They call me the Queen of Hernia Repairs. As a surgeon who specializes in complex hernias, I wear my crown with pride. I live, love and breathe hernias, but mostly I treat patients who’ve had hernia repairs and now suffer a complication. These can be complex problems with chronic pain. Examples include:

• mesh erosion into the bladder or spermatic cord;
• mesh infection, which almost always requires complete mesh removal — a tricky procedure depending on the type and size of the repair;
• folded mesh (meshoma) that bunches up into a ball; and
• nerve entrapment or nerve injury.

The cause of the pain is rarely straightforward, but there’s almost always a solution. But here’s the thing. More and more patients are calling my office in search of non-mesh repairs. Thats’ right. Despite the fact that laparoscopy, in addition to its cosmetic advantages, also tends to result in lower recurrence rates and less chronic pain than open repairs, we’re seeing a resurgence in tissue-based open inguinal hernia repairs.

Why have non-mesh repairs, like vinyl records, suddenly become a thing again? Because laparoscopy necessitates the use of mesh — and the public backlash against mesh has been fervent. Mesh and mesh-related complications are generating a lot of bad publicity, driven mostly by the failure of transvaginally placed mesh for urinary incontinence. Unfortunately, many patients are confusing hernia mesh outcomes with transvaginal mesh outcomes.

The issue is complicated by the fact that there have been quite a few mesh-related complications for hernias, especially inguinal hernias. There just haven’t been nearly as many as patients have been led to believe. So, now a great many voices out there are completely anti-mesh: It’s terrible! It should be banned! To add to their frustration, we have surgeons who don’t hear their cries.

They’re adamant that mesh works, it’s the standard of care and we should implant it in everyone. I am very in tune with these issues. I see firsthand that many are hurt and angry about mesh on herniatalk.com, the free patient-surgeon discussion board I moderate.

Non-mesh repairs

Non-mesh repairs were the standard well before any of us were born. Whereas once upon a time it was the norm for general surgeons to graduate from general residencies without ever seeing — let alone doing — open-tissue repairs for inguinal hernias, more and more surgeons are now trying to differentiate themselves by offering non-mesh open repairs.

I’m offering more non-mesh repairs than I used to. To add to the options, I’ve also reinvented an old non-mesh inguinal hernia repair based on an open procedure that was developed in the 1960s that I can now do robotically. It’s called an open posterior or iliopubic tract repair. I used to do it in open fashion for sick and complex patients who had intestinal strangulation, and in whom I couldn’t use mesh.

The robotic iliopubic tract repair is the same posterior repair. You approach the hernia from behind and sew it closed with robotic assistance. I now offer this electively for patients who don’t want, or can’t have, mesh. Whether you do it open, the way it was originally described, or with the robot, it’s a great repair for the general surgeon to learn.

The results have been very good, and we’ve shared our short-term and long-term data with this repair at SAGES and the Americas Hernia Society meetings.

In our Phase I trial, we used the technique on small non-recurrent, non-scrotal hernias in non-obese patients — basically healthy people with small hernias. They all did really well and had no recurrence at 2 years. Now we’re in Phase 3 and expanding our enrollment opportunities to larger non-recurrent inguinal hernias.

But the technique shouldn’t be widely adopted yet. It’s tricky to learn, and you definitely need to know your pelvic anatomy. It’s an option for patients who want the benefits of laparo-scopy or robotics without the risks of mesh-related complications. Of course, that doesn’t mean there are no potential complications; it’s just that potential mesh-related issues are out of the picture. We make sure patients know that if they recur from this, they’ll need to have mesh-based inguinal hernia repair.

The advent of robotics has been transformative. Robotic surgery lets us minimally invasively handle complicated procedures that previously would have had to have been done in an open fashion. That’s because the technology lets you operate in the abdomen similarly to how you would operate during an open procedure.

Robotics also provides an opportunity for many surgeons to offer minimally invasive surgery despite having little or no experience with laparoscopic hernia repair, which is difficult to master. In the absence of competition, robots remain a luxury that most outpatient surgery centers and many hospitals can’t afford. But they still represent a big step forward.

Time to listen

When I analyze the patients who are referred to me for chronic pain after hernia repair, I sometimes see how a different technique or a different size or type of mesh might have prevented the complication. In most cases, the mesh, in and of itself, didn’t contribute to the complication.

Still, the reality is we don’t have a perfect mesh. There are design flaws with many types. For example, their design might not prevent erosion into the spermatic cord or entrapment of nerves. I hope industry listens to the patient movement and makes mesh that’s less likely to contribute to complications.

Hybrid mesh may be inching us toward a perfect mesh. The hybrid idea is to combine standard synthetic mesh, but at a much lower density, with biologic mesh, which has lower inflammatory potential. That way there’s less inflammation and pain related to the biologic mesh. And once it’s absorbed, the patient still has some synthetic mesh left to reduce hernia recurrence rates.

I also think it’s a good thing that patients have become so vocal about hernia mesh. That may force surgeons to think about the techniques they’re using and to not treat every patient the same way. I tailor hernia repairs based on the patient. For example, I don’t treat a thin young female patient the same as an obese smoking male.

Ultimately, we can’t predict with any certainty who may have a complication and who may not. A common scenario is that Patient A and Patient B have similar hernias and undergo the same operation, but have different outcomes. That’s very hard to explain to patients. While medicine is a science, it’s also an art form. We aren’t like McDonald’s, where every meal is exactly the same, no matter where you go.

It’s important to maintain a historical perspective. The reason we moved to mesh repair for hernias in the first place is that patients who underwent open tissue repair were having chronic pain, slow recoveries, nerve injuries and high recurrence rates. The idea was that patching the hernias, as opposed to sewing them closed, would prevent the need to cut muscle or suture tissue tighter than usual.

There are risks for mesh-related complications, yes, but non-mesh repair has its own share of risks, with similar chronic pain complications. Offering non-mesh inguinal hernia repair may be a good thing for some patients, but not for most. Choose the least invasive operation with the lowest risk of complications, as tailored for each patient. Sometimes, that means using a mesh product. Sometimes, that means offering a tissue repair.

The blame game

The legal system is very interested in creating class-action lawsuits based on mesh-related issues. The TV solicitations by law firms are ubiquitous. A large proportion of my patients have sought legal counsel before seeing me for their complications. My office manager spends much of her time making copies of records for these firms. The reality is that all these class-action suits are good for the lawyers, but don’t really benefit patients. OSM