by Kevin C. Petersen, M.D.
If you listen to the marketing put out by manufactures of hernia mesh you would believe that the medical condition called hernia has been conquered by science and technology. Proudly proclaiming a recurrence rate of 0.5% would seem to leave little room for improvement. The fact that a majority of the surgeons in the United States propound this virtue and consider the no tension mesh hernia repair the gold standard of hernia repairs is further testament to a remarkable achievement of medical science. Or is it medical marketing?
One thing is for sure, it is not is a consensus. There is a stubborn minority of surgeons who go by their own experience and judgment and perform meshless hernia repairs. Why?
Surgery is judged not just by a narrow and focused success but also by it’s failure in the broadest terms. If we save a life we hope to not have also ruined it. If we fix one problem it is not acceptable to create another that is worse.
Pain is the big white elephant in the waiting room of the hernia surgeon. Chronic pain is the most significant problem in hernia surgery that affects up to 30% of patients after surgery.
It is interesting that American medical literature is nearly mute on this problem while the European medical literature reports and covers the problem extensively. In addition to acknowledging the problem of pain after hernia surgery the European medical community has tried to understand the causes of the problem and offer solutions. It should be noted they are using the same mesh and the same techniques that we use here in the United States. Domestic medical literature does identify the problem of pain but to a much lesser extent than the international medical literature.
It is true that the European populations are different than Americans and there are many areas where their medical results are different than ours. Their populations are more homogenous and less mobile than ours. One thing that they do much better is follow up studies. European patients tend to live their entire lives in the same communities if not in the same houses. This makes it easier to do large scale retrospective studies over long periods of time. American studies are plagued and nearly invalidated by a high rate of drop out over time. One study here that attempted to look at hernia repair results over a ten year period of time had a 47% drop out rate. European studies typically have a 20% drop out rate over the same period of time.
Mesh functions in hernia repair by producing scar tissue which forms a mesh-scar complex that acts as a barrier to herniation. The problem is that there is no way to control how much scar tissue is produced and there is no way to anticipate which patients will develop too much scar. A property of scar tissue that can cause a lot of problems is that scar contracts over time. It is like in the old time Western movies where a wet rope of rawhide is wrapped around something and allowed to dry. As it dries it shrinks with extreme force producing the desired or undesired effect. As scar tissue in the human body contracts it produces tension which in turn produces pain. When this scar contraction is around the spermatic cord or the ilio-inguinal nerve it can produce a lot of pain. One of the other unfortunate side effects of mesh scar contracture is the mesh can break away from its anchors and shrivel up into wad and become ineffective as a barrier to herniation. In the patients that I have operated on for recurrence after prior mesh hernia surgery this is what I usually find.
So what is the evidence that non-mesh hernia repairs cause less chronic pain? The most compelling evidence that I see is my own experience. I have preformed over 3,000 hernia repairs over twenty-five years. I see very few patients who have chronic pain after repairs that I perform without mesh. I see many patients operated elsewhere with chronic pain after mesh hernia repairs. The experience that I have gained treating these patients has shown me that the most effective treatment is mesh removal.
I have been interested in this problem for many years and have kept an eye on the medical literature. And after searching I have been unable to find a good prospective randomized study comparing open mesh to open non-mesh hernia surgery. But inferences can be made from a number of facts that are published. The following is a loose collection of medical articles and observations. They do not constitute an argument of proof but they certainly are food for thought and show that the issue has not been settled:
Consider pediatric inguinal hernias. There is a consensus on how to treat pediatric hernias. No one repairs pediatric inguinal hernias with mesh. These hernias are universally repaired by dissection and high ligation of the indirect sac. The technique is a marvel in its simplicity and effectiveness. Recurrence is 1% and chronic pain is zero. No one advocates using mesh to further reduce the recurrence rate to 0.5%.
Removing mesh is an effective treatment of chronic inguinal pain after mesh hernia repair.
Mesh manufactures are busy developing biologic/absorbable and partially absorbable lightweight mesh. There is evidence that light weight partially absorbable mesh has a lower incidence of chronic pain without sacrificing recurrence rate. Other studies show no difference in the rate of chronic pain between standard and light weight mesh. Completely absorbable mesh has less pain but a higher recurrence rate. Obviously this interest in developing lighter weight mesh is motivated by the problem of mesh inguinodynia.
