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CASE REPORT Open Access
Mesh removal and reconstruction withposterior components
separation techniquefor delayed mesh infection developed10 years
after abdominal incisional herniarepair: a rare case reportTetsuro
Tamura1,2,4* , Yoshihiro Ohata1,2 and Fujio Katsumoto3
Abstract
Background: Very few literatures can be found reporting cases
and treatment strategies of late-onset meshinfection after
abdominal incisional hernia reconstruction. Here, we report a rare
case of delayed mesh infectiondeveloped 10 years after abdominal
incisional hernia repair, which was successfully treated by mesh
removal andreconstruction with posterior components separation
technique.
Case presentation: A 66-year-old man, who underwent
reconstruction of abdominal incisional hernia byretroperitoneal
Composix mesh application 10 years prior, developed 12 × 6.0 × 2.5
cm subcutaneous abscessfollowed by methicillin-resistant
Staphylococcus aureus (MRSA)-related mesh infection. The operation
was performedexcising the abscess wall without damaging peritoneum,
and huge intermuscular defect was successfullyreconstructed by
posterior components separation technique application.
Conclusions: An early decision of excising contaminated mesh
would be preferable to extensive conservativetreatments when mesh
infection is suspected. Components separation technique application
can be of great helpwhen designing reconstruction of huge
intramuscular defect after removal of infected mesh.
Keywords: Incisional hernia, delayed mesh infection, components
separation technique, MRSA
BackgroundIncisional hernia is one of the major complications
afterabdominal surgery. Recently, tension-free
reconstructionconcept, which is known to reduce recurrence
comparedto conventional primary closure procedure [1], haswidely
been accepted for repairing incisional hernia, andtherefore,
nowadays, most of the reconstructions areperformed using mesh. Mesh
application is, on the otherhand, known to cause complicated
infection on occasion.However, very few literatures can be found
reporting casesand treatment strategies of late-onset mesh
infection afterabdominal incisional hernia reconstruction. Here,
we
report a very rare case of delayed mesh infectiondeveloped 10
years after abdominal incisional herniarepair, which was
successfully treated by mesh removaland reconstruction with
posterior components separationtechnique.
Case presentationA 66-year-old man, who underwent reconstruction
ofabdominal incisional hernia (8 cm in diameter) which wasdeveloped
6 months after his abdominal aorta aneurysmoperation (Y-graft
replacement) by retroperitoneal 15 ×8 cm Composix mesh application
10 years prior, visitedour department complaining discharge from
his opera-tive wound scar. At first, conservative therapy was
initi-ated since the discharge was serous and no symptom
ofinfection was observed. Despite intermittent lavage and
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indicate if changes were made.
* Correspondence: [email protected]
of Surgery and Oncology, Graduate School of Medical Sciences,Kyushu
University, Fukuoka, Japan2Department of Surgery, JR Kyushu
Hospital, Moji, Kitakyushu, JapanFull list of author information is
available at the end of the article
Tamura et al. Surgical Case Reports (2019) 5:140
https://doi.org/10.1186/s40792-019-0697-3
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drainage for 6 months, however, the discharge was notreduced,
and gradually, the properties of it changedinto infective. Mesh
infection was strongly suggested,and finally, we planned removal of
the infected mesh.At admission, his height was 165 cm, body weight
was71.5 kg, and body temperature was normal. The fluidcollection
was palpable under his upper midline opera-tive wound scar, and the
skin fistula dischargingcontaminated exudates was observed in the
middle ofthe wound (Fig. 1). Results of blood examination
werewithin normal range except for slightly elevated CRP(1.46
mg/dl). Enhanced abdominal CT showed encap-sulated 12 × 6.0 × 2.5
cm high-dense fluid collectioninvolving microbubbles, suggesting
abscess formation(Fig. 2). The operation was performed through
uppermidline incision including the skin fistula. Carefuldissection
successfully led complete removal of theabscess wall without
damaging the peritoneum andabscess wall (Fig. 3). No intestinal
fistula was observedthrough the procedure. Judging from the huge
size ofintramuscular defect of abdominal wall, simple
primaryclosure seemed impossible whereas mesh reattachmentwas not
preferable due to potential remnant infection.Therefore, we decided
to apply posterior componentsseparation technique (see schema in
Fig. 4), and ab-dominal wall reconstruction was successfully
achievedby anterior rectus sheath closure (Fig. 5).
