Chronic Abdominal Wall Collection after Umbilical Herniorrhaphy with Mesh: Persistent Infection versus Prosthetic Material Rejection: A Case Report

Abstract

Background: Prosthetic mesh reinforcement is the current standard for abdominal wall hernia repair, including umbilical hernias, because it consistently lowers recurrence compared with primary closure. Mesh placement is not risk-free, however, and has been associated with seroma, hematoma, surgical site infection, visceral erosion, and, less commonly, chronic pain or immunologic reactions to the material. Distinguishing chronic low-grade infection from a foreign-body reaction is particularly difficult, since both can present as a persistent abdominal wall collection with initially negative cultures and only partial, transient improvement with antibiotics or drainage. Case Presentation: We report the case of a 72-year-old woman who underwent open umbilical herniorrhaphy with prosthetic mesh at another institution. Imaging obtained immediately afterward suggested a surgical site infection, and a persistent mesogastric abdominal wall collection was subsequently identified on follow-up MRI and CT over more than a year, initially interpreted as an organized hematoma. She presented to our institution with abdominal pain and distension; percutaneous drainage yielded serosanguinous fluid with initially negative cultures. Six days later she was readmitted with fever, chills, and hyporexia, with leukocytosis, an elevated C-reactive protein, and cultures positive for Citrobacter spp. after catheter repositioning returned hemopurulent fluid. The abdominal wall surgery board considered probable rejection of the prosthetic material and proceeded with open surgical drainage, debridement, complete mesh removal, and negative-pressure wound therapy. Results: Histopathology of the resected specimen showed hyalinized fibroconnective tissue with fibrin deposits and severe abscessing acute inflammation, without multinucleated giant cells or granulomas, findings that favor an active infectious process over a classic foreign-body reaction, without excluding a coexisting rejection component. The patient's postoperative course was favorable, with resolution of sepsis and continued targeted antibiotic therapy and wound care. Conclusion: In a patient with a persistent or enlarging abdominal wall collection after mesh herniorrhaphy, chronic infection and foreign-body rejection should be considered as overlapping rather than mutually exclusive possibilities, and a collection labeled as an organized hematoma that fails to resolve over time warrants active reassessment. When the plane between mesh and inflamed tissue cannot be clearly identified intraoperatively, complete mesh removal is generally safer than attempting salvage, and multidisciplinary discussion is central to management in ambiguous cases.