mesh 7_edited.jpg

Is it necessary to use hernia mesh?

Use of mesh to repair hernias is the most common type of repair. It is not always absolutely necessary, but there are instances when it is the only option.

Ok, so is mesh absolutely necessary?

Well, that is a difficult question.

Perhaps the question would be better asked as, “Should mesh be used for your hernia repair?”

Because if you are asking if it is absolutely necessary? The answer is “no.”

Should it be used? And the answer is “usually yes.”

So why should mesh be used? Is there any supporting data??

Well, there have been some fairly significant and important studies published over the last 10-20 years.

So let’s first talk about inguinal (groin hernias), which as you probably read in some of the other sections here on our site, are by far the most common type of hernia.

1. In 2002 there was a study done and a paper published titled “Randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia” that was published in the British Journal of Surgery.

This study was a study from multiple centers that looked at “Non-mesh” and “Mesh" repairs for inguinal hernias with a 3 year follow up after surgery.

  • There was a representation of the most popular types of “Non-mesh” repairs (including 52% Bassini – McVay, 25% Shouldice, 18% Bassini, 2% McVay) and these repairs were compared to the best known, and still most widely used “Mesh repair,” called the Lichtenstein repair, using Marlex (permanent mesh).

 

  • There were 300 randomized patients (randomly assigned to “Non-mesh” or “Mesh” repair).

    • 143 “Non mesh” repairs

    • 146 “Mesh” repairs

    • 11 Dropouts

  • 88% of these patients were examined at 3 years

Findings:

Recurrences (hernia came back):

  • 9 in the “Non-Mesh” group

  • 1 in the “Mesh” group (and as it turns out, this patient had an “absorbable” (not permanent) mesh placed by mistake.

There was no difference in quality-of-life scores.

So, to summarize, the “Recurrence Rate” in this study was

7% for Non-mesh and 1% for Mesh

2. Another important study was also published in 2002 in the Annals of Surgery, titled “Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials."

This study produced 62 relevant comparisons in 58 eligible trials and looked at the “decreased odds of recurrence.”

  • Out of 31 studies, 21 studies showed a decrease of the recurrence using “mesh” versus 10 that did not.

It was a study of “hernia recurrence”, “mesh versus non-mesh repairs” (looking at thousands of patients).

  • Mesh 4426 repairs, 88 recurrences (2%)

  • Non-mesh 3795 repairs, 187 recurrences (4.9%)

SO… “non-mesh” repairs had more than TWICE the rate of recurrence of “mesh” repairs!

And another fact that has been definitively shown, and you should keep in mind, is that the rate of hernia recurrences increases steadily with time. So, any studies that look at patients at only one year after surgery are not going to give a clear picture of what true recurrences are.

Incidentally, but also interesting, is that this study also showed specifically:

  • No significant differences for Shouldice versus non-Shouldice tissue repair

  • And no difference between laparoscopic versus open mesh repairs

3. A large Review study was published in 2013 in the International Journal of Surgery, titled “Recurrence after groin hernia repair-revisited” showed:

 

Primary repair (non-mesh) recurrence rate:

  • Bassini: 2.9% – 25.0%

  • Schouldice: 0.2% – 2.7%

  • McVay: 1.5% - 15.5%

  • Nyhus: 3.2% to 21.0%

Compared to mesh repair recurrence rate:

  • Nyhus buttressed with mesh: 0% - 1.7%

  • Rives: 0% Dash 9.9%

  • Stoppa: 0% – 7%

  • Tension free repairs: 0% - 1.7%

  • Plug repairs: 0% - 1.6%

 

 

4. A large review article published in the Cochrane Library, published in 2001, titled “Open Mesh versus non‐Mesh for groin hernia repair” showed:

  • The use of mesh reduced the recurrence rate by 50%

 

 

5. Because the Shouldice technique is revered by so many, another Cochrane Database Systematic Review, published in 2012, titled “Shouldice technique versus other open techniques for inguinal hernia repair,” and looked at recurrence, showed:

  • Shouldice versus other primary repairs

    • 4.4% versus 6.9%

  • No Significant advantage

  • But Shouldice versus reinforcement with mesh repair

    • 3.6% versus 0.8%

  • CLEARLY A HUGE ADVANTAGE (by almost 4x)

 

 

 

So now let’s take a look at ventral (abdominal) hernias.

Do we need to use mesh to repair them?

Or again, perhaps we need to ask, "Should we use mesh to repair them?

 

Well, if we go back and look at the data from the 90's... when we see that there is a very high rate of recurrence of ventral hernia after primary (no mesh) repair.

6. In a study published in 1993 in Surgery, Gynecology, and Obstetrics, titled “An evaluation of risk factors in incisional hernia recurrence,” they looked at almost 300 patients after abdominal wall (ventral) hernia repair.

They found that if they looked out at an average date of about 30 months after the surgery, just over a third of the patients had hernia recurrence (36%), but when they followed patients out even further, up to 60 months, that rate was even higher, getting up to 41%.

 

So, it was believed that when over 40% of your patients are developing hernia recurrences, that there had to be a technique problem.

AND it was shown that if the patient had already had a previous repair of the same hernia, then the recurrence rate was even higher!

