The American Journal of Surgery (2014) -, -–-
Editorial Opinion
Hernia repair: do you know your own results? KEYWORDS: Inguinal hernia; Mesh; Inguinodynia; Recurrence
Abstract Inguinodynia is an undesirable postoperative complication reported following groin hernia repair done with and without mesh implantation. It can be minimized by a good technique. Personal recognition of less than ideal results can be helpful in the decision to pursue improved performance. Ó 2014 Elsevier Inc. All rights reserved.
In his Editorial Opinion regarding inguinal hernia repair, Dr Fischer faults the inflammatory response created by prosthetic mesh for causing high incidences of chronic inguinodynia. To avoid this problem, he advocates abandoning mesh and advises using the Shouldice or transversalis fascia repairs. It is normal for implanted prosthetic mesh to provoke inflammatory reactions in adjacent tissues; without this initial healing response, mesh would not become incorporated in the adjacent tissues. Ordinarily, reactions to inert mesh are minimal and are short lived. Symbolically related to what to give up, as in the adage about the baby and the bath water, having fewer recurrences using mesh repairs is the baby, and chronic inguinodynia is the bath water. Some investigators report significant incidences of chronic inguinodynia in their individual series, but none did randomized controlled trials within their own series comparing the frequency of inguinodynia following pure tissue versus mesh repairs. Bay-Nielsen et al reported 3.8% chronic pain remained after 2 years following mesh hernia repairs, and others have reported higher.1 Cunningham et al reported 10.6% incidence of chronic pain 2 years following inguinal hernia repairs done without mesh.2 Other published studies from the United States and abroad verified that mesh repairs (Lichtenstein mesh repair, plug and patch repair, Prolene Hernia System, laparoscopic) all have lower recurrence rates compared with pure tissue repairs for primary and recurrent groin hernias.3-5 The Shouldice and the transversalis fascia repairs are excellent operations to treat the presenting hernia, but * Corresponding author. Tel./fax: 11-305-775-7015. E-mail address: [email protected] Manuscript received October 29, 2013; revised manuscript November 7, 2013 0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2013.11.003
neither is ideal to protect against future groin hernia formation through the remaining unprotected area of the myopectineal orifice. As for longevity of pure tissue repairs, long-term follow-up of patients that had pure tissue repairs show that more than 50% of ipsilateral recurrences presented 5 or more years after the original repair. My personal experience adding mesh to the Shouldice Repair convinced me of its value. In 1976, I visited the Shouldice Hospital to observe the most experienced surgeons do its repair. I used the Shouldice operation for the next 8 years. My recurrence rates for primary hernias dropped to 2% from the 10% previously associated with the modified Bassini repair I had used. At the suggestion of Dr. Everett Shocket, in 1984, I placed a mesh patch in the preperitoneal space as a protective barrier to the suture lines of the Shouldice repair; my recurrence rate dropped from 2% to .5%. The incidence of chronic inguinodynia in my series was minimal, and when it did occur, it was usually related to one of my own recurrences. Before 1984, surgeons used mesh in less than 5% of groin hernia repairs. Its use grew about 5% each year until 1990 when with the advent of the laparoscopic approach to groin hernias it became routinely expected for all adult repairs done by either approach. I am unaware of any progressive center in the world other than the Shouldice hospital that continues to do hernia repair without mesh. In less progressive countries, where mesh is not readily available, tissue repairs remain standard, and failures are not unusual. From a practical view, regardless of the type of mesh technique performed by hernia-devoted surgeons, would any reasonable person believe those surgeons could be able to continue to attract the large quantity of patients in their practices and keep their good reputations, if chronic inguinodynia occurred more than rarely? In reports from
2
The American Journal of Surgery, Vol -, No -, - 2014
