I wouldnt use a prosthetic MESH. you can fashion a biological in the shape of the prosthetic and use it as a reinforcement of your repair.

Reinforcement of the anatomic repair with a biologic mesh would be my preference

I would be happy to use a synthetic mesh in a retromuscular position in a stable non septic patient.

I use a synthetic mesh in a retromuscular position in a stable non septic patient

I use a mesh in the same way as without a resection

I agree completely with Alberto Meyer

I think you have two options.

1. Use of a biological mesh if there is a degree of contamination but not a significant amount as these can still get infected.

2. Perform your repair without a mesh. Better to repair a recurrent hernia electively than deal with the morbidity of an infected mesh.

In the literature it is stated that the use of mesh is not contra-indicated. For many surgeons also it is controversial if the biological mesh is superior to a synthetic one. I personally wouldn’t use a mesh in contaminated environment, but this is only my personal opinion.

I will definitely use a mesh if there is no spillage after plenty of saline irrigation n good coverage for staph infections.

Assuming the patient is stable, not septic and would contamination is minimal, I would use a synthetic mesh. This patient would need adequate antibiotics and good followup after the surgery. Otherwise, If the above critera are not met I would do a tension repair and risk repairing a recurrent hernia than get wound sepsis.

It is not wise to use a mesh. Its better close the abdomen if it is feasible and if the patients suffers from a hernia then u will be able to use a mesh. If the abdomen cannot be closed is better to use a biological mesh or better use a technique using the aponeurosis of the muscles and make relaxing incisions in ordrr to close the abdomen

By the way, I would not attempt to do mesh repair if it is large bowel resection.

If resection is performed in a not contaminated field, I prefer to close the peritoneum and to locate a mesh in extraperitoneal position.

In the last 25 years i have had hunfreds of emergecy repairs with or whiout bowel resectionsin the inguinal or femoral region using prolene based meshes, fom plain Marlex to PHS devices. Any infections and very low rate of recerrences or pain.

Anyway, in an incisional hernia repair in emergency setting, biologic meshes can play a role. Not cross-linked meshes if a mild to moderate contamination is present, cross-linked in the other cases. Always in retromuscolar preperitoneal position.

The experience at our center with emergency repair of abdominal wall hernias in a contaminated field has shown that although the use of polypropylene mesh may predispose to surgical site infection but it is very infrequent to have a severe infection requiring explantation.

If contamination is significant, then the mesh is placed in onlay position with the wound left open for delayed closure once the Prolene mesh has granulation tissue over it..

a point worth pondering over is that an anatomic closure under tension predisposes a patient to the same risk for which the emergency operation is being done..

regards, raza

Article Emergency incisional hernia repair: A difficult problem wait...

We use proline mesh when there is minimal soiling or spillage. the surgical field is washed wish saline mixed with gentamycin. after surgery, the patients recieved triple antibiotic therapy to cover gram negative, gram positive and anerobic organisms,, and the patient is closely observed.

i am sure that the biological mesh is a much better option in these circumstance, put its high price still being the caue of not being used widely Egypt.

Till now, no cases of infected mesh.

Would tend not to use a mesh at all for an inguinal/femoral or small incisional hernia in the presence of infarcted bowel. I would rather repair a recurrent hernia, and in reality many will not recur and of those that do many will not represent with obstruction/strangulation. Biological mesh is an option, especially for a large complex hernia that you really don't want to come back to but funding is often an issue in NHS and they may not be available for an emergency procedure. I would still hesitate to use any form of mesh if gross contamination (faecal spillage) is present.

In theory, the only contraindication of a mesh in this case would be massive feccal soiling of the wound. In reality, as a young and (still) inexperienced surgeon, I'd stay on the safe side and not use a mesh, preferring to deal with problematic hernia recurrence at a later time rather than risk an imminent infection. Of course, this is only a matter of choice.

In limited (even feacal soiling) i would still use a mesh.

In other words, in a emergency setting you can safely repair a ventral/ inguinal hernia using Prolene mesh or Marlex mesh. For biologic meshes there are small evidences. The key point is to do not a repair in infected field with PTFEe because the mesh infection is guaranted

I would agree with David Bartlett. In resource strapped settings where getting biological meshes is an issue and the defect is small, tension repair is still the standard. Recurrences are rare especially for groin hernias and recovery for the groin hernia patients is usually uneventfully unless their was massive soiling. For large abdominal hernia on the other hand, one can make tension releasing incisions after the repair and follow up the patient closely.

