No Mesh Hernia Repair Misconceptions

Mesh Trust Issues: Understanding No Mesh Hernia Repair Misconceptions

Like finding a radio station on a road trip, locking in the ideal height and resistance during a bike ride, or getting the filter just right for the ‘gram, control is a constant adjustment of give and take that impacts virtually every aspect of our lives.

We are taught from a very young age that we can influence outcomes of almost any situation, but what happens when control is no longer in our hands? For example, when a doctor diagnoses you with a condition like a hernia that will require surgery to fix.

To get better we must give up certain levels of control to the surgeon. This requires an incredible amount of trust, which is why we spend countless hours searching for symptoms, treatments, and reading patient reviews so we can determine the best possible path forward for our situation.

When you combine several well-publicized unfortunate outcomes, lawsuits, a flood of borderline predatory advertisements questioning mesh safety, and the explosive polarizing social media environment where mesh is often blamed for causing complications, it’s easy to see why many patients simply do not trust hernia mesh.

A survey of 500 hernia patients revealed that 36% felt “No hernia mesh is safe,” 16% where “unsure, and needed to speak with a doctor,” while 48% trust the standard of care by believing “Hernia mesh is safe.”¹

Naturally if the standard of care is hard to trust, the right approach must be a “no mesh” tissue repair. While this logic makes sense, however it’s vital to understand that a no mesh hernia repair is only a viable option for select patients who meet the following criteria:

• Small defect size approximately a few centimeters wide
• Predominately only applies to inguinal or umbilical hernias, be wary of surgeons who claim to be able to repair ventral and incisional hernias with high success rates.
• Accessible anatomic location via open procedure
• Zero to “controlled comorbidities” as tissue quality is vital to achieve a positive outcome
• Ideal BMI as additional weight will increase tension on repair site which may lead to recurrence
  
  

As with any surgical procedure, no mesh hernia repair has limitations:

• Evidence indicates no mesh hernia repairs are predominately performed via an open procedure at this time. While results are encouraging, only 13 low risk patients have had a non-mesh MIS hernia repair in the US.²
• Increased likelihood of post op pain as an open procedure is more invasive and disruptive to surrounding tissue and anatomical structures compared to a robotic or laparoscopic repair using mesh.
• Longer recovery time compared to a robotic or laparoscopic repair using mesh
• Surgeon experience, very few surgeons in the US are trained, let alone experienced enough to perform successful pure tissue repairs

Rather than feel trapped by the perceived limited options of no mesh or mesh, consider the following to help you find the right hernia repair approach for you.

Fear of Mesh or Foreign Body?

Used to repair hernias prior to the moon landing, synthetic mesh made of polypropylene has been widely considered by many as the gold standard due to low cost and favorable material properties. While polypropylene is a foreign body that is bioinert, meaning it’s believed to not cause a reaction to surrounding tissue, data is now emerging that suggests otherwise in certain situations.

Thousands of patients experience no complications from sutures or hernia mesh made of polypropylene, so why does it work in one person and cause complications in another? The answer may come from within, meaning will depend on our individual foreign body response. When any foreign material enters our body, an inflammatory cellular response is triggered that has two outcomes; integrate with the surrounding area or encapsulate, meaning wall off which is a natural protective mechanism that creates scar tissue. For many this process ends after a few weeks without any major issues. Data is starting to show that complications occur during periods of prolonged foreign body responses where the protective mechanisms are overwhelmed and may require corrective surgical intervention such as an explant procedure to remove the material.

One major misconception patients have is the no mesh hernia repair approach eliminates all the mesh associated complications related to prolonged foreign body response. Viewed as the gold standard no mesh tissue repair, The Shouldice repair can utilize similar amounts of foreign body that are found in some of the available synthetic hernia meshes. A recent study examining the outcomes of a novel hernia repair technique found “the MIS ReBAR technique has less retained foreign body (0.13 grams) as compared to the “no mesh tissue” Shouldice repair (0.20 grams) and the synthetic mesh Open or MIS repair (0.97 grams),”³.

Today’s Hernia Repair, Tomorrow’s Recurrence?

