Surgery xxx (2019) 1e8

Contents lists available at ScienceDirect

Surgery
journal homepage: www.elsevier.com/locate/surg

Mesh fistula after ventral hernia repair: What is the optimal

management?
Michael R. Arnold, MDa, Angela M. Kao, MDa, Javier Otero, MDa, Julia E. Marxa,
Vedra A. Augenstein, MDa, Ronald F. Sing, DOb, Paul D. Colavita, MDa, Kent Kercher, MDa,
B. Todd Heniford, MDa,*
a
Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
b
Division of Trauma and Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC

a r t i c l e i n f o a b s t r a c t

Article history: Background: A mesh-related intestinal fistula is an uncommon and challenging complication of ventral
Accepted 23 September 2019 hernia repair. Optimal management is unclear owing to lack of prospective or long-term data.
Available online xxx Methods: We reviewed our prospective data for mesh-related intestinal fistulas from 2004 to 2017and
compared suture repair versus ventral hernia repair with mesh at the time of mesh-related intestinal
fistula takedown.
Results: Eighty-two mesh-related intestinal fistulas were treated; none of the fistulas had closed spon-
taneously, and all fistula persisted at the time of our treatment. Mean age was 61 ± 12 years with 33-
month follow-up. Comorbidities were similar between groups. Defects were 2.5-times larger in
ventral hernia repair with mesh (324 ± 392 cm2 vs 1301 ± 133 cm2; P ¼ .044). Components separation
(64% vs 21%; P ¼ .0003) and panniculectomy (35% vs 7%; P ¼ .0074) were more common in ventral hernia
repair with mesh. Mortality occurred in 4 patients. Complications were similar. In patients undergoing
ventral hernia repair with non-bridged, acellular, porcine dermal matrix, hernia recurrence was less than
in patients without mesh (26% vs 66%; P ¼ .0030). Only partial excision of the mesh involved with the
fistula resulted in a substantial increase in developing another fistula (29% vs 6%; P < .05).
Conclusion: Patients undergoing preperitoneal ventral hernia repair with mesh for mesh-related intes-
tinal fistula had a lesser rate of hernia recurrence and similar complications compared to suture repair
despite larger hernias. Complete mesh excision decreases the risk of fistula recurrence. We maintain that
ventral hernia repair with mesh during mesh-related intestinal fistula takedown represents the best
opportunity for a durable herniorrhaphy.
© 2019 Elsevier Inc. All rights reserved.

Introduction
More than 350,000 ventral hernia repairs (VHR) are performed
annually, making it one of the most common operations performed
in the United States, and the number is increasing 1% to 2%
Conception and study design was performed by M.R.A, A.M.K., J.O., P.D.C., and
B.T.H. Data acquisition was performed by M.R.A and J.E.M. Data analysis and
interpretation was performed by M.R.A., J.E.M., J.O., R.F.S., and B.T.H. Manuscript
drafting was performed by M.R.A, A.M.K., and V.A.A. Critical revision of manuscript
was performed by M.R.A, A.M.K., J.O., and B.T.H.
Accepted for oral presentation at the 70th annual Southwestern Surgical
Congress
* Reprint requests: B. Todd Heniford, MD, Carolinas Medical Center, 1025 More-
head Medical Dr., Suite 300, Charlotte, NC 28204.
E-mail address: todd.heniford@carolinashealthcare.org (B.T. Heniford).
annually.1 Since the first use of polypropylene mesh was described
by Usher et al in the 1950s,2 the use of mesh for abdominal wall
reconstruction (AWR) has emerged as the most effective method to
prevent recurrence.3,4 Numerous techniques, both open and lapa-
roscopic,5 have been described with mesh placed in various layers
of the abdominal wall.6e8 Other studies including a systematic
Cochrane Review have demonstrated the superiority of a mesh-
based repair, and it is generally recommended that essentially all
VHR should utilize mesh to decrease the rate of hernia
recurrence.9,10
Complications associated with VHR come at a greater rate than
most other general surgery operations. In fact, VHR is the second
most common operation leading to readmission in the United
States;11 postoperative wound complications range from 20% to
75%12 and mesh infection rates from 5% to 10%.13,14 The costs of such
complications have been well described and are substantial.15

