Dear Doctor Hoffman,

in case of gross contamination of the peritoneal cavity it's mandatory don't place any prosthetic device in intraperitoneal position even biologic ones. A classic Rives - Stoppa procedure with a light prolene mesh placed in properitoneal position should works very well. The use of a cross-linked biologic prosthesis instead of light prolene mesh, is to be taken into account.

Giorgio Vasquez

A similar topic had been discussed already rather profoundly at least twice (see the links below).

There is no any modern quantitive and/or qualitive bacteriological data on the hernial sac contents for the strangulated hernia at all since the 1920s. There have been none of the experimental investigations ever performed as well. So, this challenge might become a new trend of the Evidence Based Herniology that would (or will) shed some light on real conditions existing in the hernial sac fluid, peritoneal lining, and perihernial soft tissues.

These days, all the results remain empiric, and the reasons for and against the mesh placement are similarly weak for there is no real basic arguments to prove anything. I dare to mention that Semmelweis could not prove the advantage of the antiseptic method to his contemporaries. Even WITHOUT antiseptic, there were various results, and no physician could prove anything to another. It was only Lister who showed the reliable, comparable, and undoubtlful proofs, because he was the first to use bacteriological data. It was in 1868.

Empirically and only empirically, knowing that my knowledge is limited, I would agree with the Dr.Vasquez point of view: no prolene mesh if the wound contaminated severely. However, the fate of biologic prosthesis may rised some concern also, lest they have become a sort of a perished tendon or fascial patch retarding the wound healing for weeks.

Sincerely,

Andrey Borodach

https://www.researchgate.net/post/For_an_emergency_hernia_repair_requiring_bowel_resection_do_you_prefer_to_use_a_mesh_or_not/7

https://www.researchgate.net/post/Is_there_any_data_on_a_correlation_between_visual_Cruse_criteria_and_the_bacterial_count_of_hernial_sac_fluide_for_incarcerated_strangulated_hernia

At a time when I commented  the question I asked myself: who knows what he will say Andrey. He always says words of wisdom that I always read very willingly.

Many thanks Andrey,

Sincerely yours Giorgio

Thank you, Dr.Vasquez! Your profound experience will beat any sophysticated theory!

However, provided that the large incarcerated hernia incidence is low, and the queston keeps on raising again and again from the Alps to TianShan mountains, it warrants some multicentral study. What is your opinion?

I think the topic deserves a thorough study. Unfortunately, randomized controlled trials are very costly in time and money, plus case studies is poor and in a period of economic recession, I believe that the few available funds should be spent very carefully. I'd like to know what the Professor Kukleta think about it

Sincerely yours

Giorgio Vasquez

No evidence based medecine answer.

I do like much the "french" answer saying : on the road you can cross the wight line for there is not always a lorry in front ! but i disagree completly with this manner of thinking.

Pupil of René Stoppa, I have inserted manie meshes and can say  that in certain conditions you can insert a non absorbable prolen or mersilene mesh but remenber this is often an excellent result but it can also be catastrophic !

So if there is no bowell necrosis neither cellulitis and you work in perfect condition of sterility (changing dresses and instruments between septic period and this one you insert the prosthesis, you can do it. In other cases it's better to resect bowell and tissue and perform a suture with long absorbable suture (PDS or Maxon) with a recurrence rate of 40%. During the second time (recurrence) you'll isert inert prosthesis. If you are rich you can use a biological mesh in emergency : we ha ve proven that it does augmentate the infectious risk and lower the short time recurrence rate but no knoledge on long term result.

Sincerely yours

Pierre Verhaeghe

I agree with the opinion of Giorgio Vasquez: Retromuscolar preperitoneal  prosthethic repair. Biological graft better than synthetic device.

Thanks a lot Prof Negro, this is the voice of the experience. What do you think about the design of a randomized trial as suggested by Prof Andrey Borodach?

Regards,

Giorgio Vasquez

Great idea, but difficult to realize, I suppose.....

Sir

We are having lots of such patients

We are practicing bowel resection anastomosis thorough lavage of abdominal cavity and primary repair of hernia with polypropylene suture.approximately 30-40 % patients present with recurrence that we deal with mesh hernioplasty

We are not practicing use of mesh in contaminated cases

Dear All,

thank you very much for this discussion so far. I absolutely agree that mesh based reconstruction is sometime difficult to conduct in cases like this. But i performed several mesh reconstructions in such conditions (either incarcerated hernias or bowel perforation with localized contamination of abdominal cavity). I think that proper drainage of the abdomen combined with sufficient drainage of the retromuscular space, where the mesh is placed, is safe. 

Dr.Hoffmann,

My congratulations.

However, would you plan to publish the protocol developed by you and just share it with us briefly? I believe that anybody wants to learn up what are traits and tricks of your method for a difficult situation like that.

Sincerely,

Andrey

Hi

the general consensus is to avoid prosthetic mesh placement post bowel resection/ contaminated wounds in emergency hernia repair. We may get away without major problems in many patients. If u develope complications, it is difficult to defend your decision though for using prosthetic mesh.

i would prefer a primary closure and accept the risk of recurrent hernia(which I prefer to fix laparoscopically) . However if the defect is large, I would do component separation with onlay biological mesh

regards

The interesting discussion on this topic shows how it is important and timely. All the possibilities of treatment in emergency setting of a complicated hernia were discussed by individual AA  that have brought their experience. We found It all in the document from the World Society for Emergency Surgery where is also mentions the possible approach to the disease with a temporary laparostomy with a delayed abdominal closure. Good reading.

Giorgio Vasquez

Good discussion and it is an important practical problem.What our experience goes is doing a conventional repair plan for elective mesh repair as these develop recurrence.we normally teach not to use a prosthetic material.we all know that it is easier to fix a recurrence than to treat mesh infection.I donot have experience with Biological meshes.

Excuse me but I don't understand the the problem. If you have to repair a recurrence hernia and the prosthetic material is well incorporated you don't be afraid about infection. You can repair the recurrence with a pure tissue technique or doing a prosthetic technique without be frightened about risks of infection developing.

This is my opinion

Giorgio Vasquez

just a day ago a 67year old presented with Richter's hernia through a lower abdominal

scar of 5 days duration.Laparoscopically Hernia was reduced along with the omentum.There was haemorragic fluid in the sac.After 100percent oxygenation bowel regained it's colour.

In view of the haemorragic fluid in the sac,I performed repair without a mesh using transabdominal repair with a suture passer needle.Explained the probable recurrence

please comment..

Bowel incarceration with strangulation/perforation means it is an outright contaminated wound. Prosthetic mesh should never be placed in such a situation. However much you clean and irrigate the wound and then create a new plane for placing the mesh, though macroscopically it appears clean, bacteriologically it is highly likely to be contaminated. I prefer to do a component separation repair using native tissues under such circumstances. In cases where there have been multiple prior repairs and healthy tissue is not available to do a component separation repair, I'd use a biological mesh. The downside is the cost and the high chance of recurrence with biological mesh. In our series of 436 cases with ventral hernia, 24 had bowel strangulation and were treated as above and only 1 required a biological mesh.