Partial mesh removal is usually insufficient to solve a patient’s problems, according to new research presented at the 2018 International Hernia Congress in Miami.
Studying data from nearly 29,000 operations, Carolinas Medical Center Dr. Angela Kao and her colleagues found that hernia mesh patients who undergo a partial mesh excision, rather than a complete removal, are far more likely to experience severe postoperative complications, including surgical site infections, hernia recurrence and invasive reoperation.
Surgeons Note Benefits Of Complete Hernia Mesh Removal
Speaking to General Surgery News for a June 6, 2018 piece, Dr. Kao stated, “we feel that complete mesh excision and excision of any additional foreign bodies should be performed whenever possible.” Dr. Kao said the risk of post-surgical complication appeared to be highest in patients who had developed a mesh infection or fistula prior to undergoing the partial mesh removal.
Early study results show that chronic infections could be shockingly common in hernia mesh patients who undergo removal procedures. According to a 2017 study published in the American Journal of Surgery, up to 48% of patients will experience hernia recurrence and require reoperation. The authors attributed the extraordinarily-high complication rate largely to infections.
Partial Mesh Excision Increases Complication Risk
Dr. Kao and her colleagues have provided compelling evidence that a complete mesh removal has the potential to limit postoperative complications, even in patients who develop mesh infection and other serious mesh-related injuries.
In the wake of a partial removal, Dr. Kao’s team found, patients whose mesh had become infected were 4.6 times more likely to require another reoperation procedure when compared to patients who underwent complete mesh excision. A similarly-heightened risk was observed in patients who had developed fistula, when the mesh bores through internal organs to create abnormal passageways.
77% Of Patients Undergo Complete Mesh Removal
Thankfully, partial mesh removal procedures are less common than complete removals. Out of the 29,000 hernia procedures studied, Dr. Kao and her colleagues identified records from 1,904 patients who had undergone a removal surgery. Only 23% of these patients had undergone partial excision procedures; in the majority of patients, 77%, surgeons reported having completed the mesh removal.
Variations In Mesh Type
Dr. Kao’s team was careful to control for additional factors that could be affecting the results; the data was normalized, for example, to account for differences between various mesh types, some of which may lend themselves to partial removal more than others.
Biologic mesh, when compared to synthetic mesh, was far more likely to result in a partial mesh removal. Around 50% of the patients who underwent a partial excision had been implanted with a biologic mesh; only 16% of partial removal patients had received a synthetic mesh.
Partial Mesh Removal Triples Risk Of Infection, Reoperation
After controlling for these confounding variables, the risks posed by partial mesh removal remained clear. Mesh patients who underwent a partial removal had a 280% increased chance of developing a surgical site infection after the procedure and were 340% more likely to require a subsequent procedural intervention.
At the same time, post-surgical complications were extremely common across both groups, especially for people who had developed a mesh infection or fistula. Nearly 50% of these mesh patients required a procedural intervention after undergoing partial removal. Complete mesh excision led to better, but not very good, results, with 26% of patients who had their mesh implants completely removed requiring a subsequent procedure.
Study Confirms Doctor’s Suspicions
Many experts already understood that complete mesh removals are preferable to partial procedures, according to Dr. Shirin Towfigh, a hernia surgeon at Beverly Hills Hernia Center. Even so, “it’s really nice to see robust data” backing that impression, Dr. Towfigh said.
Limitations & Further Questions
In some cases, complete mesh removal isn’t a possibility, notes Penn State associate professor of surgery Dr. Eric Pauli. How, for example, should a surgeon approach a mesh that is so incorporated into the intestinal wall that removing it completely would cause severe internal injuries?
Another problem, according to Dr. Pauli, is that the data set used in this study, the Americas Hernia Society Quality Collaborative, fails to identify how much of the mesh is removed in partial excision procedures; the data only indicates whether or not the mesh was completely removed. “There is a qualitative difference,” Dr. Pauli explains, “between leaving behind a large swath of mesh that may be interacting with the new mesh going in when compared to leaving behind a small bit of well-incorporated mesh that cannot be taken out without causing an iatrogenic injury.”
Dr. Pauli’s point is that, while we may know now that complete mesh removal is the best option, there may still be legitimate reasons to leave some mesh behind.