Vol.:(0123456789) 1 3 Hernia https://doi.org/10.1007/s10029-019-02035-2 ORIGINAL ARTICLE The use of synthetic mesh in contaminated and infected abdominal wall repairs: challenging the dogma—A long‑term prospective clinical trial C. Birolini 1,2  · J. S. de Miranda 1  · E. Y. Tanaka 1  · E. M. Utiyama 1  · S. Rasslan 1  · D. Birolini 1 Received: 24 April 2019 / Accepted: 18 August 2019 © Springer-Verlag France SAS, part of Springer Nature 2019 Abstract Background Abdominal wall reconstruction in patients presenting with enteric fstulas and mesh infection is challenging. There is a consensus that synthetic mesh must be avoided in infected operations, and the alternatives to using synthetic mesh, such as component separation techniques and biologic mesh, present disappointing results with expressive wound infection and hernia recurrence rates. Methods A prospective clinical trial designed to evaluate the short- and long-term outcomes of 40 patients submitted to elective abdominal wall repair with synthetic mesh in the dirty-infected setting, and compared to a cohort of 40 patients submitted to clean ventral hernia repairs. Patients in both groups were submitted to a single-staged repair using onlay poly- propylene mesh reinforcement. Results Groups’ characteristics were similar. There were 13 (32.5%) surgical site occurrences in the infected mesh (IM) group, compared to 11 (27.5%) in the clean-control (CC) group, p = 0.626. The 30-day surgical site infection rate was 15% for the IM group vs. 10% for the CC cases, p = 0.499. One patient required a complete mesh removal in each group. The mean overall follow-up was 50.2 ± 14.8 months, with 36 patients in the IM group and 38 clean-controls completing a follow-up of 36 months. There was one hernia recurrence (4.2%) in the IM group and no recurrences in the CC group. Conclusion We demonstrated that using polypropylene mesh in the infected setting presented similar outcomes to clean repairs. The use of synthetic mesh in the onlay position resulted in a safe and durable abdominal wall reconstruction. Trial registration Study registered at Plataforma Brasil (plataformabrasil.saude.gov.br), CAAE 30836614.7.0000.0068. Study registered at Clinical Trials (clinicaltrials.gov), Identifer NCT03702153. Keywords Hernia repair · Mesh infection · Enteric fstula · Polypropylene · Synthetic mesh · Abdominal wall reconstruction Introduction “Thou shall not use synthetic mesh in contaminated felds.” Since the beginnings of the mesh era, this mantra is repeated in every publication addressing the use of mesh in clean- contaminated and contaminated operations. As stated in many publications, this general conception spreads concerns about the use of synthetic mesh in the contaminated setting: “It is generally not recommended or not recommended” [1], “Its use is contraindicated” [2], “It is of-label to use syn- thetic mesh” [3], “The concern in this scenario is the risk of mesh infection” [4], and “The use of non-absorbable syn- thetic material is historically considered contra-indicated” [5]. While it is not easy to identify the exact origins of these concerns, such understanding is possibly a result of the long-term complications, including enteric fstulas, chronic infection, and mesh extrusion, mostly reported during the second half of the last century. These complications were later associated with the inadequate use of polypropylene mesh in emergency operations, with the use of multifla- ment polyester or microporous mesh, and with intraperi- toneal mesh placement [6–8]. As asserted by Carbonell, it * C. Birolini claudio.birolini@hc.fm.usp.br 1 General and Trauma Surgery, Department of Surgery, School of Medicine, University of São Paulo, São Paulo, Brazil 2 São Paulo, Brazil