To my opinion there is no general answer available by having a look into the literature. Own experience and data (as far as I know them) show, that it depends on the ammount of contamination of the operating field. If you have to do a bowel (even large bowel) resection without presence of perforation in a clean-contamined field, I would perform a mesh-augmented repair by positioning the mesh in a preperitoneal (TAPP) or retromuscular (Sublay) position without any fear of mesh infection. There are some data, that in all of these cases a macroporous (light-weight) monofilamentary mesh (PP) should be prefered. In cases of (large) bowel perforation and contaminated or even dirty fields you have a problem. There are some data, that implantation of biogenics could be useful, but there without any doubt no consensus or even good evidence.

Yes we can use mesh and it is the same rate of infection

The aim of surgery in a patient who needs emergency for strangulated bowel is to perform a life saving procedure; the possibility of recurrence of hernia goes in the background at this juncture. I would do only an anatomical repair and if a recurrence occurs would rather treat it later in non emergency setting.

We do not use meshes in contaminated areas. This was the consensus of the IEHS meeting 2008 in Stuttgart (Germany). There was the recommendation, that when because of bowel wall defect during adhesiolysis in hernia surgery, mesh implantation should have a delay of ~ 5-6 days.

In the given situation,it is best not use a prosthtic material.It is easier to tackle a recurrence than mesh infection.

I'm sorry, but we are making a non sense discussion. In the era of EBM validation and guidelines for everything procedures, an issue in which the best level of evidence is the level 4 (personal experience), the surgeons who have got much experience, are the the experts you must follow. I have got 25 years of experience, and I have wrote what I think and what is the best practice right now.

wow.. very strong feelings from surgeons regarding both aspects of treatment... this reflects a strong commitment to patient care..

i think with no high quality evidence (level 4 being the best as mentioned by Dr Vasquez), individual surgeons can contine their practices as per their teachings and experiences.. However, in order to change practice eitherway, a higher level of evidence will be required...

regards, raza

Dear Dr Bonnano,

Thank you very much for your generous comments.. and for finding the topic 'cute'!!!

I agree that the spectrum of pathology varies, and so does the degree of contamination as mentioned in many of the comments above.. the fact remains that we need high quality studies possibly by collaboration of multiple centres in order to come up with recommendations to change practice..

regards, raza

i agree with dr. Bonano, it depends on kind of contamination, usually we found gangrenous bowel without significant contamination, in addition in any cases, we can use mesh after abdominal toilet at the absence of fecal or suppurative peritonitis!

There is a method that we used it in strangulated hernias and after enteroctomy.This method is effective even more in large ventral herniaswith defects.Close the peritoneal defect and use a prolene suture in a plication technique, darn repair. No infection and abdominal wall strengthening,100%!

The pros and cons of using a mesh seem clear. I would refrain from using a mesh because a recurrent hernia is not hard to deal with, while mesh infection can be very messy and may not clear with intervention at one go.

De Bakey postulated surgery to be: ' safe, simple and short'. In cases of emergency hernia repair ' safe' means to avoid the risk of mesh infection. As Anthony Fung mentioned mesh infection is a very messy situation to treat.

I prefer not to keep a mesh in this situation. There is an interesting article published in World journal of Surgery, recently - Prophylactic mesh reinforcement reduces stomal site incisional hernia after ileostomy closure.Liu DS, Banham E, Yellapu S. World J Surg. 2013 Sep;37(9):2039-45. doi: 10.1007/s00268-013-2109-3.Results of this study show a significant reduction in the rate of incisional herniation following routine mesh placement, without increasing the rate of wound complications despite the use of prosthetic material in a contaminated area.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Prophylactic+Mesh+Reinforcement+Reduces+Stomal+Site+Incisional+Hernia+after+Ileostomy+Closure.+Liu+DS%2Cet+al.+World+J+Surg.+2013+May+29.+%5BEpub+ahead+of+print%5D

Of course, you can use a mesh in contamination. Although the different experts opinion have advocated against their use, there is no evidence not use them. On the contrary, there is a good number of clinical studies using a mesh without adding morbidity to the procedure

Here I left you a link with a powerpoint presentation about this issue (sorry because it is in Spanish, but you have there all the references)

http://www.herniatoday.com/es/recursos-electronicos/documentos/cat_view/47-ponencias

Interesting problem which will attract varied opinions. My policy is to deploy mesh except in cases where gangrenous bowel needs resection

According to: WSES guidelines for emergency repair of complicated abdominal wall hernias. World Journal of Emergency Surgery 2013, 8:50

**Emergency hernia repair in “potentially contaminated surgical field”**

For patients with intestinal strangulation and/or concurrent bowel resection (potentially contaminated surgical field), direct suture is recommended when the hernia defect in question is small. Synthetic mesh repair may be performed, but with caution. Biological meshes may be a valid option but merit detailed cost-benefit analysis (grade 2C recommendation).

