Mesh is commonly used with inguinal hernia repairs through an open or laparoscopic approach to reinforce the weakened inguinal floor. With an open repair, an incision is placed on the lower abdomen/pubic area to allow placement of the mesh from an external approach. This allows the surgeon to use the mesh to plug or bridge the defect, however this technique does not usually bring the tissues back together. The laparoscopic approach is similar in regards to concept but approaches the hernia defect from inside the abdomen with the use of small cameras and instruments placed into the abdomen. This allows for much smaller incisions, but the mesh can only be placed over the defect acting as a patch. This technique does reapproximate tissues to their normal anatomical positions.
There are several benefits of not using mesh with a sports hernia or inguinal hernia repair. The most obvious benefit is not having a foreign material placed in the body. The complications associated mesh arise from the body’s reaction to mesh or an infection of the mesh. When the mesh is initially placed in the inguinal floor there is usually not a problem; however, as the body begins to incorporate the mesh into the tissues, it creates scar tissue. This scar tissue then adheres to structures like the intestines or nerves which can result in the common mesh complication. When the mesh adheres to the intestines, it can create a kink or hole in the bowel which can have serious consequences. More commonly the mesh and scar will adhere to the nerves in the inguinal area and pull on these small nerve branches, which results in severe pain. Often the only option is to divide the nerves and remove some of the mesh. In other cases, then mesh can become contaminated by bacteria, which then results in an infection. Often the only solution is to remove the mesh or treat the individual with antibiotics. Finally, in very thin, athletic patients, the mesh can even be palpable through the skin and this can feel like a firm area beneath the skin. This secondary deformity can in some cases be more limiting for the athlete than the initial hernia.
While mesh may be necessary in some people, it is not needed in patients who actually have good tissue quality surrounding the inguinal floor. Most patients do have good tissue and will not require the use of mesh. By meticulously placing a series of sutures to re-approximate the healthy tissues, the inguinal floor can be adequately reconstructed close to its original structure. While there are several different techniques described, I prefer the Muschaweck Minimal Tension Repair technique since this best recreates the normal anatomy.
There are certain scenarios in which a mesh repair is preferred. For example, in some cases, an obese patient may be better served with a laparoscopic or robotic inguinal hernia repair with mesh since the subcutaneous tissue layer on the surface can be very thick which can make an open, no mesh repair very challenging and place the patient at risk for wound healing complications. Another example when mesh may be necessary, occurs when the tissue quality of the inguinal floor is very weak and requires mesh to reinforce the floor since placing sutures only would likely result in a failed reconstruction.
It is import to state that not everyone is an optimal candidate for an open, no mesh repair. Despite the risks and concerns associated with mesh, it can be the safe option in the right situation. This is why it is important to get multiple opinions on your treatment options from experienced and skilled surgeons.