https://doi.org/10.1016/j.surg.2019.09.020
0039-6060/© 2019 Elsevier Inc. All rights reserved.
2 M.R. Arnold et al. / Surgery xxx (2019) 1e8
Severe adhesions and erosion of the intestine have been described
with intraperitoneal placement of polypropylene mesh in ani-
mals.16 Mesh-related enterocutaneous (EC) fistulas have been well
documented in a limited series of patients and are associated with a
high rate of morbidity and operative mortality; indeed, operative
mortality from the treatment of these mesh-related fistulas has
ranged from 16% to 54% in patients related to risk factors such as
malnutrition, recurrent fistula, and sepsis at presentation.17,18 Van’t
Riet et al attempted mesh placement in high risk patients and
demonstrated a mesh fistula rate of 17% and mesh migration into
the bowel in 11% of patients.19 Despite the severity of this
complication, mesh involvement in EC fistulas is poorly described,
and the exact frequency after routine VHR is not well known, with
literature reviews limited to small reports.20,21
Evenson et al quoted a 30% rate of spontaneous closure of
standard EC fistulas after medical management, depending on the
characteristics and etiologies of the EC fistula. Importantly, a
foreign body, such as a mesh prosthetic, is a well-known, unfa-
vorable predictive factor for spontaneous closure.22 Although some
literature exists to support mesh salvage in mesh infections, the
salvage rate is quite low in permanent mesh material, particularly
in smokers, or with polytetrafluoroethylene (PTFE) prosthetics,
heavyweight small pore propylene, or the multi-filamented mesh,
and when there is an infection with methicillin-resistant staphy-
lococcus aureus.23e25 Currently there is no evidence to support the
non-operative management of a mesh fistula, other than associated
risk of surgery or surgery-related outcomes. There is debate
regarding staging hernia repairs for patients with contaminated
wounds, with advocates for both multi-staged26,27 and single-stage
repairs.28e30 Nevertheless, the basic principles of infection control,
restoration of gastrointestinal continuity, and stable abdominal
wall reconstruction are recognized as basic goals by most authors.
Common clinical practice in single-stage repairs has evolved to use
biologic or an absorbable synthetic mesh instead of permanent
mesh in cases with a greater risk of postoperative infection. Critics
of these meshes cite a much greater expense and a greater rate of
hernia recurrence compared to permanent synthetic mesh. Given
high rates of infection associated with synthetic mesh in contam-
inated fields, the alternative approach is often a primary sutured
closure followed by staged hernia repair, possibly using a perma-
nent mesh after all the inflammation and tissue infection has
resolved31 This controversy had existed previously within our own
practice, with surgeons performing both single and multi-staged
management of mesh fistulas as previously by Schmelzer et al.32
There has also been controversy regarding the need for com-
plete versus partial mesh resection at the initial operation.
Certainly in practice, if not on paper, surgeons have attempted to
resect mesh well back from the fistula and leave unaffected,
incorporated mesh behind. The aim of this study is to demonstrate
the prospective outcomes in the care of 82 patients with a mesh
fistula.
Methods
The Carolinas Hernia Center was established in 2004 as a ter-
tiary referral center and hernia center of excellence as a part of the
Carolinas HealthCare System. Over 800 elective ventral hernia re-
pairs are performed annually by 3 surgeons. Our patient popula-
tion, generated by community, national, and international referrals,
represents generally patients who have associated comorbidities
with complex hernias.
A prospectively enrolled surgical outcomes database at our
tertiary referral hernia center was queried for hernia with mesh
infections from 2004 to 2017. The Institutional Board Review of the
Carolinas Medical Center approved the present study. It included all
patients 18 years or older who had a mesh fistula at the time of
preoperative planning or a mesh fistula discovered intraoperatively
during hernia repair. Perioperative patient characteristics, opera-
tive details, type of mesh, bacterial cultures, duration of antibiotics,
wound therapy, postoperative outcomes, and hospital charges were
collected. Hernia defect size was recorded from intraoperative
measurements. The area was calculated from the length and width
of the defect. Patients with multiple defects had the individual
defects measured and added together. For patients managed within
our institution, follow-up information was collected from the
electronic medical record, follow-up computed tomography (CT)
for a history of cancer or other reasons, and notes from family
physicians. The most recent physical exam from a physician or
advanced care practitioner was included. Patients referred from
outside centers are typically contacted via telephone annually, and
their family physician’s notes were examined.33
Outcomes of interest were time to mesh infection/fistula,
duration and type of prior fistula therapy, time to mesh excision,
predictors for mesh salvage, fistula recurrence, wound complica-
tions, hospital duration of stay, postoperative mortality, and
wound-related and overall postoperative complications. In addi-
tion, hernia recurrence after suture repair (SR) versus VHR with
mesh (VHRM) was studied.
Standard statistical methods were used, including c2, Fisher’s,
and Wilcoxon-Mann-Whitney tests. Statistical significance was set
at P  .05, and all reported P values are 2-tailed. All data were
analyzed using Statistical Analysis Software, version 9.4 (SAS
Institute, Inc, Cary, NC).
Patient preparation and operative technique
Preoperative preparation of patients with an EC fistula through
their mesh is obviously important. With the exception of emer-
gency operative intervention for overt sepsis, which is uncommon,
patients with mesh infection and mesh fistula can be managed
medically with wound therapy, drainage of any local sepsis, and
antibiotic coverage as needed. Therefore, a patient’s comorbid
medical conditions and nutritional status should be optimized
before a planned operation. A check of preoperative protein stores
is performed as needed and often depends on the extent of the
fistula and ongoing enteric losses and amount of oral intake. Our
practice often does not require total parenteral nutrition.
Patient informed consent is also important. We discuss the
extent of the operation and the possible need for future operations.
A frank discussion regarding the high rate of wound complications
and possible hernia recurrence is necessary. Surgical options are
limited to primary repair, a reinforcement with biologic or
biosynthetic mesh, or a bridged repair with a non-synthetic mesh
used in the contaminated field.34,35 These techniques are associated
with an increased risk of hernia recurrence; recurrence, however,
typically occurs after resolution of the contamination, allowing for
a definitive repair of a recurrent hernia with synthetic mesh.
The operative technique takes each patient’s situation into ac-
count, but in general, the patients are approached similarly.32 Most
patients have a CT or some other cross-sectional imaging to detail
the intra-abdominal anatomy. A colonoscopy may be performed to
rule out distal pathology. A bowel prep is often used for both small
bowel and colonic fistulas. Management and control of the fistula
drainage is important and aids in having quality skin without
breakdown or cellulitis at the time of operation.
In the operating room, we most often oversew the EC fistula site
whenever possible to decrease ongoing contamination before
prepping the abdomen. Intraoperatively, we most often begin the
intra-abdominal dissection well away from the fistula. An exami-
nation of the CT will often demonstrate the safest place for entry
 M.R. Arnold et al. / Surgery xxx (2019) 1e8
Fig 1. Pedicalized mesh fistula before excision.
into the peritoneal cavity. In essence, we get into the abdomen and
begin the intestinal adhesiolysis distinct from the fistula and then
work circumferentially around it as the intensity of the adhesiolysis
allows. Often, we are able to pedicalize the fistula, and by the time
we are working directly at the fistula site, we have one segment of
intestine going into the fistula and one coming out, which allows a
straightforward bowel resection containing the overlying fistula
drainage site (Fig 1). Our approach at this point has evolved
considerably during the study. Initially, if none of the previous
hernia repair mesh was “solid” or a nonporous mesh (such as those
containing PTFE), we might consider an extensive but partial mesh
excision as compared to complete removal of the foreign body. If a
large mesh was fully incorporated well away from the fistula, the
mesh was not always excised in toto. Most often, we performed
primary, non-mesh closures of the abdominal wall, unless we
needed to bridge a defect, and then we typically utilized a biologic
mesh. After demonstrating complications associated with leaving
mesh behind and a high hernia recurrence rate with suture clo-
sures, we began to perform complete mesh excision whenever safe
and possible and then to repair the abdominal wall defects with a
non-permanent synthetic or biologic, reinforcing mesh.
In nearly all of these cases, we placed our mesh in the preper-
itoneal space.36 Dissection of the preperitoneal space is typically
initiated in the inferior midline, carried into the space of Retzius,
and then the preperitoneal space is developed laterally, away from
areas of previous surgery. Then the midline is approached in a
‘‘lateral to medial’’ maneuver, bluntly mobilizing the peritoneum in
its entirety. After circumferential development, the peritoneum is
closed using a 2-0 absorbable suture in a running fashion. If the
peritoneum cannot be closed completely, omentum or a portion of
the hernia sac is excised and included in the peritoneal closure to
fill the gap in an attempt to completely exclude the mesh from
adherence to the intestine. Mesh is then placed within the pre-
peritoneal space. The size of mesh is selected with a goal of a
minimum of 5 cm of overlap; however, most often, a much larger
overlap is achieved, exceeding 10 cm in all directions. The largest
3
available mesh that will fit the patient was typically chosen and not
trimmed. Finally, to secure the mesh, full-thickness, transfascial,
absorbable sutures were used to secure the mesh to the abdominal
wall. The mesh was first secured inferiorly to the pubis and bilateral
Cooper ligaments (for low-lying hernia defects) or superiorly to the
xiphoid or costal margins. After placement of the inferior or su-
perior sutures, the mesh was secured at the opposite end, either
toward the head or foot with transfascial sutures. Mesh was then
secured laterally by placing transabdominal, full-thickness sutures;
the number depends on the defect size and the amount of mesh
overlap. Transfacial sutures are always placed under direct vision
using a suture passer. The goal is that the mesh will lay taut without
undue tension and will not fold at the time of fascial closure. There
are few patients who are unable to have a preperitoneal dissection,
even those with multiple prior abdominal operations. In those
patients with ongoing, woody induration of the abdominal wall,
their abdomen is either closed primarily or with a bridging biologic
mesh. With good wound care, maximizing control of the fecal
stream, and antibiotics, we work to have a “soft” abdominal wall
that will allow straightforward dissection before the definitive
repair of the fistula. In patients in whom we were unable to close
the midline rectus fascia, a component separation was performed
by releasing the posterior rectus or the transversus abdominis
muscle, or external oblique. Unilateral component separation was
initially performed, and bilateral release was performed only when
necessary. It has not been our standard practice to perform
perforator-sparing external oblique release; however, external
oblique release is typically performed as a last resort. In the present
study, all component separations were considered together given
the small number of patients with mesh fistula.
As our technique progressed, we identified what is now
accepted, that wound complications result in substantially more
hernia failures. We therefore treated patients with wound vacuum
assisted closures (VACs) until the wound healed. Given the time,
patient frustration, cost, and the problems associated with this
technique, we began to perform VAC-assisted, delayed primary
closure, which has improved our outcomes and markedly improved
patient satisfaction with their wounds.37
Results
Patient characteristics
Eighty-two consecutive patients with mesh fistula (MF) were
available for analysis, with 78 patients having undergone excision
of their MF. Most of the patients (83%) were referred to our insti-
tution for care. Preoperative characteristics are in Table I. The mean
age was 60.6 ± 11.9 years and 46 (56%) of the patients were female.
The average body mass index (BMI) of the patients was 34.7 ±
7.5kg/m2, and 57 (70%) were obese (BMI  30kg/m2). Diabetes at
the time of the hernia repair preceding development of the MF was
noted in 27 (33%) patients and 21 (26%) were smokers. Five patients
(6%) had Crohn’s disease. The average time from previous VHR to
“mesh infection” or fistula was noted as 39 months. Average follow-
up after fistula takedown was 33 months.
Prior hernia repair, choice of mesh, and mesh location
Before MF formation, the preceding VHR were most often open
(77.%), and the most common mesh position was intraperitoneal
with 57 of the 82 patients (70%) having their mesh placed directly
in contact with the intestine. Other mesh positions include 7 onlay
(9%), 5 retro-rectus/preperitoneal (6%), 4 bridging (5%), and 9 (10%)
were unable to be determined from prior records. Seventeen (21%)
of the preceding operations were performed as an emergency.
4 M.R. Arnold et al. / Surgery xxx (2019) 1e8

