take care of a lot of hernia patients. Therefore, I talk a lot with people about mesh. And most people express some level of concern about the safety of mesh and mention lawsuit commercials they have seen on television. So, I wanted to take the time to address this question. Is mesh safe? Why do we use it? What if we didn't?
In another article, I discussed the topic of what a hernia is and how we go about fixing them. To briefly recap, a hernia is a hole in the abdominal wall. To fix this, we need to close the hole and prevent it from opening up again. Strategies for this will vary somewhat depending on where the hernia is located. For the purposes of this article, however, I will not go into specific details. Suffice it to say, if we only close the hernia hole by suturing it back together, there tends to be a high recurrence rate. Conceptually, this makes sense. These are the same tissues that have already failed. Therefore, trying to sew them back together under tension often leads to them tearing apart yet again. By using mesh reinforcement, we can reduce the likelihood of developing a recurrent hernia.
But is this worth it? Is mesh safe?
In full disclosure, no! Mesh is not safe! At least, it is not safe if your definition of safe means no possibility of complication. It is a foreign body that we are implanting, and there is the possibility of developing a complication. The real question is risk. How likely is it that a complication will develop? And the answer is: it depends. When I counsel patients about the risk of mesh complications, there are multiple factors to look at. What kind of mesh should we use? Where should the mesh be placed? How big is the hernia? Does the patient have other medical problems that would increase risk? When I discuss mesh safety with patients, I look at their individual characteristics to have an individualized conversation about their risk. The next part of that conversation is to discuss a surgical strategy that offers them the best chance of success balanced by the least risk of a complication.
Thankfully, we do not see mesh complications very often.
But we do everything we can to avoid them. Overall, the benefit seems to outweigh the risk. But we are always looking for ways to do it better and to increase the benefit while decreasing the risk. It can be helpful to look at some of the individual complications and discuss things that can be done to minimize risk. Complications that can be seen with mesh include pain, infection, adhesions, migration, and erosion.
Chronic pain due to mesh is tricky to diagnose and not common. Hernia operations can be painful no matter how they are done, with or without mesh. For most people, this pain goes away after they recover from surgery. But some people can develop chronic pain. It can be challenging to discern the exact cause of pain in these situations. There are multiple possible issues, but issues with mesh is one possibility. Sometimes this requires the mesh to be removed. Thankfully, this is not common.
Mesh infection is a dreaded complication that can cause significant morbidity. As a foreign body, if mesh becomes infected it can be difficult to clear the infection and often requires that the mesh be removed. Based on the characteristics of the hernia and the medical history of the patient, we can get a general idea of the risk of developing a mesh infection. There are several strategies that can be used to reduce the risk of infection in high risk patients. This includes using a different type of mesh and trying to optimize which layer of the abdominal wall to place the mesh. When relevant, this will be discussed in the office prior to surgery. Again, thankfully, mesh infection is not common.
Adhesions to mesh are fairly common, but thankfully do not usually cause any problems. Adhesions are when abdominal contents stick to the abdominal wall and/or mesh. If the intestines have adhesions to the mesh, there is a risk of developing a bowel obstruction. There is also the risk of later bowel injury should the patient require another operation and those adhesions need to be taken down. Adhesions are common after any surgery, and usually do not cause these complications. But they can be problems and we want to do our best to avoid them. First, when possible, using minimally invasive techniques, such as laparoscopic and robotic surgery, can reduce adhesions. Second, whenever possible, I try to place mesh within the layers of the abdominal wall to have a layer between the mesh and the abdominal contents. This can reduce adhesion formation. Finally, whenever mesh has to be placed against the abdominal wall within the abdomen, we use mesh with a coating to minimize the formation of adhesions.
Erosion occurs when the mesh erodes into an adjacent organ, such as the intestines. Thankfully, this is very rare. But it will usually require removal of the mesh and repair of the involved organ. Placing the mesh within layers of the abdominal wall can help reduce this risk. But, even if mesh needs to be placed within the abdominal cavity, this is again quite rare.
Mesh migration is when the mesh shifts location after it is placed. This is not common, thankfully, and there are strategies to reduce the chance of this. Not to get too technical, but these strategies include using an adequate sized piece of mesh, closing the patient's own abdominal wall tissues together without too much tension, proper anchoring of the mesh, and placing the mesh within layers of the abdominal wall. Well, if you weren't scared before, how about now?
I want to finish this article with an effort to balance the conversation. As noted multiple times above, these complications can happen, but they are thankfully not common. The lawyer commercials will only emphasize these problems. They will not mention the people who are helped by successful repair of their hernia and they will not mention the problems that would occur if we tried to fix all these hernias without mesh. All this needs to be taken into account when we talk about a surgery, all of the potential risks and benefits of the various options.
My goal is to approach each patient individually and mutually develop a plan that minimizes your risk while maximizing your success. I look forward to discussing this further with you in person.