Surgical Science, 2013, 4, 421-425
http://dx.doi.org/10.4236/ss.2013.410082 Published Online October 2013 (http://www.scirp.org/journal/ss)
Mesh Infection and Migration after Umbilical
Hernia Repair
Valter Ripetti*, Vincenzo La Vaccara, Eleonora Angelini, Giovan Battista Giorgio, Rossana Alloni
Department of General Surgery, Campus Bio-Medico University, Rome, Italy.
Received August 16, 2013; revised September 14, 2013; accepted September 21, 2013
Copyright © 2013 Valter Ripetti et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Mesh infection and migration are dangerous and common complications after hernia repair. Many factors cause mesh
migration, which may or may not be associated to infection. Before performing hernia repair using a mesh, it is impor-
tant to choose the right device to avoid this kind of complication, above all in the presence of contaminated wounds or
fields. We describe two cases of mesh infection and migration after umbilical hernia repair which were treated, in ac-
cordance with recommendatio ns in the literatu re, by removing the infected mesh and replacing it with a biological mesh.
Our experience confirms the feasibility of using biological mesh to perform umbilical hernia repair after infection, with
consequent migration, of the previously placed mesh. Our cases are the first to be reported in which mesh migration is
associated with infection after umbilical hernia repair, and they demonstrate the advantages of biologic implants in ab-
dominal wall reconstruction.
Keywords: Umbilical; Infection; Migration Hernia; Mesh
1. Introduction
Migration of a surgical mesh, and consequent infection,
are dangerous and common complications in patients
who have undergone hernia repair. Many reports of plug
and mesh migration or dislocation after open or laparo-
scopic inguinal hernia repair can be found in literature.
This kind of complication can cause recurrence of ingui-
nal hernia, intestinal occlusion, chronic neuralgia, and
intestinal erosions, and thus peritonitis and enteric fistula
[1].
In literature, cases of mesh migration after umbilical
hernia repair are extremely rare. There is only one paper,
by Di Muria et al., describing a case of polypropylene
mesh migrating and completely penetrating an ileal loop,
with adhesion to the abdominal wall. Resection of the
ileal loop together with the surrounding abdominal wall
was performed, and the parietal defect was repaired with
single polypropylene stitches, avoiding the use of pros-
thetic material [2]. We describe 2 cases regarding mesh
migration and infection after umbilical hern ia repair, and
provide a review of the literature.
2. Case Presentation 1
The patient was a 60-year-old female whose medical
history included au toimmune thyroditis and hypertension.
She was a smoker, and her BMI was 30.
The patient underwent direct umbilical hernia repair at
the age of 36 years, and 20 years later developed a re-
currence which was treated by intra-peritonium repair
using a Composite® mesh (Bard In c., USA).
After 4 more years she was admitted to another hosp i-
tal for recurrent fever and abdominal swelling. Abdomi-
nal X-ray was negative. A subsequent abdominal CT
scan demonstrated the presence of fluid collection with
gas bubbles near the mesh. Both fever and local swelling
disappeared in response to non-specific an tibio tic th erapy,
and she was discharged after 10 days. Four months later,
she presented with periumbilical swelling with presence
of cutaneous fistula, so a new CT scan was performed.
This revealed persistence of fluid collection with gas
bubbles near the mesh (Figure 1).
Bacterial culture was positive for Streptococcus con-
stellatus. The patient was therefore admitted to our de-
partment and underwent surgical treatment. Intraopera-
tive findings revealed the presence of a subcutaneous
purulent collection and migration of the mesh into an
ileal loop (Figure 2). An intraoperative sampling con-
firmed the growth of Streptococcus constellatus. After
removing the prosthesis en bloc with surrounding skin
structures, we first performed resection of the involved
*Corresponding a uthor.
C
opyright © 2013 SciRes. SS

V. RIPETTI ET AL. 422
Figure 1. Fluid collection with gas bubbles near the mesh.
Figure 2. Prosthesis penetrated in ileal loop.
ileal loop. After primary suture, repair of the posterior
rectus sheath was performed using vicryl 2, and an
overlay mesh of PermacolTM (10 × 15 cm) was secured
with a series of sutures (2/0 prolene; ethicon). The
external rectus sheath was re-approximated at midline
with a series of 2 vicryl sutures. Additionally, a Jackson-
Pratt drain was placed in the subcutaneous plane, and
was left in place for four days. The patient was treated
with antibiotic therapy (Cefazolina Teva) until her dis-
charge. The postoperative course was uneventful and the
patient was discharged on postoperative day 6. The pa-
tient was also instructed to wear an abdominal binder for
at least two months. At 24 months follow-up, there was
no evidence of recurrence or other symptoms.