The last disclaimer that I have to make is that surgery is still more of an art than it is a science. Talent, skill, experience and style vary tremendously among surgeons. What works best for one surgeon may not work in the hands of another surgeon. This partially explains why it is so hard to come to any clear conclusions when examining the results of a large number of surgeons. In conclusion, my advise for patients is to pick your surgeon then let him pick the technique he prefers.
1: Prospective double-blind randomized controlled study
comparing heavy- and lightweight polypropylene mesh in totally
extraperitoneal repair of inguinal hernia: early results.
Agarwal BB, Agarwal KA, Mahajan KC.
Surg Endosc. 2009 Feb;23(2):242-7. Epub 2008 Oct 16.
PMID: 18923870 [PubMed - in process]
2: Neuropathy After Herniorrhaphy: Indication for Surgical
Treatment and Outcome.
Vuilleumier H, Hübner M, Demartines N.
World J Surg. 2009 Jan 21. [Epub ahead of print]
PMID: 19156462 [PubMed - as supplied by publisher]
3: Three-year follow-up of modified Lichtenstein inguinal
hernioplasty using lightweight poliglecaprone/polypropylene
Smietański M, Bigda J, Zaborowski K, Worek M, Sledziński Z.
Hernia. 2009 Jan 20. [Epub ahead of print]
PMID: 19153646 [PubMed - as supplied by publisher]
4: Low recurrence rate after laparoscopic (TEP) and open
(Lichtenstein) inguinal hernia repair: a randomized, multicenter
trial with 5-year follow-up.
Eklund AS, Montgomery AK, Rasmussen IC, Sandbue RP, Bergkvist LA, Rudberg CR.
Ann Surg. 2009 Jan;249(1):33-8.
PMID: 19106673 [PubMed - indexed for MEDLINE]
5: Randomized clinical trial comparing a polypropylene with a
poliglecaprone and polypropylene composite mesh for inguinal
Smietański M; Polish Hernia Study Group.
Br J Surg. 2008 Dec;95(12):1462-8.
PMID: 18991255 [PubMed - indexed for MEDLINE]
6: Re-operation due to severe late-onset persisting groin
pain following anterior inguinal hernia repair with mesh.
Delikoukos S, Fafoulakis F, Christodoulidis G, Theodoropoulos T, Hatzitheofilou C.
Hernia. 2008 Dec;12(6):593-5. Epub 2008 Jun 10.
PMID: 18542838 [PubMed - in process]
7: Postherniotomy dysejaculation: successful treatment with
mesh removal and nerve transection.
Aasvang EK, Kehlet H.
Hernia. 2008 Dec;12(6):645-7. Epub 2008 Apr 25.
PMID: 18437287 [PubMed - in process]
8: Total extraperitoneal hernioplasty: does the long-term
clinical course depend on the type of mesh?
Lauscher JC, Yafaei K, Buhr HJ, Ritz JP. J
Laparoendosc Adv Surg Tech A. 2008 Dec;18(6):803-8.
PMID: 19105667 [PubMed - in process]
9: Work related aspects of inguinal hernia: a literature
Hendry PO, Paterson-Brown S, de Beaux A.
Surgeon. 2008 Dec;6(6):361-5. Review.
PMID: 19110825 [PubMed - indexed for MEDLINE]
10: [Neuralgic pain, a significant complication after a
Lichtenstein procedure for inguinal hernia repair]
de Lange DH, Wijsmuller AR, Aufenacker TJ, Rauwerda JA, Simons MP.
Ned Tijdschr Geneeskd. 2008 Oct 11;152(41):2205-9. Dutch. PMID: 19009804
[PubMed - indexed for MEDLINE]
11: [Repair of bilateral inguinal hernias--sequential or
Pfeffer F, Riediger H, Küfner Lein R, Hopt UT.
Zentralbl Chir. 2008 Sep;133(5):446-51; discussion 452. Epub 2008 Oct 15. German.
PMID: 18924041 [PubMed - in process]
12: Ilioinguinal nerve excision in open mesh repair of
inguinal hernia--results of a randomized clinical trial: simple
solution for a difficult problem?
Malekpour F, Mirhashemi SH, Hajinasrolah E, Salehi N, Khoshkar A, Kolahi AA.
Am J Surg. 2008 Jun;195(6):735-40. Epub 2008 Apr 28.
