ModeratorAugust 1, 2015 at 10:50 pm
Alternatives to mesh
I’m going to give my opinion here, sprinkled with some evidence based data from accepted literature. I urge the surgeons on this Board to give their take, too, as the answers to this post are very subjective.
Hernia surgery and the mesh question has not yet become a science. We just don’t know enough to be able to match the perfect technique or mesh implant to the perfect patient. There is an art to it. We can extrapolate from our experience and from research done on patient populations that are typically heterogeneous in some respects and homogeneous (ie, controlled) in other respects.
First, the “30% chronic pain” data is an exaggeration and should be understood in context. There is a 20% chronic pain incidence after open inguinal hernia repair with mesh for all-comers. There are papers that have shown lower numbers and other studies that have shown higher numbers. Most surgeons accept this 20% number. “Chronic pain” is defined as any pain or sensation noted after 3 months after surgery. This includes tugging, pulling, twinges, catching, fleeting pains. Almost all of these pains are rated to be low level, non-debilitating, and short-lived (ie, many can last a few seconds and then they are gone when they happen). The incidence decreases when the data is followed to 12 months, and so on. There is a 3% risk of chronic debilitating pain. This is the really important number. This is pain that seriously affects the patient’s life, they cannot perform normal daily activities, cannot work, and/or the pain level is greater than a 5 or 6 out of 10.
Also note that the numbers quotes are for open inguinal hernia repair with normal weight mesh. Patients undergoing the same operation with lighter weight mesh have been shown to have lower rate of chronic pain in many studies, though some studies show no difference.
Depending on the surgeon, laparoscopic surgery is also expected to result in a significantly lower risk of chronic pain. The outcomes from this technique of operation, which includes implantation of mesh, is highly dependent on the expertise of the surgeon, moreso than with open procedures. One study showed a significant difference in recurrence rate and complications after 250 operations. Many of us believe at least 500 operations must be performed before the learning curve is surpassed. It is considered one of the main reasons why laparoscopy for hernia repairs has not become more common than open surgery (unlike gallbladder surgery).
With regard to your comments about specific populations at most risk for chronic mesh-related pain: they are young thin females. Mesh causes inflammation and I think perhaps if you don’t have enough far to buffer the inflammation, perhaps there is more perceived pain. Also, thinner patients may have more of a foreign body sensation, which can also be perceived as pain with the normal weight mesh, and so lighter weight mesh may be more appropriate for their habitus. Once again, it is less of an issue for laparoscopy, as the mesh is placed deeper, behind the muscle, but we still take these mesh weight factors into consideration.
With regard to tissue repair, it is no longer considered the “gold standard” for hernia repair, as mesh repair has a significantly lower recurrence rate. As a result, most modern surgeons do not have a large experience performing these. Those of us who employ the tissue repair into our practice may use it sparingly based on the needs of a patient. For example, I use the Bassini or Shouldice repair for inguinal hernias in some women, in those of any gender who do not wish a mesh repair, and in those with contraindications to mesh repair, such as infection or with specific reactions. The Shouldice clinic in Toronto is most famous for their tissue repair experience and have the lowest published rates of recurrence and complications. No one has been able to reproduce their data. In countries such as China, where 80-90% of hernias do not get mesh, there must be a lot of good experience with tissue repair. A rate of 30% recurrence is too high for a tissue repair. If you choose to have a tissue repair, I would seek out a surgeon who can perform this with results around 10-15% at the most, which is what the data used to show before mesh was introduced.
In conclusion, you need a consultation from a surgeon who can help you determine a) if you even need a hernia repair, b) which repair will best meet your needs with the best outcomes. As a 60-year old, and an athlete, I would not recommend a tissue repair unless you have true contraindications to mesh implantation. If you are thin, definitely a lightweight mesh is a good option. If you’re fit and healthy, laparoscopy is another good option. The type of hernia and size also factor in place (direct vs indirect).
Hope this helps!