hernia experts that use different platforms of mesh repairs, their reported incidence of inguinodynia is consistently minimal. Undoubtedly, there are isolated incidences of adverse reactions to mesh. I have seen some and on occasion have removed the mesh and did a Shouldice repair. I have had the privilege to operate with many expert herniorrhaphists who used their choice of mesh procedures with extremely low incidences of chronic inguinodynia or recurrence. I have also watched hernia repairs done by less experienced surgeons. There is a difference; it is the absence of careful surgical technique. Having seen this difference, I believe most cases of true inguinodynia and recurrence are more likely related to errors in knowledge of the anatomy of the groin coupled with less than ideal technique, not the mesh itself. In reference to surgeons doing a transversalis fascia repair, I agree with Dr Fischer’s observation ‘‘most surgeons wouldn’t know what we were talking about’’ and ‘‘the ability to carry it out has disappeared from our residency programs.’’ Surgeon instructors have become so dependent on devices and mesh support that many are unable to perform an open groin hernia tissue repair with proper technique. What we really do not know with certitude about chronic inguinodynia in 2013 is to what extent patients are lured by the goal of financial benefits in work-related events, litigation in third-party involvement, and by the load of media advertising that promise reward for it. Unfortunately, this trend seems to be growing. We know that proper technique in any operation does matter; substandard technique often yields substandard results. Poor hernia repair technique with or without mesh will cause higher failure
rates, both recurrences and inguinodynia. I support retaining the progress we have made using mesh. I propose surgeons view Dr Fischer’s Editorial Review as a call to monitor one’s own personal results regarding the incidences of inguinodynia and recurrence with the technique they do most frequently and comfortably. Based on their own results, not that of others, they can consider their need for additional training. Let us not throw the baby out with the bath water. Arthur I. Gilbert, M.D.* Associate Clinical Professor of Surgery University of Miami-Miller Medical School Hernia Institute of Florida 6200 Sunset Drive 501 Miami, FL 33147
References 1. Bay-Nielsen M, Perkins FM, Kehlet H, et al. Pain and functional impairment 1 year after inguinal herniorrhaphy. Ann Surg 2001;233: 1–7. 2. Cunningham J, Temple WJ, Mitchell P, et al. Cooperative hernia study. Pain in the postrepair patient. Ann Surg 1996;224:598–602. 3. Nienhuijs S, Kortman B, Boerma M, et al. Preferred mesh-based inguinal hernia repair in a teaching setting: results of a randomized study. Arch Surg 2004;139:1097–100. 4. Nienhuijs SW, Boelems QB, Strobbe LJ. Pain after anterior mesh hernia repair. J Am Coll Surg 2005;200:885–9. 5. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European hernia society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009;13:343–403.
Editorial Opinion
Hernia repair: do you know your own results? KEYWORDS: Inguinal hernia; Mesh; Inguinodynia; Recurrence
Abstract Inguinodynia is an undesirable postoperative complication reported following groin hernia repair done with and without mesh implantation. It can be minimized by a good technique. Personal recognition of less than ideal results can be helpful in the decision to pursue improved performance. Ó 2014 Elsevier Inc. All rights reserved.
In his Editorial Opinion regarding inguinal hernia repair, Dr Fischer faults the inflammatory response created by prosthetic mesh for causing high incidences of chronic inguinodynia. To avoid this problem, he advocates abandoning mesh and advises using the Shouldice or transversalis fascia repairs. It is normal for implanted prosthetic mesh to provoke inflammatory reactions in adjacent tissues; without this initial healing response, mesh would not become incorporated in the adjacent tissues. Ordinarily, reactions to inert mesh are minimal and are short lived. Symbolically related to what to give up, as in the adage about the baby and the bath water, having fewer recurrences using mesh repairs is the baby, and chronic inguinodynia is the bath water. Some investigators report significant incidences of chronic inguinodynia in their individual series, but none did randomized controlled trials within their own series comparing the frequency of inguinodynia following pure tissue versus mesh repairs. Bay-Nielsen et al reported 3.8% chronic pain remained after 2 years following mesh hernia repairs, and others have reported higher.1 Cunningham et al reported 10.6% incidence of chronic pain 2 years following inguinal hernia repairs done without mesh.2 Other published studies from the United States and abroad verified that mesh repairs (Lichtenstein mesh repair, plug and patch repair, Prolene Hernia System, laparoscopic) all have lower recurrence rates compared with pure tissue repairs for primary and recurrent groin hernias.3-5 The Shouldice and the transversalis fascia repairs are excellent operations to treat the presenting hernia, but * Corresponding author. Tel./fax: 11-305-775-7015. E-mail address: [email protected] Manuscript received October 29, 2013; revised manuscript November 7, 2013 0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2013.11.003
