Implant rejection in alloplasty of abdominal hernias: analysis of causes and surgical correction methods

Abstract

Hernias of the anterior abdominal wall, particularly postoperative ones, remain an ever‑present problem in modern abdominal surgery. The introduction of alloplasty using mesh implants has significantly improved the results of surgical treatment of abdominal hernias, reducing the recurrence rate to 8 – 20% and with hybrid‑laparoscopic techniques to 2.7%. However, the use of mesh implants is accompanied by specific complications. Unsatisfactory results of the mesh integration process after alloplasty are explained by the distorted course of the local inflammatory reaction, namely, the transformation of aseptic inflammation into bacterial inflammation.

Objective – to systematize and generalize modern ideas and own experience in the surgical treatment of infectious complications of abdominal hernia alloplasty, analyze the causes of their occurrence, and identify promising areas for improving treatment outcomes.

Materials and methods. We studied 28 patients who had previously undergone abdominal hernia repair and subsequently developed inflammatory complications at the site of implantation. The diagnosis of mesh implant rejection was based on a comprehensive assessment of clinical, laboratory, instrumental, and morphological data. The presence of persistent clinical symptoms for a prolonged period after alloplasty was considered an indication for an in‑depth examination to exclude or confirm implant rejection and to determine the optimal treatment strategy for a particular patient. Laboratory tests, ultrasound, CT, or MRI were used for this purpose.

Results. The leading cause of implant rejection in the general group was chronic infection of the implantation site, detected in 46.4% of cases, which was combined with fistula formation in 28.6% of patients. In all 7 patients with inflammatory complications after alloplasty of inguinal hernias, complete explantation of the mesh implant, careful restoration of the normal anatomy of the inguinal canal, tissue sanitation, and excision of fistula passages with autoplasty in the presence of concomitant hernia recurrence were performed. Among patients with ventral hernias, complete explantation of the mesh was performed in 15 of 21 cases (71.4%), while partial explantation was performed in 6 cases (28.6%), prioritizing preservation of integrated areas.

Conclusions. Complications after alloplasty of ventral hernias, especially when the onlay method and heavy polypropylene meshes are used, account for 75.0% of cases of mesh implant rejection. The leading cause of implant rejection is chronic infection of the alloplasty area, whereas the formation of branched multiple fistulas is one of the most common clinical manifestations. Complete explantation of the infected implant, combined with autoplasty and vacuum drainage, is the method of choice for the surgical treatment of such complications. Partial explantation with staged reconstruction is possible in carefully selected patients with ventral hernias, but it is accompanied by longer treatment and increases the risk of recurrence.