# Mesh-Augmented Ventral Hernia Repair Despite Iatrogenic Staphylococcus aureus-Peritonitis Due to Progressive Pneumoperitoneum: A Case Report

## TL;DR

A patient with a large hernia and a Staphylococcus aureus infection from a medical procedure was successfully treated with mesh repair and antibiotics.

## Contribution

Demonstrates safe single-stage ventral hernia repair despite iatrogenic peritonitis caused by progressive pneumoperitoneum.

## Key findings

- A 47% loss-of-domain hernia was repaired successfully despite Staphylococcus aureus peritonitis.
- Antibiotic treatment with flucloxacillin resolved the infection after mesh placement.
- Single-stage repair was feasible and resulted in an uneventful recovery.

## Abstract

Loss-of-domain in large incisional hernia needs to be addressed by mesh-augmented repair combined with a combination of component separation techniques: progressive pneumoperitoneum (PPP) and chemical component separation with botulinum toxin A. In this case report, successful management of an iatrogenic Staphylococcus aureus peritonitis caused by PPP with nevertheless definitive treatment of a giant loss-of-domain ventral hernia is presented.

A female patient with M1-3W3 recurrent incisional hernia with a loss-of-domain of 47% was prepared for definitive ventral hernia repair by chemical component separation with botulinum toxin A-infiltration and PPP via an intraperitoneally placed central venous catheter. A significant increase of inflammatory markers was found after 28 days. An emergency CT scan was performed, which showed the PPP and perihepatic/perisplenic contrast-enhancing fluid collections. Exploratory laparoscopy and laparotomy revealed no bowel perforation but fibrinous peritonitis due to an iatrogenic PPP-catheter-associated peritonitis. Despite the fibrinous peritonitis, we decided to proceed with definitive ventral hernia repair (Rives-Stoppa-Sublay-Herniotomy with transversus abdominis release (left) and anterior component separation (right), 42 × 30 cm permanent polypropylene mesh). Initial calculated antibiotic treatment was performed with piperacillin/tazobactam. Microbiologic examinations revealed Staphylococcus
aureus in the intraoperative specimens on postoperative day 1 and the antibiotic treatment was changed to intravenous flucloxacillin for 14 days after surgery. The further hospital stay was uneventful and the patient was discharged on the 20th postoperative day.

The presented case demonstrates the possibilities in complex ventral hernia repair to achieve a satisfying outcome for the patients. Even in cases with infectious complications, a single-stage procedure might be performed safely and a complete reconstruction of the abdominal wall might be achieved. The risk of chronic mesh infection in contaminated situations, especially during the presence of Staphylococcus aureus, remains uncertain and has to be weighed against possible benefits.