Table I
Overall characteristics of patients with mesh fistula

Patient characteristics n ¼ 82 Mesh excision characteristics n ¼ 78

Age (y) 60.6 ± 11.9 Operative details

Body mass index (kg/m2) 34.4 ± 7.5 Defect size (cm2) 300.0 ± 374.9
Number of comorbidities 5.3 ± 7.5 Complete mesh excision 82%
Female 56.% Mesh placed at time of excision 61%
Referral for mesh fistula 83% Fascial closure 821%
Obesity 70% Panniculectomy 25%
Diabetes 33% Component separation performed 47%
Crohn's disease 6% Delayed primary closure 36%
Current smoker 26% Wound VAC 33%
History of intra-abdominal infection 60% Operative outcomes
Interval surgery preceding MF 67% Duration of stay (d) 12.1 ± 7.9
Attempted procedural intervention 83% Follow-up (mon) 33 ± 8
Attempted antibiotic therapy 98% Recurrent hernia 49%
Duration from VHR to MF (mo) 3 ± 58 Recurrent hernia repaired 32%
Duration of antibiotic Therapy (weeks) 65 ± 102 Post excision wound infection 39%
VHR technique prior to MF Cellulitis 21%
Emergency VHR 21% Abscess 26%
Open 77% Seroma requiring intervention 22%
Infected mesh type Recurrent fistula 10%
Polypropylene (PPE) 35% Other complication 47%
Polytetrafluoroethylene (PTFE) 15% Any complication 74%
Composite PTFE/PPE 22% Readmission within 30 d 28%
Polyester 7% Achieved second stage repair 19%
Biologic 5% Death 5%
Unknown 16% New mesh position n ¼ 49
Infected mesh position
Intraperitoneal 70% Preperitoneal 55%
Preperitoneal 6% Bridging 29%
Bridging 5% Retrorectus 4%
Onlay 9% Onlay 8%
Unknown `0% Intraperitoneal 4%

Numbers represent% or mean ± SD unless otherwise specified.

