Post-surgical Hidden Costs: Infections

  • Massimo PuotiEmail author
  • Dalila Patrizia Greco
  • Marco Merli
  • Claudia Abbati


Surgical site infection (SSI) represents a possible complication after abdominal wall surgery, estimated between 0% and 10% of cases. As for all SSIs, patient’s clinical status at the time of surgical intervention mainly determines the risk of infections. Staphylococcus species is the most common causative agents. Especially when involving the mesh, post-abdominal wall surgery infections are burdened by a dramatic increase in the costs (up to ten times in the case of sepsis) of post-operative medical and nursing care, both in terms of new hospital admissions and outpatients visits and treatments. In order to reduce the risk of infection, prosthetic materials need to be accurately selected on the basis of patient’s clinical and anatomical characteristics. Moreover, antimicrobial prophylaxis needs to be administered in case of urgent operation and/or contaminated surgical field and should also be considered in patients with increased preoperative risk for infection. When infection has already occurred, imaging and microbiological assessment are mandatory in order to provide the exact extension of the infectious process and the implicated pathogen. These clue data will guide the appropriate treatment. Early definite diagnosis is necessary for appropriate management, even to permit a successful conservative treatment. Nonetheless, combined surgical and medical approach is usually required to achieve clinical cure and avoid hernia and/or infection recurrence.


Surgical infection Hernia mesh Health care costs 


  1. 1.
    Burger JWA, Luijendijk RW, Hop WCJ, Halm JA, Verdaasdonk EGG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg. 2004;240(4):578–83; discussion 583-585PubMedPubMedCentralGoogle Scholar
  2. 2.
    den Hartog D, Dur AHM, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev. 2008;3:CD006438.Google Scholar
  3. 3.
    Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital infection control practices advisory committee. Infect Control Hosp Epidemiol. 1999;20(4):250–78; quiz 279–80PubMedGoogle Scholar
  4. 4.
    Woods RK, Dellinger EP. Current guidelines for antibiotic prophylaxis of surgical wounds. Am Fam Physician. 1998;57(11):2731–40.PubMedGoogle Scholar
  5. 5.
    Juvany M, Hoyuela C, Trias M, Carvajal F, Ardid J, Martrat A. Impact of surgical site infections on elective incisional hernia surgery: a prospective study. Surg Infect. 2018.
  6. 6.
    Othman I. Prospective randomized evaluation of prophylactic antibiotic usage in patients undergoing tension free inguinal hernioplasty. Hernia. 2011;15(3):309–13.PubMedGoogle Scholar
  7. 7.
    Shankar VG, Srinivasan K, Sistla SC, Jagdish S. Prophylactic antibiotics in open mesh repair of inguinal hernia—a randomized controlled trial. Int J Surg Lond Engl. 2010;8(6):444–7.Google Scholar
  8. 8.
    MacCormick AP, Akoh JA. Survey of surgeons regarding prophylactic antibiotic use in inguinal hernia repair. Scand J Surg. 2018;107:208–11.PubMedGoogle Scholar
  9. 9.
    Bower C, Roth JS. Economics of abdominal wall reconstruction. Surg Clin North Am. 2013;93(5):1241–53.PubMedGoogle Scholar
  10. 10.
    Totten CF, Davenport DL, Ward ND, Roth JS. Cost of ventral hernia repair using biologic or synthetic mesh. J Surg Res. 2016;203(2):459–65.PubMedGoogle Scholar
  11. 11.
    Römling U, Kjelleberg S, Normark S, Nyman L, Uhlin BE, Åkerlund B. Microbial biofilm formation: a need to act. J Intern Med. 2014;276(2):98–110.PubMedGoogle Scholar
  12. 12.
    Lynch AS, Robertson GT. Bacterial and fungal biofilm infections. Annu Rev Med. 2008;59:415–28.PubMedGoogle Scholar
  13. 13.
    Lewis K. Persister cells. Annu Rev Microbiol. 2010;64:357–72.PubMedGoogle Scholar
  14. 14.
    Bueno-Lledó J, Torregrosa-Gallud A, Sala-Hernandez A, Carbonell-Tatay F, Pastor PG, Diana SB, et al. Predictors of mesh infection and explantation after abdominal wall hernia repair. Am J Surg. 2017;213(1):50–7.PubMedGoogle Scholar
  15. 15.
