Elsevier

Biomaterials

Volume 167, June 2018, Pages 15-31
Biomaterials

Review
Infections associated with mesh repairs of abdominal wall hernias: Are antimicrobial biomaterials the longed-for solution?

https://doi.org/10.1016/j.biomaterials.2018.03.017Get rights and content

Abstract

The incidence of mesh-related infection after abdominal wall hernia repair is low, generally between 1 and 4%; however, worldwide, this corresponds to tens of thousands of difficult cases to treat annually. Adopting best practices in prevention is one of the keys to reduce the incidence of mesh-related infection. Once the infection is established, however, only a limited number of options are available that provides an efficient and successful treatment outcome. Over the past few years, there has been a tremendous amount of research dedicated to the functionalization of prosthetic meshes with antimicrobial properties, with some receiving regulatory approval and are currently available for clinical use. In this context, it is important to review the clinical importance of mesh infection, its risk factors, prophylaxis and pathogenicity. In addition, we give an overview of the main functionalization approaches that have been applied on meshes to confer anti-bacterial protection, the respective benefits and limitations, and finally some relevant future directions.

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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