PMID: 18440489 [PubMed - indexed for MEDLINE]
13: Validation of an Inguinal Pain Questionnaire for
assessment of chronic pain after groin hernia repair.
Fränneby U, Gunnarsson U, Andersson M, Heuman R, Nordin P, Nyrén O, Sandblom G.
Br J Surg. 2008 Apr;95(4):488-93. PMID: 18161900
[PubMed - indexed for MEDLINE]
14: Long-term pain after inguinal hernia repair in a
population-based cohort; risk factors and interference with
Kalliomäki ML, Meyerson J, Gunnarsson U, Gordh T, Sandblom G.
Eur J Pain. 2008 Feb;12(2):214-25. Epub 2007 Jul 2.
PMID: 17606392 [PubMed - indexed for MEDLINE]
15: Long-term sequelae after 1,311 primary inguinal hernia
Massaron S, Bona S, Fumagalli U, Valente P, Rosati R.
Hernia. 2008 Feb;12(1):57-63. Epub 2007 Sep 13.
PMID: 17851727 [PubMed - indexed for MEDLINE]
16: Analysis of post-surgical pain after inguinal hernia
repair: a prospective study of 1,440 operations.
Massaron S, Bona S, Fumagalli U, Battafarano F, Elmore U, Rosati R.
Hernia. 2007 Dec;11(6):517-25. Epub 2007 Jul 24.
PMID: 17646895 [PubMed - indexed for MEDLINE]
17: Randomized clinical trial of mesh versus non-mesh primary
inguinal hernia repair: long-term chronic pain at 10 years.
van Veen RN, Wijsmuller AR, Vrijland WW, Hop WC, Lange JF, Jeekel J.
Surgery. 2007 Nov;142(5):695-8.
PMID: 17981189 [PubMed - indexed for MEDLINE]
18: The role of hernia sac ligation in postoperative pain in
patients with elective tension-free indirect inguinal hernia
repair: a prospective randomized study.
Delikoukos S, Lavant L, Hlias G, Palogos K, Gikas D.
Hernia. 2007 Oct;11(5):425-8. Epub 2007 Jun 27.
PMID: 17594052 [PubMed - indexed for MEDLINE]
19: Short postal questionnaire and selective clinical
examination combined with repeat mailing and telephone reminders
as a method of follow-up in hernia surgery.
López-Cano M, Vilallonga R, Sánchez JL, Hermosilla E, Armengol M.
Hernia. 2007 Oct;11(5):397-402. Epub 2007 May 23.
PMID: 17520168 [PubMed - indexed for MEDLINE]
20: Chronic pain after mesh repair of inguinal hernia: a
Nienhuijs S, Staal E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R.
Am J Surg. 2007 Sep;194(3):394-400. Review.
PMID: 17693290 [PubMed - indexed for MEDLINE]
21: Chronic pain after hernia surgery--an informed consent
Aroori S, Spence RA.
Ulster Med J. 2007 Sep;76(3):136-40.
PMID: 17853638 [PubMed - indexed for MEDLINE]
22: A single-surgeon randomized trial comparing three
composite meshes on chronic pain after Lichtenstein hernia
repair in local anesthesia.
Hernia. 2007 Aug;11(4):335-9. Epub 2007 May 10.
PMID: 17492341 [PubMed - indexed for MEDLINE]
23: Hernia repair with porcine small-intestinal submucosa.
Ansaloni L, Catena F, Gagliardi S, Gazzotti F, D'Alessandro L, Pinna AD.
Hernia. 2007 Aug;11(4):321-6. Epub 2007 Apr 19.
PMID: 17443270 [PubMed - indexed for MEDLINE]
24: Chronic pain after childhood groin hernia repair.
Aasvang EK, Kehlet H.
J Pediatr Surg. 2007 Aug;42(8):1403-8.
PMID: 17706504 [PubMed - indexed for MEDLINE]
25: Risk factors for chronic pain after inguinal hernia
Dennis R, O'Riordan D.
Ann R Coll Surg Engl. 2007 Apr;89(3):218-20.
PMID: 17394701 [PubMed - indexed for MEDLINE]
26: Chronic sequelae of common elective groin hernia repair.
Loos MJ, Roumen RM, Scheltinga MR.
Hernia. 2007 Apr;11(2):169-73. Epub 2007 Feb 6.