    Brown RH, Subramanian A, Hwang CS, Chang S, Awad SS. Comparison of infectious complications with synthetic mesh in ventral hernia repair. Am J Surg. 2013;205(2):182–7.PubMedGoogle Scholar
  16. 16.
    Chung L, Tse GH, O’Dwyer PJ. Outcome of patients with chronic mesh infection following abdominal wall hernia repair. Hernia. 2014;18(5):701–4.PubMedGoogle Scholar
  17. 17.
    Shubinets V, Carney MJ, Colen DL, Mirzabeigi MN, Weissler JM, Lanni MA, et al. Management of infected mesh after abdominal hernia repair: systematic review and single-institution experience. Ann Plast Surg. 2018;80(2):145–53.PubMedGoogle Scholar
  18. 18.
    Tolino MJ, Tripoloni DE, Ratto R, Garcia MI. Infections associated with prosthetic repairs of abdominal wall hernias: pathology, management and results. Hernia. 2009;13(6):631–7.PubMedGoogle Scholar
  19. 19.
    Petersen S, Henke G, Freitag M, Faulhaber A, Ludwig K. Deep prosthesis infection in incisional hernia repair: predictive factors and clinical outcome. Eur J Surg. 2001;167(6):453–7.PubMedGoogle Scholar
  20. 20.
    Langbach O, Holmedal SH, Grandal OJ, Røkke O. Adhesions to mesh after ventral hernia mesh repair are detected by MRI but are not a cause of long term chronic abdominal pain. Gastroenterol Res Pract. 2016;2016:2631598.PubMedGoogle Scholar
  21. 21.
    Pérez-Köhler B, Bayon Y, Bellón JM. Mesh infection and hernia repair: a review. Surg Infect. 2016;17(2):124–37.Google Scholar
  22. 22.
    Aufenacker TJ, Koelemay MJW, Gouma DJ, Simons MP. Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia. Br J Surg. 2006;93(1):5–10.PubMedGoogle Scholar
  23. 23.
    Erdas E, Medas F, Pisano G, Nicolosi A, Calò PG. Antibiotic prophylaxis for open mesh repair of groin hernia: systematic review and meta-analysis. Hernia. 2016;20(6):765–76.PubMedGoogle Scholar
  24. 24.
    Cevasco M, Itani KMF. Ventral hernia repair with synthetic, composite, and biologic mesh: characteristics, indications, and infection profile. Surg Infect. 2012;13(4):209–15.Google Scholar
  25. 25.
    Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg. 2000;190(6):645–50.PubMedGoogle Scholar
  26. 26.
    Grant AM, EU Hernia Trialists Collaboration. Laparoscopic versus open groin hernia repair: meta-analysis of randomised trials based on individual patient data. Hernia. 2002;6(1):2–10.PubMedGoogle Scholar
  27. 27.
    Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg. 2003;238(3):391–9; discussion 399-400PubMedPubMedCentralGoogle Scholar
  28. 28.
    Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2012;2:CD003769.Google Scholar
  29. 29.
    Stremitzer S, Bachleitner-Hofmann T, Gradl B, Gruenbeck M, Bachleitner-Hofmann B, Mittlboeck M, et al. Mesh graft infection following abdominal hernia repair: risk factor evaluation and strategies of mesh graft preservation. A retrospective analysis of 476 operations. World J Surg. 2010;34(7):1702–9.PubMedGoogle Scholar
  30. 30.
    Simchen E, Rozin R, Wax Y. The Israeli Study of Surgical Infection of drains and the risk of wound infection in operations for hernia. Surg Gynecol Obstet. 1990;170(4):331–7.PubMedGoogle Scholar
  31. 31.
    Samel S, Keese M, Kleczka M, Lanig S, Gretz N, Hafner M, et al. Microscopy of bacterial translocation during small bowel obstruction and ischemia in vivo—a new animal model. BMC Surg. 2002;2:6.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Edwards JR, Peterson KD, Mu Y, Banerjee S, Allen-Bridson K, Morrell G, et al. National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009. Am J Infect Control. 2009;37(10):783–805.PubMedGoogle Scholar
  33. 33.
    Malone DL, Genuit T, Tracy JK, Gannon C, Napolitano LM. Surgical site infections: reanalysis of risk factors. J Surg Res. 2002;103(1):89–95.PubMedGoogle Scholar
  34. 34.
    Meagher H, Clarke Moloney M, Grace PA. Conservative management of mesh-site infection in hernia repair surgery: a case series. Hernia. 2015;19(2):231–7.PubMedGoogle Scholar
  35. 35.
