Invasive Candida albicans fungal infection requiring explantation of a noncrosslinked porcine derived biologic mesh: a rare but catastrophic complication in abdominal wall reconstruction A bdominal wall hernias are a generally underappreciated but morbid complication of abdominal laparotomy. In high-risk settings, the incidence rate of developing postoperative hernia can be as high as 69%. 1 Unfortunately, simple primary tissue repair of these hernias is fraught with poor results, and worsens every time another operation is performed. 2 Thus, in contemporary practice, mesh is typically used to augment the fascial reapproximation, as its use is associated with a reduced rate of hernia recurrence. 3,4 This benefit is such that prophylactic use of mesh in elective surgery to prevent potential future ventral hernias is recommended. 5 Synthetic meshes are now used ubiquitously in most surgical settings involving elective groin and ventral abdominal wall repairs. While synthetic mesh has been a tremendous advancement, benefitting countless patients, these products have unfavourable characteristics, particularly when infected. Although rare, synthetic mesh infections are disastrous for patients when they occur. Therefore, when an abdominal wall repair is either contemplated or necessitated in a contaminated operative field, biologic meshes are used as an alternative. Biologic meshes are derived from either porcine or bovine tissue, can be either crosslinked or not, and have been purported to be more resistant to infection. 6-9 Further, it has been suggested that noncrosslinked meshes have reduced infection rates compared with crosslinked biologic meshes. 10 The same finding has previously been reinforced by our own group, and we thus feel especially obligated to caution surgeons to not perceive biologic mesh to be "infection-resistant" or "infection-proof." 8 We report a devastating case of infiltrative infection of a noncrosslinked biologic mesh (Strattice) with Candida albicans following a ventral abdominal wall repair, where clinical improvement was seen only after explantation of the infiltrated mesh and treatment with systemic antifungal medications.

Summary The comparative performance of synthetic and biologic meshes in complex and contaminated abdominal wall repairs remains controversial. Though biologic meshes are generally favoured in contaminated fields, this practice is based on limited data. Standard dictum regarding infected mesh is to either explant it early or pursue aggressive conservation measures depending on mesh position and composition. Explantation is typically morbid, leaving the patient with recurrent hernias and few reconstructive options. We report a case in which a hernia repaired with synthetic mesh recurred and was reconstructed with underlay biologic mesh. Delayed wound hematoma occurred after initiating anticoagulation for late postoperative pulmonary embolism, which became chronically infected. After multiple failed attempts at medical and interventional salvage of the mesh infection, the patient underwent selective explantation of synthetic mesh with conservation of the underlying biological mesh. She recovered completely without recurrent abdominal wall failure at long-term follow-up. We suggest the “salvageable” characteristics of biologic meshes may allow conservation, rather than explantation, in select cases of infection.