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Non Mesh Repair Questions


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  • Non Mesh Repair Questions

    Hi Dr. Towfigh/Surgeons - I've found a few docs both close by and where I would need to travel, that will repair my hernia without mesh. My hernia is 4cm (buldge), so not small, but not large, and casues no pain. I wanted to highlight for everyone on here that you can typically reach out to any surgeon and discuss whether or not they can repair your hernia without mesh. If they have been in practice for a long time, they will most likely have the training and experience to do a good repair. This isn't always the case, so make sure you do your due diligence.

    All that said, I wanted to confirm with you/surgeons what the typical complications are with a non-mesh repair (whether it's bassini, mcvay, etc.) and what the risks are as compared to mesh. I know the reccurence rate is higher, but that's something I'm willing to risk to avoid mesh. I would also like to get your opinion on which would be the best route for a 33 year old, healthy person. My BMI is normal, if not on the lower side. Let me know if there is any other information I can provide that would be helpful to answer my questions.

    Thanks for your help and insight!

  • #2
    Just to clarify the last question - wanted to get Dr. Towfigh's opinion on which route a young, healthy person should take (mesh or non-mesh). Thanks.


    • #3
      Most patients are candidates for a non-mesh inguinal hernia repair, as long as they are aware of the associated risks.

      A hernia recurrence is the is the most common risk. It shouldn't be taken lightly. A redo hernia repair will always provide a worse outcome than a primary repair. Also, often the recurrence can be larger than the first hernia, as it is due to a tear, and so repair will be more difficult and in the setting of less healthy tissue.

      Nerve injury is another risk. When sewing the tissue repair, all three nerves are at risk of injury and/or entrapment, resulting in neuropathic pain. That can be tricky to treat.

      Chronic pain has always been a risk for tissue repair. It was not as well studied back in the day, as we are doing now, because recurrence was a bigger problem. That said, it's false to believe that chronic pain is not a risk with non-mesh tissue repair. The chronic pain is due to tight repair (it is not a tension free repair), nerve entrapment, and possible pubic bone related pain.

      As with any repair, the more the experience of your surgeon with that type of repair, the lower the risk of these complications.


      • #4
        Hello Dr. Towfigh - a couple of questions to add to this thread:

        - I understand that the risk of recurrence is greater with a non-mesh repair but are you also saying that the risk of nerve injury is greater with a tissue repair than it is with mesh? If so, is this because of the physical stitching required vs placing of mesh?

        - In terms of chronic pain, what are the most likely causes with a laparoscopic mesh repair? Is it the mesh itself or are there other ways in which this procedure can injure nerves?

        Thank you!


        • #5
          - There is a real risk of direct nerve injury with tissue repairs. Mostly, due to direct injury (cut, burn) or entrapment in the sutures. With mesh repair, there is the added risk of mesh-related injury to the nerve, such as erosion, entrapment, yet most surgeons don't manipulate the nerves as much during a mesh repair, as it is not necessary. To think that there is no risk of nerve injury with non-mesh repair is not factual.

          - Similar to open procedure, the risk of nerve injury from laparoscopic repair is due to direct injury (cutting, burning) or mesh-related injury. That said, the risk of mesh-related nerve injury is limited to direct mesh impingement or erosion, which are quite rare.


          • #6
            Thanks for the replies, Dr. Towfigh. Can you provide percentages as they tie to recurrence rates and the chances of nerve damage in open, non-mesh repairs? I'm still weighing my options on which direction to take (lap mesh, vs. open non-mesh). The surgeon I met with stated the recurrence rate for non-mesh repair, bassini technique, is around 10%, and chronic pain percentage around 5-7%. It would be great if you could share these numbers to justify going one way or the other. And again, if you had a healthy, 33 year old male come in for hernia surgery, which route you would recommend for long term quality of life?

            Other surgeons can feel free to chime in as well.



            • #7
              I thank you to enable me to chime in this discussion. I am a 62 year old hernia surgeon in S. Korea.

              If we talk about car driving, we can say there are some fearful dangers. Nonetheless we usually drive our cars without accident. If we talk about the risks of hernia repair, we can say all kind of fearful and dangerous possibilities. But we need to talk about it, based on real experience and results rather than on theoretical possibilities which make us confused.

              As you know well, there are some surgeons who prefer mesh repair and others non mesh tissue repair. I myself am one of those who strongly assert that inguinal hernia must be repaired without using mesh.

              The reason is that mesh repair problems currently take place in reality (even in this forum we can find some who suffer from mesh complications). Contrastingly risks of tissue repair are discussed mostly on theoretical basis. Its like we say car-driving is dangerous. For your reference I talk to you I have no accident in more than 30 years driving.