    Cobb WS, Carbonell AM, Kalbaugh CL, Jones Y, Lokey JS. Infection risk of open placement of intraperitoneal composite mesh. Am Surg. 2009;75(9):762–7; discussion 767-768PubMedGoogle Scholar
  36. 36.
    Eriksen JR, Gögenur I, Rosenberg J. Choice of mesh for laparoscopic ventral hernia repair. Hernia. 2007;11(6):481–92.PubMedGoogle Scholar
  37. 37.
    Engelsman AF, van Dam GM, van der Mei HC, Busscher HJ, Ploeg RJ. In vivo evaluation of bacterial infection involving morphologically different surgical meshes. Ann Surg. 2010;251(1):133–7.PubMedGoogle Scholar
  38. 38.
    Baucom RB, Ousley J, Oyefule OO, Stewart MK, Phillips SE, Browman KK, et al. Evaluation of long-term surgical site occurrences in ventral hernia repair: implications of preoperative site independent MRSA infection. Hernia. 2016;20(5):701–10.PubMedGoogle Scholar
  39. 39.
    Hawn MT, Gray SH, Snyder CW, Graham LA, Finan KR, Vick CC. Predictors of mesh explantation after incisional hernia repair. Am J Surg. 2011;202(1):28–33.PubMedGoogle Scholar
  40. 40.
    Jezupovs A, Jezupors A, Mihelsons M. The analysis of infection after polypropylene mesh repair of abdominal wall hernia. World J Surg. 2006;30(12):2270–8; discussion 2279-2280PubMedGoogle Scholar
  41. 41.
    Falagas ME, Kasiakou SK. Mesh-related infections after hernia repair surgery. Clin Microbiol Infect. 2005;11(1):3–8.PubMedGoogle Scholar
  42. 42.
    Sanchez VM, Abi-Haidar YE, Itani KMF. Mesh infection in ventral incisional hernia repair: incidence, contributing factors, and treatment. Surg Infect. 2011;12(3):205–10.Google Scholar
  43. 43.
    Taylor SG, O’Dwyer PJ. Chronic groin sepsis following tension-free inguinal hernioplasty. Br J Surg. 1999;86(4):562–5.PubMedGoogle Scholar
  44. 44.
    Yerdel MA, Akin EB, Dolalan S, Turkcapar AG, Pehlivan M, Gecim IE, et al. Effect of single-dose prophylactic ampicillin and sulbactam on wound infection after tension-free inguinal hernia repair with polypropylene mesh: the randomized, double-blind, prospective trial. Ann Surg. 2001;233(1):26–33.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Paton BL, Novitsky YW, Zerey M, Sing RF, Kercher KW, Heniford BT. Management of infections of polytetrafluoroethylene-based mesh. Surg Infect. 2007;8(3):337–41.Google Scholar
  46. 46.
    Trunzo JA, Ponsky JL, Jin J, Williams CP, Rosen MJ. A novel approach for salvaging infected prosthetic mesh after ventral hernia repair. Hernia. 2009;13(5):545–9.PubMedGoogle Scholar
  47. 47.
    Slomka JM, Laker S, Chandrasekar P, Paull DE. Failure to obtain microbiological culture and its consequence in a mesh-related infection. BMJ Case Rep. 2013;2013
  48. 48.
    Szczerba SR, Dumanian GA. Definitive surgical treatment of infected or exposed ventral hernia mesh. Ann Surg. 2003;237(3):437–41.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Langer C, Schaper A, Liersch T, Kulle B, Flosman M, Füzesi L, et al. Prognosis factors in incisional hernia surgery: 25 years of experience. Hernia. 2005;9(1):16–21.PubMedGoogle Scholar
  50. 50.
    Nobaek S, Rogmark P, Petersson U. Negative pressure wound therapy for treatment of mesh infection after abdominal surgery: long-term results and patient-reported outcome. Scand J Surg. 2017;106(4):285–93.PubMedGoogle Scholar
  51. 51.
    Tamhankar AP, Ravi K, Everitt NJ. Vacuum assisted closure therapy in the treatment of mesh infection after hernia repair. Surgeon. 2009;7(5):316–8.PubMedGoogle Scholar
  52. 52.
    Berrevoet F, Vanlander A, Sainz-Barriga M, Rogiers X, Troisi R. Infected large pore meshes may be salvaged by topical negative pressure therapy. Hernia. 2013;17(1):67–73.PubMedGoogle Scholar
  53. 53.
