22 Aug 2026 Revision Surgery After Inguinal Hernia Repair: Mesh Removal and Beyond

Revision Surgery After Inguinal Hernia Repair: Mesh Removal and Beyond

Laparoscopic and robotic inguinal hernia repair has become increasingly preferred worldwide in recent years, as it offers less pain, faster recovery, and lower recurrence rates compared to open surgery. However, as with every surgical method, undesired outcomes can occur in some patients after repair with minimally invasive surgery (MIS): recurrence, chronic pain, foreign body sensation, or mesh infection.

In this article, I will describe revision surgery performed again with the laparoscopic/robotic technique in patients who present with such problems. This is certainly one of the most challenging and specialized areas of inguinal hernia surgery. It should be noted that the revision techniques described here are for meshes previously placed in the preperitoneal space via a laparoscopic/robotic approach; removal of meshes placed with the open technique requires a different surgical approach and is not the subject of this article. In addition, mesh removal and revision surgery for anterior abdominal wall hernias (umbilical, epigastric, incisional hernias, etc.) are also outside the scope of this article; that topic will be addressed in a separate blog post.

Why Do Problems Occur After Laparoscopic/Robotic Repair?

Although the success rate of MIS inguinal hernia operations is high, the complication rates reported in the scientific literature are not negligible. The most common problems are as follows:

Recurrence — Technical reasons are generally the most important causes of recurrence. These include the use of an undersized mesh, shrinkage of a low-quality mesh due to inflammation, insufficient coverage area of the mesh, improper positioning of the mesh, its migration (displacement), curling or even folding, or insufficient fixation, resulting in the hernia recurrence. You can click to read my blog post about recurrences!

Chronic pain — Pain that continues for more than 3 months after the operation. In MIS, this is most often associated with entrapment of the genitofemoral nerve (less commonly injury to the ilioinguinal and/or iliohypogastric nerves), irritation caused by the staple material used to fix the mesh, or fibrotic tissue forming around the mesh.

Foreign body sensation — The patient describes an uncomfortable sensation of fullness/pressure in the groin area, resulting from the stiffness of the mesh, its shrinkage, or contact with the cord structures. This is generally related to mesh quality.

Mesh infection — Although rare after inguinal hernia operations (under 1%), this is a serious complication that can present with sinus formation, abscess, or chronic discharge.

Why Is the MIS Technique Preferred in Revision?

In the past, switching to open surgery was the standard approach for such complications. Today, however, revision operations can also be performed laparoscopically or robotically in experienced centers. The main reasons for this are:

1. Anatomical clarity: When the preperitoneal space in the groin is entered through the abdomen, the anatomical structures, the previous mesh, and the myopectineal orifice (space of Fruchaud) can be visualized much more clearly; the magnification and three-dimensional view offered especially by the robotic system facilitate the operation. Compared with laparoscopy, robotic surgery takes this a step further and definitely reduces the level of difficulty of the operation.

2. Less surgical trauma: This actually means a shortcut. While open surgery requires a large incision and passing through many healthy structures to reach the preperitoneal space, the minimally invasive route reaches the problematic area directly through three small incisions. This benefits the patient with less pain, a shorter hospital stay, and a faster return to work compared to open revision.

Nevertheless, these operations are technically challenging, carry a high risk of serious complications, and should be performed by experienced surgeons who have received advanced training in abdominal wall and hernia surgery.

Surgical Interventions: What Is Done?

1. Mesh Removal

An infected, migrated, curled, folded mesh, or one causing chronic pain, is carefully dissected out of the preperitoneal space. The main difficulty at this stage is the dense fibrotic reaction that develops around the mesh and the possibility that the mesh has adhered to neurovascular structures (particularly the external iliac vessels, vas deferens, and gonadal vessels). In experienced hands, this dissection can be completed safely. However, if preserving these structures does not appear possible, part of the mesh may be left in place. This generally does not adversely affect clinical outcomes.

2. Neurectomy

If the source of chronic pain can be clearly localized to one or more nerves (ilioinguinal, iliohypogastric, genitofemoral), that nerve can be selectively transected (neurectomy), and its proximal end can be buried into suitable tissue to prevent retraction. A preoperative diagnostic nerve block can guide the surgeon in determining which nerve is responsible. The nerve most commonly injured after laparoscopic inguinal hernia repair is the genitofemoral nerve, and this nerve is also selectively transected at the same time as mesh removal. Laparoscopic transection of the ilioinguinal and iliohypogastric nerves has important consequences; this is the development of a bulge on that side of the abdomen due to denervation. These two nerves originate from the L1 and L2 levels and contain both sensory and motor fibers until they approach the inguinal canal. In the groin region, however, they consist entirely of sensory fibers. In a more proximal neurectomy — that is, one performed more anteriorly, laparoscopically — the motor fibers are also disabled, causing the transversus abdominis and internal oblique muscles in that area to atrophy due to denervation. This in turn leads to bulging or asymmetry in this region. Cosmetically, this is an undesirable outcome. The patient must absolutely be informed about this before the operation. You can click to read my blog post on this topic!

