Well, Here’s Another Fine Mesh We’ve Gotten Into! Part 2

First uses of mesh for Hernias

The first hernia mesh that stood the test of time was a Marlex knitted polypropylene mesh in the late 1950’s.  In contrast to other materials, such as silk, or cotton, this is a synthetic monofilament thread.  In comparison to present day alternatives, the Marlex was on the heavy side, and since its introduction, other meshes have been developed that have had fewer issues with intolerance, infection, or other complications.  And yet, any mesh implanted in a human body is “foreign” and is at risk of being rejected rather than being incorporated.  It’s taken some decades for surgeons to learn how and when mesh can be used safely.

During my surgical residency years in the 1980s, the use of mesh for routine hernia repairs was frowned upon, except perhaps for someone with a failed initial repair, because of the concern for rejection or infection. However, there was an ever-increasing number of peer reviewed publications that supported the use of mesh for a routine hernia repair.  The theme of most such publications was that use of mesh decreased the risk for a recurrence of the hernia, with a low risk for complications related to the mesh, most notably, infection, or rejection.

Expanded Mesh Options

Surgical product manufacturers took notice of the increasing demand for mesh products, and thus began the expansion of the availability of various mesh products, with various materials, with differing weaves or knits, pre-shaped, three-dimensional, biologic, etc. There are at least 70 different mesh products that have been marketed over the years. A few of these mesh options had inherent design flaws that made them more likely to cause problems, and for the most part those have fallen by the wayside.

It should be no surprise that larger more complicated hernias seemed to be those best suited for using mesh, since the recurrence risk was so high. But as use of mesh increased in these more complicated cases, it became clear that if mesh is placed directly in contact with the bowels, there was a significant risk that the bowels might be negatively impacted by the mesh, with possible secondary infection, obstruction of the bowels, or frank perforation.

A similar situation occurred when mesh was utilized in repairs of vaginal prolapse.  And as the number of adverse events accumulated, there was an increasing number of lawsuits filed against surgeons, hospitals, and manufacturers for these cases involving mesh. Not all these lawsuits were successful, but in the process, attorneys became educated on the nuances of how mesh should and should not be used, and so followed the increase in attorney advertising to find patients who may have suffered bad outcomes related to use of these meshes.

Appropriate Uses of Mesh for Hernias

When used in the appropriate setting, and not adjacent to the intestines, or vagina, mesh products are indeed a valuable adjunct for performing a durable hernia repair. In particular, the light and medium weight, knitted polypropylene meshes reliably incorporate into the surrounding tissues without rejection or infection, without any increase in pain, and the reinforcement of the mesh serves to minimize the risk of recurrence.

Mesh Free Hernia Repair

There are, however, a few patients who remain convinced that any mesh is bad for them, and absolutely refuse to allow mesh to be used for their hernia repair.  They can be assured that there are options for repair of most any hernia without mesh, however, the risk for a recurrence is likely to be higher. For example, in my personal experience, a routine initial repair of an inguinal (groin) may have a risk for recurrence of about 5-8% without mesh, and less than 1% with mesh. Repairs of recurrent incisional hernias would have a much higher recurrence risk if mesh is not used.

For someone averse to using mesh, those statistics may be acceptable.  One should also be aware that non-mesh repairs are not taught much anymore, so more recently trained surgeons may have very little experience with it.  If you want to have a non-mesh repair for your hernia, be sure you find a surgeon who has done lots of them.

Here is a link to the information on our website about hernias. If you would like to schedule an appointment with us please call our office at 404-508-4320.