Inguinal hernias are one of the most common surgical conditions encountered in clinical practice, representing a significant healthcare burden worldwide. They occur when a portion of the intestine or fatty tissue protrudes through a weak spot in the abdominal wall, specifically in the inguinal canal, which is located in the groin area.
This condition can affect individuals of all ages and genders, though they are more prevalent in men. Inguinal hernias can cause a variety of symptoms, including pain, discomfort, and visible swelling in the groin area, and they may lead to complications if not treated appropriately. Here, I’ll review the causes and treatment options for inguinal hernias, with a particular focus on surgical options, including mesh and meshless techniques.
Inguinal Hernia Epidemiology and Risk Factors
Inguinal hernias represent a significant medical condition affecting approximately 7.7% of the general population,1 with striking demographic variations in their occurrence. Boys and men face a particularly high risk, primarily due to their distinct anatomical structure — specifically, a natural weakness in the abdominal wall resulting from testicular descent during fetal development. As explained by Cincinnati Children’s Hospital:2
“Approximately 80% to 90% of inguinal hernias appear in boys. They are more common on the right side, but in about 10% of cases, they occur on both sides (bilaterally) …
An inguinal hernia can occur at any age, but one-third of hernias in children appear in the first 6 months of life … In premature infants, the occurrence of inguinal hernia is increased by up to 30%.”
While women can develop inguinal hernias, their incidence is notably lower, typically occurring in conjunction with risk factors such as obesity, previous pregnancies, or chronic cough conditions.
Age plays a crucial role in hernia development, with incidence rates climbing significantly among older adults due to the natural deterioration of abdominal wall strength and connective tissue integrity over time.
The condition manifests in two primary forms: congenital and acquired. Congenital hernias, present from birth, stem from incomplete closure of the processus vaginalis — a peritoneal pouch that normally seals following testicular descent. When this closure fails, it creates a natural weakness that can lead to hernia formation.
The interplay of these demographic, anatomical, and age-related factors creates a complex risk profile that varies significantly among individuals. The recognition of these risk factors and their underlying mechanisms helps inform both preventive measures and therapeutic interventions, ultimately contributing to more effective patient care and outcomes.
Risk Factors for Acquired Inguinal Hernias
Acquired inguinal hernias develop later in life and are associated with several risk factors, including:
• Increased intra-abdominal pressure — Activities or conditions that increase abdominal pressure can contribute to hernia formation. These include heavy lifting, chronic coughing, obesity, and straining during bowel movements.
• Age — As mentioned earlier, aging is a significant factor due to the weakening of connective tissues.
• Previous surgery — Previous surgical procedures in the groin area can create weak spots in the abdominal wall, leading to hernia development.
• Genetic predisposition — Some individuals may have a family history of hernias, indicating a genetic component that predisposes them to this condition.
Potential Complications That Can Be Very Serious
Treatment for inguinal hernias typically involves surgical intervention, particularly when symptoms are present or if the hernia is at risk of complications, such as incarceration or strangulation.
Incarceration refers to a condition where the herniated contents (usually a portion of the intestine) become trapped in the hernia sac and cannot be pushed back into the abdominal cavity. Key points about incarcerated hernias include:3
- It is considered a medical emergency requiring prompt attention.
- Signs include a painful, irreducible bulge in the groin area.
- Diagnosis typically involves physical examination and may be confirmed with imaging like ultrasound or CT scan.
- Treatment often requires emergency surgery to release the trapped tissue and repair the hernia.
Strangulation is a more severe complication that can develop from an incarcerated hernia. It occurs when the blood supply to the trapped tissue is cut off, leading to tissue death. This is a life-threatening emergency requiring immediate surgical intervention. Symptoms may include severe pain, fever, nausea, vomiting, and signs of systemic illness. The affected area may appear warm, tender, or discolored.4
Both incarceration and strangulation are serious complications that significantly increase the risks associated with inguinal hernias. They are primary reasons why surgical repair is often recommended, even for asymptomatic hernias, to prevent these potentially life-threatening situations.
Treatments for Inguinal Hernias
There are two main surgical approaches for inguinal hernias: mesh repair and meshless repair techniques.
1. Mesh repair techniques
• Open hernia repair (Lichtenstein technique) — This is the most common method of inguinal hernia repair using mesh. It involves making an incision in the groin, pushing the hernia back into the abdomen, and placing a synthetic mesh over the weakened area to reinforce it. This technique is effective and has a high success rate, although it does require general or regional anesthesia.
• Laparoscopic hernia repair — This minimally invasive approach involves making small incisions and using a camera and instruments to place mesh in the abdominal cavity. Techniques like Transabdominal Preperitoneal (TAPP) and Totally Extraperitoneal (TEP) offer reduced recovery times and less postoperative pain compared to open repair.
