Treatment of Postherniorrhaphy Inguinal Abscess by Hydrofiber: A Possible Option of Leaving Mesh In situ?
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Hernia surgery is one of the most commonly performed operations in surgical practice. Groin hernia surgery is associated with a number of complications including visceral injury, neuro-vascular injury, seroma formation, anesthetic complications, infection, and those related to prosthesis. With the increasing utilization of prosthesis in hernia surgery a number of complications became evident, and several dismal outcomes occurred as a result of prosthesis misuse. Previously it was believed that the incidence of infection in mesh hernioplasty was more common than conservative surgery.1,2 However, recent data suggests that acceptable rates of infection (lower than 2%) can be achieved in patients undergoing mesh hernioplasty.3–5 Although, when infection occurs it should be treated promptly in order to prevent local and systemic measures. The following case examines a postherniorrhaphy inguinal abscess treated with a silver-containing wound care product.
Case Report
A 75-year-old woman was admitted to the authors’ clinic with pain, swelling, and purulent discharge located in the right inguinal region. She had undergone a right inguinal herniorraphy at another clinic 2 weeks prior to presentation. Physical examination discovered the patient was septic with a 38˚C body temperature, 109/min pulse, and 100/60 mmHg blood pressure. The patient’s right groin was swollen, the suture line was hyperemic, and she had muscular tenderness in the same area. Abdominal computerized tomography (CT) performed at another clinic revealed the presence of collection (abscess) located at the right lower quadrant of the abdomen with possible interaction with the peritoneal cavity. Abdominal ultrasound detected approximately 500 cc of subcutaneous pus collection, gallbladder and urinary bladder stones, and grade II hydronephrosis at the right kidney. The patient’s leukocyte count was 11.900/cc; hemoglobin 13.4 g/dL; and platelet count 358,000/cc. The blood glucose level was 82 mg/dL and liver function tests were within normal limits. Blood urea nitrogen (BUN) was 104 mg/dL (N: 7–22), creatinine 9.5 mg/dL (N: 0.3–1.3), and potassium 6.6 mEq/L (N: 3.5–5.5). Other electrolytes were within normal range. The patient was diagnosed with acute renal failure, and was given precedence for immediate hemodialysis before surgery. A double-lumen jugular catheter was applied prior to hemodialysis. After dialysis treatment, her BUN level was 48 mg/dL, creatinine 6.8 mg/dL, and potassium 5.1 mEq/l. The patient underwent surgical drainage and 1 g of cefamezin sodium was administered before surgery for prophylaxis. A 15 cm x 10 cm abscess cavity was found in the inguinal region below the external oblique fascia during the surgical procedure. Samples for culture and antibiogram were taken, the pus was aspirated, all necrotic tissue was excised, and the cavity was washed with 2 L of saline. The prosthesis (polypropylene mesh) was not removed and was left in situ (Figure 1). The entire cavity was filled with (15 cm x 10 cm) of hydrofiber product containing silver (Aquacel Ag Hydrofiber®, ConvaTec, Skillman, NJ) and was left open for secondary healing. The hydrofiber dressing was replaced daily during the first week, and after the first week it was replaced every other day. The patient followed an uncomplicated postoperative course and was discharged 15 days from initial presentation. At the time of discharge, the surface of the mesh was granulated, and there was mild scarring around the wound (Figure 2). Two months later, the wound was almost completely healed without complication (Figure 3).
Discussion
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