Mesh Migration into the Neobladder and Ileum with Complicated Fistula Formation following Incisional Hernia Repair

Background. Tension-free repair using mesh has become the standard treatment for abdominal wall incisional hernias. However, its postoperative complications reportedly include mesh infection, adhesions, and fistula formation in other organs. Here, we report an extremely rare case of mesh migration into the neobladder and ileum with entero-neobladder and neobladder-cutaneous fistulas. Case Presentation. An 80-year-old male who had undergone radical cystectomy 5 years ago and abdominal wall incisional hernia repair 3 years ago presented with fever and abdominal pain. Computed tomography (CT) scan revealed mesh migration into the neobladder and ileum. He was treated conservatively with antibiotics for a month but did not show improvement; hence, he was transferred to our hospital. He was diagnosed with mesh migration into the neobladder and ileum with complicated fistula formation. He underwent mesh removal, partial neobladder resection, and partial small bowel resection. He developed superficial incisional surgical site infection, which improved with drainage and antibiotics, and he was discharged 40 days after the surgery. Conclusions. We reported a rare case of mesh migration into the neobladder and ileum with fistula formation. Successful conservative treatment cannot be expected for this condition because mesh migration into the intestinal tract causes infection and fistula formation. Hernia repair requires careful placement of the mesh such that it does not come into contact with the intestinal tract. Early surgical intervention is important if migration into the intestinal tract is observed.

A Study on the Prevalence and Source of Staphylococci and Methicillin-resistant Staphylococcus aureus Causing Superficial Incisional Surgical Site Infection

Staphylococcus aureus and coagulase-negative staphylococci (CoNS) are common causatives of superficial incisional surgical site infection (SSI). The source of the pathogens is still not fully diagnosed whether it is endogenous or exogenous particularly with regard to the extent of its resistance to antibiotics. Therefore, this study is designed to determine the rate of infection, the source of pathogens, and the extent of their resistance to antibiotics. For this purpose, pre-, intra- and post-operative swabs from the nasal and skin of patients undergoing surgeries and samples from the hospital environment have been collected and processed for isolation and identification of staphylococci. Bacterial analysis and antibiotic susceptibility profiles of the isolates are assessed by unweighted pair group method with arithmetic mean (UPGMA) analysis based on random amplified polymorphic DNA-polymerase chain reaction (RAPD-PCR) and disc diffusion test for antibiotics susceptibility profile. The microbiological and PCR results indicate that SSIs are found in 113/512 (22.07%), Staphylococcus spp. rated 67/512 (13.09%) of infections. Further analysis indicates that S. aureus, CoNS, and both of them were causes SSI with different rates 41/67 (61.2%), 23/67 (34.3%), and 3/67 (4.5%), respectively. Results of RAPD-PCR for 70 isolates reveal that 52/70 (74.28%) of SSIs are from endogenous source, followed by 10/70 (14.29%) and 8/70 (11.43%) from hospitals acquired and undetermined sources, respectively. Moreover, results of antibiotic susceptibility test reveal that 24/44 (54.5%) of isolates belong to methicillin-resistant Staphylococcus aureus; from both endogenous and exogenous sources with 13/24 (54.17%) and 11/24 (45.83%), respectively.

Subcutaneous Fat Thickness and the Risk of Superficial Incisional Surgical Site Infection Following Open Appendectomy

Obesity is a known risk factor for surgical site infection (SSI). Recent studies have demonstrated that fat burden at the incisional site rather than body mass index (BMI) is a more precise and sensitive measure to predict the risk of SSI. The purpose of the study was to evaluate the correlation between subcutaneous fat thickness (SCFT) at the level of Mc Burney’s point and the occurrence of superficial incisional SSI among the patients undergoing open appendectomy. A total of 120 patients who underwent open appendectomy were included in the study. SCFT was measured preoperatively with ultrasonography (USG). The occurrence of superficial incisional SSI was evaluated in relation to SCFT. Previously identified well established risk factors for the development of SSI were also considered by the study. Statistical analysis was performed using SPSS version 17. Overall, superficial incisional SSI was observed in 27 (22.5%) participants. Mean SCFT at the level of Mc Burney’s point among male and female population was 2.26 cm ± 0.74 (SD) and 2.02 cm ± 0.83 (SD) respectively. Patients with superficial incisional SSI had a mean fat thickness of 2.80 cm and those without SSI had mean fat thickness of 1.97 cm. The difference in SCFT was statistically significant (p=.001). More interestingly, the area under the ROC curve was more for SCFT, in comparison to BMI among the patients who developed superficial incisional SSI (81% vs. 73%). Furthermore, we analysed the occurrence of superficial incisional SSI with SCFT cut off at 2.80 cm, which was statistically significant. As majority of the study population were young adults, risk factors like smoking, diabetes mellitus and nutritional status failed to demonstrate significant correlation with post appendectomy wound site complications. The study demonstrated that the thickness of subcutaneous fat at the site of inci sion is a good predictor of superficial incisional SSI following open appendectomy and the risk of superficial wound site infection increases as the thickness of subcutaneous fat at the site of incision increases.