Article WSES guidelines for emergency repair of complicated abdomina...

I prefer not to use a mesh. I would use it only if it is absolutely necessary and the bowel ressection did not contaminate the wound.

A superior percentage of mesh infections, even if low, badders me.

Joan Viñas

Absolutely no! Too dangerous mesh implant in potentially infected site. We usually use Bassini tecnique in strangulated inguinal hernias. The recurrence rate is 6%, if i remember right.

Biological or third generation mesh products have been making a move forward in this particular field. Surely enough, studies still need to prove which particulat mesh can be the best prosthesis.

I believe if there is mild to moderate contamination, and an adequate "control and cleaning" can be achieved, a biological mesh can be used to prevent or repair a hernia defect.

Alternatively with darn repair that I mentioned above,I use a light mesh from Bard(It is the lihtest mesh Ive seen, very macroporous,)and medicate it in Voncon or Fucidin (there is strong literature support to this medication)solution .I ve never had problems with that technique.

I insist. Do not fear to use a mesh. You must read this quite interesting review

http://www.ncbi.nlm.nih.gov/pubmed/24035085

we are loosing the core of disease. In strangulated inguinal, crural or incisional hernias the real problem is quoad vitam. The hernia recurrence is secondary. I confirm that is better a recurrence in an healthful patient than the risk of infected mesh. i'll read with interest the article you cited but i think that in in emergency surgery the common sense should prevail

I'm a little bit skeptical about a recurrence rate of 6% in a Bassini's procedure in emergency setting, this could be a good result in elective surgery. Anyway, if You're afraid to do a prosthetic repair, Shouldice procedure may be a better solution. Anyway in my experience, I have operated on dozens of strangled hernias, putting prolene meshes, and I'm still waiting the 1st prosthetic infection.

Contrary to the traditional belief of significant risk of infection of mesh following resection of strangulated bowel, there is an increasing use of prosthetic materials in a contaminated field after proper debridement and post-operative antibiotics administration, leading to satisfactory outcomes. Clearly, infected mesh is a disaster, which, fortunately, does not happen as often as presumed. Bassini or Shouldice repairs are option for those who are against mesh repair in these situations.

Options would definitely be linked to the physiological status of the patient,the amount of contamination, level of experience of the surgeon performing the operation, but above all else common sense to avoid post operative infection should prevail over untested personal preferences

It is interesting to see how we are evolving in hernia surgery. From anatomical repairs to mesh repairs and statistics to confirm the improvement in recurrence rates.Well just a decade back we were practising nil per oral for patients who have had bowel surgery.Now we practice early start of oral feeds!! I think with development in mesh technology and antibiotics, it is not far when the recommendation would soon be to repair infected herniae with mesh and there will be statistics to back it too!! Although at the present time i do tend to agree with the more conservative management of playing safe.

Probably the incidence of mesh infection after a simple bowel anastomosi without fecal contamination is low. However, we should consider two other aspects: first a recurrent hernia is not a real life-threatening problem. Second, consider the risk of malpractice claim in case of infection....

I agree with Bencini's thoughts. Deal with the emergency and if you feel the risks of infection are high just do a modified Basinis repair. Personally I have seen very low recurrence rates with modified Bassinis repair, of which I used to practice frequently more than 10years ago ( Odula et al, 2004). However, mesh infection in a patient who had bowel resection can cause quite a bit of anxiety to everybody compared to a hernia recurrence. I am sure surgeons in the developed world would have a slightly different experience.

think about the present -remove the affected bowel , do a Bassini or Shouldice and save the patients life-he will then live to get his hernia repaired (in case of a recurrence) ----later as a peaceful elective procedure.

Patient age is very important.In elderly Bassini or Shouldice.In young man and adult mesh repair.

Either biological mesh or repair with the 'darning' technique described by Maingot

Also please refer "WSES guidelines for emergency repair of complicated abdominal wall hernias".

