Patient questions about mesh in hernia repair

Almost daily I have patients ask me about mesh. We are all hearing the growing dialogue over the use of mesh in hernia surgery.  The majority of this hysteria is generated by lawyers, especially through several class action lawsuits that are trying to gain traction.  This has also prompted some surgeons to promote mesh free hernia repair, as if that is a new and improved technique. I think of these surgeons as the anti-vaxers of the hernia community.  Unfortunately the legal and promotional questions have little to do with the realities of mesh in hernia repair.  The majority of mesh complaints come from the early days of mesh, when uncoated mesh was placed in the abdominal cavity.  Surgeons in the early 1960s were just learning about the disasters of mesh in growth into bowel and other structures.  More recently a problem with transvaginal mesh has come to light.  However, that has nothing to do with hernia repair.  From a surgeon’s perspective, mesh has been a godsend.  The magic word is recurrence.  Even when the oldest know mesh (Marlex) was studied, the recurrence rate was dramatically decreased.  One prominent study shows a 8% recurrence rate in incisional hernia repair with mesh compared to a 25% recurrence rate with no mesh.  Similar studies show a dramatic reduction in inguinal hernia rates, from 15 % without mesh to less than 1% with mesh.  So why the fuss with recurrence?  Well recurrence means repeat surgery with repeat surgical risks, repeat anesthesia, repeat complications from the hernia itself, repeat pain, and a huge expense to the patient.  There are certainly problems with mesh, however they are relatively infrequent, and not the recipe for disaster the legal community would have us believe.  Mesh itself has also changed dramatically.  Modern mesh designed for intraabdominal use has a non-adherent coating that prevents the earlier problems of in growth into bowel and other organs.  All mesh is immunologically invisible to the body, and cannot be rejected.  The techniques for mesh placement have also changed.  The latest trend is to place mesh within the abdominal wall rather than in the abdominal cavity.  This avoids any contact with the abdominal organs and can be performed either open, laparoscopically or with the robot.  Some complimentary technique changes include; component separation which creates a tension free repair, the avoidance of bridge repairs where mesh was the only component covering a large hole, and abdominal wall nerve blocks that minimize discomfort and often turn huge repairs into outpatient procedures.  I hope this helps clarify some of your questions.  I am always happy to discuss this problem with you or any of your patients.

James Rifenbery, MD, FACS

General Laparoscopic and Robotic Surgery

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