CASE REPORT Open Access

Mesh removal and reconstruction withposterior components separation techniquefor delayed mesh infection developed10 years after abdominal incisional herniarepair: a rare case reportTetsuro Tamura1,2,4* , Yoshihiro Ohata1,2 and Fujio Katsumoto3

Abstract

Background: Very few literatures can be found reporting cases and treatment strategies of late-onset meshinfection after abdominal incisional hernia reconstruction. Here, we report a rare case of delayed mesh infectiondeveloped 10 years after abdominal incisional hernia repair, which was successfully treated by mesh removal andreconstruction with posterior components separation technique.

Case presentation: A 66-year-old man, who underwent reconstruction of abdominal incisional hernia byretroperitoneal Composix mesh application 10 years prior, developed 12 × 6.0 × 2.5 cm subcutaneous abscessfollowed by methicillin-resistant Staphylococcus aureus (MRSA)-related mesh infection. The operation was performedexcising the abscess wall without damaging peritoneum, and huge intermuscular defect was successfullyreconstructed by posterior components separation technique application.

Conclusions: An early decision of excising contaminated mesh would be preferable to extensive conservativetreatments when mesh infection is suspected. Components separation technique application can be of great helpwhen designing reconstruction of huge intramuscular defect after removal of infected mesh.

Keywords: Incisional hernia, delayed mesh infection, components separation technique, MRSA

BackgroundIncisional hernia is one of the major complications afterabdominal surgery. Recently, tension-free reconstructionconcept, which is known to reduce recurrence comparedto conventional primary closure procedure [1], haswidely been accepted for repairing incisional hernia, andtherefore, nowadays, most of the reconstructions areperformed using mesh. Mesh application is, on the otherhand, known to cause complicated infection on occasion.However, very few literatures can be found reporting casesand treatment strategies of late-onset mesh infection afterabdominal incisional hernia reconstruction. Here, we

report a very rare case of delayed mesh infectiondeveloped 10 years after abdominal incisional herniarepair, which was successfully treated by mesh removaland reconstruction with posterior components separationtechnique.

Case presentationA 66-year-old man, who underwent reconstruction ofabdominal incisional hernia (8 cm in diameter) which wasdeveloped 6 months after his abdominal aorta aneurysmoperation (Y-graft replacement) by retroperitoneal 15 ×8 cm Composix mesh application 10 years prior, visitedour department complaining discharge from his opera-tive wound scar. At first, conservative therapy was initi-ated since the discharge was serous and no symptom ofinfection was observed. Despite intermittent lavage and

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* Correspondence: tetsurot@surg1.med.kyushu-u.ac.jp1Department of Surgery and Oncology, Graduate School of Medical Sciences,Kyushu University, Fukuoka, Japan2Department of Surgery, JR Kyushu Hospital, Moji, Kitakyushu, JapanFull list of author information is available at the end of the article

Tamura et al. Surgical Case Reports (2019) 5:140 https://doi.org/10.1186/s40792-019-0697-3

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drainage for 6 months, however, the discharge was notreduced, and gradually, the properties of it changedinto infective. Mesh infection was strongly suggested,and finally, we planned removal of the infected mesh.At admission, his height was 165 cm, body weight was71.5 kg, and body temperature was normal. The fluidcollection was palpable under his upper midline opera-tive wound scar, and the skin fistula dischargingcontaminated exudates was observed in the middle ofthe wound (Fig. 1). Results of blood examination werewithin normal range except for slightly elevated CRP(1.46 mg/dl). Enhanced abdominal CT showed encap-sulated 12 × 6.0 × 2.5 cm high-dense fluid collectioninvolving microbubbles, suggesting abscess formation(Fig. 2). The operation was performed through uppermidline incision including the skin fistula. Carefuldissection successfully led complete removal of theabscess wall without damaging the peritoneum andabscess wall (Fig. 3). No intestinal fistula was observedthrough the procedure. Judging from the huge size ofintramuscular defect of abdominal wall, simple primaryclosure seemed impossible whereas mesh reattachmentwas not preferable due to potential remnant infection.Therefore, we decided to apply posterior componentsseparation technique (see schema in Fig. 4), and ab-dominal wall reconstruction was successfully achievedby anterior rectus sheath closure (Fig. 5). Resectedspecimen contained an everted mesh, and methicillin-resistant Staphylococcus aureus (MRSA) was identifiedin the abscess contents by postoperative microbialcultivation (Fig. 6). He discharged without any signifi-cant complications, and no recurrence of hernia andsymptom of infection were observed at least 3 yearsafter the reconstruction.

