Hernia Repair With or Without Mesh

In short

• Mesh is not compulsory. Some hernias are properly repaired without it, and in others leaving it out means accepting a much higher chance of recurrence.
• Suture repair trades fewer mesh problems for a higher chance of the hernia returning. The size of the defect decides which way that falls.
• Ask three things before you consent: which mesh, what size, and in which plane. Those answers say more than any brand name does.

This question is usually asked after someone has read about mesh complications online. It deserves a straight answer rather than reassurance.

Mesh is not compulsory. There are hernias that are properly repaired without it. There are also hernias where refusing mesh means accepting a much higher chance of the hernia coming back. You should be told which of the two you have.

The honest summary is this. Suture-only repair trades a lower chance of mesh problems for a higher chance of recurrence. Which way that trade falls depends almost entirely on the size of the defect, and on the quality of the tissue around it.

When a repair without mesh is reasonable

Small umbilical and epigastric defects. Below roughly 1 to 2 cm, in an adult of normal build with healthy tissue, a simple suture repair is a recognised option and recurrence is low. This is the commonest situation in which patients are genuinely offered a choice.

Children. A hernia in a child is a different problem. The defect closes on a growing abdominal wall, and mesh is not used.

A contaminated or infected field. Where a hernia is operated alongside bowel that is obstructed, perforated or infected, putting synthetic mesh in is often the wrong move. The repair may be done with sutures, or with a biological mesh. Sometimes it is deliberately staged: control the emergency now, repair the wall properly later.

Where the patient has decided, having been told the numbers. If you understand that you are accepting a higher recurrence risk, and you still prefer no implant, that is a legitimate choice. It should be documented, not argued out of you.

When leaving mesh out is not a fair trade

Adult groin hernias. The evidence here is not ambiguous. Mesh repair of a groin hernia in an adult recurs a good deal less often than suture repair. That is why mesh became standard, and it is the situation where declining mesh costs the most.

Incisional hernias. These happen precisely because a previous closure failed. Closing the same failed tissue with the same sutures invites the same result. Large incisional hernias repaired without mesh come back at rates most patients, once told, do not accept.

Any defect that will not close without tension. Tension is what pulls a repair apart. If the muscle edges have to be dragged together, sutures alone are carrying a load they were not designed for.

Recurrent hernias. A hernia that has already come back once has told you something about the tissue it sits in.

What mesh complications actually are, and how common

The concerns are real, but they are not all the same size, and online accounts rarely separate them.

• Stiffness or mild discomfort. The commonest genuine complaint. Usually mild, and settles over months. Lightweight, large-pore meshes were designed to reduce it.
• Pain bad enough to need treatment. Uncommon. Modern evidence points more often to how the nerves were handled during the operation than to the mesh itself.
• Infection of the mesh. Uncommon in clean, planned surgery. Serious when it happens, because it can mean taking the mesh out.
• Mesh eroding into bowel. Rare, and largely a problem of older meshes laid directly against bowel with no barrier. It is why the plane the mesh sits in matters as much as the mesh.
• Migration or shrinkage. Rare, where fixation and overlap are adequate.

Set against all this, recurrence is not a benign outcome either. A hernia that comes back means a second operation in scarred tissue. That is harder, carries more risk to nerves and bowel, and more often needs mesh anyway.

Mesh concerns, in proportion

If you want the mesh question answered for your own hernia rather than in general, bring your scans to the OPD.

Where the mesh is placed matters as much as whether

Much of what patients read about mesh comes from an era when it was routinely placed inside the abdomen, against bowel.

Current practice is the opposite, and it is the main argument for the robotic route. The mesh is placed within the layers of the abdominal wall, behind the muscle and in front of the peritoneum, so that it never touches bowel at all. The retromuscular and extraperitoneal planes exist for exactly this reason.

If you are being consented for a hernia repair, it is fair to ask three things. Which mesh. What size. In which plane. Those three answers tell you more about the repair you are being offered than the brand name does.

Frequently asked questions

Related pages

The main page on this site is robotic hernia surgery in Ahmedabad. These cover the neighbouring questions.

Where to find us

Dr Harsh Shah, MS, MCh (Surgical Gastroenterology), DrNB (Surgical Gastroenterology)
Shah's Gastro, Cancer & Robotic Surgery Centre
Apollo Hospital, Bhat, Gandhinagar
Gota OPD, Ahmedabad
Bring your reports. Second opinions are welcome.