Hernia Mesh Alternatives

About nine in 10 hernia repairs in the U.S. rely on hernia mesh. But the U.S. Food and Drug Administration cautions that mesh repairs for hernias may not be the best option for everyone.

Recurrence was the most common complication before the hernia mesh’s invention. Research is mixed on how long a mesh hernia repair will last. A 2022 study followed 100 patients for ten years after a ventral abdominal hernia repair.

No recurrence was recorded after three years, while about 10% had a recurrence after roughly eight years. Two patients had a central breakdown of the mesh at about seven years. Mesh had stretched across the defect by an average of 21%. Mechanical testing showed that the mesh lost its elasticity at low forces.

There are several surgical alternatives to implanting this type of medical device. Medicine or monitoring may also put off the need for surgery for some patients.

Current surgical alternatives to hernia mesh date back to the 1880s. There are at least five surgical techniques to repair hernias without using mesh.

Doctors may call these techniques “pure-tissue” or “non-mesh” repairs. They involve stitching the patient’s own tissue back together.

Each technique differs in how it tries to prevent hernias from returning. They fall into two categories: tension repairs and tension-free repairs.

Tension repairs place tension on muscle tissue around the hernia. Tension-free repairs place no tension on muscle or other tissue.

The Shouldice repair is the primary non-mesh hernia repair. Canadian Dr. Edward Earle Shouldice developed the technique during World War II.

Shouldice founded a hospital in Toronto, Canada, in the 1940s. It still specializes in the procedure.

Fewer than two percent of Shouldice Hernia Hospital hernia repairs use mesh.

The Shouldice repair is a complex, tension repair technique. That means it places tension on muscle tissue around the hernia. A surgeon cuts through three separate layers of muscle and connective tissue. He then places the intestine and other tissue back inside the abdomen. The surgeon stitches each layer closed so that it overlaps the previous layer. The pattern reinforces the abdominal wall.

Study Found 5 Times Better Results for Shouldice vs. Hernia Mesh Repairs

A 2016 study by Dr. Atiqa Malik and colleagues compared the Shouldice repair with mesh repairs in Toronto. It looked at 315,000 hernia patients. Researchers wanted to know how many hernias recurred – or came back. They found that hospitals that used mesh had recurrence rates between 4.8 and 5.2 percent. The Shouldice Hernia Hospital recurrence rate was 1.15 percent.

“Most patients could see good results with the Shouldice or other pure-tissue repair,” Dr. Robert Bendavid told Drugwatch. “The only problem is that you have to know how to do them. And universities have given up teaching the procedures.”

Bendavid is a hernia surgeon with the University of Toronto and the Shouldice Hernia Hospital.

Italian surgeon Dr. Edoardo Bassini introduced this technique in 1887. By then, Bassini had performed the procedure more than 250 times. He is sometimes called the father of modern inguinal hernia surgery.

The Bassini technique is a tension repair. Bassini stitched the muscle on the upper side of hernias to the ligament below. He reported a 3 percent recurrence rate, according to an article in The American Surgeon by Wei Phi Tan and colleagues.

Since then, there have been modifications to the procedure. These changes and doctors’ skill levels have affected the success rate. The recurrence rate is closer to 10 to 15 percent for Bassini repairs performed today.

American Dr. Chester McVay introduced his technique in 1942. It improved on the Bassini repair and proved suitable for repairing large hernias.

A surgeon sutures muscle on one side of the hernia opening to the Cooper’s ligament. The technique closes the femoral canal in the process. This made it a popular repair technique for femoral hernias before mesh.

Indian surgeon Dr. Mohan Desarda presented the technique bearing his name in 2001. The Desarda repair is tension-free. A surgeon sutures a strip of one muscle to another muscle and a ligament in the abdomen.

A 2012 study compared the Desarda repair to the Lichtenstein technique. The Lichtenstein technique is an open surgery using mesh. Researchers looked at three-year follow ups for 208 men. They found that the complication rate for the two procedures was about the same. The results appeared in the World Journal of Surgery.

Italian surgeon Dr. Antonio Guarnieri first used this repair in 1988. It is a tension-free technique surgeons can perform with or without mesh. Only about 15 percent of the Guarnieri Hernia Center’s repairs use mesh.

The Guarnieri Hernia Center performed more than 4,800 pure-tissue repairs between 1988 and 2009. It reported a less than 1 percent recurrence rate among pure-tissue repairs.

The Guarnieri hernia repair involves altering the inguinal canal’s physiology. A surgeon overlaps the muscle in a “double-breasted fashion.” This reinforces the repair.

Patients should consider differences between mesh and non-mesh repair. The following can help them discuss any concerns with their surgeon.

Doctors may recommend a “watchful waiting” approach for some hernias, particularly for patients who have other serious medical conditions that make them poor operative candidates. The doctor and patient monitor the hernia to see if it worsens. This can put off surgery until symptoms show up. But this may not work for all hernias.

Some surgeons suggest surgery as soon as possible for groin hernias. They may do this even if there are no symptoms. Groin hernias can trap loops of the intestine. If this cuts off blood supply, a surgeon may have to remove part of the intestine.

Surgery is the only way to fix a hernia. Hernias can become medical emergencies in some cases. People should seek medical supervision in treating any hernia.

Straining can worsen groin hernias. A doctor may recommend cough medications to reduce chronic coughing. He may also recommend products that relieve constipation to reduce abdominal pressure. But the hernia could still get worse.

Doctors may also recommend medicine for hiatal hernias. These happen when part of the stomach presses through a hole in the diaphragm.

Hiatal hernia pain generally comes from gastroesophageal reflux (GERD). This can cause burning in the chest.

Doctors may treat this with heartburn medications including proton pump inhibitors. Patients should be aware of these drugs’ potential side effects.