The use of synthetic mesh in contaminated and infected abdominal wall repairs: challenging the dogma—A long-term prospective clinical trial



Abdominal wall reconstruction in patients presenting with enteric fistulas and mesh infection is challenging. There is a consensus that synthetic mesh must be avoided in infected operations, and the alternatives to using synthetic mesh, such as component separation techniques and biologic mesh, present disappointing results with expressive wound infection and hernia recurrence rates.


A prospective clinical trial designed to evaluate the short- and long-term outcomes of 40 patients submitted to elective abdominal wall repair with synthetic mesh in the dirty-infected setting, and compared to a cohort of 40 patients submitted to clean ventral hernia repairs. Patients in both groups were submitted to a single-staged repair using onlay polypropylene mesh reinforcement.


Groups' characteristics were similar. There were 13 (32.5%) surgical site occurrences in the infected mesh (IM) group, compared to 11 (27.5%) in the clean-control (CC) group, p = 0.626. The 30-day surgical site infection rate was 15% for the IM group vs. 10% for the CC cases, p = 0.499. One patient required a complete mesh removal in each group. The mean overall follow-up was 50.2 ± 14.8 months, with 36 patients in the IM group and 38 clean-controls completing a follow-up of 36 months. There was one hernia recurrence (4.2%) in the IM group and no recurrences in the CC group.


We demonstrated that using polypropylene mesh in the infected setting presented similar outcomes to clean repairs. The use of synthetic mesh in the onlay position resulted in a safe and durable abdominal wall reconstruction.

Trial registration

Study registered at Plataforma Brasil (, CAAE 30836614.7.0000.0068. Study registered at Clinical Trials (, Identifier NCT03702153.

This is a preview of subscription content, access via your institution.


  1. 1.

    The Ventral Hernia Working Group, Breuing K, Butler CE, Ferzoco S, Franz M, Hultman CS, Kilbridge JF, Rosen M, Silverman RP, Vargo D (2010) Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery 148:544–558

    Article  Google Scholar 

  2. 2.

    Itani KM, Rosen MJ, Vargo D, Awad SS, DeNoto G III, Butler CE (2012) Prospective study of single-stage repair of contaminated hernias using a biologic porcine tissue matrix: the RICH Study. Surgery 152:498–505

    Article  Google Scholar 

  3. 3.

    Rosen MJ, Bauer JJ, Harmaty M, Carbonell AM, Cobb WS, Matthews B, Goldblat MI, Selzer DJ, Poulose BK, Hansson BM, Rosman C, Chao JJ, Jacobsen GR (2017) Multicenter, prospective, longitudinal study of the recurrence, surgical site infection, and quality of life after contaminated ventral hernia repair using biosynthetic absorbable mesh: The COBRA Study. Ann Surg 265:205–211

    Article  Google Scholar 

  4. 4.

    Carbonell AM, Criss CN, Cobb WS, Novitsky YW, Rosen MJ (2013) Outcomes of synthetic mesh in contaminated ventral hernia repairs. J Am Coll Surg 217:991–998

    Article  Google Scholar 

  5. 5.

    Atema JJ, de Vries FEE, Boermeester MA (2016) Systematic review and meta-analysis of the repair of potentially contaminated and contaminated abdominal wall defects. Am J Surg 212:982–995

    Article  Google Scholar 

  6. 6.

    Voyles CR, Richardson JD, Bland KI, Tobin GR, Flint LM, Polk HC Jr (1981) Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications. Ann Surg 194:219–223

    CAS  Article  Google Scholar 

  7. 7.

    Leber GE, Garb JL, Alexander AI, Reed WP (1998) Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 133:378–382

    CAS  Article  Google Scholar 

  8. 8.

    Basoglu M, Yildirgan MI, Yilmaz I, Balik A, Celebi F, Atamanalp SS, Polak KY, Oren D (2004) Late complications of incisional hernias following prosthetic mesh repair. Acta Chir Belg 104:425–428

    CAS  Article  Google Scholar 

  9. 9.

    Sahoo S, Haskins IN, Huang LC, Krpata DM, Derwin KA, Poulouse BK, Rosen MJ (2017) Early wound morbidity after open ventral hernia repair with biosynthetic or polypropylene mesh. J Am Coll Surg 225:472–480

    Article  Google Scholar 

  10. 10.

    Garner JS (1986) CDC guidelines for prevention of surgical wound infections, 1985. Supersedes guidelines for prevention of surgical wound infections published in 1982. Infect Control 7:193–200 (originally published in November 1985)

    CAS  Article  Google Scholar 

  11. 11.