3. Case Presentation 2
A 56-year-old female, also a smoker, who had a history
of umbilical hernia repair with a Goretex® (Japan Gore-
Tex, Inc., Japan) mesh six years previously, was admit-
ted to our department with pus ou tput from a periumbili-
cal swelling, and external mesh migration (Figure 3).
BMI was 31. Bacterial culture, done before admission,
was positive for Escherichia coli, Streptococcus agalac-
tiae and Streptococcus dysgalactiae.
The patient underwent surgical treatment, and intraop-
Figure 3. External mesh migration.
erative findings revealed the presence of a subcutaneous
purulent collection confirming the multiple infections
mentioned above. We performed complete removal of
the mesh, together with surrounding skin structures, and
an underlay abdominal wall repair using a mesh of
PermacolTM (10 × 15 cm ) which was secured with a
series of sutures (2/0 prolene; ethicon) to the posterior
rectus sheath. Primary suture repair of the posterior and
external rectus sheath was performed using vicryl 2.
Additionally, a tubular suction drain was placed in the
subcutaneous plane. the drain was left in place for two
days until it expressed less than 50 ml/24h. The patient
was treated with antibiotic therapy (Cefazolina Teva)
until her discharge. The postoperative course was un-
eventful and the patient was discharged on postoperative
day 3. The patient was also instructed to wear an ab-
dominal binder for at least two months. At 24 months
follow-up, there was no evidence of recurrence or other
symptoms.
4. Discussion
Umbilical hernia is relatively common in adults, but ac-
counts for only 3% - 8.5% of abdominal hernias, third in
incidence after inguinal (70% - 75%) and femoral (6% -
17%) hernias [3]. Meshes have significantly reduced the
incidence of recurrence after umbilical hernia repair,
from 54% to less than 10% [4]. On the other hand,
Arroyo et al. did not report a significant relationship be-
tween recurrence rate and size of the hernia, comparing
suture and mesh repair of umbilical defects in a random-
ized clinical trial [5]. Although open primary repair still
remains the operation of choice for some surgeons faced
with defects of less than 2 cm in diameter [6], others
prefer the use of a mesh plug for defects of up to 3 cm in
diameter, and a mesh sheet for larger lesions [5].
Regardless of the technique used, the risk of mesh in-

V. RIPETTI ET AL. 423
fection remains a serious problem. The incidence of
mesh infection in op en su rgery ( 6% - 10%) [7,8 ] drop s to
0% - 3.6% with laparoscopic procedure [9], thanks to
mesh introduction through trocars, which avoids skin
contact, and placement far from the trocar incisions [10].
In literature, most prosthetic infections are reported to be
due to skin pathogens [11], although in our experience
the pathogens involved were not part of the cutaneous
flora.
In 2001, an experts’ meeting about the classification
and treatment of incisional hernia reported a higher mesh
removal rate after infection in laparoscopic repair (0% -
7%) than after open repair (0% - 4%) [12]. This was
probably due to a more prevalent use of ePTFE mesh in
laparoscopic repair: this type of mesh produces less
bowel adhesion than polypropylene or polyester mesh
but, once infected, must more often be removed [13]. In
fact, infection of polypropylene mesh can be managed
locally with surgical drainage and excision of exposed
unincorporated segments, whereas infection of ePTFE
mesh requires removal of the prosthetic material because
its microporous (10 µm) surface allows fluid retention
and bacterial contamination, but not leukocyte diapedesis
[8]. The removal of infected ePTFE mesh becomes nec-
essary because of its intraperitoneal placement, in contact
with the intestinal loops, which leads to the involvement
of adjacent organs.
According to a meta-analysis of cohort studies based
on 2418 patients, publish ed in 2011 by Mavros et al., our
patients had risk factors significantly associated with the
development of mesh infection after hernioplasty, such as
high BMI score and tobacco smoking [14]. In our two
cases, mesh migration was caused by infection of the
mesh, as suggested by Agrawal and Avill [15], who hy-
pothesized two possible mechanisms of mesh migration.
In the first of these, displacement of the mesh occurs
along a path of low resistance resulting either from in-
adequate fixation or from external displacing forces. In
the second, referred to as secondary migration, the mesh
moves gradually and slowly through the anatomic planes
due to erosion induced by foreign body reaction; the mi-
gration depends on the nature of the mesh biomaterial
and the type of fixation of the mesh, if fixed. On the
other hand, Chowbey et al. suggested that the cut edges
of the mesh become sharp, damaging the surface of the
viscus and evoking an inflammatory reaction, thereby
leading to weakness, erosion, and finally infection [16].
Because of a high morbidity rate due to mesh explan-
tation after mesh infection (hernia recurrence, damage to
surrounding structures, loss of domain, risk of entero-
tomy or enterocutaneous fistula formation), it is essential
to observe rigorous asepsis during surgical placement of
an appropriate mesh, to avoid the formation of intrapa-
rietal haematomas which could cause infection and, in
the end, mesh explantation [13].