• Robotic hernia repair — Similar to laparoscopic techniques, robotic-assisted surgery provides enhanced precision and visualization during the procedure. However, it often comes at a higher cost and requires specialized equipment.
2. Meshless repair techniques
• Desarda technique — Developed by Dr. A. Desarda, this technique focuses on using the patient’s own tissue for repair. It employs the external oblique aponeurosis to create a new internal ring, strengthening the inguinal canal without the use of synthetic materials.
The Desarda technique is associated with a lower risk of complications, such as chronic pain and recurrence, as it eliminates issues related to foreign body reactions caused by mesh. Studies show favorable outcomes with low recurrence rates, ranging from 0.8%5 to 2.1%.6
• Shouldice method — Named after the renowned Shouldice Hospital in Toronto Canada, this technique involves a multi-layered repair using the patient’s own tissue. The Shouldice method uses four layers of tissue to reinforce the inguinal canal, providing robust support without the use of synthetic mesh.
This method has a long-standing reputation for its effectiveness, demonstrating very low recurrence rates, generally between 2%7 and 6.7%.8 It emphasizes meticulous surgical technique and anatomical reconstruction, contributing to excellent long-term outcomes.
Comparison of Desarda Technique and Shouldice Method for Inguinal Hernia Repair
The Desarda technique represents a significant advancement in inguinal hernia repair, offering a distinctive meshless approach that prioritizes the use of the patient’s natural tissues. Rather than relying on prosthetic materials, this innovative method employs a single layer of the external oblique aponeurosis to create a new internal ring and reinforce the inguinal canal, resulting in a durable repair that maintains anatomical integrity.
One of the technique’s notable advantages lies in its surgical versatility, as it can be performed through both open and laparoscopic approaches. This flexibility allows surgeons to tailor the procedure to individual patient needs and their own expertise.
Proponents of the Desarda method particularly emphasize its reduced risk profile for post-operative complications. By eliminating the need for prosthetic materials, patients typically experience lower rates of chronic pain and favorable recovery trajectories.
These outcomes, combined with the technique’s documented success in preventing hernia recurrence, have established the Desarda approach as a compelling option in modern hernia repair, especially for patients seeking alternatives to mesh-based procedures.
The Shouldice method is another well-established technique in inguinal hernia repair, distinguished by its meticulous, four-layered reconstruction approach that eschews artificial mesh in favor of the patient’s native tissue. However, despite a proven track record of success, the Shouldice method does present certain notable drawbacks.
As an open surgical procedure, it requires a larger incision to access the abdominal wall, resulting in significantly longer recovery times compared to modern laparoscopic approaches. Additionally, the technique relies on stainless steel sutures to secure the tissue layers, introducing a permanent metal presence in the body — a factor that some medical professionals consider less than optimal for long-term health outcomes.
Nevertheless, the method’s enduring popularity stems from its extensive clinical history and documented efficacy. The careful dissection and precise re-approximation of tissue layers, while time-consuming, creates a robust repair that has demonstrated excellent long-term durability with minimal complications.
This balance of proven success against its inherent limitations makes the Shouldice method a significant, albeit somewhat controversial, option in the modern surgeon’s arsenal of hernia repair techniques.
Both the Desarda technique and the Shouldice method demonstrate low recurrence rates, but the Shouldice method often boasts slightly better long-term outcomes in larger studies. However, both methods are generally regarded as effective.
In terms of postoperative pain and recovery, studies suggest that both techniques result in manageable pain levels, though individual experiences vary. Some patients report less discomfort with the Desarda technique due to its less invasive nature. However, the Shouldice method’s reputation for a comprehensive, meticulous repair may contribute to better long-term results, balancing initial pain with later effectiveness.
The choice between these two techniques often depends on the surgeon’s experience and preference. Some surgeons trained in the Shouldice method advocate for its thorough approach, while others favor the Desarda technique for its innovative use of local tissue and potentially quicker recovery.
Mesh Options for Inguinal Hernia Repair
Inguinal hernia repair with mesh involves several techniques and types of mesh that are tailored to the patient’s health condition, hernia type, and surgical preferences. Here’s a comprehensive look at the common approaches, including their advantages and disadvantages.
• Non-absorbable meshes
| Advantages | Disadvantages |
|---|---|
| Polypropylene mesh | |
| Durable, resistant to infection, integrates well with host tissue, and has a low degradation rate. It’s commonly used in Lichtenstein repairs. | Can cause foreign body reactions, may lead to chronic pain, and has the potential for mesh migration or erosion over time.