neither is ideal to protect against future groin hernia formation through the remaining unprotected area of the myopectineal orifice. As for longevity of pure tissue repairs, long-term follow-up of patients that had pure tissue repairs show that more than 50% of ipsilateral recurrences presented 5 or more years after the original repair. My personal experience adding mesh to the Shouldice Repair convinced me of its value. In 1976, I visited the Shouldice Hospital to observe the most experienced surgeons do its repair. I used the Shouldice operation for the next 8 years. My recurrence rates for primary hernias dropped to 2% from the 10% previously associated with the modified Bassini repair I had used. At the suggestion of Dr. Everett Shocket, in 1984, I placed a mesh patch in the preperitoneal space as a protective barrier to the suture lines of the Shouldice repair; my recurrence rate dropped from 2% to .5%. The incidence of chronic inguinodynia in my series was minimal, and when it did occur, it was usually related to one of my own recurrences. Before 1984, surgeons used mesh in less than 5% of groin hernia repairs. Its use grew about 5% each year until 1990 when with the advent of the laparoscopic approach to groin hernias it became routinely expected for all adult repairs done by either approach. I am unaware of any progressive center in the world other than the Shouldice hospital that continues to do hernia repair without mesh. In less progressive countries, where mesh is not readily available, tissue repairs remain standard, and failures are not unusual. From a practical view, regardless of the type of mesh technique performed by hernia-devoted surgeons, would any reasonable person believe those surgeons could be able to continue to attract the large quantity of patients in their practices and keep their good reputations, if chronic inguinodynia occurred more than rarely? In reports from
2
The American Journal of Surgery, Vol -, No -, - 2014
hernia experts that use different platforms of mesh repairs, their reported incidence of inguinodynia is consistently minimal. Undoubtedly, there are isolated incidences of adverse reactions to mesh. I have seen some and on occasion have removed the mesh and did a Shouldice repair. I have had the privilege to operate with many expert herniorrhaphists who used their choice of mesh procedures with extremely low incidences of chronic inguinodynia or recurrence. I have also watched hernia repairs done by less experienced surgeons. There is a difference; it is the absence of careful surgical technique. Having seen this difference, I believe most cases of true inguinodynia and recurrence are more likely related to errors in knowledge of the anatomy of the groin coupled with less than ideal technique, not the mesh itself. In reference to surgeons doing a transversalis fascia repair, I agree with Dr Fischer’s observation ‘‘most surgeons wouldn’t know what we were talking about’’ and ‘‘the ability to carry it out has disappeared from our residency programs.’’ Surgeon instructors have become so dependent on devices and mesh support that many are unable to perform an open groin hernia tissue repair with proper technique. What we really do not know with certitude about chronic inguinodynia in 2013 is to what extent patients are lured by the goal of financial benefits in work-related events, litigation in third-party involvement, and by the load of media advertising that promise reward for it. Unfortunately, this trend seems to be growing. We know that proper technique in any operation does matter; substandard technique often yields substandard results. Poor hernia repair technique with or without mesh will cause higher failure
rates, both recurrences and inguinodynia. I support retaining the progress we have made using mesh. I propose surgeons view Dr Fischer’s Editorial Review as a call to monitor one’s own personal results regarding the incidences of inguinodynia and recurrence with the technique they do most frequently and comfortably. Based on their own results, not that of others, they can consider their need for additional training. Let us not throw the baby out with the bath water. Arthur I. Gilbert, M.D.* Associate Clinical Professor of Surgery University of Miami-Miller Medical School Hernia Institute of Florida 6200 Sunset Drive 501 Miami, FL 33147
References 1. Bay-Nielsen M, Perkins FM, Kehlet H, et al. Pain and functional impairment 1 year after inguinal herniorrhaphy. Ann Surg 2001;233: 1–7. 2. Cunningham J, Temple WJ, Mitchell P, et al. Cooperative hernia study. Pain in the postrepair patient. Ann Surg 1996;224:598–602. 3. Nienhuijs S, Kortman B, Boerma M, et al. Preferred mesh-based inguinal hernia repair in a teaching setting: results of a randomized study. Arch Surg 2004;139:1097–100. 4. Nienhuijs SW, Boelems QB, Strobbe LJ. Pain after anterior mesh hernia repair. J Am Coll Surg 2005;200:885–9. 5. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European hernia society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009;13:343–403.