              Another reason why I prefer non mesh hernia repair is that no mesh tissue repair, if done properly, can show even lower recurrence rate than mesh repair. Actually I have performed more than 5,000 no mesh inguinal hernia repairs for the past 4 years and the actual recurrence rate so far is about 0.5%.

              It is not a wrong decision that you dont go through mesh repair. I strongly recommend that you find a good surgeon who does non mesh repair properly.

              Thank you!


              • #8
                Hi. Dr. Kang. Just curious about tissue (non mesh) repair for femoral hernias. What technique do you use and are the results (low recurrence) the same for inguinal repairs?


                • #9
                  Non mesh femoral hernia repair is much easier than non mesh inguinal hernia repair.
                  After small incision and treating the hernia sac, the hernia opening is closed securely by continuous non-absorbable suture.
                  All procedure is done under local anesthesia, and it takes about 15 minutes.
                  Femoral hernia is relatively uncommon, so I have just about 20 cases experience.
                  No recurrence so far.
                  Thank you!


                  • #10
                    Thanks for your reply. 6 years ago I had a laparoscopic mesh repair for what turned out to be both a direct and indirect hernia. I had issues post surgery and starting last Feb debilitating pain. It turned out the mesh had curled up into a rock hard ball and I had the mesh removed (robotic assisted laparoscopically). He was able t remove about 90% of the mesh with some having to be left in the illiac vein and illiac artery.
                    he said there was no direct hernia (scar tissue filled in the area) and no indirect hernia but some weakeness in the indirect space which was sutured with absorbable sutures.
                    my question is the surgeon said the was slight weakeness in the femoral area and he could not reinforce this with sutures while he was in there Bc there area is very vascular and didn't want to risk any bleeding (he was in there laparoscopically ).
                    He said in the future i am at risk for a possible femoral hernia. So I am just trying to be procactive and have a plan should I develop a femoral hernia . and have a surgeon in the US who has experience treating femoral hernias with no mesh
                    so a few questions:
                    are there any steps I can take in regards to nutrition, diet and excercise or any others steps proactive or preventative to increase the odds that I don't have a femoral hernia down the line?
                    also when you repair a femoral hernia with out mesh is there risk or likelihood that the inguinal area is compromised?
                    thank you for your input?


                    • #11
                      Hi, Jnomesh.

                      I don't think there is any exercise to prevent hernias, though many people want to know about it.
                      Because muscular tissues consisting of hernia openings usually are not used actively during physical exercise.
                      So it's very difficult to strengthen those muscles.
                      Furthermore, femoral canal, through which femoral hernia comes out, consists of ligamentous tissue which is very tight and fixed.
                      So it cannot be strengthened by any exercise at all.
                      Umbilial hernia and epigastric hernia also have hard and tight ligamentous hernia openings.
                      On the contrary, many exercises which increase intraabdominal pressure contribute to hernia development.

                      Regarding diet, balanced nutrition is recommendable.
                      As you know, food which increases intraabdominal fat is bad for hernia.

                      I don't think non mesh femoral hernia repair will compromise inguinal area.
                      The repair is not done at inguinal area, but at femoral area.

                      Thank you!


                      • #12
                        Thanks doctor for your prompt response that is awesome and much appreciated. While I have your ear I thought I'd throw a few more questions your way:
                        1)how long does it usually take for a non tissue repair with absorbable sutures for a inguinal hernia to fully heal? I've read at 6 months the area should be about 75% healed and at a year 100%.
                        does this seem accurate?
                        The reason I ask is because when I had my mesh removed laparoscopically 5 weeks ago the surgeon reinforced the indirect space which had weakness by bringing the internal oblique muscle down to the illiopubic tract and stitched with absorbable sutures. So I am just curious how long will that area take to heal and how long should I be extra careful as to not risk reinjuring the area?
                        2)Also do you have any contact with or know iof any surgeons in the US that specialize in pure tissue repairs?
                        3)also what technique do you use to repair inguinal hernias (shouldice, bassini, Mccvey, desarda etc
                        4) and what technique do you use to repair femoral hernias
                        5) what are the pros and cons of absorbable and non absorbable sutures
                        6) i know you mentioned that femoral hernias are less prevalent and thus you have done less of these repairs but what are the symptoms patients usually present with a femoral hernia outside of an y obvious bulge? I have some burning in my upper thigh right about where the bio bone ball and socket is-sometimes there is slight burning that radiates around to my lower back. Both of these are only brought on when I sit not when I walk.
                        7) are you aware of any advances in the area of hernia repair: stem cell therapy or tissue regeneration?
                        8) is there anything that can be done to make a hernia area that is weak (but no hernia present) stronger such as prolotherapy or PRP therapy. My surgeon noted I had some weakness in the femoral area and was wondering if there are some things I can do to strengthen the area?
                        Thanks again-look forward to hearing back from you!