This is pure plastic and loaded with and thicker and disrupting chemicals that will activate estrogen receptors, not recommended. |
| Polytetrafluoroethylene (PTFE) | |
| Features a smooth surface that reduces tissue adhesion, resulting in a lower chance of adhesions to internal organs. | More expensive and has less tensile strength compared to polypropylene, with a higher risk of seroma formation.
This is pure plastic and loaded with hormone-disrupting chemicals that will activate estrogen receptors, which is not recommended. |
| Polyester mesh | |
| High tensile strength and good tissue incorporation, often used for large hernias. | Can provoke more tissue reactions, leading to discomfort and increased risk of shrinkage.
This is pure plastic and loaded with hormone-disrupting chemicals that will activate estrogen receptors, which is not recommended. |
• Absorbable meshes
| Advantages | Disadvantages |
|---|---|
| Polyglactin 910 (Vicryl) | |
| Completely absorbed within 60 to 90 days; useful for temporary support or in contaminated fields. | Provides short-term support and is not suitable for permanent repairs, leading to a higher risk of recurrence. |
| Polyglycolic acid (PGA) | |
| Can be engineered to absorb at different rates, promoting tissue regeneration. | Similar to polyglactin, its temporary nature increases the risk of hernia recurrence. |
• Partially absorbable meshes
| Advantages | Disadvantages |
|---|---|
| Composite meshes (e.g., Proceed, Parietex) | |
| Combines absorbable with non-absorbable components, reducing visceral adhesions while providing long-term strength. | More complex in manufacturing and higher costs, with potential for complications if the absorbable component degrades unevenly. |
• Biological meshes
| Advantages | Disadvantages |
|---|---|
| Human dermis (Alloderm) | |
| Lower risk of infection and integrates naturally into host tissue. | Very expensive, weaker initial tensile strength, and longer recovery time. |
• Gore Bio-A mesh — Gore Bio-A is a synthetic mesh made from a blend of 67% polyglycolic acid (PGA) and 33% trimethylene carbonate (TMC), designed for inguinal hernia repair.
| Advantages | Disadvantages |
|---|---|
| Its absorbable nature helps reduce long-term complications associated with permanent mesh, while its structure promotes rapid cellular infiltration and vascularization.
Additionally, Gore Bio-A is suitable for use in contaminated environments, which lowers infection risk. It also provides cost-effective benefits compared to many biological meshes. |
While absorbable, the temporary nature of Gore Bio-A may lead to concerns about long-term support, especially in large or recurrent hernias.
The potential for higher recurrence rates exists if the supportive function is not adequately replaced by the body in time, and it requires surgeon experience for optimal outcomes in complex repairs.9 |
Why I Believe that Surgisis Mesh May Be the Best Choice for Hernia Repair
Surgisis stands out as a premier choice for hernia repair mesh, primarily due to its unique composition and exceptional biocompatibility. Comprising approximately 80% collagen, Surgisis promotes a natural healing process, allowing for superior integration into host tissue.
This collagen-rich structure not only enhances tissue regeneration but also significantly reduces the risk of complications often associated with synthetic meshes, such as chronic inflammation and foreign body reactions.
One of the primary concerns with many synthetic meshes is their potential to leach endocrine-disrupting chemicals into your body. These plastics can lead to long-term health issues that impact hormonal balance and overall well-being. In contrast, Surgisis, being a biological mesh derived from porcine small intestine submucosa, does not contain these harmful substances, making it a safer alternative.
Its natural composition fosters a healing environment, encouraging cellular infiltration and vascularization, which are essential for effective tissue repair.
Moreover, Surgisis exhibits excellent performance in contaminated surgical fields, reducing the risk of infection — a significant advantage for patients with complex medical histories or those undergoing repairs in less-than-ideal conditions. Unlike many biological meshes that may have variable strength and durability, Surgisis provides a reliable solution that adapts well to the body’s healing processes.
