What is a no mesh or non-mesh inguinal hernia repair?
No mesh hernia surgery has been around for over 100 years. In fact, until the 1950s, there was no other way to fix an inguinal hernia. Mesh repairs have only been around for 70 years and didn’t really take off until the Lichtenstein Repair and Plug and Patch repairs were modernized in the early 1990s. At Boston Hernia, we are not big fans of these two mesh repairs, as they may lead to chronic pain. When we offer mesh, it’s usually posterior mesh. However, we also specialize in no-mesh inguinal hernia repairs. Dr. Reinhorn has recently authored an entire chapter in the go-to textbook for surgeons on these repairs. These are great repairs for the right patient. Below is a very high-level overview of the non-mesh repairs commonly used:
Bassini Repair:
The first described repair of an inguinal hernia where interrupted sutures are used to repair the weakness in the abdominal wall. It’s a solid repair, but there is a lot of tension, which can lead to more pain and higher recurrence rates.
McVay Repair (Cooper Ligament Repair):
This is very similar to Bassini, also involving an interrupted single layer of suture, but the middle layers are deeper, allowing for the repair of femoral hernias. This is a good option for emergency surgery patients who have a strangulated femoral hernia that requires removal of the intestine at the time of surgery.
Shouldice Repair:
This has been the gold standard for over 70 years. While similar to Bassini, it involves 4 layers of closure, reducing pain, tension, and recurrence. Think about how easy it is to pull a piece of paper out of a three-ring binder compared to a spiral notebook. That’s the difference between Bassini (three-ring binder) and Shouldice (spiral notebook).
Desarda Repair:
This is a newcomer to the “no-mesh” market. The premise is that the body’s natural tissues are used to fix the hernia instead of mesh. The repair is identical to the Lichtenstein repair, with the exception that natural tissue is used instead of mesh. It seems to have a good track record reported by a couple of centers over a 20-year timeline. It’s too early to tell what the long-term results will be. It does have some drawbacks. The first is that femoral hernias are ignored in the dissection, leading to missed hernias in 2-3% of patients. Secondly, the same physics principles apply to this “anterior” repair, so a high failure rate could be expected over time.
Where to go for a no mesh or non-mesh inguinal hernia repair?
Several centers across the world specialize in no mesh hernia surgery. Places like the Shouldice Hospital just outside of Toronto, Canada, have been doing mostly no mesh repairs for over 70 years. Their experience with no mesh hernia surgery and training in high-volume hernia care is rarely reproduced. The Desarda center also offers a non-mesh hernia repair option, though in our opinion, the Shouldice technique is superior and has been tested and studied for decades. At Boston Hernia, our mission is to provide the same level of hernia care as places like Shouldice for patients who want mesh or non-mesh repair options for their inguinal hernia. We perform approximately 1000 hernias per year, of which 800 are inguinal. We offer at least 4 ways to fix a hernia and have done over 100 suture-only or non-mesh inguinal hernia repairs each year since 2016. We routinely study and publish our outcomes so that we can continuously improve the care we provide.
Why we offer non-mesh hernia surgery?
In 2015, a patient asked us to perform the non-mesh hernia repair, also known as Shouldice hernia repair, for an inguinal hernia. For many years, and even today, most surgical teaching suggests that mesh hernia surgery improves overall outcomes for the majority of patients. Over the last two decades, surgical thinking and guidelines have evolved, bringing non-mesh hernia repair options back in favor. For example, in thin patients with small umbilical or inguinal hernias, non-mesh repairs may be equally effective in fixing the hernia while leaving minimal foreign material in the body. After this patient requested a Shouldice repair, we researched the technique and found that the outcomes for this non-mesh repair are excellent, especially when performed at a high volume. The Shouldice Hospital in Canada are the experts in this repair, as they developed the technique decades ago and still perform thousands a year even today. Over the last few years, we started offering non-mesh repair for certain patients with inguinal and umbilical hernias. The decision to proceed with no mesh repair is made on an individual basis.
Our experience with non-mesh hernia surgery:
Since 2015, we have performed over 600 no mesh inguinal hernia repairs. Dr. Reinhorn has observed the Shouldice repair technique by visiting the famous Shouldice Hospital in Toronto. After performing several dozen cases, he was observed by a Shouldice surgeon and coached in order to improve his technique. After completing over 300 succesful Shouldice operations, he was invited to teach this repair to many surgeons across the US and internationally through collaboration with surgery societies. He has authored several articles and book chapters in order to educate more surgeons about this excellent technique. Our thinking about non-mesh inguinal hernia surgery has evolved over the last decade. In 2015, a single patient asked about the downside of mesh hernia surgery; today, the majority of patients ask about the risks and benefits of mesh use. The percentage of cases that we perform without mesh is increasing. Currently, almost every week, we perform several non-mesh hernia repair surgeries, accounting for more than 10% of our cases. Our philosophy, and the philosophy of doctors at the Shouldice Hospital, is that high-volume hernia specialists can deliver better results.
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Check out this surgical calculator to see which repair options may be best tailored to you.
About Dr. Reinhorn & Dr. Fullington
Dr. Michael Reinhorn is a specialist in inguinal hernia and umbilical hernia. Dr. Reinhorn started his practice as a full service general surgeon in 2001. In 2012 Dr. Reinhorn started to focus on the care of hernia and pilonidal patients. In 2020, Dr. Nora Fullington was recruited from her work as a general surgeon performing hundreds of laparoscopic hernia repairs to Boston Hernia. Together with their physician assistant team, they provide a focused practice designed to provide a superior clinical experience. The team performs approximately 1000 hernia surgeries every year and offers a tailored approach for each patient from anesthesia type to consideration of mesh and no mesh repairs, laparoscopic and open surgery. We have published outcomes and continue to participate in hernia and surgery societies. Our research led to a reduction in opioid prescribing after hernia surgery. Currently, Dr. Reinhorn serves as the chair of the Opioid Reduction Task Force of the Americas Hernia Society Quality Collaborative.
For more detail about the surgery, read more on our non mesh repair page.