I was one of the co-authors of this study.

There is no definite guideline for this situation. Due judgement has to be made at the time of surgery. Strangulation without perforation in a patient who otherwise is well re-hydrated, resuscitated and has received adequate antibiotic cover at induction can safely receive a mesh with the comparable risk as in an elective repair. In a very ill patient, or where perforation and/spillage is evident, better to err on the side of a recurrence later than use a mesh with high risk of infection.

Your opinion is sound Dr. Kyamanywa but for the fact that a strangulated bowel without perforation could still produce infected/toxic fluid, which will surely predispose to mesh infection.

Agreed Dr. Rangarajan. Surgical principles of handling sepsis still have to be observed even without perforation. Although there is fluid and flora translocation with Strangulation the infection risk from an open bowel is much higher.

Point taken sir

In strangulated hernia that too in an emergency setting mesh application is probably not advisable. Again site of hernia is even more important. A strangulated ventral hernias will be more prone to infection

i prefer to do a macvay. I do not use mesh.

We use mesh unless the bowel is ruptured. Our experiences of 94 cases are described in the following paper. The summary is written in English.

Clinical study of incarcerated inguinal and femoral hernia

Shinichi Umeda, Takehiro Hachisuka, Nobuhiko Kurata

Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association) 01/2014; 75(3).

Dr.Hachisuka,

Would be so kind as to give a short answer is there or not any bacteriological data in the article of yours, please? If yes, what was CFU count and which genera were found in your investigation?

I have read this topic consisting of 64 answers and thousands of words (partly truncated though) from various countries and surprised, honestly to say. There is no any bacteriological data on the hernial sac contents for the strangulated hernia at all.

So that, all the results remain empiric, the very discussion is just a collection of monologues, 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.

In the light of this discovery about the informational gap existing for now, I am going to start a serious investigation on the strangulated herniae microlandscape in my hospital, but forced to wait for them. It is pity (or lucky) that there has no any true strangulation in the city district for the last 6 months! We have seemingly cured all the hernia...

Thank you for you comment, Prof. Andrey Borodach.

We do not have any bacterological data in our paper.

It is only a result after our challenge.

We try to collect data from now. TH

If a bowel resection is needed, the best solution in my opinion is to postpone the use of a mesh for another surgical procedure if necessary. The risk of septic contamination of the mesh seems to me high enough to disagree with the use of a mesh during the same procedure with bowel resection.

I would prefer to have a recurrence rather than an infected mesh, which has to be removed and not very pleasant. However I have seen some of my colleagues use mesh after small bowel resection with no problems.

I prefer to do darn repair than using mesh. The risk of getting infected mesh seems to be high.

Please remember suture material is as much of a foreign body as a mesh is. Best not to use anything at all and go back later to repair the hernia properly. Saying that I do use a piper mesh repair if I feel there is no contamination at all. It is a risk, I believe.

Dr Bhutiani, Do you mean you do not perform ANY repair and come back later ?

Suture repair only

NO MESH

No mesh. High risk of infection.

Nothing to disagree with Bruno Benini. The summom bonnum is summated in what he says. If consumed by a desire to prevent recurrence in a backdrop of physiologically optimized healthy patient, anatomical reconstruction is the corner stone of evidence based practice. If & only if the visceral cover is not achievable anatomically than a biological mesh will be appropriate surgical rescue.

I am sorry Brij, I am lost. I would totally agree with Bruno. It is better to have a alive healthy patient with a recurrent hernia than a dead patient with repaired hernia. Yes Biological mesh is an alternative, but at what cost. Is it really worth it?

Always an open repair in the above mentioned circumstances.This what I teach my students.Instead of doing a series of operations,repair the recurrence if they develop.

Completely agree - acutely in this situation I would not use mesh. I often tighten the deep ring medially with sutures ("Marcy repair") and would come back for elective hernia repair once they are over it, ideally in a virgin plane i.e. TEP repair.

I have worked with colleagues who have used resorbable mesh e.g. Vypro in such situations without problems. My feeling is why take the risk, so I don't use mesh, absorbable or not.

Does anyone have any experience with the "Desarda repair". It's an elegant tissue repair that negates the need for mesh, has similar recurrence rates and seems ideal in such cases?

Thanks,

J.

Exactly Dr. Bhutiani, i said the same thing & agreed with Bruno in entirety,:-)