Hernia Infections: Pathophysiology - Diagnosis - Treatment - Prevention PDF

Preface

The purpose of this book is to persuade surgeons of the need for a change in surgical attitude that will allow the performance of mesh hernia surgery with virtually no infections. There is evidence in the literature that such a goal is attainable through awareness and judicious utilization of newer ideas and techniques.

The necessity to address a surgical complication is directly proportional to its impact on human health. Approximately 700,000 inguinal and 50,000 ventral herniorrhaphies are performed yearly in the United States and about 85% of these procedures utilize a prothesis. The reported infection rate is between 1 to 3% for inguinal hernias and from 4 to 6% for ventral hernias; therefore, approximately 16,000 individuals per year require further surgical treatment because of infection. The infection rate for herniorrhaphy has not changed significantly in the last three decades, but what has increased is the number of meshes inserted. In terms of human suffering and cost, the impact of wound infection in the presence of mesh is significant. The core of this problem is that prosthetic materials, bathed in nutritious body fluids, become fertile grounds for bacterial colonization, accentuating the need for stricter infection control measures.

The field of hernia repair has changed drastically in the last 20 years with the creation of European and American Hernia Societies and their joint journal: HERNIA. Simultaneously, international, national, and regional conferences have been held on techniques for mesh hernia repair. Such technology changes the wound biology by exponentially increasing the amount of foreign material left in the wound. The presence of infected mesh converts a simple ambulatory surgical procedure into a protracted and complex clinical situation requiring further surgery and may be associated with long-term disability.

Curiously, our attitude confronting postoperative infections has remained similar for hundreds of years. During the pre-antiseptic era, wound infections occurred in over 99% of all clean surgical operations; they were not only expected but considered a normal outcome. Surgeon's attitudes, based on limited knowledge, did not permit the conceptualization that infections could be curtailed. Semmelweiss, Pasteur, Lister, and others elucidated the role of bacteria, identifying the operating room environment and the surgical team as their vector, which brought about changes in attitude. This eventually led to the institution of measures to diminish the wound bacterial load, lowering the infection rate to approximately 10%. The discovery and introduction of antibiotics further reduced these figures to their present 2 to 3% level, but these drugs created a false sense of security that led to the relaxation of operating room antiseptic routines. During the last 20 years no significant drop in the incidence of wound infection has been reported.

Orthopedics surgeons faced a similar problem when in the 1960s, Charnley inserted a large metallic prothesis that if infected became anathema to both patient and surgeon. It was then recognized that the wounds had been exposed to bacteria emanating from the operating room air and the surgical team. Diminishing the bacterial wound load by introducing laminar air flow, improved hooded gowns, local and systemic antibiotic regimes, and antibiotic-releasing polymers significantly lowered the incidence of orthopedic infections.

The various chapters of this book give strong evidence that mesh hernia repair should be performed using the same precautions as for a total joint replacement, because the dissected wound surface for a large ventral herniorrhaphy is greater than the one produced during a total joint replacement. Most importantly, the total surface of a 15615 cm polypropylene or ePTFE prothesis is larger than any orthopedic prothesis. Plugs utilized for inguinal repairs also exhibit large surfaces. Nevertheless, surgeons continue to perform mesh hernia surgery in ordinary operating theaters often following clean-contaminated or even infected cases.

During the last 20 years the bacterial load introduced into clean wounds has been reduced by the introduction of new antibacterial technology at every level of the surgical procedure. Bactericidal soaps and skin antiseptics, barrier drapes, hooded and ventilated head gear, less injurious electrocoagulation devices, systems for instrument sterilization, and new prosthetic materials incorporating antibacterial agents are all additive factors that should facilitate infection prevention. At the same time, improved conceptualization of the ultramicroscopic relationship between bacteria and host has emerged, enlightening the operating surgeon about the need to reduce the wound bacterial load. New diagnostic imaging permitting early detection plus fast and efficient bacteria identification by laboratories are all factors that will contribute to prevention improvement and better treatment of existing infections.

The authors hope that this book will help surgeons to fully avail themselves of the knowledge and armamentarium that will allow them to radically reduce postherniorrhaphy wound infections. The implementation of such measures will require additional perioperative and operating room costs, but this will be offset by the reduction in expenditures incurred for the treatment of over 16,000 yearly infections.

The contributors to this textbook are surgeons, engineers, and biologists widely acclaimed for their intellectual accomplishments. They are also practicing healers with great hands-on expertise in their particular fields. Their advice emanates from years of accumulated practice and wisdom. Their goal, to help change the attitude of all surgeons about the realities of surgical infections, will be fully met, I am sure, if a single life is saved, if a single infection has been stemmed.