                        • #13
                          In Korea, everything is fast, so I am also accustomed to it. (joking!)

                          It is somewhat difficult also for me to give you correct answers to all of your questions, because I don't have perfect knowledge or experience.
                          So I am afraid that there could be some incorrect answer.

                          1) As far as I know, the wound strength reaches maximal point in 6 weeks after operation, which is about 80% of preinjury level.
                          So I usually recommend my patient to return to full nornal activity including exercise in 3 weeks after repair, as our musle has surplus strength to ordinary activity.
                          You can find some reference at the following address.

                          2) I am afraid that I have no idea about US hernia surgeons.

                          3) I do two different type of operation respectively, according to the type of inguinal hernia - indirect or direct.
                          For indirect inguinal hernia, I just close the hernia opening. It is somewhat similar to Marcy operation.
                          And for direct hernia, my technique is a bit similar to Shouldice in one aspect, and to Desarda in another aspect, but as a whole, it is done with much smaller incision and much stronger than those two operations, I think.

                          4) For femoral hernia, I just close the hernia opening with continuous nonabsorbable suture as I told you before, which is very simple procedure.

                          5) I think any suture material is OK for inguinal hernia. It depends on surgeon's preference. But for femoral or umbilical or epigastric hernia, of which hernia opening is very tight and dense, non-absorbable suture material must be used.

                          6) I don't think the symptoms you have now are not related to femoral hernia. The symptoms of femoral hernia are buldging(which is like cystic ball) and sometimes pain. I don't know of any other symptoms besides.

                          7) Sorry, I don't know about stem cell therapy or tissue regeneration. But I think that kind of treatment is not necessary, as tissue repair can show excellent result if it is done properly.

                          8) As I told you at previous answer, I don't think there is anything to help you in the matter of femoral hernia thing. But one good news is that femoral hernia seldom occur in men. Actually so far I had just one male femoral hernia patient who is US citizen. It is just one out of more than 10,000 hernia repairs. And another good news is, as I told you, non mesh femoral hernia repair is very simple and secure.
                          Don't worry too much about femoral hernia occurence.

                          Thank you!


                          • #14
                            Again thanks for the prompt reply!! I am 5 weeks out from having a large mesh removed so I am probably still healing from that 3 1/2 procedure.
                            i appreciate the work you are doing in offering an alternative to hernia mesh repair, as this is causing many problems to many people here in the US and other countries. I only wish that we had similar options in the US.
                            one last question
                            I know you don't use mesh but maybe you can help me with a anatomical question: my surgeon was able to get 90% of the mesh out but had to leave some small amounts of mesh on the illiac vein and illiac artery.
                            im wondering if these two structures are near the upper thigh where I have some burning when sitting. I'm thinking that maybe when I sit and compress the area that maybe the mesh fragments is compressing these two structures and resulting in the burning sensation. But again I have no idea where exactly these two structures are although I think i read somewhere that one of these turns into the femoral artery which I know is in the leg-thus my question.
                            thanks again!


                            • #15
                              Dear rcl0223,

                              Very good questions about nerve damage and chronic pain with mesh vs with tissue non-mesh repair. It is a myth that non-mesh repair has lower chronic pain or nerve damage risk. The best study on this was also the first to study such an issue. It clearly shows a significant chronic pain risk with non-mesh tissue repair. See attached. Note that this study was done during an era where most of the surgeons were skilled in non-mesh tissue repair. Everyone was focused on reducing hernia recurrence back then (hence the advent of mesh repairs) and that was the main outcome that was measured. Pain was assumed to be part of the profile of hernia surgery. But once hernia recurrence was a lesser issue (due to use of mesh), then the importance of and interest in chronic pain increased.

                              Today, the outcome numbers quoted for non-mesh tissue repairs are all over the place. The reason may be that the recurrence and pain/nerve injury rate is very much a factor of the surgeon's technique and experience. Each surgeon and institute has their own data. For example, recurrence rate may be between 0.5% and 15%. Chronic pain may be between 1% and 20%. The outcomes from tissue repair are no longer as predictable as the more standardized mesh technique.

                              Attached Files


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