Overall, the combination of safety, biocompatibility, and effectiveness makes Surgisis a highly favorable option among all mesh choices, reinforcing its position as a preferred material in hernia repair surgeries. Here are some key considerations that support this conclusion:
|
Collagen composition — The high collagen content in Surgisis (around 80%) enhances its biocompatibility, allowing for better integration with host tissue. This characteristic is crucial for effective healing, as collagen plays a significant role in tissue repair and regeneration. |
|
Safety profile — Unlike many synthetic meshes, which contain endocrine-disrupting chemicals, Surgisis is derived from natural biological materials. This absence of harmful substances makes it a safer alternative, reducing the risk of long-term complications associated with synthetic materials. |
|
Performance in contaminated fields — Surgisis has demonstrated efficacy in challenging surgical conditions, including contaminated environments. Its ability to minimize infection risk is a critical advantage, especially for patients with complex medical histories. |
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Tissue regeneration — The design of Surgisis promotes rapid cellular infiltration and vascularization, which are essential for a successful healing response. This regenerative capability surpasses that of many traditional synthetic meshes. |
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Comparative advantages — When compared to other biological meshes, Surgisis offers a consistent and reliable performance. While some biological options may exhibit variability in strength and durability, Surgisis has a proven track record in providing robust support during the healing process. |
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Holistic health considerations — Choosing a mesh like Surgisis not only focuses on the mechanical aspects of hernia repair but also prioritizes the overall health of the patient, emphasizing the importance of materials that support long-term wellness. |
Ultimately, the choice of mesh is crucial for successful hernia repair. With its high collagen content, lack of harmful chemicals, and proven track record in various surgical scenarios, Surgisis emerges as the best option among all available meshes, offering patients a combination of safety, efficacy, and long-term health benefits. Choosing Surgisis means prioritizing a mesh that supports not only physical recovery but also holistic health.
Comparing Open and Laparoscopic Approaches to Hernia Repair
The choice between open and laparoscopic surgical techniques is another crucial decision in hernia repair, as each approach offers distinct advantages and challenges. Traditional open hernia repair provides surgeons with direct tissue visualization and manipulation capabilities. However, it requires a larger incision, typically resulting in extended recovery periods and increased postoperative discomfort.
As surgical techniques have evolved, modern minimally invasive alternatives have increasingly challenged this time-tested approach. Laparoscopic hernia repair has emerged as a sophisticated option that employs small incisions and camera-guided visualization to achieve optimal results. This method encompasses two primary techniques: the Totally Extraperitoneal (TEP) and Transabdominal Preperitoneal (TAPP) methods.
The TEP procedure, which places mesh in the extraperitoneal space, has gained particular favor due to its reduced risk of intra-abdominal complications and superior postoperative outcomes, including decreased pain and accelerated recovery times compared to open surgery. However, the TAPP method, while also effective, involves entering the abdominal cavity to place the mesh, which introduces a higher risk of intra-abdominal complications compared to TEP.
The integration of robotic assistance into these procedures, particularly with the use of the Da Vinci surgical system, significantly enhances the TAPP approach. The robotic platform provides greater visualization and precision, allowing surgeons to navigate the intricate anatomy with ease. When a surgeon has extensive training with the Da Vinci robot — having performed more than 500 cases — the TAPP method may yield even better outcomes than traditional laparoscopic techniques.
Ultimately, one of the most important factors in deciding between these approaches is the comfort and expertise of the surgeon. If they are more comfortable and experienced with the TEP and mesh option, then that may be the best choice. Conversely, if they have extensive training with Da Vinci robots, the TAPP approach is likely to be superior.
Understanding these differences is essential as you consider your options for hernia repair. The choice of surgical method — whether open, laparoscopic, robotic, or non-mesh repair techniques — should be guided by the specific circumstances of each patient, including the characteristics of the hernia, patient anatomy, and surgeon expertise.
Conclusion
Navigating the various surgical options for inguinal hernia repair can seem daunting, but understanding the pros and cons of each approach can empower both patients and surgeons to make informed decisions about the best course of action. The advances in surgical techniques, particularly the integration of robotic systems like Da Vinci, represent significant progress in hernia repair technology, allowing for more precise and less invasive options.
For most patients, the ideal choice will often lean towards the closed laparoscopic approach, particularly utilizing the TEP technique, which minimizes harm and complications. However, it’s important to note that this method does not include meshless options, which cannot be performed laparoscopically.
While traditional meshes have raised concerns due to potential endocrine-disrupting chemicals, alternatives like Surgisis have emerged as favorable options. This newer mesh is biocompatible and promotes tissue integration, with clinical evidence suggesting that it is replaced by favorable type I collagen within the body. This advancement allows for enhanced healing and reduced complications.
Additionally, if you choose to use Surgisis, that is mostly collagen, consider incorporating therapies such as photobiomodulation with near-infrared light. Applying 10 to 100 milliwatts per square centimeter can significantly enhance the integration of the mesh into your tissue, supporting healing and improving overall outcomes.
There are several devices on the market that provide this treatment, just be sure that the energy irradiance of 10 to 100 milliwatts is confirmed. Ideally use that for about 8 minutes twice a day over the area where the mesh was installed as this will help integrate the collagen into your body.
As you prepare for your hernia repair journey, keep these insights in mind. Collaborate closely with your surgeon to discuss your options and preferences and consider their comfort level with the chosen technique. The path to recovery can be streamlined and effective when guided by the latest surgical innovations and a personalized approach to your health.
