Comment on: Conservative management of an infected laparoscopic hernia mesh: A case study.

INTRODUCTION: We recently published an article in this journal describing the successful conservative treatment of a patient with an infected laparoscopically inserted hernia mesh using gentamycin flushes via a pig-tail drain and long term oral antibiotics. This prevented the need for major reconstructive surgery. However, 3 months after we published our report, the patient re-presented with symptoms of a recurrence of infection. PRESENTATION OF CASE: Seven months after stopping oral antibiotics, our patient represented with fever and swelling and redness over his left sided inguinal hernia mesh. This mesh had to be surgically removed. The procedure was laparoscopic and showed infection confined to the central 5cm of the mesh. Microbiology culture results were the same as on initial presentation. DISCUSSION: The microbiology results suggest that it is likely that the infection was never fully eradicated and that our intervention merely kept the infection at bay. Once long term antibiotics were stopped it is likely that the infection was able to eventually recur.
CONCLUSION: Consequently, we have been unable to show that our method of conservative management of infected hernia meshes is effective to prevent long term recurrence of infection.

Dear Sir,

We recently published an article in the International Journal of Surgical Case Reports describing the successful conservative treatment of a patient with an infected laparoscopically inserted hernia mesh. As we previously described, the patient underwent ultrasound guided insertion of a pigtail drain which was then used for two gentamycin flushes and then 6 weeks of saline flushes. He also took oral antibiotics for 12 weeks.

After 7 months there was no recurrence of his symptoms and we published our report. However, 3 months later (10 months in total from first presentation) he re-presented with a 5 day history of fever, and swelling and redness over the left sided inguinal mesh. It was decided to remove this mesh surgically. At operation the infection was seen to be confined to the central 5 cm of the mesh. There was pus present. The edges of the mesh were strongly adherent to the surrounding structures including the ipsilateral external iliac vein which required three hours of careful laparoscopic surgery to dissect. Visualisation was good throughout the operation and there was no need to convert to an open procedure. Intraoperative culture results showed the same results as initial cultures on first presentation (heavy growth of Staphylococcus aureus, resistant to penicillin). Our patient remained in hospital for 7 days and returned home fully recovered from his symptoms.

With respect to our choice of mesh material (polyester Patietex Tyco mesh), Kingsnorth et al. have recently demonstrated a significantly lower infection rate compared to polypropylene mesh (2.0 vs. 7.2%, P = 0.032), supporting our choice.

Our culture results suggest that in fact it is unlikely that we ever completely eradicated the initial infection. It is likely that our conservative management of this infected laparoscopically inserted mesh merely kept the infection at bay and that once long term antibiotics were stopped this allowed eventual recurrence of infection. Consequently, we have been unable to show that this is an effective method for long term management of this condition.

Conflict of interest

None.

Funding

None.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author Contributions

Duncan Alston – writing the follow up letter; Stephanie Parnell – involved in original publication; Bhupinder Hoonjan – involved in original publication; Arun Sebastian – involved in original publication; Adam Howard – senior author.