Alternatives to mesh

[DrBachman]

Alternatives to mesh

John,

I’d be interested to hear a little more detail about your experience with foreign implants and the specific symptoms you had. There is definitely a huge variation in the body’s response to foreign bodies. The immune and inflammatory pathways clearly have genetic variation at a level which we can’t yet detect. We know that certain populations of patients (for example people with red hair) have a higher rate of aggressive FB reactions than others, but we don’t understand all the subtleties (yet).

Biologic meshes and resorbable synthetic meshes (such as phasix and tigr) do eventually go away, but it is via the same biologic pathway as the foreign body response to a permanent mesh. So, if you tend to have a brisk or aggressive inflammatory response, it may still occur with these mesh types (it just will end, eventually). There are some surgeons who have published results on inguinal repairs with biologic mesh, so it can be done with ok short-term outcomes. But none of us know how long a hernia defect needs to be covered by mesh to prevent a recurrence. Weeks? Months? Years? Forever? We really don’t know. The published follow-up for biologic mesh inguinal hernia repairs has been very short, only a year or two. It’s unclear why no-one has published long term results, as it has been almost 10 years since the first papers came out.

There was a recent review of TiMesh in the hernia literature. Much of the research is in animal models. There are only a few studies looking at inguinal repair in humans. They rated the data as moderately good. Here were their conclusions:

1. Titanized polypropylene meshes can be used in inguinal hernia repair in Lichtenstein technique instead of heavy-weight pure
polypropylene meshes

2. In the TAPP technique for inguinal hernia repair, the ultra-light titanized polypropylene mesh can be preferred to heavy-weight
meshes in defect sizes less than or equal to 3 cm

3. Titanized polypropylene meshes can be used for laparoscopic (TAPP) and endoscopic (TEP) repair for unilateral and bilateral inguinal hernias

So, to interpret these recommendations, in the first two studies lightweight TiMesh was put head to head with heavyweight mesh. That isn’t a fair comparison, as many of use would no longer use heavyweight mesh in the groin, because we know those patients are more symptomatic post-operatively. The last statement just says TiMesh can be used for hernia repair. There really isn’t convincing data in humans that TiMesh has significant decrease in post-op symptoms compared to uncoated light/medium weight mesh.

What we do know without doubt is that the greater the density of material in your mesh, the more chronic inflammatory cells will be present trying to attack the mesh, increasing your risk of pain or sensation. Lightweight mesh definitely decreases the local inflammation; nothing totally obliterates it, but most patients aren’t aware of that low-level of response.

You are in a tough bind. I spent a lot of time earlier in my career removing mesh from patients with chronic pain. It was usually due to a heavyweight material or a plug, and as more surgeons have transitioned to lighter-weight materials, the number of patients seeking mesh removal seems to have fallen, in my experience. The number of patients I saw who truly seemed to react to having any foreign material at all in their body were very few. But they were miserable.

If your hernias are reducible and you haven’t had complications from them, you could always try a mechanical support such as a truss to help support your weak areas during exercise and activity. But I would agree with Dr. Towfigh that a lightweight synthetic mesh is probably your best bet to allow you unlimited activity long-term. One option might be having one side repaired and seeing how it goes before having the second side fixed. That means undergoing two procedures, but if you are very concerned about chronic pain, it is a viable option.