19 Mar 2024 Mesh-Free Hernia Repair: Exploring Alternatives
I’ve been wanting to write this article for a long time. Some of my patients express their preference for hernia repair without mesh. Some avoid it due to concerns about having a ‘foreign object’ in their body, while others fear complications they’ve read about online or seen in forums regarding hernia surgery. That’s why I’m addressing this topic. We categorize mesh-free hernia repairs as Sewn tissue repairs’. Someone call them ‘Non-mesh repairs’, ‘Pure tissue repairs’, etc… Here, I’ll summarize these repairs for the three main types of abdominal wall hernias: inguinal, umbilical, and incisional hernias.
Groin Hernia
Let’s start with the most commonly performed hernia surgeries, which are for inguinal hernias. Italian surgeon Edoardo Bassini (1844-1924) performed the first successful sewn repairs for inguinal hernias, marking the beginning of modern hernia surgery. Bassini is considered the father of hernia surgery. Later, this technique was diversified, giving rise to repairs such as Shouldice, McVay, and Marcy. The most commonly practiced sewn tissue repair technique today is the Shouldice technique. Shouldice Hospital still operates in Thornhill, Canada.
I perform mesh-free inguinal hernia repairs for my patients, but as always, we make decisions together after discussing the outcomes. It should be noted that mesh repairs generally have a higher success rate in preventing hernia recurrence and chronic pain, compared to non-mesh repairs I always share this information with my patients as it’s supported by scientific evidence. All the information I provide in my blog posts is based on scientific evidence, and I always specify when it’s not. Mesh-free repairs can be performed in young, fit patients with relatively small hernias. However, in cases such as those involving a hernia extending into the scrotum, obese patients, elderly patients, or large defects in the posterior wall, mesh-free repairs would be challenging and carry a higher risk of both short-term and long-term recurrence.l hernias. However, in cases such as those involving a hernia extending into the scrotum, obese patients, elderly patients, or large defects in the posterior wall, mesh-free repairs would be challenging and carry a higher risk of both short-term and long-term recurrence.
Another reason for choosing sewn repairs is a theoretical allergy to mesh material. Mesh allergy has not been scientifically proven. There are claims that it could trigger autoimmune reactions, but there’s weak evidence regarding its cautious use in patients with allergies or autoimmune diseases. However, there’s no scientific evidence for either scenario, only anecdotal reports. Personally, I haven’t encountered such a case in my long career in hernia surgery.
Regarding absorbable meshes for inguinal hernias, there’s no published study on their long-term outcomes yet, but unpublished studies show promising results. These meshes are absorbed over time, stimulating collagen formation in the hernia area before completely disappearing. There are currently four types of absorbable meshes available, which disappear within 1-6 months, 6 months, 12 months, and 36 months, respectively. However, there’s sufficient evidence for the use of such meshes in umbilical and incisional hernias.
Umbilical Hernia
Sewn tissue repairs have their place in umbilical hernias and are endorsed in hernia guidelines. Roughly speaking, sewn repairs can be applied in non-obese patients with a hernia defect diameter of less than 2 cm. Even in such cases, there’s a relatively increased risk of recurrence compared to repairs with mesh. However, in this group of patients, laparoscopic/robotic repairs would be overkill and unnecessary. A small incision to place a mesh in front of the fascia or the preperitoneal space is sufficient. This surgery can be comfortably performed under local anesthesia and sedation and falls under the category of outpatient surgery. There’s a relatively new technology that recently arrived in our country called ‘Mesh Suture’. I wrote a blog post about this years ago. Typically, we use monofilament polypropylene thread for sewn repairs. Suture mesh replaces this classic polypropylene thread. A single suture cuts the fascia with the tension over time. Due to its multi-filament structure, mesh suture prevents the suture from cutting through the tissues and weakening the suture line. Although there are yet to be sufficient published studies, it’s becoming increasingly popular. I was the first to apply it in our country, and patients are quite satisfied. The same principles I’ve stated for umbilical hernias also apply to another primary hernia of the abdominal wall, epigastric hernias.
Incisional Hernia
Lastly, sewn repairs for incisional hernias. Is there a place for them? Hardly any. If I had to mention a type of incisional hernia where sewn repair could be considered, it would be in patients with a short life expectancy and a small hernia. Incisional hernias generally do not stop growing and must be reinforced with a mesh. Even in repairs with mesh, while the average worldwide recurrence rates are in the 30% range, theoretically speaking, for sewn repairs, it’s 100%.
To sum up briefly about meshes and conclude with my final thoughts, the precursors of the meshes used today started being used in the late 1950s. Before that, metal and thread-based meshes were used and failed. Meshes support weak tissue and stimulate the formation of collagen-based tissue there. When implanted in the body, meshes trigger a foreign body reaction and undergo an inflammation process. This is the body’s natural and physiological response. Following this, fibroblastic activity leads to collagen accumulation. In mesh science, we aim to produce the best mesh with advancements in polymer (thread), polymer thickness, weave style, mesh pore size, and various coating and material combinations. The meshes we currently use are of high quality and are very compatible with the body.
The important thing is to prepare the patient well for surgery and to select the most suitable repair technique and mesh for the patient. The experience of the surgeon is crucial here. This is the only way to achieve successful outcomes.