Mesh types included polypropylene in 29 patients (35%), PTFE in 12
(15%), composite PTFE/polypropylene in 18 (22%), polyester in 6
(7%), and biologic mesh in 4 (5%), whereas 13 (16%) patients had
unknown synthetic meshes placed at the hernia repair before
development of MF. Mean time from mesh implantation to the
development of MF was 39 ± 58 months. Fifty-five (67%) patients
had an interval procedure between the time of hernia repair and
the development of MF. Forty-two (76%) of the patients with in-
terval procedures before the development of the MF had gastro-
intestinal operations, and 3 (6%) underwent gynecologic
procedures. Exact details of the procedures were not available
because of the high referral rate, but interval operations included
both laparoscopic and open procedures for bowel obstruction,
diverticulitis, colon polyps, and hysterectomies. The remaining 10
(18%) were unsure of their surgical history and did not have suffi-
cient outside medical records for review.
Bacterial growth and attempted mesh salvage
Fifty-four patients had culture data available before mesh
excision, while the remainder had obvious open intestine in the
field and were not cultured. Of those that did have a culture, 37
(69%) had polymicrobial infections. The most common bacteria
encountered was Staphylococcus aureus occurring in 37 (69%) pa-
tients and methicillin-resistant staphylococcus aureus in 23 (43%)
patients. Streptococcal infections were found in 18 (33%) patients.
Gram-negative rods were present in 30 (56%) and anaerobes in 21
(39%) patients. Other infections encountered were Enterococcus 18
(33%), E. coli 12 (22%), and Candida 9 (17%). Fifteen (19%) of the 82
cases did not have a documented MF before planned operative
mesh excision for infection. All patients as per our normal pro-
cedure underwent attempted mesh salvage with a 100% failure rate.
During preoperative treatment at the original referring institution,
80 (98%) patients received antibiotics before mesh excision. At
outside institutions, the duration of antibiotic therapy was quite
long, lasting an average of 65 weeks. Operative debridement,
percutaneous drainage, or vacuum-assisted device treatment was
attempted in 69 (84%) patients. All patients (100%) failed nonexci-
sional treatment owing to recurrent or ongoing infections or in-
testinal leak.
Suture repair versus mesh repair
Seventy-eight patients underwent mesh excision and fistula
takedown with the remaining 4 currently undergoing medical
optimization prior to planned mesh excision (Table I). Of the pa-
tients who have undergone removal of mesh-induced EC fistula, 49
(63%) were performed with the concomitant placement of biologic
or absorbable synthetic mesh, and 29 (38%) patients had a suture
repair of their hernia defect. The most commonly used mesh was
acellular porcine dermal matrix (APDM) (Allergan, Madison, NJ). Of
patients receiving mesh, APDM was used in 36 (74%), followed by
human acellular dermis (Allergan) used in 7 (14%), absorbable bio-
synthetic in 4 (8.2%) (W. L. Gore & Associates, Flagstaff, AZ), 1 (2.0%)
bovine collagen (Integra LifeSciences, Princeton, NJ), and 1 (2.0%)
unspecified biologic. Of the meshes that were placed, 27 (55%) were
placed in the preperitoneal position, with another 14 (29%) as an
inlay or bridge, 4 (8%) as an onlay, 2 (4%) intraperitoneal, and 2 (4%)
in the retrorectus position.
When comparing patients undergoing VHRM to those under-
going SR (Table II), age (61.5 ± 10.3 vs 59.6 ± 13.7 years), BMI (34.3 ±
7.7 vs 35.1 ± 7.5), number of comorbidities (5.1 ± 2.5 vs 5.6 ± 2.6),
and smoking (22.5% vs 31.0%) were similar between groups (all P >
.05). There were no differences in utilization of delayed primary
skin closure (39% vs 31%; P ¼ .49) or prolonged use of a wound VAC
(33% vs 35%); P ¼ .86) between VHRM and SR groups. The mean
 M.R. Arnold et al. / Surgery xxx (2019) 1e8 5

Table II
Univariate comparison of abdominal wall reconstruction with and without mesh

Preoperative characteristics Mesh No mesh P value

n ¼ 49 n ¼ 29

Age (ys) 61.5 ± 10.3 59.6 ± 13.7 .49

Body mass index (kg/m2) 34.3 ± 7.7 35.1 ± 7.5 .66
Number of comorbidities 5.1 ± 2.5 5.6 ± 2.6 .40
Female 57% 51.7% .64
Referral for mesh fistula 82% 82.8% .90
Obesity 69% 72.4% .77
Diabetes 37% 27.6% .41
Crohn's disease 6% 6.9% 1.00
Current smoker 23% 31.0% .40
History of intra-abdominal infection 61% 58.6% .82
Interval surgery preceding MF 65% 69.0% .74
Duration from VHR to MF (mo) 42 ± 69 37.5 ± 36.2 .28
Duration of antibiotic therapy (weeks) 48 ± 43 51.9 ± 59.7 .87
Operative details
Defect size (cm2) 323 ± 392 130.6 ± 132.5 .044
Complete mesh excision 80% 86.2% .46
Fascial closure 73% 92.9% .04
Panniculectomy 35% 7.4% .0074
Component separation performed 63% 20.7% .0003
Delayed primary closure 39% 31.0% .49
Wound VAC 33% 34.5% .86
Postoperative outcomes
Duration of stay (d) 13.2 ± 8.3 12.5 ± 14.4 .10
Follow-up (mon) 30 ± 25 41 ± 34 .16
Recurrent hernia 45% 66% .07
Recurrent hernia repaired 48% 21% .07
Cellulitis 21% 29% .44
Abscess 21% 43% .041
Seroma requiring Intervention 25% 26% .93
Recurrent fistula 10% 10% .98
Other complication 50% 48% .88
Any complication 70% 82% .28
Readmission within 30 d 25% 30% .66
Death 4% 7% .63
Total operating room charge (USD) 34,414 ± 24,845 18,438 ± 9,752 .0018

