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Plug and Patch Hernia Repair
I had a consultation with a General Surgeon to discuss the treatment of my inguinal hernia. The surgeon informed me he will repair the hernia with an open mesh procedure. If it is an indirect hernia he will do a plug and patch repair. If it is a direct hernia he will do an onlay repair without the plug.
Before the consultation I was aware of the International Guidelines for Groin Hernia Management which recommends against the plug and patch procedure for repairing inguinal hernias therefore I expressed my concerns about the use of a mesh plug if I have an indirect hernia. The surgeon told me the problems/complications are related to the improper placement of the plug. I may be wrong but from my understanding no matter how the plug is placed not only does it increase the amount of foreign body exposure it also increases the risk of complications such as chronic pain, excessive scarring of the internal ring, erosion of the plug into the spermatic cord, plug migration and potential organ perforation and others. Although I have concerns about mesh if the surgeon had offered me a Lichtenstein or Laparoscopic TEP repair with mesh I would have arranged for the surgery but I do not want to agree to any surgery that may involve the use of a mesh plug.
From reading some of the discussions on this forum, other information on the internet and listening to Dr. Towfigh’s Hernia Talk Live sessions most if not all hernia specialists have abandoned the plug and patch repair but this repair continues to remain popular. An August 27, 2020 article by Dr. Guy Voeller in General Surgery News indicated the plug and patch repair was the second most common open inguinal hernia repair performed in the US. I assume this is the case in other countries. The doctor I saw who is a respected and skilled surgeon but not a hernia specialist is teaching the plug and patch repair to his residents. I realize this repair is easy to learn and does not take a lot of time to complete but why are the surgeons continuing to perform and teach it? Are they not aware of the International Guidelines or is it as Dr. Towfigh posted on a 2016 discussion “It’s hard for surgeons to get rid of old habits.”?
I am in Canada where we have Universal Health Care or what Dr. Towfigh and others call Social Medicine. In the province where I live I require a referral to get an appointment with a surgeon. I don’t think I will be able to get another referral to obtain a second opinion and even if I can I may end up seeing another surgeon who does plug and patch repairs. There is a private surgical clinic walking distance from where I live that repairs hernias but due to Health Canada’s regulations I am not allowed to have my hernia repaired at this or any other private clinic in the province. To get a second opinion I will have to travel outside the province. Unfortunately for me I am dealing with some other health issues and right now I don’t feel well enough to travel. Hopefully this will change. The Shouldice Clinic is on the top of my list provided I am a suitable candidate and I can get there.
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4 Replies
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Dr Towfigh:
Thank you for the advice. It confirms and reinforces my need to do what I can to avoid a plug and patch repair and any other repair that is no longer recommended such as the bilayer Prolene Hernia System. When it comes to medical treatment I am extremely cautious. I had a life altering but not life threatening reaction to a treatment many years ago. If it was not for the information mainly provided by your Hernia Talk Live session and this forum I would have not been aware of the increased risks associated with the plug and patch repair. Fortunately I have put aside some funds so I can pursue the private route if I have to.
I also want to thank you for making this discussion forum possible and making your Hernia Talk Live sessions available on your YouTube channel as I have no plans at this time to listen in live via social media. Both of these platforms have provided me with a wealth of information about hernias and hernia repairs/treatments. Some of your guests have even discussed one of the other health issues that I am dealing with which I found interesting.
ajm222 and Alephy:
As I said to Dr. Towfigh I want to thank you for your advice.
I don’t know if my hernia is too large for a tissue repair at Shouldice but currently I am too large for the repair. I am trying to walk my way down to a normal BMI but I will need to curb my appetite to be successful. I am not obese just overweight. My preference is to get a tissue repair if possible but as Dr. Towfigh said I should seek a surgeon who can offer a tailored approach including laparoscopic.
Right now my hernia is sometimes uncomfortable but tolerable. Provided it doesn’t progress and get too bad I will be calling some private surgical clinics to find out what type of hernia repairs they do and what is involved in booking an appointment/consultation.
I do know exactly what hospital in the city where I live that I will go to if the need arises.
There definitely needs to be more surgeons who specialize in hernias because it is not “just a hernia”.
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This reply was modified 3 years, 10 months ago by Johnso.
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This reply was modified 3 years, 10 months ago by
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Though it’s true that plug and patch repair can be performed safely and it is still among the most common repair types for inguinal hernia, it remains fraught with risks. There is no need to do an operation that has risks when there are perfectly better alternatives. If your surgeon only does open surgery, then an open Lichtenstein or laparoscopic repair is better. I would stay away from the plug and patch.
I also don’t jump out of airplanes or plan to learn to tightrope without a net under it. I know many do it and they are fine. To me it’s just not worth the risks.
It sounds like your surgeon is a general surgeon. He/she learned a particular way of doing things and has continued that for years. There has been no improvement if hernia care and also no tailoring to your particular needs.
I strongly suggest you take your health as something worth investing in. If you can’t see a second surgeon within your system (you should be able to), then seek a surgeon outside the system who actually has an interest in hernias.
Another analogy: I wouldn’t want someone who has no interest in hair color to dye my hair.
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If you are in an emergency, you might try and find an older surgeon who did use a non mesh technique in the old days…..the other option would be to find one that uses a “normal” mesh…
These days online consultations are also an option (although I am with you when it comes to claiming back expenses, especially after a surgery)…
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How bad are your symptoms? Can you wait? Plug and patch is definitely not the way to go. Certainly there are people with a plug who do just fine, but it’s no longer considered good practice by the experts. Shouldice would be ideal if you can hold off. I think the hernia has to be a certain size and the patient a certain weight (and probably a non-smoker, etc etc). But that’s what I would recommend if you can hold off. If not, I would try and at least get a second opinion if you are able (would be really disappointing is this isn’t allowed) and hope they don’t use that method. Just my opinion. Good luck.
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