ReviewInfections associated with mesh repairs of abdominal wall hernias: Are antimicrobial biomaterials the longed-for solution?
Section snippets
Introduction to mesh-associated infection after hernia repair
Abdominal wall hernia is a common surgical problem affecting patient populations across the world. The main causes of abdominal wall hernia are related to collagen disorders and/or insufficient suture closing techniques after laparotomies (called incisional hernia). The surgical repair of abdominal wall hernia, involves repositioning the contents of the hernia sac (protruded organs) into the abdominal cavity, and consequently the closure and reinforcement of the defect using either a suture
Surgical site infection in herniatology
The Centers for Disease Control (CDC) in the US distinguishes between incisional surgical site infections (SSI) occurring superficially and deeper within the body. By definition, a superficial incisional SSI is an infection involving only the skin or subcutaneous tissues, requiring relatively simple treatment based on wound drainage accompanied by antibiotics administered systematically. Mesh-related infection occurring after hernia surgery is, in contrast, considered a deep incisional SSI, and
Management of mesh-related infections
Generally, early wound SSIs (occurring within 30 days) are relatively easy to identify, with patients presenting symptoms characteristic of infection or inflammation, such as fever, focal tenderness, erythema or swelling [7]. However, late mesh infection can be indolent and more difficult to diagnose [42]. Clinically, the diagnosis of deep abdominal wall infection involving mesh material relies on the localization of peri-prosthetic inflammation with abscess or fistula using radiological
Advances in antibacterial meshes
In order to decrease the risk of developing an infection, a significant amount of work has been done focusing on the functionalization of the prostheses to exhibit anti-infective behaviour. Those strategies can be basically categorized as passive (i.e. optimizing mesh design and macro-/micro-architecture) or active (combining therapeutics to the mesh materials) systems.
Manufacturing technologies
Another important aspect to take into consideration in the development of antimicrobial meshes relies on the available options which are offered for the manufacturing of such bioactive implants. Several physical and chemical methodologies have been reported to combine antimicrobial components to mesh substrates, which will be presented in the next paragraphs.
New strategies to endow mesh with antibacterial resistance
Among the alternatives to pharmaceutical drugs combined to implants to endow anti-bacterial properties, surfaces tethered with polycationic macromolecules have gained lots of interest. Positively charged long-chain quaternary ammoniums are among the ones with the greatest potential. Indeed, polyquaternary ammoniums (PQAs) can interact with the negatively charged membranes of bacteria, inducing biocidal activity by cell lysis. Diverse synthetic substrates have been functionalized using PQAs
Commercially available products and clinical efficacy
Innovation in biomaterials and bioactive systems have paved the way to the development and to the recent commercialization of advanced meshes offering, among the activities, anti-infective protection [124]. Few companies have succeeded in obtaining the FDA clearance of antibiotic-loaded grafts (listed Table 5 and illustrated Fig. 10). The first antibiotic-loaded meshes were developed by GORE (MycroMesh® Plus and DualMesh® Plus, Fig. 10A and B) based on ePTFE patches impregnated with a
Conclusion
The purpose of this review is to provide a broad vision of the problem of mesh-related infection in abdominal wall reconstruction and to expose how the hernia community endeavours to address it. From Deysine's 2004 provoking question “Are we doing all we can?”, we can affirm that tremendous effort has been undertaken from every actor in this field, from biomaterial scientists, microbiologists up to clinicians. One must be aware that, to an apparently minimal 1–4% risk of mesh-related infection
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