Numbers represent% or mean ± SD unless otherwise specified.

defect size was 2.5 times greater in the VHRM group (324 ± 392cm2
vs 131 ± 133cm2; P ¼ .044). Components separation (63% vs 21%;
P ¼ .0003) and operative complication rates after takedown of the
MF including mortality (4% vs 7%), recurrent fistula (10% vs 10%),
30-day readmission (25% vs 39%), cellulitis (21% vs 29%), and
seroma requiring drainage (25% vs 26%) were similar between
groups (P > .05). Abscess rate was greater in the suture repair group
(21% vs 43%; P ¼ .041). When including bridging repairs, the overall
rate of hernia recurrence was similar between groups (445% vs 66%;
P ¼ .07); however, when excluding patients with bridged repair, the
overall recurrence rate for all meshes was 31%. Patients receiving a
non-bridged APDM in the preperitoneal position (Table III) had
lowest hernia recurrence rate, which was better than SR alone (26%
vs 66%; P ¼ .0030). In those patients who did not have a wound
complication, the patients with a mesh repair had a 15% recurrence
rate, despite the defects being 2.5 times greater than the SR oper-
ations. There was a greater follow up in the SR group (28 ± 20 vs 41
± 34 months; P ¼ .19).
Of the patients with hernia recurrence after SR, only 7 under-
went a second, staged, definitive repair. Three of these 7 patients
had hernia recurrence. Four of the patients received a biologic mesh
owing to ongoing wound issues, whereas 2 had permanent syn-
thetic mesh placed. The seventh patient had a second SR.
Influence of wound infection
After excluding patients undergoing bridged repairs, 42% of the
patients developed a wound infection postoperatively. The
presence of this complication increased recurrence rates after
abdominal closure (67% vs 27%; P ¼ .023). In those patients who had
a primary SR, the hernia recurrence rate when a wound infection
occurred was 10/12 compared to 6/14 when there was no wound
infection (P ¼ .051). After a mesh repair with complete fascial
closure, a wound infection resulted in a recurrent hernia in about
half the patients (6 of 12), whereas only 3 of 20 (15%) of these
complex patients recurred when mesh was used and there was no
infection (P ¼ .049).
Complete versus incomplete mesh excision
Sixty-four (82%) patients had complete mesh excision, whereas
14 (18%) had partial excision of the mesh. For the patients who had
complete mesh excision, a new mesh was placed in 39 (601%), and
for those who had incomplete mesh excision, a new mesh was
placed in 10 (71%) (P ¼ .46). When comparing patients who had
complete mesh excision to those who had an incomplete mesh
excision at the time of fistula takedown, there were no differences
in age, BMI, number of comorbidities, smoking status, or hernia
defect size (P > .05 for all). Furthermore, there was no difference in
the ability to achieve fascial closure, performance of components
separation, panniculectomy, delayed primary closure, healing
assisted with wound VAC, or recurrent hernia (P > .05 for all).
Unfortunately, of those who underwent a partial mesh excision, the
incidence of recurrent fistula was 4.5 times greater (29% vs 6%; P <
.05). There was no difference in mortality in patients who had
complete versus incomplete mesh excision (5% vs 7%; P ¼ .55).
6 M.R. Arnold et al. / Surgery xxx (2019) 1e8

Table III
Univariate comparison of patients with nonbridged APDM repair vs no mesh

Preoperative characteristics Nonbridged APDM No mesh P value

n ¼ 26 n ¼ 29

Age (y) 64.1 ± 10.8 59.6 ± 13.7 .19

Body mass index (kg/m2) 31.7 ± 5.1 35.1 ± 7.5 .11
Number of comorbidities 5.4 ± 2.9 5.6 ± 2.6 .68
Female 50% 52% .90
Referral for mesh fistula 78% 83% .64
Obesity 56% 72% .19
Diabetes 33% 28% .64
Crohn's disease 4% 7% .60
Current smoker 15% 32% .15
History of intra-abdominal infection 67% 59% .53
Interval surgery preceding MF 59.3% 69% .45
Duration from VHR to MF (mo) 32 ± 53 38 ± 36 .21
Duration of antibiotic therapy (weeks) 51 ± 42 52 ± 6- .74
Operative details
Defect size (cm2) 253±107 131 ± 132 .053
Complete mesh excision 82% 862% .72
Fascial closure 100% 93% .49
Panniculectomy 44% 7% .0019
Component separation performed 89% 20% < .0001
Delayed primary closure 52% 31% .11
Wound VAC 26% 35% .49
Postoperative outcomes
Duration of stay (d) 11.2 ± 5.7 12.5 ± 14.4 .37
Follow-up (mo) 28 ± 20 42 ± 3349 .19
Recurrent hernia 26% 665% .0030
Recurrent hernia repaired 43% 21% .34
Cellulitis 15% 29% .22
Abscess 15% 43% .0221
Seroma requiring intervention 26% 26 1.00
Recurrent fistula 7% 10% 1.00
Other complication 48% 48% .99
Any complication 67% 82% .21
Readmission within 30 d 19% 30% .34
Death 0% 6.9% .49

Number represent% or mean ± SD unless otherwise specified.

