Non-Mesh Hernia Repair: Back To The Future
With over 70,000 inguinal hernia repairs performed in the UK every year, it is one of the most common operations that a surgeon performs.
Simon Marsh MA MD FRCS
With over 70,000 inguinal hernia repairs performed in the UK every year, it is one of the most common operations that a surgeon performs. A quarter of men will eventually get one and half of men get one by the time they are 75. Because in women the anatomy in the groin is a little bit different only 2% get an inguinal hernia, but it is still the most common type of hernia in women. The vast majority of hernias these days are fixed using some kind of artificial mesh patch technique and it can either be done from the front, with a single scar in the groin, or from the inside using a laparoscopic technique which leaves several smaller scars. Whilst I should point out that most people having a mesh hernia repair report no persistent problems there is now increasing awareness that these mesh operations are not trouble free and can lead to long-term problems, particularly chronic pain, in some people. So, why are they done at all?
Until the mid-1990s all hernias were repaired using stitches (sutures) and the repair required a thorough understanding of the anatomy of the groin muscles, as well as their function. Getting the tension right in the repair was a matter of surgical skill and experience and vital to prevent the hernia coming back. Those of us who trained in that era(!) were brought up on textbooks such as “The Surgical Anatomy of Hernias of the Groin”, by the great French Surgeon Henri Fruchaud and we all developed the skills required to anatomically repair hernias, stitching the muscles back together to repair the hernia and leave the groin muscles in the right place, with the right tension, to make the groin “normal” again.
In the 1990s the mesh patch technique was developed in Europe and very quickly spread around the world. The idea was that this was a relatively simple technique for an inexperienced surgeon to perform and it would reduce the complication rate of the operation and particularly the recurrence rate (the risk of the hernia coming back). In the UK this was taken up by the NHS very quickly, the reason being that, at that time, most hernias were repaired by junior surgeons (surgical registrars). It was an operation that was felt to be good for training! Initially the hernias were repaired from the front (termed an “open” repair) but then the laparoscopic surgeons took it up and used an even larger mesh patch placed inside the abdomen. So, has it achieved its aim?
In fact, since the mesh patch repair came in the recurrence rate for hernias has not changed at all! The most important factor for stopping the hernia coming back is to have it repaired by an experienced surgeon! What has become apparent, however, is that there is a significant risk of developing chronic pain after a mesh patch repair and there has been much publicity about the use of these artificial meshes in the last year or so, and not just in groin hernia surgery. In fact, if you have a laparoscopic mesh hernia repair you are proportionally twice as likely to get chronic pain as with an open mesh patch repair, and whereas mesh patches placed from the front can be removed, a laparoscopic hernia is, to all intents and purposes, an irreversible operation. So, what can we do?
Well, one solution is to go back to a completely non-mesh technique. Another option is to use the mesh “plug”. In this operation, which is performed with a 4-5cm cut at the front of the groin, the hernia is pushed back and a small “plug” is used to seal the hole before the muscles are repaired anatomically with sutures. This operation is termed “an open mesh plug repair with muscular reconstruction” and it is the one I have been doing for the last 20 years or so. Not only is the recurrence rate very low (less than 1 in 500) but also the risk of chronic pain (while it can still occur) is 50 times lower. So why don’t we all do that?
The concern is that, like the pigment in the Blue Glass of Chatres, or the Stradivarius Violin, the expertise required may have been lost. We have been so quick to popularise a technique which could not deliver what it promised that we were blinkered not only to the problems but also to the potential dilution of surgical skill it produced. Once again, I would point out that it seems that most people have a mesh patch repair do not get any problems, but then of course you wouldn’t know until it was too late. What is important is being able to have a choice based on a full understanding of the risks and benefits of each type of technique.
Simon Marsh is a Consultant Surgeon and Surgical Director of the Gilmore Groin and Hernia Clinic, 108 Harley Street.