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Page 2 of 9 O’Connor et al. Plast Aesthet Res 2019;6:26 I http://dx.doi.org/10.20517/2347-9264.2019.38

on the defect size and presence of contamination. Stage 1 hernias are less than 10 cm and in clean fields and
have been found to have a SSO and recurrence rate of 10%. Stage 2 hernias are larger, 10-20 cm or < 10 cm
in contaminated fields, and have an SSO rate of about 20% and recurrence rate of 15%. Stage 3 hernias are
> 20 cm wide or > 10 cm in contaminated fields and have the highest risk of SSO at 42% and recurrence of
26%. This system allows surgeons to have a frank discussion with their patients pre-operatively about their
expected complication risk.

While such staging systems are helpful in risk stratification, SSO remains a broad category including 5
types of complications and fails to account for their clinical significance. Separate systems exist for each
category of SSO to document a difference between small asymptomatic seromas and large, symptomatic
[4]
seromas requiring intervention for example .

EARLY COMPLICATIONS
Mesh infection
Much attention has been paid to prevention of SSI in hernia repair, especially with the increased use of
prosthetic mesh. These are divided into superficial, deep, and organ space SSI and are directly correlated
with the level of contamination during the case. Superficial SSI should be managed using general surgical
principles of drainage and, possibly, short-course antibiotics. Management of deep and organ space SSI
[5]
hinges greatly on the concern for infection of the prosthetic mesh .

The true diagnosis of mesh infection requires a positive culture of fluid from around the mesh or a culture
of the mesh itself. Periprosthetic fluid on imaging can often represent sterile seroma or hematoma, so fluid
should be aspirated and sent for culture if there is concern for mesh infection. However, deep infections
should be treated aggressively, and with a high index of suspicion, as seeding of the mesh can be subclinical
and may lead to long-term complications. A retrospective review of 21 mesh infections found that 76% of
mesh infections were due to Staphylococcus aureus and about half of these were methicillin-resistant. The
minority of infections are due to Staphylococcus epidermidis or Streptococcus pyogenes or Gram-negative
[6,7]
species of Escherichia coli or Klebsiella in the case of gastrointestinal contamination .
Prevention of mesh infection begins with tailoring the type of mesh chosen for the clinical scenario.
We recommend the use of medium-weight macroporous polypropylene (PP) in clean fields due to their
resistance to biofilm formation, improved clearance of infection, and repair durability compared to PTFE-
[5]
based meshes . In contaminated or clean-contaminated fields, the evidence on mesh selection is not as clear,
[8]
and absorbable mesh is recommended due to the high risk of synthetic mesh infection. Itani et al. and
[9]
Rosen et al. showed in a prospective trial that using biosynthetic absorbable mesh resulted in improved
SSI rates (18% vs. 35%) as well as long-term recurrence rates (17% vs. 28%) when compared to previous
trials of porcine mesh in these settings More recently, however, macroporous synthetic mesh has been
[10]
found to have equivalent infection rates in contaminated fields and is also an acceptable option .
Once a mesh infection has been confirmed, early source control and antibiotics are required. An effort
should be made to salvage the mesh, avoiding removal. Patients showing signs of sepsis may require early
operative intervention characterized by pulse-lavage antibiotic solution irrigation, followed by wide closed
suction drain placement adjacent to the mesh and fascial closure once again if the mesh had been placed
retromuscular. In the setting of florid sepsis, source control, wound packing, and interval abdominal wall
closure is often all the patient will tolerate. Some small series have shown the success of mesh removal
with single stage primary closure with bilateral myofascial rectus abdominis release; however, the hernia
recurrence rates range 35%-88% [11,12] . This setting is an ideal application for absorbable biosynthetic mesh,
[9]
where it can substantially reduce recurrence rates down to 17% . Absorbable mesh should be placed as a
sublay in the retrorectus space and can be placed at the index operation or in a staged approach.