In patients with non-bridged hernia repairs, complete mesh
excision improved hernia recurrence rates. In non-bridged hernia
repairs at the time of MF takedown, a complete mesh resection had
a recurrence rate of 19% compared with 75% if a partial mesh
excision was performed (P ¼ .0058).
Optimal repair of MF
Considering the impact complete mesh excision and wound
infections have on hernia recurrence; an ideal cohort of patients
was analyzed. Patients who had complete mesh excision, fascial
closure with biologic mesh reinforcement, and no wound infection
were selected. The hernia recurrence rate in this group was 11%
with mean follow-up of 27 months.
Operating room charges
Total operating room charges for each patients’ care during the
study period was collected. The average operating room (OR)
charge as opposed to cost per patient was $28,074 ± $21,616. The
average OR charge per patient was greater in the VHRM group
compared to the SR group ($34,414 ± 24,845 vs 18,438 ± 9,752; P ¼
.0018).
Recurrent MF
A total of eight patients developed a recurrent MF. Of these
patients, 2 were found to have inflammatory bowel disease with
fistulating Crohn’s disease. In both cases, subsequent control of the
Crohn’s disease lead to control of the fistulous disease and allowed
for subsequent VHRM. Four other cases of recurrent MF were
associated with postoperative wound infections. One patient was
diagnosed with an organ space infection from an anastomotic leak.
The other 3 patients were noted to have deep surgical site in-
fections with associated old mesh from previous partial mesh ex-
cisions, which have impacted our decision making since. Lastly, a
patient was noted to have chronic colonic dysmotility on workup
with residual contrast noted within the colon more than 2 months
after a barium enema study. Subsequent subtotal colectomy and
VHRM yielded good results with no evidence of further fistula.
Mortality
The mortality rate was 5% (4 patients) and occurred secondary
to pulmonary embolism, anastomotic leak after discharge with
readmission presenting with sepsis, and a myocardial infarction,
aspiration pneumonia, and pulmonary failure in a comorbid 82-
year-old patient.
Discussion
In the largest series of MF to date, our findings demonstrate that
MFs occur most commonly with intraperitoneal synthetic mesh but
may occur with a variety of mesh types and in any placement. MF
may develop long after the preceding hernia repair and may be
associated with subsequent intrabdominal procedures, even in
patients with mesh placed in the retrorectus and onlay positions.
Mesh in direct exposure to the intestine, whether at the time of
initial placement if the protective anatomic plane breaks down,
such as the posterior rectus sheath, or from subsequent operative
intervention can lead to a MF. Attempting mesh salvage in the
 M.R. Arnold et al. / Surgery xxx (2019) 1e8
setting of a MF is not in our experience advisable. In the current
study, of those who had attempted non-operative management,
100% failed despite treatment with prolonged antibiotics and local
wound therapy. Interestingly, 15 (19%) patients did not have a
documented MF before planned operative mesh excision for
infection. These patients appeared to have small, chronic draining
sinus tracts, similar to the majority of patients with mesh in-
fections. Therefore, they received no further fistula workup. Pa-
tients with drainage suspicious for a fistula did not have a
fistulagram routinely or other direct contrast imaging other than a
CT. Most often, a CT provides adequate detail for operative plan-
ning. Pinpointing the area of drainage in the mid small bowel or
colon would not change our operative approach. If there were
questions concerning a more difficult or unusual anatomic area,
such as possibly the rectum or a urostomy, then greater attention to
anatomic origins would be pursued.
Previously, the decision to attempt a more definitive repair with
non-permanent mesh versus a primary closure with the thought of
“coming back to fight another day” had little data to support either
side. In the current study, hernia recurrence was decreased by more
than 3-fold in patients with preperitoneal placement of an APDM,
the most common means of mesh repair in this series, compared to
a SR alone, without an increase in complications rates. This
outcome is despite the mesh repaired hernias being on average 2.5
times greater in size with nearly two-thirds of them requiring a
component separation. The hernia recurrence rate in these very
complicated operations was 26% with long-term follow-up, and it
decreased the need for reoperation in these complex patients. This
observation suggests that performing concomitant abdominal wall
reconstruction with biologic mesh at the time of resection of the MF
and excision of the infected mesh may be the best option for pa-
tients if tissue planes allow. Interestingly, patients with a MF are at
a greater risk (4.5-fold) for fistula recurrence when their synthetic
mesh is not removed completely. Furthermore, the rate of hernia
recurrence was increased when a complete mesh excision was not
performed. The most important findings in the current study re-
inforces the notion that wound infection impacts markedly on the
rate of hernia recurrence.13,37,38 Indeed, in both mesh repair and
suture closure, the presence of a wound infection increases hernia
recurrence by 2.2 times in primary SR and 3.3 times after a mesh
repair.
The management of mesh EC fistula in the setting of concom-
itant infected mesh is not well described in the literature and is a
challenging situation. When Krpata et al described their experi-
ence with simultaneous AWR and EC fistula takedown, only 6 of
their 37 patients in that series actually had a MF.28 Despite this,
the fistula recurrence in their study is comparable to ours when
comparing to patients in our series with complete mesh excision.
Furthermore, the rates of superficial and deep wound infections
appear to be similar between both studies. With regard to hernia
recurrence, all but 1 of their patients received retrorectus mesh
placement, and when comparing patients with similarly placed
mesh in our group, their recurrence rate was somewhat greater.
The exact reason is not clear, however, their group used a variety
of mesh types, such as non-crosslinked human cadaveric dermal
matrix as well as non-crosslinked, porcine dermal matrix from
multiple manufacturers that have since been shown to be asso-
ciated with a greater risk of hernia recurrence.34 Itani et al
demonstrated a hernia recurrence rate of 23% at 2 years with an
APDM, which is similar to recurrence rate in the current study.39
In another series, Zerbib et al described their experience per-
forming single stage AWR with biologic mesh in patients with
mesh infection or EC fistula.40 Unfortunately, a direct comparison
between these 2 studies is difficult given the very small numbers
of patients with mesh-induced EC fistulas. They did not report
7
recurrent EC fistulas but did note a greater rate of hernia
recurrence.
Resection of MFs are complex, difficult operations with
considerable rates of wound complication and are not without
mortality.17,18 The current study provides information that we