  • 2nd repair 56%

  • 3rd repair 48%

  • 4th repair 47%

 

They also found that the “size“ of the hernia really does matter.

  • greater than 4 cm had recurrence rate of 41%

  • Less than 4 cm had a recurrence rate of 25%

 

  • So the larger the hernia, the higher the rate of recurrence.

 

 

 

7. A large analysis of many studies of open ventral hernia repair was published in the Surgical Clinics of North America in 2008, titled “Open Repair of Ventral Hernias” and you can see that summative data from many different studies showed:

Results of primary suture repair techniques

Author/Year                                  N                    Recurrence (%)      Follow-up (mos)

Langer, et al, 1985 [6]                    154                  31                            48–120

George, et al, 1986 [2]                   81                    46                           14

Van der Linden, et al, 1988 [52]   151                   49                           39

Read, et al, 1989 [9]                      206                  24.8

Gecim, et al, 1996 [15]                  109                   45                           7–92

Luijendijk, et al, 2000 [3]             97                     46                          36

Burger, et al, 2004 [4]                   97                     63                          120

Sauerland, et al, 2005 [53]           305                    18                           60

Al-Salamah, et al, 2006 [54]        72                     20.8                        37.5

-Adapted from Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg

2002;89:534–45; with permission of Blackwell Science Ltd.

  • The recurrence rate ranges anywhere from 18 to almost 50%

So, it’s like a roll of the dice. If we repair your hernia, there’s a 50/50 chance that you’re going to have a recurrence.

We can definitively say that primary repair of ventral hernias has unacceptably high recurrence rate, even for small hernias.

 

Mesh enters the picture………………

Does mesh fix our recurrence rate for ventral hernias???

 

8. One of the seminal studies comes from a Dutch Group, who did a clinical trial which set out to answer just that. It was a very good study, and it was published in the New England Journal of Medicine in 2000. It was titled, “A comparison of suture repair with mesh repair for incisional hernia.”

 

They looked at two groups:

  • 200 patients, 100 in each group

  • One group had a standard suture closure (1 cm deep bites of suture, 1 cm apart)

  • The other group underwent a repair using a standard heavy weight mesh (which was available at the time), with a 2 - 4 cm overlap and was sutured to the posterior.

 

And when they looked at their patients at a time point of approximately 2 to 3 years out, they could see that the patients that had mesh, even with this technique they used, that today we would not consider to be gold standard, the use of mesh decreased the recurrence rate by HALF.

  • 23% recurrence – Mesh Repair

  • 46% recurrence – Primary Repair (No mesh)

 

So, they found the same 46% recurrence rate without mesh that we saw in the previous study above.

 

9. Because they have an excellent database, and because they have a small population, they were able to follow those patients out to 10 years. They went on to publish another study looking at their long-term data. They published a paper in the Annals of Surgery in 2004, titled “Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia.”

  • They located 126 of the original 200 patients, and you can see that over time a couple different things happened.

    • The primary hernia repair recurrence rate increased.

      • It went from 23% of 32%.

      • So over time, more and more patients were developing recurrences

    • We also saw that the recurrence rate was twice as high in the group that had no mesh, and we can also see how unacceptable the recurrent rates are.

 

Summary:

 

At 10 years

 

  • Primary Repair (No Mesh)  --   63% Recurrence

  • Mesh Repair                         --   32% Recurrence

 

 

So, for the high 63% recurrence rate with a suture repair 10 years later, you might as well not have had surgery, if you’re looking at odds.

 

So, that’s very significant data! And that’s not even the best repair we can do!

 

 

10. Another group decided to look to see if we put all the randomized controlled data together, what kind of an outcome we could get. They did a large review of the many studies available, and they published their review in the World Journal of Surgery in 2016. The paper was titled “Suture Versus Mesh Repair in Primary and Incisional Ventral Hernias: A Systematic Review and Meta-Analysis

  • They found 11 papers from 10 trials, and when they crunched all the data by group analysis, what they saw was a pretty strong risk ratio (RR=0.36, p<0.00001) which translated to a 64% reduction in the risk of having a hernia by using mesh.

 

So, to recap…. Do you need mesh to repair your hernia???

There answer is, "you don’t need it"… "but it sure seems like a good idea!"

When a patient sits in my office and asks, “do I really need a piece of mesh in me?” 

 

I say, "we have pretty good data, at least for right now, that says yes you do, because it’s going to significantly reduce your risk of your hernia recurring."

 

Come and see us at Advanced Hernia Specialists if you want to discuss it further:

Or take some more time exploring our website. Give us a call to learn more. We are experts in the field of hernia surgery. We are committed to delivering excellent care and the best patient outcomes possible.

 

We offer both Tissue (no mesh) and Mesh repairs. We have effective and cost-effective options for patients who are paying out of pocket, as well as the most advanced laparoscopic, minimally invasive, and robotic surgical hernia repair.

If you have been diagnosed with a hernia or you think you may have a hernia, please schedule an appointment with us by calling 904-808-5658, emailing us​, using our online Contact Form, or Book Online.

Call 

904-808-5658

Email 

Follow

  • Facebook
  • Twitter
  • LinkedIn
  • Instagram