While getting better is the top priority, no one looks forward to having surgery regardless of how routine the procedure. A no mesh hernia repair may seem like the right treatment today, but please consider “tomorrow’s” recurrence, which most likely will require a more complex hernia repair. Literature has shown that a no mesh suture repair has a 45% chance of recurrence at 36 months, compared to 20% with a mesh repair.⁴

Amplified by social media, blaming mesh for complications has become common practice among patients. What often loses context in these discussions or takes place in the DMs, are the other factors that contributed to the adverse event. In addition to mesh related complications, consider the following factors that may play a role in recurrence:

• Underlying comorbidities or “defective biology” where patients collagen levels are impaired which may impact the durability of the repair.⁵
• Disregarding the doctors’ orders for prehabilitation such as smoking cessation, weight loss, exercise, and diet changes.
• Elevated stress and anxiety as studies show higher anxiety leads to slower, and in some cases worse wound healing.⁶
• Returning to physical activity too quickly
• Neglecting to make recommend lifestyle changes post-surgery
• In certain cases, technical error by the surgeon can occur
  
  

Which hernia repair approach is right for me?

Just like we are all different, the same goes for hernias. The treatment is relatively routine, however there are a variety of interconnected factors that can add complexity which is why it’s important to find the right surgeon. Look for a healthcare provider who offers:

• Empathy by actively listening to your concerns without bias or judgement
• Explanations of scientifically proven options that may include non-surgical, no mesh tissue repair, reinforced tissue repair, and mesh repair
• Empowerment to make a choice based on your preferences and clinical need

Data suggests that patients who get to play an active role in the decision-making process have lower anxiety than patients that do not.⁷

Explore Your Hernia Repair Options

After going through the process with your doctor and they recommend a hernia repair with mesh and something in your gut is still making you apprehensive; there is a compromise that’s growing in popularity because of encouraging clinical outcomes and patient demand for more natural alternatives.

Whether you are more concerned with recurrence or prolonged foreign body response, what if there was a way to have both addressed in the same hernia repair procedure? A study of 619 patients demonstrates a recurrence rate of 1.2% by leveraging the surgeon’s existing tissue repair techniques augmented with a permanent reinforced biologic, named appropriately the ReBAR technique.³

Whatever option you decide, please do not delay seeking care because of hernia mesh related fear as that could cause a medical emergency you can’t control anymore.

Need help sharing your fears and concerns about potential hernia treatments with your doctor?

For a more comfortable experience, use the SCAFFOLD Guide to prepare for your next appointment. Click here to begin.

References

1. Pollfish Market Research Survey. Data on file
2. Huynh, D., Fadaee, N., Al-Aufey, B., Capati, I., & Towfigh, S. (2020). Robotic iliopubic tract (r-IPT) repair: technique and preliminary outcomes of a minimally invasive tissue repair for inguinal hernia. Hernia : the journal of hernias and abdominal wall surgery, 24(5), 1041–1047.
3. Ankney C, Banaschak C, Sowers B, Szotek P. Minimizing Retained Foreign Body in Hernia Repair Using a Novel Technique: Reinforced Biologic Augmented Repair (ReBAR). J Clin Med Res. 2021;3(4):1-11.
4. Luijendijk, R. W., Hop, W. C., Van Den Tol, M. P., De Lange, D. C., Braaksma, M. M., IJzermans,. (2000). A comparison of suture repair with mesh repair for incisional hernia. New England Journal of Medicine, 343(6), 392-398.
5. Klinge U, Binnebösel M, Rosch R, Mertens P. Hernia recurrence as a problem of biology and collagen. J Minim Access Surg. 2006;2(3):151-154. doi:10.4103/0972-9941.27729
6. Gouin JP, Kiecolt-Glaser JK. The impact of psychological stress on wound healing: methods and mechanisms. Immunol Allergy Clin. 2011;31(1):81-93.
7. Bieber C, Nicolai J, Gschwendtner K, Müller N, Reuter K, Buchholz A, Kallinowski B, Härter M, Eich W. How does a shared decision-making (SDM) intervention for oncologists affect participation style and preference matching in patients with breast and Colon Cancer?.J Cancer Educ. 2018;33(3):708-15.