Why does Boston Hernia recommend a POSTERIOR mesh repair?

Updated March 2025

 

At Boston Hernia, we offer a variety of hernia repair techniques tailored to each patient’s individual needs. While there are multiple approaches, we generally recommend posterior mesh repair for the majority of our patients, as it provides the best outcomes in most cases(1-3).

In 1889, Edoardo Bassini introduced the first tissue-only hernia repair, which was the standard method before the advent of mesh. Over 120 years ago, when mesh was not available, tissue-based repairs were the only option. Today, both patients and surgeons have many more options, including the use of mesh(4,5).

Dr. Reinhorn and Dr. Fullington are extensively trained in hernia repair, including techniques with and without mesh, and are experts in several methods. Mesh repairs have become the standard of care for inguinal hernias due to their ability to significantly reduce the risk of recurrence(4,5). However, as mesh complications have surfaced, concerns about its use have increased. Advertisements asking, “Have you been injured by inguinal hernia surgery mesh?” have raised awareness of the risks associated with mesh, particularly in relation to chronic pain.

It’s important to note that the risk of chronic pain is more closely related to the placement of the mesh than the mesh material itself. Traditional mesh repairs place the mesh anteriorly (on the outside of the muscular and strength portion of the abdominal wall), where three nerves are exposed. These nerves can become entrapped in stitches or irritated by the overlying mesh, which increases the risk of chronic pain. Anterior mesh placement is associated with up to 15% risk of chronic pain, an unacceptably high risk for a potentially debilitating complication. Fortunately, this risk can be avoided by using a different surgical approach that places the mesh in a different plane (6-9).

Posterior mesh repairs, performed either laparoscopically or through our advanced open preperitoneal repair, significantly reduce the incidence of chronic pain. This is because the mesh is placed on the inside of the abdominal wall, thus avoiding the nerves on the outside of the abdominal wall(8). In our experience, posterior mesh repair reduces the risk of chronic pain from 5-15% to about 0.3%.

The advanced open preperitoneal repair is the least invasive method for posterior mesh placement. It is less invasive than laparoscopic repair because it stays within the layers of the abdominal wall rather than entering the abdominal cavity. This approach results in less post-operative pain and faster recovery1. The procedure is performed through a small incision with direct visualization, without the need for a camera, under sedation and local anesthesia, allowing for better pain control post-surgery. This repair is suitable for about 75% of the patients we see in our office, based on the patient’s specific characteristics, assessed during consultation. For the remaining patients, a laparoscopic or robotic approach is necessary to place the mesh behind the abdominal muscles.

In 2018, several international hernia societies published guidelines for groin hernia surgery, which confirmed what we have known for over 15 years. Local anesthesia is preferred over general anesthesia when possible(10,11), and placing mesh behind the abdominal wall is more effective than placing it between muscle layers(12-14). We have studied these concepts extensively and, through our participation in a national hernia database, have published peer-reviewed studies showing that our Fast Recovery Inguinal Hernia Surgery—the open preperitoneal repair—results in faster recovery, less pain, reduced opioid use, and a lower risk of complications such as recurrence or infection(1–3,15).

A posterior mesh repair, particularly with the open preperitoneal approach, offers optimal long-term outcomes while significantly reducing the risk of complications like chronic pain that can be associated with traditional repairs.

 

 

References: 

  1. Reinhorn M, Fullington N, Agarwal D, Olson MA, Ott L, Canavan A, Pate B, Hubertus M, Urquiza A, Poulose B, Warren J. Posterior mesh inguinal hernia repairs: a propensity score matched analysis of laparoscopic and robotic versus open approaches. Hernia. 2023 Feb;27(1):93-104. doi: 10.1007/s10029-022-02680-0. Epub 2022 Sep 20. PMID: 36125632; PMCID: PMC9931785.
  2. Bharani T, Agarwal D, Fullington N, Ott L, Olson M, McClain D, Lima L, Poulose B, Warren J, Reinhorn M. Open preperitoneal inguinal hernia repair has superior 1-year patient-reported outcomes compared to Shouldice non-mesh repair. 
  3. Agarwal D, Bharani T, Fullington N, Ott L, Olson M, Poulose B, Warren J, Reinhorn M. Improved patient-reported outcomes after open preperitoneal inguinal hernia repair compared to anterior Lichtenstein repair: 10-year ACHQC analysis. Hernia. 2023 Oct;27(5):1139-1154. doi: 10.1007/s10029-023-02852-6. Epub 2023 Aug 8. PMID: 37553502; PMCID: PMC10533599.
  4. Hassler KR, Saxena P, Baltazar-Ford KS. StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. Open inguinal hernia repair. – PubMed
  5. Komorowski AL. “History of the inguinal hernia repair.” IntechOpen. 2014.
  6. Incidence and predictors of chronic pain after inguinal hernia surgery: a systematic review and meta-analysis. Chu Z, Zheng B, Yan L. Hernia. 2024 Aug;28(4):967-987. doi: 10.1007/s10029-024-02980-7. Epub 2024 Mar 27. PMID: 38538812 Review.
  7. Aasvang E, Kehlet H. Surgical management of chronic pain after inguinal hernia repair. Br J Surg. 2005;92:795–801. doi: 10.1002/bjs.5103. – DOI – PubMed
  8. Sevonius D, Montgomery A, Smedberg S, Sandblom G. Chronic groin pain, discomfort and physical disability after recurrent groin hernia repair: impact of anterior and posterior mesh repair. Hernia. 2016;20:43–53. doi: 10.1007/s10029-015-1439-5. – DOI – PubMed
  9. Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. Ann Surg. 2001;233:1–7. doi: 10.1097/00000658-200101000-00001. – DOI – PMC – PubMed
  10. Balentine CJ, Meier J, Berger M, et al. Using local rather than general anesthesia for inguinal hernia repair is associated with shorter operative time and enhanced postoperative recovery. Am J Surg. 2021;221:902–907. doi: 10.1016/j.amjsurg.2020.08.024. – DOI – PMC – PubMed
  11. Prakash D, Heskin L, Doherty S, Galvin R. Local anaesthesia versus spinal anaesthesia in inguinal hernia repair: a systematic review and meta-analysis. The Surgeon. 2017;15:47–57. doi: 10.1016/j.surge.2016.01.001. – DOI – PubMed
  12. Simons MP, Smietanski M, Bonjer HJ, et al. International guidelines for groin hernia management. Hernia. 2018;22:1–165. doi: 10.1007/s10029-017-1668-x. – DOI – PMC – PubMed
  13. Stabilini C, van Veenendaal N, Aasvang E et al (2023) Update of the international herniasurge guidelines for groin hernia management. BJS Open 7:zrad080. https://doi.org/10.1093/bjsopen/zrad080 – DOI – PubMed – PMC
  14. 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. doi: 10.1007/s10029-009-0529-7. – DOI – PMC – PubMed
  15. Lorenz R, Akkersdijk W, Paiva De Oliveira G, Warren T, Soler M. Acceptance of Open Preperitoneal Repair in Inguinal Hernia Surgery Delphi-Consensus After an Anonymous International Survey Among European Hernia Society Members. J Abdom Wall Surg. 2025 Feb 4;3:13840. doi: 10.3389/jaws.2024.13840. PMID: 39967918; PMCID: PMC11833113.

 

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.