3. Paravasal Denervation

If the patient has testicular pain, its source is not damage to a specific nerve but rather the autonomic nerve network surrounding the spermatic cord (the spider web-like micro-nerve branches around the cord). In this case, selective dissection of the microfascial structures and small nerve branches surrounding the spermatic cord (paravasal denervation) can be applied. During this procedure, the deferential vessel — the artery of the vas deferens, which arises retrograde from the internal iliac artery — must be preserved. Some patients experience ejaculatory pain, described as pain during and after ejaculation. Among the mechanisms behind this are pressure from the mesh and/or compression of the vas deferens by scar tissue that has formed. In the treatment of ejaculatory pain, paravasal denervation together with mesh removal and excision of scar tissue provides significant improvement in symptoms.

4. Mesh Removal and Re-placement (MoMi)

After a mesh is removed due to recurrence or infection, the abdominal wall is generally not sufficiently reinforced, so repair with a new mesh is required in most cases. If the mesh is infected, its removal is unavoidable. In most cases, broad-spectrum antibiotic use, interventional and surgical drainage procedures, and drain placement are unsuccessful. Bacteria form biofilms and settle within the pores of the mesh. In this situation, it is nearly impossible for the body’s defense cells, the leukocytes, to act, or for antibiotics to reach the site. In the presence of infection, this is generally done in two stages: first, the infected mesh is removed and the area is cleaned, and after healing (within weeks to months), a new hernia repair is performed in a second session. Complete removal of the infected mesh is important. Otherwise, the infection will not heal in most cases because of the presence of a foreign body and will require repeated surgical interventions. You can click to read my blog post about mesh infection!

If the issue is recurrence, mesh removal and re-repair can be completed in a single operation. We call this MoMi (Mesh out, Mesh in — that is, removing and re-placing the mesh). However, this is not easy. After the mesh is removed, the resulting anatomical plane must be ready to properly accommodate the new mesh. In addition, after the new mesh is placed, the remaining peritoneum must be able to close completely, and the mesh must be isolated from the abdominal cavity. Direct contact of the mesh with intra-abdominal organs must be avoided. Coated meshes with an anti-adhesion barrier can also be an option. However, their use should be avoided unless necessary.

If these conditions cannot be met, and there is an obvious hernia defect, then a mesh repair using the open technique is the safest option.

If the underlying cause is recurrence, it may not always be necessary to remove the old mesh. In some cases, using the old mesh to complete a peritoneal defect is a very sensible option.

5. Tack Removal

Especially if the patient is being operated on for chronic pain, all permanent fixation materials — that is, tacks — should be removed. Before the operation, either a plain pelvic X-ray should be taken to determine the location and number of tacks, or this should be done with CT. Even if the tacks were not placed near nerves, fixation into bony structures can cause chronic pain. As with neuropathic pain, the pain intensity is not high, but it is noticeable and impairs the patient’s quality of life. In some cases, these tacks may be the sole cause of chronic pain.

Tips and Tricks of Mesh Removal

I would like to share with my surgeon colleagues, based on my experience, some tips and tricks for mesh removal: First and foremost, the approach must be with the TAPP technique. It is very difficult with TEP and its variant, eTEP. Since you will be removing the mesh, you must try to preserve the peritoneum and cause minimal loss. Maintaining this control with TEP is possible only if you are lucky. With TAPP, anatomical control and dissection are much better.

You will usually see the silhouette of the old mesh in the groin. Peritoneal dissection should always be advanced starting from the healthy peritoneum at the upper edge, just as in a standard TAPP. Since you will be separating the mesh, you must enter the plane between the mesh and the anterior abdominal wall. To preserve the peritoneum, you also need to enter the plane between the mesh and the peritoneum. Entering this plane between the mesh and the peritoneum is difficult laterally, since there is little fatty tissue in front of the peritoneum; most of the peritoneal loss occurs here. Medially, however, thanks to the fatty tissue in front of the bladder and around the urachus, one can enter behind the mesh and obtain a generous peritoneal flap. This plane also protects the bladder. Once the medial edge is reached, reaching the symphysis pubis and Cooper’s ligament is relatively easy. The mesh is separated from the wall medially, and dissection is advanced laterally.

On reaching the lateral edge of the mesh, it is lifted off the wall while traction is applied medially: this dissection must proceed simultaneously in two planes. The other plane is the lateral-inferior edge of the mesh, i.e., where it sits on the surface of the psoas muscle. This is the riskiest and most critical part of the operation, where important structures are at risk of injury. The genitofemoral nerve, vas deferens, spermatic vessels, and iliac vessels are the key structures at risk here. In fact, one can often anticipate before the operation how the dissection will proceed and whether the mesh will be separable from these structures. If preoperative CT or MRI shows a fat plane between the mesh and these structures, this is a sign that the dissection will proceed easily. If it is unclear, however, this is a sign that it will be difficult. In this case, part of the mesh can be left in place during the operation to reduce these risks. In women, the round ligament is present in this region and can be safely divided during mesh removal.

