Abdominal Wall Incisional Hernias - Infected Prosthesis: Treatment and Prophylaxis

Regarding the clinical presentation, whether it be a late abscess or simply a chronic sinus, the mesh itself is always infected. How to deal with this challenging complication: Partial or complete removal of the mesh, or an attempt for a conservative treatment? The reference treatment is the complete removing of the mesh and it’s fixation means. This treatment quickly heals the infectious part of the problem but leads the surgeon to being faced with the challenging parietal repair of a larger defect in contaminated tissues. This parietal repair requires a 2 step-surgery. The first step consists in closing the gap, as well as can be. The technical difficulty increases with the size of the defect. Which may require technical adaptations to avoid a compartment syndrome. Sometimes the complete removal is mandatory, but easy done, especially when a sequestered mesh is floating in pus. Sometimes it is mandatory but difficult or dangerous to address, especially if some parts of the mesh are strongly integrated and/or real close to the abdominal viscera. Leave in place, some parts of the mesh can be done, provided they are very well integrated. Moreover superficial prosthesis can be salvaged by detersive and watchful daily dressings. Free grafts or pedicle flaps are rarely required. The retraction of the edges due to the scar formation dramatically reduces the size of the defect. Wound healing is shortened using a negative pressure dressing therapy. For intra-peritoneal prosthesis, especially after laparoscopic repairs, this kind of treatment cannot be done.The medical imaging helps to assess whether a conservative treatment can be attempted or not. In some cases the mesh can be salvaged by percutaneous drainage under CT scan vision provided the collection is fluid, homogeneous, without wrinkled mesh and enteric fistula. In a large series of unselected cases the success rate was only 20% but the success rates are higher in the selected cases recently published. The fistulography combined to CT scan may helps to individualize the part of the mesh to be removed. A similar technic, simpler and helpful in the operative room, has been described by R. Stoppa and P. Verhaeghe: Inspired from the anal fistulectomy it consists in removing in block the fistula tract and the not fully integrated part of the mesh coloured with the methylene blue, thus sparing this way the main part of the mesh. In conclusion: This kind of challenging problem may lead to a local collegial discussion in the way to consider all the treatment options, including a referral to a specialized team.