DiscussionIncidence of mesh infection after reconstruction ofabdominal incisional hernia is known to be higher thanthat of inguinal hernia. Although several cases of acute-onset mesh infection after abdominal incisional herniareconstruction were reported, very few reports can befound concerning late-onset (here, we defined "late"as above 6 months after previous hernia repair) mesh in-fection. Only three cases were found to be reported in-cluding descriptions of the details of the case progress[2–4]. In 2006, Jezupovs et al. reported, in their retro-spective analysis of 375 patients applying polypropylenemesh, a case of polyfilament mesh infection developed18 months after recurrent incisional hernia repairfollowed by right subtribe laparotomy [2]. After 1-monthunsuccessful abscess drainage, the 77-year-old manunderwent partial removal of the Citrobacter koseri-in-fected mesh. No description was found how the

Fig. 1 Abdominal appearance of the patient at operation. Dashedcircle shows the range of palpable subcutaneous fluid collection andan arrow indicates the skin fistula

Fig. 2 Preoperative CT suggesting subcutaneous encapsulated 12 ×6.0 × 2.5 cm abscess formation (arrow)

Fig. 3 Complete removal of the abscess wall (dashed circle) withoutdamaging the peritoneum and abscess wall was performed

Tamura et al. Surgical Case Reports (2019) 5:140 Page 2 of 4

reconstruction was performed in the report. In the sameyear, Bliziotis et al. presented a 59-year-old female caseof late-onset mesh infection developed 6 months afterhypogastric abdominal hernia repair followed by anovarian cancer operation 2 years prior [3]. S. aureus wasidentified in his abscess contents. Initial 7 days antibioticmanagement failed, and removal of mesh combined with2-week antibiotic medication led to the cure of infection.Unfortunately, details of the reconstruction were eithernot described. In 2016, Mohamed et al. reported a 44-year-old woman case of huge seroma formation diagnosed5 years after ventral incisional hernia repair [4]. She

underwent an open Roux-en-Y gastric bypass surgery andumbilical hernia repair 7 years prior, and a ventral inci-sional hernia repair using composite mesh 2 years later.Five months of conservative management led to evidenceof highly resistant Pseudomonas aeruginosa infection, andshe underwent mesh explantation and definitive repairwith complex abdominal reconstruction combined withmacroporous monofilament synthetic mesh and porcinedermal graft.These rare cases may propose us at least two import-

ant points of discussion concerning delayed mesh infec-tion after ventral hernia repair. First is that what causesdelayed mesh infection after abdominal incisional herniarepair. At least three mechanisms can be supposed asfollows: (i) remnant infection related to previous oper-ation accompanying with contamination (which mightbe in association with bacterial biofilm formation onmesh), (ii) bacterial translocation followed by some kindof septic events, and (iii) de novo infection, either bymesh-intestine fistula formation or by transcutaneous.Given the four case reviews, the main cause of delayedmesh infection seems retrograde transcutaneous infec-tion arising from prolonged drainage, accompanyingbacterial biofilm, by two facts. One is that all four previ-ous operations were performed in clean, or at least insemi-clean, conditions, and no septic event was observedin their past medical history. The other is that the typesof cultured bacteria (C. koseri, P. aeruginosa, and S.aureus) are known to produce rich biofilm and to causesecondary remnant infection. Another point of discus-sion is how to manage delayed mesh infection afterventral hernia repair. It is possible to recommend avoid-ing prolonged conservative treatments including lavageand drainage when highly biofilm-associated bacteriawere identified from the seroma/abscess contents. Add-itionally, as all four infected meshes were removed, meshremoval seems essential to treat delayed mesh infection

Fig. 4 Schema of the posterior components separation techniqueapplied for the present case. Arrows indicate directions of incision. Adashed line shows midline. 1 Rectus abdominis muscle, 2 externaloblique muscle, 3 internal oblique muscle, 4 transversus abdominismuscle, 5 transversalis fascia and peritoneum, and 6 hernia sac

