Why does Boston Hernia recommend a POSTERIOR mesh repair?

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.

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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 700 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.