CAUSE FOR CONCERN Hernia repair, one of the most common surgical procedures, carries a serious risk: mesh-related infection.

Scott A. Cassidy, MD, FACS, has seen 2 hernia mesh infections in the 14 years he's been in practice. Neither was his fault. The first patient contracted a Salmonella infection at a restaurant a month after surgery. The second presented for surgery with an undiagnosed MRSA infection. Besides explanting those 2 pieces of infected mesh, Dr. Cassidy's hernia infection record is unblemished, no small feat when you consider that he performs several hundred laparoscopic hernia repairs per year. His secret? The surgeon from Coosa Valley Medical Center in Sylacauga, Ala., follows a detailed infection prevention protocol with all his hernia repair patients.

• Hibiclens bathing. He asks patients to bathe with Hibiclens antimicrobial liquid soap for several days before surgery and to apply a body lotion such as Aveeno to prevent the skin from chapping and drying.
• Bactroban in the nares. He instructs patients to use Bactroban (mupirocin calcium ointment, 2%) in their nostrils BID for 1 week before surgery.
• Wash, prep and drape. In the OR, staff wash patients with Hibiclens. Dr. Cassidy preps patients with DuraPrep or ChloraPrep, then drapes them with impermeable 10/10 drapes topped by an Ioban antimicrobial incise drape. "This will keep patients clean, dry and warm," he says. "This also ensures that the graft never touches the patient."
• Rifampicin-soaked mesh. Dr. Cassidy soaks mesh in a concentrated rifampin solution before implantation. "This helps protect the mesh from contamination in the air before you even implant it," he says.
• Laparoscopic technique. He does almost all of his hernia repairs laparoscopically. Studies show infection rates are higher in open hernia repair than in laparoscopic repair. "With a minimally invasive approach, the mesh is rolled up and put through the port so it doesn't touch the skin," he says. "You can never make the skin sterile. Anything you can do to decrease contact improves the chances you'll get a good outcome."
• Topical skin adhesive. Dr. Cassidy places Dermabond on the wounds. "I'm doing this more and more, using it as an infection barrier for 48 hours," he says.

Big concern?
The reported incidence of mesh-related infection following hernia repair has been 1% to 8%. The incidence is influenced by several factors, including underlying co-morbidities, the type of mesh, the surgical technique and your infection prevention protocols. "Technique and judgment are more crucial than mesh material," says John Kitzmiller, MD, chief of plastic surgery at the University of Cincin-nati. "The paradox of hernia repair is that the prosthetic meshes you use to treat the condition can cause an infection."

"Any foreign body has a potential of increasing infection," says Margo Regas, MSN, RN, CNOR, RN-BC, clinical educator at Riley Hospital for Children at Indiana University Health in Indianapolis. "If mesh is to be used, we administer pre-op antibiotics." At the Physicians Ambulatory Surgical Center in Circleville, Ohio, they soak the mesh in an antibiotic solution before they implant it, says materials manager Mark Wetzel, CST.

While newer synthetic mesh devices are better than traditional sutures at reinforcing the abdominal wall, they can irritate nerves and carry a slightly higher risk of infection. "But," notes Jodie Stom, OR tech at Women's Christian Association Hospital in Jamestown, N.Y., "most are antibiotic-impregnated."

Mesh may migrate, contract, flex, stiffen and become altered in the body — "a balled-up mush," is how Dr. Cassidy puts it. Another way to reduce the risk of adhesion and infection risk is to limit the amount of foreign body that's implanted by using today's thinner, lighter, more porous mesh designs. "Thinner mesh that is more porous is surgically easier to position in the body and less damaging to surrounding tissues," says Lynn Razzano, RN, MSN, ONCC, a clinical nurse consultant from Westborough, Mass. "It's the 'tearing' that sets up the infection process."

The market for biologic materials is expected to grow faster than that for polymer or prosthetic mesh, according to "Hernia Repair Devices Market," a new market report published by Transparency Market Research. The reason, the report says, is that biologic materials offer more flexibility and strength, and a lower chance of rejection and infection. New biologic meshes, including some made from pig skin, are being used in complex repairs because they can reduce the chance of infection, but are more expensive.

Preventive measures
Although it's widely held that laparoscopic hernia repair has fewer post-op complications compared with open repair, there are no specific data regarding mesh-related infection rates. It's also believed that foreign body reaction depends on the amount of mesh used. Here's more preventive advice:

• Never perform the procedure if the patient has shaved with a razor. "We only use clippers in pre-op holding," says Sherry Rogers, RN, CNOR, CASC, administrator at the Tullahoma (Tenn.) Surgery Center.
• Shower with CHG for 3 days before surgery. On the day of surgery, wipe the patient with a CHG cloth in pre-op and once more before transporting the patient to the OR, says Faith True, MBA, BSN, RN-NE-BC, CNOR, director of perioperative services at SoutheastHEALTH in Cape Girardeau, Mo.
• Finally, this simple, sound advice from a manager who asked that we not use her name: Thorough scrubbing, prophylactic antibiotics and prayers.