Advancing from the upper edge of the mesh, one will always encounter the epigastric vessels. In most cases, these structures can be preserved. Otherwise, sealing them with an energy device or controlling them with clips is safe. When approaching the iliac vessels, care must be taken with these vessels. Injuries near their origin are difficult to control.

Once the medial and lateral dissections are completed, the mesh is finally separated from Cooper’s ligament as well, completing its removal. The myopectineal orifice of Fruchaud is then inspected and checked for a hernia defect. Sometimes the hernia may not be visible due to fibrosis. The presence of a cord lipoma should always be checked. If there is no hernia defect, a new mesh may not need to be placed. Do not forget: if you are operating for chronic pain, you are putting out a fire. For this reason, achieving the main goal and completing the operation, and performing a new repair later if a hernia develops, is the right decision.

If a new mesh will not be placed after the old one is removed, the surgical field should be closed with peritoneum if possible. If there is not enough peritoneum to close it, then it should be left completely open. In partial closures, potential blind spots may form, and bowel may enter this area, causing mechanical bowel obstruction. If a mesh will be placed, it must always be covered with peritoneum. For this reason, the dissection area can be extended, and peritoneum can be obtained from the contralateral groin area. Likewise, peritoneal flaps can be prepared laterally and inferiorly to gain additional coverage. Peritoneal openings can also be patched, up to a certain limit, by bringing in omentum.

I would also like to touch on the possible complications, precautions, and treatments here. The most important is vascular injury, especially to the external iliac vein. Injury to this vessel can cause extensive hemorrhage. For this reason, extreme care must be taken during this part of the operation. In case of possible injury, a gas sponge and a 4/0 vascular needle pp suture, or 4/0 V-Lock® should be placed in a suitable location inside the abdomen at the very beginning of the operation. If a vessel is at risk, a portion of the mesh should be left in place at that location. Another organ injury risk is to the bladder. Sometimes the mesh forms a mass (meshoma) that presses on and adheres tightly to the bladder. These patients often report frequent urinary urgency. The bladder can be opened during dissection in this area. Being aware of this is important. As preparation, these patients should have a three-way urinary catheter placed before the operation begins. During the operation, methylene blue testing should be used to reveal any suspected injury. In case of injury, a two-layer repair should be performed with an absorbable suture. The catheter should be kept in place for one week after the operation.

Another important organ is the vas deferens. In young adult patients and those who have not had children, utmost care should be taken to preserve the vas. In case of injury, anastomosis should be attempted. In older patients, it might be sacrificed. The testicular vessels are also at risk of injury. Efforts should be made to protect these structures by finding a suitable plane between them and the mesh and by using sharp dissection.

The Superiority of Robotic Surgery

When comparing the laparoscopic and robotic approaches in MIS inguinal hernia operations, the situation in which robotic surgery is by far superior is mesh removal. The robotic approach provides superior results by offering important advantages such as three-dimensional visualization, superior maneuverability, and increased precision in the surgical field. In this type of surgery, where the risk of injury to important structures and organs is high, the robotic platform provides significant gains. It gives the surgeon better camera control. It is also ergonomically less tiring. Click to read my blog post!

Which Patients Are Candidates?

This revision surgery is particularly considered in the following patients:

– Those with chronic groin pain lasting longer than 3 months that has not responded to conservative treatment (physical therapy, painkillers, nerve block)

–  Those with recurrent hernia confirmed by physical examination and imaging (ultrasound/MRI)

– Those with findings of mesh infection (discharge, sinus, abscess)

– Patients whose quality of life is impaired by a pronounced foreign body sensation

Before making a decision, the source of the pain should be clarified through a detailed history, physical examination, imaging (usually dynamic ultrasound or pelvic MRI), and, when necessary, a diagnostic nerve block.

Who Should Perform It?

Scientific studies show that referring recurrent hernias to specialists/clinics with expertise in this area results in higher treatment success rates. Mesh removal and the accompanying additional procedures certainly fall into this category, and indeed are at the very top of it. Excellent knowledge of the three-dimensional posterior anatomy of the groin wall is required. Having advanced laparoscopic/robotic skills is important. It is also essential to know the potential risks and complications of the operation and to be prepared for them. Click to read my blog post!

Postoperative Process

Most patients can be discharged the same day as the operation or the day after. Mild to moderate pain and swelling are expected in the first few days. Patients who undergo neurectomy may experience temporary or permanent numbness in the sensory area of the relevant nerve; this must absolutely be explained to the patient before the operation. In procedures performed for chronic pain, complete pain reduction may take shape over a period of several weeks to several months.

Conclusion

Problems that can be seen after MIS inguinal hernia repair — such as pain, recurrence, foreign body sensation, and mesh infection — can now largely be managed safely, again using minimally invasive techniques, whether laparoscopic or robotic. Procedures such as mesh removal, selective neurectomy, paravasal denervation, and, when necessary, placement of a new mesh can provide a marked improvement in patients’ quality of life when performed by an experienced surgical team. Due to the complexity of this type of revision surgery, it is recommended that patients be evaluated at specialized centers/experts in hernia surgery.

The 48th annual congress of the European Hernia Society was held this year in Porto. At the congress, I presented a video submission on robotic mesh removal. Click here to watch the edited video…