Hernia Mesh: The Debate and the History
In this excellent article by General Surgery News (here) the history of hernia mesh as well as the present day debate is laid out despite the fact that it is linked to chronic pain, mesh erosion into adjacent tissues or organs, infection and fistulas, among other problems.
General Surgery News reports on the March 2014 annual meeting of the American Hernia Society (AHS).
Dr. Robert Bendavid, MD, is the voice for the thousands of patients who have been harmed by the use of polypropylene mesh.
Dr. Bendavid is with the Shouldice Hospital in Toronto which rarely uses mesh (3%) and is very selective in its indications. Mesh is indicated in femoral hernias, inguinofemoral hernias and even then, the mesh is properly fashioned so that there is minimal contact with any adjacent structures (urinary bladder, femoral/iliac vessels and occasionally vas deferens and fallopian tubes). Occasionally mesh is used in direct or recurrent direct hernias and most rarely in indirect inguinal hernias. Incisional hernias were not commented upon here.
Dr. Bendavid tells Mesh News Desk, “Although mesh is a necessity in certain surgeries, like incisional hernia repairs, femoral and complex recurrent groin , femoral and complex recurrent groin hernias, the need for mesh in the groin is infrequent. Part of the problem as seen in recurrences is the fact that many surgeons are not familiar with the anatomy of the groin as reflected by the number of missed hernias. There is little need to ever place mesh in the groin or pelvis.”
Dr. Bendavid questions why use mesh for repairs when it has not lowered the rate of recurrence, especially in women who generally have indirect inguinal hernias and when they have a femoral hernia, their tendency to recur is far less than in men? For every hundred femoral recurrences we see, 80 are in men!
But doctors love to use mesh because mesh companies promote the idea that with mesh you do not need to know your anatomy! You can create an anatomically correct repair easily with mesh.
At the AHS meeting, Dr. Guy Voeller, MD with the University of Tennessee, stands by a mesh repair as helping many patients and lowering the recurrence rate of inguinal as well as incisional and ventral hernias. Dr. Voeller backs off a bit when he says, “we should shy away from employing a shotgun approach of putting mesh in everyone when sometimes an autogenous repair would work just as well or better.”
An autologous or autogenous repair uses the body’s own tissues harvested from the patient and placed in the area in place of synthetic mesh.
Dr. Bendavid uses a suture only repair in the majority of cases and is among a minority of surgeons to do so. The Shouldice and Bassini repairs are suture hernia repair while mesh used to treat hernias include Kugel, prolene or plug and patch. There are more than 300 types of meshes to choose from). These are made of polypropylene (PP) and other synthetics can be used such as polyester or ePTFE (polytetrafluoroethylene) or a composite mesh.
Shouldice reports recurrence rates using autogenous inguinal hernia repairs of less than one percent.
One must understand that assessing the success of any surgery includes quality-of-life issues. An anatomically perfect repair that leaves the patient in chronic pain with ongoing infections, would not be considered a success by the patient, though it might be considered a success if the hernia didn’t recur.
The article includes a definition of the Edoardo Bassini , MD repair, considered the father of modern hernia surgery as well as the Shouldice repair technique. Synthetic mesh entered the picture over the past 50 years but only on such a market scale in the last 20 years.
Mesh News Desk’s associate Bruce Rosenberg, himself hernia mesh injured, answers many questions from hernia-mesh injured folks. Reach him at 954-701-5094.
General Surgery News, October 2014, A Century Later Debate on Hernia Repair is Stronger Than Ever, here
Dr. Robert Bendavid, International Journal of Clinical Medicine, May 2014, Surreptitious Irreversible Neuralgia or SIN Syndrome, which is not responsive to treatment, unrelenting and progressive pain
Dr. Robert Bendavid, Uwe Klinge, International Journal of Clinical Medicine, July 2014, Bias-Variation Dilemma Challenges Clinical Trials: Inherent Limitations of Randomized Controlled Trials and Meta-Analysis Comparing Hernia Therapies
Dr. Robert Bendavid, Intl Journal of Clinical Medicine, July 2014, Hernia Societies- A Blessing or a Curse?
International Journal of Clinical Medicine, July 2014, Editorial on the Status of Hernia Surgery – Back to Pure Tissue Repair or Forward to Tohubohu, Earl Byrnes Shouldice, See Editorial Here