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To Mesh or not to Mesh
To summarise my background:
Late October 2015:
suffered a twisted small bowel.
A&E admission.
6-7cms of bowel excised.
Within 3 or 4 days it was clear that there was an infection and the bottom half of the operative wound was opened and the wound packed with aquacel and allowed to heal from the inside out.Late feb – march 2016 (can’t remember exactly):
Noticed a bulge then diagnosed as abdominal incisional hernia.
GP insisted on watch and wait approach.June’ish 2016:
Consulted the British Hernia Centre.
A consultant confirmed abdominal incisional hernia and advised repair laparoscopically using mesh and sutures.
Eventually convinced GP to refer me to head of colorectal unit that did the bowel excision to assess hernia repair.December 2016:
The consultant confirmed abdominal incisional hernia and advised repair using Component Release Technique i.e. no mesh and put me on his waiting list … he did warn me it might be a long wait!May 2017:
Decided to go private rather than continue to wait for the NHS.
Hernia repaired early May 2017.
All went well.Unfortunately at sometime within about 3 weeks I had a sneezing fit and the top portion of the operative wound parted very slightly and started to bleed a little.
This was no big deal and eventually the wound healed up.At the 6 week follow up consultation it was noted that, although the majority of the repair was sound, there was a soft area at the top end.
I could feel a small hole about 3cms across at most.
The consultant said he thought the top suture may have failed but as nothing was poking through we should wait and see how it developed. Might need to use mesh to repair it.
He advised that I continue to wear a support belt if I were to do any significant heavy work.The hole has enlarged as one might expect and now a prominent bulge is apparent if not lying down.
Tomorrow 18/10/2017 I go for another consultation to discuss the way forward.From my minimal research it seems to me that a significant (> 10%) proportion of hernia repairs using mesh, result in chronic long term pain at some point, not necessarily immediately after the repair.
Also there seems to be a growing awareness that polypropylene mesh is not universally tolerated by the body. (ref vaginal sling procedure and numerous anecdotal reports on the Patient website https://patient.info/forums/discuss/browse/hernia-1145)
I realise that nothing in this life is without risk but what is the best way forward?
Mesh: possible life changing complications with further complex surgery.
Sutures: given that this would be the third attempt (including the original closure of the bowel resection)) to achieve a sound closure the likelihood of failing to close the hernia are increasing all the time.
Do nothing: literally do nothing because I won’t be able to lift anything much!Any comments would be gratefully received.
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3 Replies
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In most hernia repair, including inguinal hernia, the mesh is intended to form a strong barrier by causing adhesion to the surrounding tissues and to prevent recurrence as a result, although I do not agree to use it.
However, in my opinion, the role of the material in the incisional hernia repair, where the material may be brought into direct contact with the bowel, is to relieve the force exerted on the sutured defect margin, not by adhesion, but by sharing the force. It’s like reinforcing a worn-out outfit with a new fabric.I think Gore-Tex Dual is what I said.
But if the peritoneum/barrier could be closed and the direct contact between the bowel and the material would be blocked, then you can use any material for reinforcement including polypropylene mesh.I hope you shall have a good result.
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Hi Dr Kang,
Thank you for your very helpful and informative response. I shall bare all you have said in mind at my consultation and report back. I have strong faith in my consultant, he too shuns the use of mesh, hence using component separation technique and locally is a very well respected and sought after surgeon.
You have also answered an unasked question that I had, i.e. if mesh/some material is used, isit just “patched” across the opening or is it used to reinforce the sutured repair. I shall be sure to ascertain exactly how the repair will be done and what mesh/material will be used.
You mention the use of Goretex cloth would that be “Gore-Tex Dual” mesh? Which I believe has some anti-adhesion properties.
Having read (“Biologic versus Synthetic Mesh Reinforcement: What are the Pros and Cons? FitzGerald and Kumar”) further about the use of mesh and component release technique I am wondering if some sort of mesh/material should have been used to reinforce the repair.
Thanks once again.
Regards,
Phil. -
My suggestion:
First, take the surgery as soon as possible.
The incisional hernia should be operated as early as possible.
The larger the hole, the harder the operation and the greater the risk of postoperative recurrence.
Incisional hernia has been reported to be highly recurrent compared to other hernias such as inguinal hernia.Second, use reinforcement material, but a Goretex cloth if possible.
I am a strong advocate of no mesh inguinal tissue repair. However, my principle of incisional hernia is to use mesh/material.
As mentioned above, it is a highly recurrent hernia, its opening is usually much larger than inguinal hernia, and the border of hernia opening is firmly fibrous and resistant to be put together.
However, I use Goretex cloth instead of polypropylene mesh to prevent the bowel from sticking to it. (in many cases, peritoneum/barrier is torn and absent and the bowel could contact directly to mesh/membrane. Goretex is resistant to sticking of bowel)Third, be sure to close the hernia opening itself.
Some doctors do not close the hernia opening by direct suture, but merely cover the hole with a mesh.
However, this would cause a lot of recurrence.
Therefore, the hernia opening must be tightly sealed.
In addition to this, it is better to put mesh deeply inside the tissue closure layer.Thank you!
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