    Muysoms F, Campanelli G, Champault GG, DeBeaux AC, Dietz UA, Jeekel J, Klinge U, Köckerling F, Mandala V, Montgomery A, Morales Conde S, Puppe F, Simmermacher RK, Śmietański M, Miserez M (2012) EuraHS: the development of an international online platform for registration and outcome measurement of ventral abdominal wall hernia repair. Hernia 16:239–250

    CAS  Article  Google Scholar 

  12. 12.

    Tanaka EY, Yoo JH, Rodrigues AJ Jr, Utiyama EM, Birolini D, Rasslan S (2009) A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain. Hernia 14:63–69

    Article  Google Scholar 

  13. 13.

    Haskins IN, Horne CM, Krpata DM, Prabhu AS, Tastaldi L, Perez AJ, Rosenblatt S, Poulose BK, Rosen MJ (2018) A call for standardization of wound events reporting following ventral hernia repair. Hernia 22:729–736

    CAS  Article  Google Scholar 

  14. 14.

    STATACorp (2007) Stata Statistical Software: Release 10.0. Stata Corporation, College Station

  15. 15.

    Rosen MJ, Krpata DM, Ermlich B, Blatnik JA (2013) A 5-year clinical experience with single-staged repairs of infected and contaminated abdominal wall defects utilizing biologic mesh. Ann Surg 257:991–996

    Article  Google Scholar 

  16. 16.

    Birolini C, Utiyama EM, Rodrigues AJ Jr, Birolini D (2000) Elective colonic operation and prosthetic repair of incisional hernia: does contamination contraindicate abdominal wall prosthesis use? J Am Coll Surg 191:366–372

    CAS  Article  Google Scholar 

  17. 17.

    Kelly ME, Behrman SW (2002) The safety and efficacy of prosthetic hernia repair in clean-contaminated and contaminated wounds. Am Surg 6:524–529

    Google Scholar 

  18. 18.

    Geisler DJ, Reilly JC, Vaughan SG, Glennon EJ, Kondylis PD (2003) Safety and outcome of use of nonabsorbable mesh for repair of fascial defects in the presence of open bowel. Dis Colon Rectum 46:1118–1123

    Article  Google Scholar 

  19. 19.

    Campanelli G, Nicolosi FM, Pettinari D, Contessini Avesani E (2004) Prosthetic repair, intestinal resection, and potentially contaminated areas: safe and feasible? Hernia 8:190–192

    CAS  Article  Google Scholar 

  20. 20.

    Majumder A, Winder JS, Wen Y, Pauli EM, Belyansky I, Novitsky YW (2016) Comparative analysis of biologic versus synthetic mesh outcomes in contaminated hernia repairs. Surgery 160:828–838

    Article  Google Scholar 

  21. 21.

    Franklin ME Jr, Trevino JM, Portillo G, Vela I, Glass JL, Gonzalez JJ (2008) The use of porcine small intestinal submucosa as a prosthetic material for laparoscopic hernia repair in infected and potentially contaminated fields: long-term follow-up. Surg Endosc 22:1941–1946

    Article  Google Scholar 

  22. 22.

    Machairas A, Liakakos T, Patapis P, Petropoulos C, Tsapralis D, Misiakos EP (2008) Prosthetic repair of incisional hernia combined with elective bowel operation. Surgeon 6:274–277

    CAS  Article  Google Scholar 

  23. 23.

    Garvey PB, Martinez RA, Baumann DP, Liu J, Butler CE (2014) Outcomes of abdominal wall reconstruction with acellular dermal matrix are not affected by wound contamination. J Am Coll Surg 219:853–864

    Article  Google Scholar 

  24. 24.

    Madani A, Niculiseanu P, Marini W, Kaneva PA, Mappin-Kasirer B, Vassiliou MC, Khwaja K, Fata P, Fried GM, Feldman LS (2017) Biologic mesh for repair of ventral hernias in contaminated fields: long-term clinical and patient-reported outcomes. Surg Endosc 31:861–871

    Article  Google Scholar 

  25. 25.

    Huntington CR, Cox TC, Blair LJ, Schell S, Randolph D, Prasad T, Lincourt A, Heniford BT, Augenstein VA (2016) Biologic mesh in ventral hernia repair: outcomes, recurrence and charge analysis. Surgery 160:1517–1527

    Article  Google Scholar 

  26. 26.