Resectedspecimen contained an everted mesh, and
methicillin-resistant Staphylococcus aureus (MRSA) was identifiedin
the abscess contents by postoperative microbialcultivation (Fig.
6). He discharged without any signifi-cant complications, and no
recurrence of hernia andsymptom of infection were observed at least
3 yearsafter the reconstruction.
DiscussionIncidence of mesh infection after reconstruction
ofabdominal incisional hernia is known to be higher thanthat of
inguinal hernia. Although several cases of acute-onset mesh
infection after abdominal incisional herniareconstruction were
reported, very few reports can befound concerning late-onset (here,
we defined "late"as above 6 months after previous hernia repair)
mesh in-fection. Only three cases were found to be reported
in-cluding descriptions of the details of the case progress[2–4].
In 2006, Jezupovs et al. reported, in their retro-spective analysis
of 375 patients applying polypropylenemesh, a case of polyfilament
mesh infection developed18 months after recurrent incisional hernia
repairfollowed by right subtribe laparotomy [2]. After
1-monthunsuccessful abscess drainage, the 77-year-old manunderwent
partial removal of the Citrobacter koseri-in-fected mesh. No
description was found how the
Fig. 1 Abdominal appearance of the patient at operation.
Dashedcircle shows the range of palpable subcutaneous fluid
collection andan arrow indicates the skin fistula
Fig. 2 Preoperative CT suggesting subcutaneous encapsulated 12
×6.0 × 2.5 cm abscess formation (arrow)
Fig. 3 Complete removal of the abscess wall (dashed circle)
withoutdamaging the peritoneum and abscess wall was performed
Tamura et al. Surgical Case Reports (2019) 5:140 Page 2 of 4
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reconstruction was performed in the report. In the sameyear,
Bliziotis et al. presented a 59-year-old female caseof late-onset
mesh infection developed 6 months afterhypogastric abdominal hernia
repair followed by anovarian cancer operation 2 years prior [3]. S.
aureus wasidentified in his abscess contents. Initial 7 days
antibioticmanagement failed, and removal of mesh combined
with2-week antibiotic medication led to the cure of
infection.Unfortunately, details of the reconstruction were
eithernot described. In 2016, Mohamed et al. reported a 44-year-old
woman case of huge seroma formation diagnosed5 years after ventral
incisional hernia repair [4]. She
underwent an open Roux-en-Y gastric bypass surgery andumbilical
hernia repair 7 years prior, and a ventral inci-sional hernia
repair using composite mesh 2 years later.Five months of
conservative management led to evidenceof highly resistant
Pseudomonas aeruginosa infection, andshe underwent mesh
explantation and definitive repairwith complex abdominal
reconstruction combined withmacroporous monofilament synthetic mesh
and porcinedermal graft.These rare cases may propose us at least
two import-
ant points of discussion concerning delayed mesh infec-tion
after ventral hernia repair. First is that what causesdelayed mesh
infection after abdominal incisional herniarepair. At least three
mechanisms can be supposed asfollows: (i) remnant infection related
to previous oper-ation accompanying with contamination (which
mightbe in association with bacterial biofilm formation onmesh),
(ii) bacterial translocation followed by some kindof septic events,
and (iii) de novo infection, either bymesh-intestine fistula
formation or by transcutaneous.Given the four case reviews, the
main cause of delayedmesh infection seems retrograde transcutaneous
infec-tion arising from prolonged drainage, accompanyingbacterial
biofilm, by two facts. One is that all four previ-ous operations
were performed in clean, or at least insemi-clean, conditions, and
no septic event was observedin their past medical history. The
other is that the typesof cultured bacteria (C. koseri, P.
