Ok, so is mesh absolutely necessary?

Well, that is a difficult question.

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

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

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

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

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

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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.

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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.

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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.

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• 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

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• 88% of these patients were examined at 3 years

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Findings:

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Recurrences (hernia came back):

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• 9 in the “Non-Mesh” group

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

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

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

7% for Non-mesh and 1% for Mesh

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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."

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

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

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

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• Mesh 4426 repairs, 88 recurrences (2%)

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

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

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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.

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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

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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%

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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:

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• 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:

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• Shouldice versus other primary repairs

  • 4.4% versus 6.9%

• No Significant advantage

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• 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.

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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.

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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.

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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:

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