There are many different types of hernia repairs, but we recommend a posterior mesh repair to the majority of our patients. Dr. Reinhorn studied engineering before medical school. He constantly looks at any medical problem in an analytical way. Over 120 years ago, when mesh was not around, primary tissue (non-mesh) repairs were the only way to go. Today, patients and surgeons have many more options than were available back then. In 1889, Edoardo Bassini first described his tissue only repair, and it was the only option for hernia repair, as mesh was not yet available.
Dr. Reinhorn and Dr. Fullington learned non-mesh repairs in residency, along with mesh repairs. Using mesh for hernia repair is currently the standard of care in the United States because the use of mesh has decreased rate of hernia recurrence after surgery. The traditional mesh repair places the mesh anteriorly, or on the outside of the abdominal wall. Anterior mesh placement is associated with close to 15% risk of chronic pain. We find this to be an unacceptable number of patients with chronic pain, so we rarely recommend an anterior mesh repair.
Posterior mesh repairs, via laparoscopic surgery or our advanced open preperitoneal repair, are associated with decreased incidence of chronic pain. This is likely because the mesh is placed on the inside of the abdominal wall, therefore avoiding nerves that run along the outside of the abdominal wall. A posterior mesh repair greatly reduces the risk of chronic pain from about 5-15% to about 0.3% in our experience.
The open approach to posterior mesh repair, via the advanced open preperitoneal repair, allows for less acute post-operative pain. This repair is performed under direct visualization and under local anesthesia, which allows for better pain control after surgery.
In 2018, several international hernia societies combined to publish guidelines for groin hernia surgery. The recommendations out of these guidelines confirm what we have known for over 15 years. Patients do better with local anesthesia as compared to general anesthesia when this is possible, and placing mesh under the abdominal wall is better than placing it between muscle layers. When enough data is available, our Fast Recovery Inguinal Hernia Surgery is likely to be shown to be one of the best ways to fix an inguinal hernia with mesh. This repair is suitable for about 75% of patients we see in our office. For some patients a laparoscopic or robotic approach is required to get mesh behind the abdominal muscles. While mesh may be best for most patients, some patients are best served by non mesh inguinal hernia repairs. Below are some references. We continue to work hard to study the outcomes of posterior repairs more closely.
References:
- HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22(1):1-165. doi:10.1007/s10029-017-1668-x
- Köckerling F, Bittner R, Kofler M, Mayer F, Adolf D, Kuthe A, Weyhe D. Lichtenstein Versus Total Extraperitoneal Patch Plasty Versus Transabdominal Patch Plasty Technique for Primary Unilateral Inguinal Hernia Repair: A Registry-based, Propensity Score-matched Comparison of 57,906 Patients. Ann Surg. 2019 Feb;269(2):351-357. doi: 10.1097/SLA.0000000000002541. PMID: 28953552.
About Dr. Reinhorn & Dr. Fullington
Dr. Michael Reinhorn is a specialist in inguinal hernia and umbilical hernia. He started his practice as a general surgeon in 2001, and in 2012 he transitioned to focus on the care of hernia patients. In 2018, he co-founded Boston Hernia, an ambulatory surgery practice focused exclusively on hernia surgery. In 2020, Dr. Nora Fullington was recruited from her work as a general surgeon, where she performed hundreds of laparoscopic hernia repairs, to Boston Hernia where she was intensively trained by Dr. Reinhorn in the open preperitoneal and Shouldice techniques. Together with their physician assistant team, they perform approximately 800 hernia surgeries every year. Both surgeons offer a tailored approach for each patient, taking into account individual patient factors to decide if surgery is recommended or not, what type of repair (open, laparoscopic, mesh, non-mesh) is best, and what type of anesthesia is safest. At Boston Hernia, our focus is on each individual patient and continuously improving our own surgical techniques and outcomes. We do this by participating in various hernia societies, studying our own outcomes through a national database, and publishing our data to influence the care of hernia patients nationally and internationally. Boston Hernia is an affiliate practice of the Mass General Brigham system. In addition to operating at Newton-Wellesley Hospital, a Mass General Brigham Hospital, we offer care at ambulatory surgery centers in Waltham, MA and Derry, NH.