    Atema JJ, Furnee EJ, Maeda Y, Warusavitarne J, Tanis PJ, Bemelman WA, Valzey CJ, Boermeester MA (2017) Major complex abdominal wall repair in contaminated fields with use of a non-cross-linked biologic mesh: a dual-institutional experience. World J Surg 41:1993–1999

    CAS  Article  Google Scholar 

  27. 27.

    Birolini C, de Miranda JS, Utiyama EM, Rasslan S (2015) A retrospective review and observations over a 16-year clinical experience on the surgical treatment of chronic mesh infection. What about replacing a synthetic mesh on the infected surgical field? Hernia 19:239–246

    CAS  Article  Google Scholar 

  28. 28.

    Connoly PT, Teubner A, Lees NP, Anderson ID, Scott NA, Carlson GL (2008) Outcome of reconstructive surgery for intestinal fistula in the open abdomen. Ann Surg 247:440–444

    Article  Google Scholar 

  29. 29.

    Slater NJ, Bokkerink WJV, Konijn V, Bleichrodt RP, van Goor H (2015) Safety and durability of one-stage repair of abdominal wall defects with enteric fistulas. Ann Surg 261:553–557

    Article  Google Scholar 

  30. 30.

    Wind J, van Koperen PJ, Slors JF, Bemelman WA (2009) Single-stage closure of enterocutaneous fistula and stomas in the presence of large abdominal wall defects using the components separation technique. Am J Surg 197:24–29

    Article  Google Scholar 

  31. 31.

    Kugler NW, Bobbs M, Webb T, Carver TW, Milia D, Paul JS (2016) A dual-stage approach to contaminated, high-risk ventral hernia repairs. J Surg Res 204:200–204

    Article  Google Scholar 

  32. 32.

    van Geffen HJAA, Simmermacher RKJ, van Vroonhoven TJMV, van der Werken C (2005) Surgical treatment of large contaminated abdominal wall defects. J Am Col Surg 201:206–212

    Article  Google Scholar 

  33. 33.

    Krpata DM, Stein SL, Eston M, Ermlich B, Blatnik JA, Novitsky YM, Rosen MJ (2013) Outcomes of simultaneous large complex abdominal wall reconstruction and enterocutaneous fistula take-down. Am J Surg 205:354–359

    Article  Google Scholar 

  34. 34.

    Zerbib P, Caiazzo R, Piessen G, Rogosnotzky M, Sequier C, Koriche D, Truant S, Boleslawski E, Chambom JP, Pruvot FR (2015) Outcome in porcine acellular dermal matrix reinforcement of infected abdominal wall defects: a prospective study. Hernia 19:253–257

    CAS  Article  Google Scholar 

  35. 35.

    Pandey H, Thakur DS, Somashekar U, Kothary R, Agarwal P, Sharma D (2018) Use of polypropylene mesh in contaminated and dirty strangulated hernias: short term results. Hernia 22:1045–1050

    CAS  Article  Google Scholar 

  36. 36.

    Birolini C, de Miranda JS, Utiyama EM, Rasslan S, Birolini D (2016) Active Staphylococcus aureus infection: Is it a contra-indication to the repair of complex hernias with synthetic mesh? A prospective observational study on the outcomes of synthetic mesh replacement, in patients with chronic mesh infection caused by Staphylococcus aureus. Int J Surg 28:56–62

    Article  Google Scholar 

  37. 37.

    Arnold MR, Kao AM, Gbozah KK, Heniford BT, Augenstein VA (2018) Optimal management of mesh infection: evidence and treatment options. Int J Abdom Wall Hernia Surg 1:42–49

    Article  Google Scholar 

  38. 38.

    Blatnik JA, Krpata DM, Jacobs MR, Gao Y, Novitsky YM, Rosen MJ (2012) In vivo analysis of the morphological characteristics of synthetic mesh to resist MRSA adherence. J Gastrointest Surg 16:2139–2144

    Article  Google Scholar 

Download references


No external funds or financial support were used for this study.

Author information



Corresponding author

Correspondence to C. Birolini.

Ethics declarations

Conflict of interest

None of the authors has conflicts of interests to declare.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Human and animal rights

This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Birolini, C., de Miranda, J.S., Tanaka, E.Y. et al. The use of synthetic mesh in contaminated and infected abdominal wall repairs: challenging the dogma—A long-term prospective clinical trial. Hernia 24, 307–323 (2020).

Download citation


  • Hernia repair
  • Mesh infection
  • Enteric fistula
  • Polypropylene
  • Synthetic mesh
  • Abdominal wall reconstruction