Mesh Use in Incarcerated Hernia Repair

Decision Algorithm Based on CDC Wound Classification

The American College of Surgeons recommends using synthetic mesh for all incarcerated hernias without signs of intestinal strangulation or concurrent bowel resection in clean surgical fields (CDC class I) due to significantly lower recurrence rates 1, 2
Mesh repair significantly reduces recurrence rates compared to tissue repair without increasing wound infection rates in clean and clean-contaminated surgical fields (CDC classes I and II) 3, 4
The use of synthetic mesh is recommended for both ventral and groin hernias in clean surgical fields (CDC class I) 1, 5
In clean-contaminated fields (CDC class II), synthetic mesh can be used even with intestinal strangulation and/or concomitant bowel resection without gross enteric spillage 1, 2
Emergent prosthetic repair with synthetic mesh can be performed without increased 30-day wound-related morbidity in clean-contaminated fields (CDC class II) 1, 2

For small defects (<3 cm) with bowel necrosis and/or gross enteric spillage in contaminated or dirty fields (CDC classes III and IV), primary repair without mesh is recommended 1, 2, 6
When direct suture is not feasible for larger defects in contaminated or dirty fields (CDC classes III and IV), consider biological mesh 1, 2, 6
The choice between cross-linked and non-cross-linked biological mesh depends on defect size and contamination degree in contaminated or dirty fields (CDC classes III and IV) 1, 2

Short-term prophylaxis is recommended for CDC class I (clean field) 1, 2
48-hour antimicrobial prophylaxis is recommended for CDC classes II and III (clean-contaminated and contaminated) 1, 2
Full antimicrobial therapy is recommended for CDC class IV (dirty field) 1, 2, 6

Mesh should not be avoided in clean or clean-contaminated fields due to fear of infection, as evidence shows it's safe and reduces recurrence 3
Synthetic mesh should not be used in grossly contaminated fields (CDC class III/IV) as infection rates can be high 6
Appropriate antimicrobial prophylaxis based on wound classification is crucial 1, 2
The size of the defect should be considered when choosing between primary repair and mesh placement 1, 2, 6