aeruginosa, and S.aureus) are known to produce rich biofilm and to
causesecondary remnant infection. Another point of discus-sion is
how to manage delayed mesh infection afterventral hernia repair. It
is possible to recommend avoid-ing prolonged conservative
treatments including lavageand drainage when highly
biofilm-associated bacteriawere identified from the seroma/abscess
contents. Add-itionally, as all four infected meshes were removed,
meshremoval seems essential to treat delayed mesh infection
Fig. 4 Schema of the posterior components separation
techniqueapplied for the present case. Arrows indicate directions
of incision. Adashed line shows midline. 1 Rectus abdominis muscle,
2 externaloblique muscle, 3 internal oblique muscle, 4 transversus
abdominismuscle, 5 transversalis fascia and peritoneum, and 6
hernia sac
Fig. 5 Anterior rectus sheath closure
Fig. 6 Excised abscess containing everted mesh. MRSA
wasidentified in the abscess contents
Tamura et al. Surgical Case Reports (2019) 5:140 Page 3 of 4
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in terms of biofilm debridement. However, the decisionof mesh
removal may often be hesitated by technicalreasons especially when
primary closure seems difficultor impossible due to huge
intramuscular defect aftermesh removal. Components separation
technique appli-cation, which is described in the present case, can
be ofgreat help of designing reconstruction after removal
ofinfected mesh for such cases. This technique is firstintroduced
in 1990 by Ramirez et al. [5], of which theprinciple is basically
bridging the fascial gap by separat-ing fascial and muscular layers
without using prostheticmeshes. Defects up to 20 cm in diameter can
be recon-structed in a “tension-free” condition
maintainingphysiological abdominal wall function. Although
recur-rence rate is relatively high compared to mesh repair,this
technique is still attractive especially in contami-nated cases
when mesh application should be avoided.
ConclusionsHere, we report a very rare case of delayed
MRSA-re-lated mesh infection developed 10 years after
abdominalincisional hernia repair, which was successfully treatedby
mesh removal and reconstruction with posteriorcomponents separation
technique. An early decision ofexcising contaminated mesh would be
preferable to ex-tensive conservative treatments, and components
separ-ation technique can be a strong option when primaryclosure is
not applicable for reconstruction due to ahuge defect after mesh
removal.
AbbreviationsCRP: C-reactive protein; CT: Computed tomography;
MRSA: Methicillin-resistant Staphylococcus aureus
AcknowledgementsThe authors greatly appreciate Takafumi Kamei,
Shun-ichi Takahata, SeiichiroJimi, Akifumi Hayashi, Chizu Kameda,
and Rieko Kurihara for their advice andassistance of completing
this case report.
Authors’ contributionsTT wrote the manuscript. FK, YO, and TT
performed the surgery. All authorsdiscussed, read, and approved the
final version of the manuscript.
FundingNone.
Availability of data and materialsThere is no available data and
materials to be shared.
Ethics approval and consent to participateNot applicable.
Consent for publicationWritten informed consent for the
publication of this case report wasobtained from the patient.
Competing interestsThe authors declare that they have no
competing interests.
Author details1Department of Surgery and Oncology, Graduate
School of Medical Sciences,Kyushu University, Fukuoka, Japan.
2Department of Surgery, JR Kyushu
Hospital, Moji, Kitakyushu, Japan. 3Katsumoto Day Surgery
Clinic, Kitakyushu,Japan. 4Department of Surgery, Shimonoseki City
Hospital, 1-13-1 Koyocho,Shimonoseki, Yamaguchi 750-8520,
Japan.
Received: 25 June 2019 Accepted: 26 August 2019
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Publisher’s NoteSpringer Nature remains neutral with regard to
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