Highlight
- The cumulative risk of mesh removal for infection after elective open ventral hernia repair is low, under 3% over 10 years.
- Patients with 30-day postoperative wound complications have an increased risk of mesh removal, with a 10-year cumulative hazard of 7.94% versus 2.48% in those without complications.
- Most clinically significant infections leading to mesh removal occur within the first five years postoperatively, with a median removal time around eight months.
- These findings support the continued broad use of mesh in elective open ventral hernia repair.
Study Background
Open ventral hernia repair is a common surgical procedure in which synthetic mesh is frequently implanted to reinforce the abdominal wall and reduce hernia recurrence. Given the large number of surgeries performed annually, understanding the long-term safety profile of mesh usage—especially concerning infections necessitating mesh removal—is critical. While early postoperative complications such as surgical site infections (SSIs) are documented, the long-term risk profile for clinically significant mesh-related infections requiring explantation remains poorly characterized. This gap in knowledge impacts surgical decision-making and patient counseling.
Study Design
This study utilized a retrospective cohort design analyzing comprehensive administrative claims from the entire Medicare fee-for-service population over an 11-year period from 2011 to 2021. The cohort included adults aged 18 years or older who underwent elective inpatient open ventral hernia repair with mesh placement. The primary outcome assessed was mesh removal identified via Current Procedural Terminology (CPT) codes, serving as a surrogate for clinically significant mesh infection. Secondary analyses examined associations between 30-day postoperative wound complications and the subsequent incidence of mesh removal. The extensive dataset enhances the generalizability to older and comorbid populations often represented in Medicare.
Key Findings
Among 59,453 patients (59.2% female), only 1,330 (2.2%) required mesh removal during follow-up. The median time to mesh removal was 238 days (approximately 8 months), with the interquartile range spanning 49 to 757 days (2 months to 25 months), indicating most removals occurred within the first five years post-surgery. Patients undergoing mesh removal were more frequently female (63.0% vs 59.1%, P=0.005) and had higher rates of enterectomy during the initial surgery (3.5% vs 2.3%, P=0.008).
Importantly, 30-day wound complications were strongly associated with mesh removal. Approximately 23.6% of patients with mesh removal experienced an early wound complication compared to only 6.6% who did not require removal (P<0.001). The cumulative 10-year hazard of mesh removal was 7.94% (95% CI, 7.03–8.84) in patients with wound complications versus 2.48% (95% CI, 2.31–2.64) in those without. This finding highlights early wound healing status as a critical predictor of long-term mesh safety.
The overall low incidence of mesh removal underscores that clinically significant mesh infection requiring explantation is an uncommon event after elective open ventral hernia repair, even among higher-risk groups.
Expert Commentary
These results provide robust, real-world evidence to address longstanding concerns about the risks of synthetic mesh infection in ventral hernia repair. Despite the retrospective nature and reliance on administrative data, the large sample size and long follow-up lend confidence to the conclusions. The use of mesh removal as a surrogate for clinically significant infection is reasonable given the procedural context.
The higher incidence of removal in patients with early wound complications aligns with biological plausibility that postoperative infections or poor wound healing predispose to chronic mesh infection. This finding suggests targeted vigilance and perhaps prophylactic strategies in patients with early wound issues could improve outcomes.
Limitations include lack of granular clinical details such as mesh type, exact infection microbiology, or surgical techniques, which could modulate infection risk. Additionally, the Medicare population skews older, so extrapolation to younger cohorts requires caution.
Conclusion
This comprehensive Medicare cohort study demonstrates that the long-term risk of clinically significant mesh infection necessitating mesh removal after elective open ventral hernia repair is low, with a cumulative incidence under 3% over 10 years. Early postoperative wound complications substantially increase this risk but still affect a minority. These findings support the continued broad use of synthetic mesh in elective open ventral hernia repair due to its favorable risk-benefit profile. Future prospective research should focus on refining risk stratification and optimizing perioperative management to further reduce infectious complications.
References
Ehlers AP, Sinamo JK, Howard R, Hallway AK, O’Neill SM, Collins C, Rubyan M, Shao JM, Telem DA. Long-Term Risk of Mesh Infection Requiring Removal After Elective Ventral Hernia Repair. JAMA Surg. 2025 Oct 1:e253915. doi:10.1001/jamasurg.2025.3915. Epub ahead of print. PMID:41032292; PMCID:PMC12489794.
HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22(1):1-165.
9th International Abdominal Wall Reconstruction Surgery Consensus Meeting (IAWRS). Surgical site infection prevention and management in hernia repair: evidence-based guidelines.
“Guidelines for Prevention of Surgical Site Infection,” Centers for Disease Control and Prevention (CDC), 2017.