Fig. 5 Anterior rectus sheath closure

Fig. 6 Excised abscess containing everted mesh. MRSA wasidentified in the abscess contents

Tamura et al. Surgical Case Reports (2019) 5:140 Page 3 of 4

in terms of biofilm debridement. However, the decisionof mesh removal may often be hesitated by technicalreasons especially when primary closure seems difficultor impossible due to huge intramuscular defect aftermesh removal. Components separation technique appli-cation, which is described in the present case, can be ofgreat help of designing reconstruction after removal ofinfected mesh for such cases. This technique is firstintroduced in 1990 by Ramirez et al. [5], of which theprinciple is basically bridging the fascial gap by separat-ing fascial and muscular layers without using prostheticmeshes. Defects up to 20 cm in diameter can be recon-structed in a “tension-free” condition maintainingphysiological abdominal wall function. Although recur-rence rate is relatively high compared to mesh repair,this technique is still attractive especially in contami-nated cases when mesh application should be avoided.

ConclusionsHere, we report a very rare case of delayed MRSA-re-lated mesh infection developed 10 years after abdominalincisional hernia repair, which was successfully treatedby mesh removal and reconstruction with posteriorcomponents separation technique. An early decision ofexcising contaminated mesh would be preferable to ex-tensive conservative treatments, and components separ-ation technique can be a strong option when primaryclosure is not applicable for reconstruction due to ahuge defect after mesh removal.

AbbreviationsCRP: C-reactive protein; CT: Computed tomography; MRSA: Methicillin-resistant Staphylococcus aureus

AcknowledgementsThe authors greatly appreciate Takafumi Kamei, Shun-ichi Takahata, SeiichiroJimi, Akifumi Hayashi, Chizu Kameda, and Rieko Kurihara for their advice andassistance of completing this case report.

Authors’ contributionsTT wrote the manuscript. FK, YO, and TT performed the surgery. All authorsdiscussed, read, and approved the final version of the manuscript.

FundingNone.

Availability of data and materialsThere is no available data and materials to be shared.

Ethics approval and consent to participateNot applicable.

Consent for publicationWritten informed consent for the publication of this case report wasobtained from the patient.

Competing interestsThe authors declare that they have no competing interests.

Author details1Department of Surgery and Oncology, Graduate School of Medical Sciences,Kyushu University, Fukuoka, Japan. 2Department of Surgery, JR Kyushu

Hospital, Moji, Kitakyushu, Japan. 3Katsumoto Day Surgery Clinic, Kitakyushu,Japan. 4Department of Surgery, Shimonoseki City Hospital, 1-13-1 Koyocho,Shimonoseki, Yamaguchi 750-8520, Japan.

Received: 25 June 2019 Accepted: 26 August 2019

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García-Alamino JM. Balancing mesh-related complications and benefits inprimary ventral and incisional hernia surgery. A meta-analysis and trialsequential analysis. PLoS One. 2018;13(6):e0197813. https://doi.org/10.1371/journal.pone.0197813.

2. Bliziotis IA, Kasiakou SK, Kapaskelis AM, Falagas ME. Mesh-related infectionafter hernia repair: case report of an emerging type of foreign-body relatedinfection. Infection. 2006;34:46–8.

3. Jezupors A, Mihelsons M. The analysis of infection after polypropylene meshrepair of abdominal wall hernia. World J Surg. 2006;30:2270–8.

4. Mohamed M, Elmoghrabi A, Shepard WR, McCann M. Delayed onsetseroma formation ‘opting out’ at 5 years after ventral incisional herniarepair. BMJ Case Rep. 2016. https://doi.org/10.1136/bcr-2016-215034.

5. Ramirez OM, Ruas E, Dellon AL. “Components separation” method forclosure of abdominal-wall defects: an anatomic and clinical study. PlastReconstr Surg. 1990;86:519–26.

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https://doi.org/10.1371/journal.pone.0197813https://doi.org/10.1371/journal.pone.0197813https://doi.org/10.1136/bcr-2016-215034

AbstractBackgroundCase presentationConclusions

BackgroundCase presentationDiscussionConclusionsAbbreviationsAcknowledgementsAuthors’ contributionsFundingAvailability of data and materialsEthics approval and consent to participateConsent for publicationCompeting interestsAuthor detailsReferencesPublisher’s Note