The safety and efficacy of prosthetic hernia repair in clean-contaminated and contaminated wounds

Prosthetic mesh reinforcement of abdominal wall hernias has gained acceptance as a result of its ease of placement and a favorably low incidence of hernia recurrence. However, its use in contaminated wounds secondary to open bowel exposure is felt to be contraindicated because of potential septic complications and lack of incorporation. The impact of permanent mesh placement in contaminated fields on wound morbidity, hernia recurrence, and mortality was examined. Records of 24 consecutive patients having permanent mesh placement in contaminated wounds for repair of abdominal wall hernias between 1994 and 2001 were reviewed. Factors examined included age, hernia type, body mass index, comorbidity, degree of contamination, concurrent gastrointestinal procedures, wound morbidity, and mortality. The mean age and body mass index were 63 years and 26.1 kg/m2 respectively. Twelve patients had risk factors for wound complications or were immunocompromised. There were 11 incisional, eight parastomal, two femoral, and two inguinal repairs and one obturator hernia repair. Twenty-three were repaired with polypropylene and one with Gore-Tex mesh. Prosthetic herniorrhaphy was performed in nine patients with ostomies already in place and in 15 patients with concomitant bowel resections. Of those with bowel resections five had enterocutaneous fistulae, three had bowel resection because of injury during mobilization, six had resections for necrotic bowel, and one had enterostomy closure. Fourteen cases were clean contaminated and ten contaminated. Eight cases were performed under emergency conditions. Wound-related morbidity occurred in five patients (21%) and in all but one was limited to cellulitis and minor wound infections. Three patients died, but in all cases death was unrelated to the surgical procedure. No patient required mesh removal. One patient had a recurrent hernia after parastomal repair. Placement of permanent mesh prostheses in clean-contaminated and contaminated operative fields can be performed with minimal wound-related morbidity and patient mortality. Utilization of permanent mesh in these wounds is associated with a low incidence of hernia recurrence and eliminates the need for further surgery.