Changing gloves during cesarean section for prevention of postoperative infections: a systematic review and meta-analysis

This systematic review and meta-analysis was conducted to assess associations between changing gloves during cesarean section (CS) and postoperative infection. A literature search was conducted using the major electronic databases MEDLINE, Scopus, ISI Web of Science, PubMed, CINAHL, and CENTRAL from their inception to September 2020. Randomized controlled trials (RCTs) comparing glove change during CS to no glove change were included. Outcomes of interest were endometritis, febrile morbidity, and incisional surgical site infection (SSI). GRADE approach was applied to assess the quality of evidence. Ten reports of six studies involving 1707 participants were included in the analyses. Glove change was associated with a reduction in the risk of incisional SSI following CS (pooled RR 0.49, 95% CI 0.30, 0.78; moderate quality of evidence). Compared to no glove change, glove change during CS did not reduce the risks of endometritis (pooled RR 1.00, 95% CI 0.80, 1.24; low quality of evidence) or febrile morbidity (pooled RR 0.85, 95% CI 0.43, 1.71; very low quality of evidence). Changing gloves during CS was associated with a decreased risk of incisional SSI. The risks of postoperative endometritis and febrile morbidity were not altered by changing gloves.

Thickness of subcutaneous fat is a risk factor for incisional surgical site infection in acute appendicitis surgery: a prospective study

Background Incisional surgical site infection (SSI) is a significant source of postoperative morbidity resulting in increased length of stay and cost. In this study, our aim was to evaluate the association between thickness of subcutaneous fat (TSF) and incisional SSI among patients undergoing open appendectomy in low-resource settings. Methods 90 patients with acute uncomplicated appendicitis who underwent emergency open appendectomy from December 2017 to August 2018 were included in this prospective study. TSF was measured preoperatively using ultrasound. TSF and other possible predictors of incisional SSI, including body mass index and other clinical characteristics, were assessed by univariate and multivariable logistic regression analysis. Receiver operating characteristic (ROC) curve analysis evaluated the predictive value of TSF and the optimum cut-off value for TSF was determined using the Youden index. Results The prevalence of incisional SSI was 13.3% (12/90). TSF was independently associated with incisional SSI (P < 0.001). Additionally, history of smoking (P = 0.048) was also associated with incisional SSI. A model of incisional SSI using a cut-off of 23.0 mm for TSF was moderately accurate (area under curve 0.83, confidence interval 0.70–0.97; sensitivity 83.3%; specificity 76.9%). Conclusions The study demonstrated that TSF, as evaluated by ultrasound, is a predictor in the development of incisional SSI in patients with acute appendicitis undergoing open appendectomy. These findings suggest that ultrasound is useful both for the evaluation of TSF and the prediction of incisional SSI risk factor in low-resource settings.

Incisional surgical site infections in obstetric and gynecological procedures in a tertiary care hospital in Northern India

Background: To find the incidence of incisional surgical site infection (ISSI) in obstetric and gynecological procedures, the risk factors, the microbial spectrum, the antibiotic sensitivity and the impact on the hospital stay. Methods: A prospective observational study was done under the department of obstetrics and gynecology, Era’s Lucknow medical college and hospital. All consecutive patients who underwent caesarean section, vaginal delivery with episiotomy, laparotomy, and hysterectomy were included in this study. Laparoscopic surgeries were excluded. Results; In this series of 646 surgeries, 6.18% developed ISSI. In the category of major surgeries, the ISSI rate was 8.89%. Amongst the 185 episiotomies 1.6% gaped. Anemia, diabetes mellitus, excess body weight, emergency or elective surgery, rapid built up of hemoglobin with blood transfusion, previous caesarean scar and tobacco intake were the risk factors identified. Coagulase negative staphylococcus was the dominant microbe. Antibiotic sensitivity to linezolid was found in 50% of the ISSI cases followed by amikacin, clindamycin and some others. The mean hospital stay was 13 days while the maximum was 26 days.Conclusions: The study established the current status of incisional surgical site infections, identified the risk factors, the microbial spectrum, the antibiotic sensitivity and the need for further studies using a preventive approach.