PMID: 17279317 [PubMed - indexed for MEDLINE]
27: Late-onset deep mesh infection after inguinal hernia
Delikoukos S, Tzovaras G, Liakou P, Mantzos F, Hatzitheofilou C.
Hernia. 2007 Feb;11(1):15-7. Epub 2006 Aug 29.
PMID: 16941077 [PubMed - indexed for MEDLINE]
28: Improving outcomes in hernia repair by the use of light
meshes--a comparison of different implant constructions based on
a critical appraisal of the literature.
Weyhe D, Belyaev O, Müller C, Meurer K, Bauer KH, Papapostolou G, Uhl W.
World J Surg. 2007 Jan;31(1):234-44. Review.
PMID: 17180568 [PubMed - indexed for MEDLINE]
29: Three-year results of a randomized clinical trial of
lightweight or standard polypropylene mesh in Lichtenstein
repair of primary inguinal hernia.
Bringman S, Wollert S, Osterberg J, Smedberg S, Granlund H, Heikkinen TJ.
Br J Surg. 2006 Sep;93(9):1056-9.
PMID: 16862613 [PubMed - indexed for MEDLINE]
30: Prophylactic ilioinguinal neurectomy in open inguinal
hernia repair: a double-blind randomized controlled trial.
Mui WL, Ng CS, Fung TM, Cheung FK, Wong CM, Ma TH, Bn MY, Ng EK.
Ann Surg. 2006 Jul;244(1):27-33.
PMID: 16794386 [PubMed - indexed for MEDLINE]
31: Groin hernia repair: postherniorrhaphy pain.
O'Dwyer PJ, Alani A, McConnachie A.
World J Surg. 2005 Aug;29(8):1062-5. Review.
PMID: 15981040 [PubMed - indexed for MEDLINE]
32: Routine ilioinguinal nerve excision in inguinal hernia
Dittrick GW, Ridl K, Kuhn JA, McCarty TM.
Am J Surg. 2004 Dec;188(6):736-40.
PMID: 15619492 [PubMed - indexed for MEDLINE]
33: A prospective trial of primary inguinal hernia repair by
Miedema BW, Ibrahim SM, Davis BD, Koivunen DG.
Hernia. 2004 Feb;8(1):28-32. Epub 2003 Aug 1.
PMID: 12898290 [PubMed - indexed for MEDLINE]
34: Randomized clinical trial of lightweight composite mesh
for Lichtenstein inguinal hernia repair.
Post S, Weiss B, Willer M, Neufang T, Lorenz D.
Br J Surg. 2004 Jan;91(1):44-8.
PMID: 14716792 [PubMed - indexed for MEDLINE]
35: Mesh implants in hernia repair. Inflammatory cell
response in a rat model.
Rosch R, Junge K, Schachtrupp A, Klinge U, Klosterhalfen B, Schumpelick V.
Eur Surg Res. 2003 May-Jun;35(3):161-6.
PMID: 12740536 [PubMed - indexed for MEDLINE]
36: Chronic pain after laparoscopic and open mesh repair of
Kumar S, Wilson RG, Nixon SJ, Macintyre IM.
Br J Surg. 2002 Nov;89(11):1476-9.
PMID: 12390395 [PubMed - indexed for MEDLINE]
37: Open mesh versus non-mesh for repair of femoral and
Scott NW, McCormack K, Graham P, Go PM, Ross SJ, Grant AM.
Cochrane Database Syst Rev. 2002;(4):CD002197. Review.
PMID: 12519568 [PubMed - indexed for MEDLINE]
38: Mesh inguinodynia: a new clinical syndrome after inguinal
Heise CP, Starling JR.
J Am Coll Surg. 1998 Nov;187(5):514-8.
PMID: 9809568 [PubMed - indexed for MEDLINE]
39: Recurrent inguinal hernias in infants and children.
Steinau G, Treutner KH, Feeken G, Schumpelick V.
World J Surg. 1995 Mar-Apr;19(2):303-6.
PMID: 7754639 [PubMed - indexed for MEDLINE]
"Milan—Chronic groin pain after hernia surgery is now considered the most important issue facing inguinal hernia surgeons and their patients. Yet, there is still much uncertainty surrounding what causes the pain and how to prevent it." - Victoria Stern, General Surgery News