What is the difference between "tissue repair" and "mesh repair?"
Well, this is absolutely one of the most frequently asked questions.
"Tissue" vs "Mesh"
A “tissue repair” is performed using the patient’s own muscle and tendon (called fascia) to close the hernia defect (hole). This is typically performed using sutures (stitches), though some surgeons may use metal tacks or staples.
A “mesh repair” is performed by closing the defect (hole) with stitches (sutures), then using a special sheet of woven or interlacing material (mesh) to reinforce the closure. The mesh is typically trimmed to a custom shape and size for the individual location and the size of the defect. There are several different types of mesh used for this purpose, depending on the specific setting and the preference of the surgeon.
In today's world of hernia surgery, the use of mesh to repair hernias is the most common type of repair. Is it always absolutely necessary? The short answer is no, but there are instances when it is the ONLY option. Mesh is absolutely required when a "tissue repair" is simply not possible. There are times when a hernia defect is so large that the patient simply does not have enough of their own tissue to cover or close the defect (hole). There are also situations where the patient’s own tissues are simply not strong enough to hold sutures or to keep the defect closed for any length of time.
But in most cases, what's the difference? Which is better, mesh or tissue repair??
Well, honestly, that is a very tricky question. The purpose of mesh used for hernia repair is to increase the durability of the repair, or in other words, decrease the risk of failure of the repair, the chance of recurrence (comes back). As stated in other sections on our website, surgery for recurrent hernias (repair one that has come back) is much more technically difficult (due to scar tissue and disruption of the normal tissues), and thus results not only in increased risk for complications and injury to important structures, but also a significantly increased risk that the hernia will recur. The tissues become weaker and weaker with repeated surgeries, and this fact is well documented in many research studies.
The degree to which mesh is more beneficial than a tissue repair depends heavily on so many factors that it's hard to explain, and even hard to study. The factors that determine the durability of the type of hernia include considerations such as size of the defect, location of the hernia, type of hernia, age of the patient, overall health status of the patient (smoker, obesity, diabetes, malnutrition, steroids), surgical approach and technique, and previous surgery. Although there has been a great deal of conflicting information in studies over the years, there has been a fairly clear consensus that the use of mesh in general and overall, has a much higher success rate and thus a much lower recurrence rate. There is always a risk for recurrence for any hernia repair, and this risk varies due to all of the factors mentioned above, but overall, looking at all hernia repairs combined, the use of surgical hernia mesh significantly decreases the risk of recurrence (that the hernia will come back).
In general, studies have shown that the risk of hernia recurrence is decreased typically by 50% when mesh is used for repair versus not using mesh. Mesh is very safe and we use it every day. Thus, the use of mesh for most hernia types overall is the Standard of Care in the United States. However, there are some instances where it has not been conclusively shown that there is a distinct advantage, or sometimes the advantage is very small.
Today, mesh can be divided up into an almost unbelievable number of categories. Mesh technology is now advancing at a staggering rate, so quickly, and to such a degree, that it is actually difficult for most surgeons to keep up. We now have so many different types of mesh, with categories such as Permanent, Synthetic, Biologic, Synthetic Biologic, Synthetic Absorbable, Biologic absorbable, and even Hybrid meshes that are both partially permanent and partially absorbable. There are many manufacturers of surgical mesh (such as BD, Ethicon, Medtronic, Atrium, LifeCell, and many others). These companies are very large and are all conducting constant research to develop different mesh components, materials, construction, manufacturing processes, and designs for different uses and applications, etc. It is truly and absolutely astounding.
So, we are constantly comparing different techniques and approaches against each other and we are constantly comparing the use of mesh, as well as various types of mesh. There are just so many variables that are sometimes hard to control and compare.
As far as the categories of “permanent” mesh and “absorbable” (dissolving) mesh:
“Permanent” mesh, as the name suggests, is meant to be permanent and will last forever. Some are a simple woven or interlacing fibers of polypropylene (like fine fishing line), some are a woven Dacron (more like clothing), and others are made of Gore-Tex and are an extruded sheet.
“Absorbable” (dissolvable) mesh, as the name suggests, dissolves over time and is meant to be only temporary. Different materials used to make the mesh last for differing lengths of time. Some last for as little as 4 weeks, and others last for as long as 6 months, but eventually they will be completely gone. Some dissolving meshes are manufactured materials, while others are made naturally made, either as the fibrous elements of animal or human skin after the cells have been removed, or the linings of animal or human organs. Most of the dissolving meshes we use today are manufactured.
And as mentioned, several companies are now manufacturing "Hybrid" meshes, that have components that are permanent and some components that are absorbable.
In the section titled “Is it necessary to use mesh?” I explain that the reason to use mesh is that it strengthens weak tissues (like rebar in cement) and therefore significantly decreases the risk of recurrence (that the hernia will come back). It is also stronger than any tissue you have in your body, thus it will not tear under the wear and tear of the continued movement of your body. In essence, if we repair a defect or hole with your tissues that wouldn’t hold in the first place, there is a very high risk that the hernia will recur (return), sometimes soon after surgery, and sometimes years later. The tissue is weak, and it is this weakness that leads to the defect in the first place. It stands to reason that sewing the weak tissue back together with only threads (sutures), that it is less likely to remain repaired. Mesh gives that tissue initial strength right after surgery, and more importantly. it provides a “scaffolding” in which your body will deposit scar tissue (in the form of fibrin) that will reinforce that tissue and make it stronger than before. The permanent mesh will offer that strength to weak tissue for life. Dissolving mesh will provide the matrix or scaffold on which to deposit scar tissue and will completely disappear over time.
At AHS, we specialize in many approaches and techniques, both tissue (non-mesh) and mesh repairs. We always give the patient the option to choose the type of repair if the option is possible.
If you are interested in learning more:
Please feel free to give us a call or come and see us at Advanced Hernia Specialists.