At the 30th International Congress of the European
Hernia Society in 2009, different properties of the pros-
thesis (such as pore size, geometry, active surface area,
memory, affinity for water, elasticity, and polymer type)
were taken into account to identify an “ideal” mesh
prosthesis. The po re size of meshes is crucial in defining
the surgical activity profile, which includes handling,
flexibility, memory, fibrosis, and foreign body reaction.
Although lightweight macroporous meshes may lead to a
higher risk of adhesions, the panel agreed that they seem
to be safer to use in a contaminated environment because
of their greater flexibility and lower risk of foreign body
reaction an d fibrosi s [17].
Recently, greater use of biocompatible implants, such
as PermacolTM, has been necessary, because of complica-
tions with infection, and adhesions associated with wide-
spread use of prosthetic materials, such as polypropylene
mesh and ePTFE, to reconstruct abdominal wall defects.
PermacolTM (acellular porcine dermis) is used as a der-
mal scaffold, vascularised and remodelled to reconstruct
the abdominal wall, particularly in the presence of con-
taminated or potentially contaminated wounds [18].
Thanks to its structure, which is similar to human dermis,
PermacolTM is considered to be equally non-allergenic,
nontoxic, and devoid of foreign body reaction. Addi-
tional collagen crosslinking, which allows fibroblast in-
filtration and neovascularisation, incorporating the im-
plant into the surrounding host tissue [19], confers
greater stability, decreasing degradation by collagenase
and resulting in a more long-term prosthesis [20].
Literature report conflicting results with regard to
Permacol’s ability to become vascularized and incorpo-
rated into host tissue [20-23], showing conflicting data
on how chemical crosslinking influences vascular incor-
poration. However, a recent report demonstrated clinical
and histological evidence of vascular incorporation in a
full-thickness [24]. Regardless of whether or not chemi-
cal crosslinking may lead to integration of the mesh and
decreased ability for vascularization, this is offset by its
resistance to degradation and its long-term strength. In
fact it was demonstrated the chemical crosslinking of
collagen in PermacolTM confers more long-term stability
and strength [25].
According to a report on histologic and biomechanical
evaluation of crosslinked and non-crosslinked biologic
meshes in a porcine model of ventral incisional hernia
repair, PermacolTM showed increased cellular infiltration
between 1 and 6 months, with some scores to the non-
crosslinked materials at 6 months, and persistence of
these scores at 12 months. However, because all cross-
linked and non-crosslinked biologic meshes showed
equivalent cellular infiltration at later time points, it is
possible that crosslinking might not influence cellular

V. RIPETTI ET AL. 424
infiltration substantially in the long term. In general, the
crosslinked materials also demonstrated increased scores
at 12 months for cell types, ECM deposition, scaffold
degradation, fibrous encapsulation, and neovasculariza-
tion compared with their scores at 1 month. Although
many differences were identified among the biologic
meshes examined in this study, it is difficult to say
whether any of these biologic meshes are more biocom-
patible than the others for ventral hernia repair because
there are such wide variations in both the clinical sce-
narios analyzed and the biological responses of individ-
ual patients [26]. Also, a retrospective comparative study,
in 2012, on synthetic and biological meshes in compo-
nent separation for abdominal wall hernia repairs,
showed a recurrence rate in PermacolTM repair in con-
taminated fields of 7.7%, compared with Alloderm
(19%), synthetic mesh (25.6%), and component separa-
tion (12%). This review suggests that the crosslinked
mesh, PermacolTM, has the lowest failure rate and the
longest time to failure, particularly in contaminated or
infected fields [27]. In our cases there was a late clinical
presentation of mesh migration, where pus output was
the only sign of infection, with none of the abdominal
pain or bowel occlusion reported by Di Muria [2]. In the
first case the periumbilical pus output was caused by
enterocutaneous fistula formation, and in the second it
was due to partial external mesh migration. In both cases
we decided, in accordance with the literature concerning
mesh infection, to remove the infected mesh and perfo rm
an abdominal wall repair using bioprosthesis mesh to
ensure lower risk of recurrence and infection. Our ex-
perience confirms this biodegradable matrix as a safe and
useful tool; therefore it should be the device of choice
when there is high risk of infection and migration, or of
major complications such as intestinal perforation. In
conclusion, our cases are the first to be reported in which
mesh migration is associated with infection after umbili-
cal hernia repair, and they demonstrate the advantages of
biologic implants in abdominal wall reconstruction. Bio-
logical devices such as PermacolTM should be considered
in cases of contaminated wounds, immunesuppressed
patients, and previously placed, infected mesh, even if
high cost limits th eir routine use.
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