believe can improve care in these intricate surgeries. Our data
demonstrate that incomplete mesh excision, even when the mesh
is resected well back from the fistula into normal appearing tissue
and mesh, is associated with the greatest rates of wound infections,
hernia recurrence, and formation of recurrent fistulas. The mor-
tality observed in this series is as might be expected from other
difficult abdominal operations with no definable or direct rela-
tionship to mesh or hernia surgery.
Our results show that there is an increased charge associated
with patients receiving biologic mesh as is supported in the liter-
ature.34,41 The reliability of the exact numbers, however, are
questionable. While charge information is available, obtaining
actual cost data would be very helpful and more reliable. The
markup of surgical products by the hospital (resulting in the charge
numbers) is quite variable and can alter a financial cost/charge data
analysis tremendously. This occurrence is unfortunate, because it
tends to obscure an assessment of the true value of a procedure or
product when comparing it to other possible treatments. In this
study, the marked decrease in long-term recurrence in these very
complicated abdominal wall reconstructions with bowel resections
appears to strongly support the additional OR cost we document
when an APDM is used because of the value added to the patient.42
We believe that our study is the largest reported review of
mesh-induced fistulas to date, but it does have limitations. First,
true prospective collection of all data is limited by the large number
(82%) of patients referred from outside hospitals for treatment.
Despite the lack granular data prior to the original hernia repair,
details like type of mesh and its placement were available in large
enough numbers to demonstrate that intraperitoneal mesh is a risk
for the development of a MF. Some specifics appear to be a bit less
important in guiding treatment, because all MFs failed medical
management and required operative intervention.
In conclusion, resection of MFs are complex, difficult operations
that carry an expectedly high rate of wound complications. MFs do
not close spontaneously and consideration should be given to
operative repair when the patient is appropriately optimized for
operative repair. Patients undergoing definitive VHR with biologic
mesh at the time of takedown of the MF decreases the rate of hernia
recurrence without an increase in complications compared to SR
alone. Complete mesh excision as compared to partial mesh
resection decreases the incidence of recurrent MF and improves the
rate of hernia recurrence when mesh is used for abdominal wall
reconstruction. Wound infection plays an important role in
decreasing wound infection and increases recurrence rates by 3-
fold after a mesh repair. Thus, optimal therapy for a MF appears
to include management (resection/repair) of the intestinal fistula,
complete mesh excision, repair of the hernia with a biologic mesh,
and elimination of wound infection.
Funding/Support
This research did not receive any specific grants from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest/Disclosures
Dr. Heniford has prior grants and honoraria from W.L. Gore,
Allergan, and Stryker. Dr. Augenstein has prior grants and honoraria
from W.L. Gore, Ethicon, Intuitive, Allergan, and KCI. Dr. Kercher has
received honoraria from Bard Inc., Ethicon, and W.L. Gore.
8 M.R. Arnold et al. / Surgery xxx (2019) 1e8
Dr. Colavita has prior honoraria from Allergan. The remainder of the
authors have no relevant financial conflicts or disclosures.
References
1. Poulose BK, Shelton J, Phillips S, et al. Epidemiology and cost of ventral hernia
repair: making the case for hernia research. Hernia. 2012;16:179e183.
2. Usher FC, Ochsner J, Tuttle LL. Use of marlex mesh in the repair of incisional
hernias. Am Surg. 1958;24:969e974.
3. Burger JWA, Luijendijk RW, Hop WCJ, Halm JA, Verdaasdonk EGG, Jeekel J.
Long-term follow-up of a randomized controlled trial of suture versus mesh
repair of incisional hernia. Ann Surg. 2004;240:578e583; discussion 583-585.
4. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair
with mesh repair for incisional hernia. N Engl J Med. 2000;343:392e398.
5. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral
hernias: nine years’ experience with 850 consecutive hernias. Ann Surg.
2003;238:391e399; discussion 399-400.
6. Alexandre JH. Jean-Paul Chevrel (1933-2006). Hernia. 2007;11:293e296.
7. Rives J, Pire JC, Flament JB, Palot JP, Body C. Treatment of large eventrations. New
therapeutic indications apropos of 322 cases. Chirurgie. 1985;111:215e225.
8. Stoppa RE. The treatment of complicated groin and incisional hernias. World J
Surg. 1989;13:545e554.
9. Ventral Hernia Working Group, Breuing K, Butler CE, et al. Incisional ventral
hernias: review of the literature and recommendations regarding the grading
and technique of repair. Surgery. 2010;148:544e558.
10. den Hartog D, Dur AHM, Tuinebreijer WE, Kreis RW. Open surgical procedures
for incisional hernias. Cochrane Database Syst Rev. 2008:CD006438.
11. Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hos-
pital readmission following surgery in the United States. JAMA. 2015;313:
483e495.
12. Ferzoco SJ. A systematic review of outcomes following repair of complex
ventral incisional hernias with biologic mesh. Int Surg. 2013;98:399e408.
13. Hawn MT, Gray SH, Snyder CW, Graham LA, Finan KR, Vick CC. Predictors of
mesh explantation after incisional hernia repair. Am J Surg. 2011;202:28e33.
14. Sanchez VM, Abi-Haidar YE, Itani KMF. Mesh infection in ventral incisional
hernia repair: Incidence, contributing factors, and treatment. Surg Infect
(Larchmt). 2011;12:205e210.
15. Cox TC, Blair LJ, Huntington CR, et al. The cost of preventable comorbidities on
wound complications in open ventral hernia repair. J Surg Res. 2016;206:
214e222.
16. Matthews BD, Pratt BL, Pollinger HS, et al. Assessment of adhesion formation to
intra-abdominal polypropylene mesh and polytetrafluoroethylene mesh. J Surg
Res. 2003;114:126e132.
17. Connolly PT, Teubner A, Lees NP, Anderson ID, Scott NA, Carlson GL. Outcome
of reconstructive surgery for intestinal fistula in the open abdomen. Ann Surg.
2008;247:440e444.
18. Martinez JL, Luque-de-Leo
n E, Ballinas-Oseguera G, Mendez JD, Jua
rez-
Oropeza MA, Rom
an-Ramos R. Factors predictive of recurrence and mortality
after surgical repair of enterocutaneous fistula. J Gastrointest Surg. 2012;16:
156e163; discussion 163-164.
19. van’t Riet M, de Vos van Steenwijk PJ, Bonjer HJ, Steyerberg EW, Jeekel J. Mesh
repair for postoperative wound dehiscence in the presence of infection: is
absorbable mesh safer than non-absorbable mesh? Hernia. 2007;11:409e413.
20. Foda M, Carlson MA. Enterocutaneous fistula associated with ePTFE mesh: case
report and review of the literature. Hernia. 2009;13:323e326.
21. Losanoff JE, Richman BW, Jones JW. Entero-colocutaneous fistula: a late
consequence of polypropylene mesh abdominal wall repair: case report and
review of the literature. Hernia. 2002;6:144e147.
22. Evenson AR, Fischer JE. Current management of enterocutaneous fistula.
J Gastrointest Surg. 2006;10:455e464.

