Complex Hernia with Infected Mesh

IFT in a case of multi-recurrent incisional hernia with exposed, infected mesh

Cisanello University Hospital, Pisa, Italy - February 2025

Dr. Luigi Cobuccio reports this case involving a 56-year-old male with a history of multiple failed abdominal wall reconstructions, presenting with exposed mesh, chronic infection, and recurrent hernia. The clinical scenario was further complicated by previous mesh removals, surgical site infection, and a lack of prehabilitation options. Given the challenging surgical field and patient factors, an open approach was planned with the use of intraoperative fascial traction to facilitate direct closure.

Case Overview

A 56-year-old obese man (BMI 36.5), ex-smoker, presented with a complex history of recurrent umbilical incisional hernia and multiple failed repairs performed at other institutions. He had previously undergone umbilical hernia repair with a preperitoneal mesh in 2022, followed by laparoscopic cholecystectomy and suture hernia repair in 2023, which was complicated by small bowel obstruction, re-exploration, and mesh removal. In 2024, he underwent an open Rives-Stoppa repair with polypropylene mesh and anterior component separation (M2M3 W3 defect), followed by a significant postoperative retromuscular hematoma requiring bilateral angioembolization. The course was complicated by surgical site infection and dehiscence, ultimately exposing the mesh.

The patient presented with exposed mesh (4 cm diameter), surrounding erythema, and evidence of hernia recurrence (13 cm wide on CT) cranially associated with rectus diastasis. Wound swabs showed Staphylococcus aureus and Corynebacterium simulans. Due to the progressively enlarging exposed mesh and poor compliance, it was decided to proceed with surgical intervention. Prehabilitation was not feasible (no botulinum toxin A or weight loss possible).

Surgical exploration revealed significant inflammation and a 15 cm wide residual fascial gap. Complete mesh removal was performed en bloc with erythematous skin. Fasciotens®Hernia was applied to the anterior and posterior rectus sheaths (where present) for 28 minutes to facilitate medialization. This allowed for tension-free midline fascial closure using small-bite PDS 0 sutures. One subcutaneous drain was placed for seroma prevention.

The patient received cefazolin and metronidazole for 72 hours. The drain was removed on postoperative day 4 and he was discharged on day 5 with good pain control and no complications. Microbiological analysis of the explanted mesh revealed Staphylococcus aureus, Staphylococcus caprae, and Proteus mirabilis. He is under close follow-up, with future plans for a mesh-based reconstruction after adequate prehabilitation in a clean surgical field.