    Kathju S, Nistico L, Melton-Kreft R, Lasko L-A, Stoodley P. Direct demonstration of bacterial biofilms on prosthetic mesh after ventral herniorrhaphy. Surg Infect. 2015;16(1):45–53.Google Scholar
  54. 54.
    Liang MK, Li LT, Nguyen MT, Berger RL, Hicks SC, Kao LS. Abdominal reoperation and mesh explantation following open ventral hernia repair with mesh. Am J Surg. 2014;208(4):670–6.PubMedGoogle Scholar
  55. 55.
    Nguyen MT, Li LT, Hicks SC, Davila JA, Suliburk JW, Leong M, et al. Readmission following open ventral hernia repair: incidence, indications, and predictors. Am J Surg. 2013;206(6):942–8; discussion 948-949PubMedGoogle Scholar
  56. 56.
    Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis. 2003;9(2):196–203.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Plymale MA, Ragulojan R, Davenport DL, Roth JS. Ventral and incisional hernia: the cost of comorbidities and complications. Surg Endosc. 2017;31(1):341–51.PubMedGoogle Scholar
  58. 58.
    Wade A, Plymale MA, Davenport DL, Johnson SE, Madabhushi VV, Mastoroudis E, et al. Predictors of outpatient resource utilization following ventral and incisional hernia repair. Surg Endosc. 2018;32(4):1695–700.PubMedGoogle Scholar
  59. 59.
    Deysine M. Infection control in a hernia clinic: 24 year results of aseptic and antiseptic measure implementation in 4,620 “clean cases.”. Hernia. 2006;10(1):25–9.PubMedGoogle Scholar
  60. 60.
    HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22(1):1–165.Google Scholar
  61. 61.
    Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343–403.PubMedPubMedCentralGoogle Scholar
  62. 62.
    Köckerling F, Bittner R, Jacob D, Schug-Pass C, Laurenz C, Adolf D, et al. Do we need antibiotic prophylaxis in endoscopic inguinal hernia repair? Results of the Herniamed Registry. Surg Endosc. 2015;29(12):3741–9.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Birindelli A, Sartelli M, Di Saverio S, Coccolini F, Ansaloni L, van Ramshorst GH, et al. 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg. 2017;12:37.PubMedPubMedCentralGoogle Scholar
  64. 64.
    Wiegering A, Sinha B, Spor L, Klinge U, Steger U, Germer CT, et al. Gentamicin for prevention of intraoperative mesh contamination: demonstration of high bactericide effect (in vitro) and low systemic bioavailability (in vivo). Hernia. 2014;18(5):691–700.PubMedGoogle Scholar
  65. 65.
    Reinbold J, Hierlemann T, Urich L, Uhde A-K, Müller I, Weindl T, et al. Biodegradable rifampicin-releasing coating of surgical meshes for the prevention of bacterial infections. Drug Des Devel Ther. 2017;11:2753–62.PubMedPubMedCentralGoogle Scholar
  66. 66.
    Gurusamy KS, Allen VB. Wound drains after incisional hernia repair. Cochrane Database Syst Rev. 2013;12:CD005570.Google Scholar
  67. 67.
    Ehrlich G, Hu F, Lin Q. Intelligent implants to battle biofilms. ASM News. 2004;70(3):127–33.Google Scholar
  68. 68.
    Williamson ED, Savage VL, Lingard B, Russell P, Scott EA. A biocompatible microdevice for core body temperature monitoring in the early diagnosis of infectious disease. Biomed Microdevices. 2007;9(1):51–60.PubMedGoogle Scholar
  69. 69.
    Schmidt DJ, Moskowitz JS, Hammond PT. Electrically triggered release of a small molecule drug from a polyelectrolyte multilayer coating. Chem Mater. 2010;22(23):6416–25.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Massimo Puoti
    • 1
    Email author
  • Dalila Patrizia Greco
    • 2
  • Marco Merli
    • 1
  • Claudia Abbati
    • 3
    • 4
  1. 1.Division of Infectious DiseaseNiguarda HospitalMilanItaly
  2. 2.Day&Week Surgery UnitOspedale Niguarda Ca’ GrandaMilanoItaly
  3. 3.General Surgery DepartmentNiguarda HospitalMilanItaly
  4. 4.University of MilanMilanItaly

Personalised recommendations