Inguinal hernia repair and controversies in the use of mesh
Comment on recent article : Chronic pain after surgery is a very topical subject and one of the commonest questions I am fielding in clinics surrounds the use of mesh. This is a controversial subject that has featured in the national press in recent times. This article summarises the recent evidence surrounding the use of mesh. No surgeon would ever claim that complications such as pain following surgery are impossible. For the small proportion of patients suffering with these problems it can undoubtedly be debilitating. However we also have a responsibility to interpret the scientific data accurately for our patients. Good decision making, good technique and identifying patients at risk of problems are key factors in minimising these issues. There is good evidence that pain issues after surgery are the same regardless of whether a mesh is used or not.
Inguinal hernia repair is one of the commonest surgical procedures performed in the UK. Most people present with a simple lump in the groin that can be uncomfortable. Severe pain with a hernia is very unusual and should prompt an urgent consultation.
Hernia repair has featured prominently in the national press in recent years, largely because of the use of prosthetic material (mesh) that has become standard in this type of surgery over the last 20-30 years.
Firstly, despite some sensationalist headlines, the vast majority of patients with groin hernias do extremely well following surgery. Most patients elect for surgical repair because hernias tend to get larger and more symptomatic over time. Most operations can be performed safely under general anaesthesia as a day case. After a few weeks most patients are back to normal day to day activities and more strenuous exercise can begin at 6 weeks. This rest period limits the chances of hernia recurrence (2-4% risk in large studies).
Many patients ask about the different techniques for repairing hernias e.g. open and keyhole (laparoscopic) surgery. Numerous large trials have been conducted and overall the results are very similar. Patients with hernias on both sides or with a recurrence of a previous open repair should probably be considered for laparoscopic surgery. A surgeon familiar with both techniques should be more than happy to discuss the pros and cons of each option with you.
Prior to the use of mesh in hernia surgery, recurrence rates were extremely high (10-20% in some studies) and there is little doubt that its use has dramatically improved statistics by strengthening the groin after surgery. Most of the recent negative coverage has focussed on post-operative pain issues but there is a danger that these articles may be taken out of context.
Firstly, the original reports of mesh complications featured gynaecological (pelvic) surgery which is entirely different to patients having a groin hernia repair. On the back of this, some surgeons quoted extremely high rates of chronic pain following hernia repair, a phenomenon they attributed to the use of mesh. Unsurprisingly, their personal preference was for non-mesh techniques.
Results from reputable publications would suggest that chronic pain occurs in 1-6% of patients (rather than the 30-50% quoted in the press) and that this is equally (un)likely in patients with and without mesh placement, followed up for over ten years. Mesh continues to be recommended by national and international hernia societies as well as the Royal College of Surgeons.
Many patients justifiably ask the question “what would you do?” Some years ago I went out into the garden to move half a tonne of tiles into our kitchen. I noticed my hernia shortly afterwards but I didn’t (and still wouldn’t) consider having a repair without mesh. Having surgery yourself certainly gives you a different perspective and in my opinion, mesh repair (open/laparoscopic) clearly remains the gold standard.