J, Torregrosa-Gallud A, Carren ~ o-Sae

nz O, et al. Partial versus
23. Bueno-Lledo
complete removal of the infected mesh after abdominal wall hernia repair. Am J
Surg. 2017;214:47e52.
24. Chung L, Tse GH, O’Dwyer PJ. Outcome of patients with chronic mesh infection
following abdominal wall hernia repair. Hernia. 2014;18:701e704.
25. Paton BL, Novitsky YW, Zerey M, Sing RF, Kercher KW, Heniford BT. Manage-
ment of infections of polytetrafluoroethylene-based mesh. Surg Infect
(Larchmt). 2007;8:337e341.
26. Fabian TC, Croce MA, Pritchard FE, et al. Planned ventral hernia. Staged man-
agement for acute abdominal wall defects. Ann Surg. 1994;219:643e650; dis-
cussion 651-653.
27. Jernigan TW, Fabian TC, Croce MA, et al. Staged management of giant
abdominal wall defects: acute and long-term results. Ann Surg. 2003;238:
349e355; discussion 355-357.
28. Krpata DM, Stein SL, Eston M, et al. Outcomes of simultaneous large complex
abdominal wall reconstruction and enterocutaneous fistula takedown. Am J
Surg. 2013;205:354e359.
29. Rosen MJ, Krpata DM, Ermlich B, Blatnik JA. A 5-year clinical experience with
single-staged repairs of infected and contaminated abdominal wall defects
utilizing biologic mesh. Ann Surg. 2013;257:991e996.
30. Wind J, van Koperen PJ, Slors JFM, Bemelman WA. Single-stage closure of
enterocutaneous fistula and stomas in the presence of large abdominal wall
defects using the components separation technique. Am J Surg. 2009;197:
24e29.
31. Sahoo S, Haskins IN, Huang LC, et al. Early Wound morbidity after open ventral
hernia repair with biosynthetic or polypropylene mesh. J Am Coll Surg.
2017;225:472e480.e1.
32. Schmelzer TM, Iannitti DA, Heniford BT. The management of enterocutaneous
fistulas involving mesh placed for ventral hernia repair. Oper Tech Gen Surg.
2008;10:30e38.
33. Tastaldi L, Barros PHF, Krpata DM, et al. Hernia recurrence inventory: inguinal
hernia recurrence can be accurately assessed using patient-reported outcomes.
Hernia; 2019. Available from: https://doi.org/10.1007/s10029-019-02000-z.
34. Huntington CR, Cox TC, Blair LJ, et al. Biologic mesh in ventral hernia repair:
Outcomes, recurrence, and charge analysis. Surgery. 2016;160:1517e1527.
35. Rosen MJ, Bauer JJ, Harmaty M, et al. 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. 2017;265:205e211.
36. Heniford BT, Ross SW, Wormer BA, et al. Preperitoneal ventral hernia repair: A
decade long prospective observational study with analysis of 1023 patient
outcomes. Ann Surg; 2018. Available from: https://doi.org/10.1097/SLA.
0000000000002966.
37. Basta MN, Fischer JP, Kovach SJ. Assessing complications and cost-utilization in
ventral hernia repair utilizing biologic mesh in a bridged underlay technique.
Am J Surg. 2015;209:695e702.
38. Cobb WS, Warren JA, Ewing JA, Burnikel A, Merchant M, Carbonell AM. Open
retromuscular mesh repair of complex incisional hernia: predictors of wound
events and recurrence. J Am Coll Surg. 2015;220:606e613.
39. Itani KMF, Rosen M, Vargo D, et al, and the RICH Study Group. Prospective
study of single-stage repair of contaminated hernias using a biologic porcine
tissue matrix: the RICH Study. Surgery. 2012;152:498e505.
40. Zerbib P, Caiazzo R, Piessen G, et al. Outcome in porcine acellular dermal
matrix reinforcement of infected abdominal wall defects: a prospective study.
Hernia. 2015;19:253e257.
41. Reynolds D, Davenport DL, Korosec RL, Roth JS. Financial implications of ventral
hernia repair: A hospital cost analysis. J Gastrointest Surg. 2013;17:159e167.
42. Porter ME. What is value in health care? N Engl J Med. 2010;363:2477e2481.