores to the non-

crosslinked materials at 6 months, and persistence of

these scores at 12 months. However, because all cross-

linked and non-crosslinked biologic meshes showed

equivalent cellular infiltration at later time points, it is

possible that crosslinking might not influence cellular

V. RIPETTI ET AL.

424

infiltration substantially in the long term. In general, the

crosslinked materials also demonstrated increased scores

at 12 months for cell types, ECM deposition, scaffold

degradation, fibrous encapsulation, and neovasculariza-

tion compared with their scores at 1 month. Although

many differences were identified among the biologic

meshes examined in this study, it is difficult to say

whether any of these biologic meshes are more biocom-

patible than the others for ventral hernia repair because

there are such wide variations in both the clinical sce-

narios analyzed and the biological responses of individ-

ual patients [26]. Also, a retrospective comparative study,

in 2012, on synthetic and biological meshes in compo-

nent separation for abdominal wall hernia repairs,

showed a recurrence rate in PermacolTM repair in con-

taminated fields of 7.7%, compared with Alloderm

(19%), synthetic mesh (25.6%), and component separa-

tion (12%). This review suggests that the crosslinked

mesh, PermacolTM, has the lowest failure rate and the

longest time to failure, particularly in contaminated or

infected fields [27]. In our cases there was a late clinical

presentation of mesh migration, where pus output was

the only sign of infection, with none of the abdominal

pain or bowel occlusion reported by Di Muria [2]. In the

first case the periumbilical pus output was caused by

enterocutaneous fistula formation, and in the second it

was due to partial external mesh migration. In both cases

we decided, in accordance with the literature concerning

mesh infection, to remove the infected mesh and perfo rm

an abdominal wall repair using bioprosthesis mesh to

ensure lower risk of recurrence and infection. Our ex-

perience confirms this biodegradable matrix as a safe and

useful tool; therefore it should be the device of choice

when there is high risk of infection and migration, or of

major complications such as intestinal perforation. In

conclusion, our cases are the first to be reported in which

mesh migration is associated with infection after umbili-

cal hernia repair, and they demonstrate the advantages of

biologic implants in abdominal wall reconstruction. Bio-

logical devices such as PermacolTM should be considered

in cases of contaminated wounds, immunesuppressed

patients, and previously placed, infected mesh, even if

high cost limits th eir routine use.

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