For patients who develop an SSI after VHR, the first step is to determine if the infection actually involves the prosthetic material. Ultrasound and CT imaging is useful in determin­ing the extent of any abdominal wall fluid collections and if there is direct connection with the space in which the mesh was placed. If a prosthetic mesh infection is present, the various options for management must be considered, rang­ing from antibiotic therapy alone to complete mesh exci­sion, and must be tailored to the clinical condition of the patient. The operative technique, particularly the position of the mesh within the abdominal wall, the prosthesis involved, and the bacteriology of the SSI are all critically important factors that determine the ultimate success or failure of mesh salvage. A multidisciplinary approach is often helpful, including the surgeon, wound care, and infec­tious disease. Perhaps most importantly, the expectations of the patient must be managed. Prolonged wound care, repeated operations, and a high risk of hernia recurrence require patience and perseverance from both patient and surgeon.

As already alluded to, the position of the mesh within the abdominal wall plays a significant role in the ability to salvage mesh. Retromuscular mesh position provides a well- vascularized compartment for mesh placement that is separate from the viscera, with musculocutaneous tissue coverage of the mesh, making this space ideal for decreasing the risk of infection and salvaging prosthetic mesh in the event of infection [13, 22, 24, 25]. This is our preferred tech- nique for open VHR, using large pore PP mesh, and we very rarely remove mesh for infection in this space. Mesh onlay has been shown to have a higher rate of SSO and SSI in many studies [9, 46, 47], but local wound care, including partial mesh excision, can be successful. Mesh infection of intraperitoneal mesh is more difficult to preserve. This may be in part due to differing mesh properties, as mesh placed in an intraperitoneal position typically has some barrier coating designed to prevent visceral adhesions. The effect of these various tissue-separating layers on bacterial adherence and infection is unknown. Additionally, mesh placed over the peritoneum does not necessarily truly incorporate into the abdominal wall; rather, a neoperitoneum forms over the vis­ceral mesh surface and the mesh is held to the abdominal wall by this thin layer and whatever fixation was used to secure the mesh. This is evidenced clinically in our experi­ence with mesh removal, which typically peels off of the abdominal wall quite easily, leaving the posterior rectus sheath and even native peritoneum intact. In our experience with over 10 years of infected mesh management, we have found intraperitoneal mesh infection to be rarely salvage­able, while large pore PP mesh placed in the retromuscular space was preserved 100 % of the time [14, 23].