At our practice, we believe that the most effective hernia repairs shouldn't compromise your long-term well-being or athletic performance. Our specialized mesh-free hernia repair techniques represent the gold standard for athletes and active individuals seeking lasting relief without chronic complications. While conventional mesh repairs have become common practice in many surgical settings, our expertise in advanced tissue-based techniques allows us to deliver superior outcomes with significantly reduced risk of persistent pain, foreign body reactions, and activity limitations.
We've dedicated our practice to perfecting mesh-free approaches that honor your body's natural healing capacity while providing the structural support needed for complete recovery. Our evidence-based methodology is particularly valuable for competitive athletes, young patients, and anyone seeking to maintain an active lifestyle without the long-term concerns often associated with mesh implantation.
What is Mesh?
Surgical mesh is a sheet of synthetic material resembling a fine fishing net used to reinforce and repair hernias. Most commonly made from monofilament fibers such as polypropylene or polyester, mesh is designed to provide structural support to weakened tissue during hernia repair.
Despite its widespread use, mesh presents several significant challenges that can impact patient outcomes, particularly for athletes.
Mesh Properties and Concerns:
Pore Size
The holes between mesh strands critically affect healing. When the pore size is too small, scar tissue forming around adjacent strands can bridge together, causing the mesh to contract, stiffen, and lose flexibility—qualities essential for athletic movement.
Elasticity Limitations
The abdominal wall naturally stretches and contracts with every movement. Ideally, mesh should mirror this flexibility, but even the highest-quality mesh stretches only half as effectively as natural abdominal tissue. This elasticity mismatch creates shear stress at the junction between mesh and tissue, potentially compromising athletic performance.
Significant Shrinkage
Most meshes contract approximately 40% over time. When implanted between muscle layers near sensitive structures, this shrinkage pulls on surrounding tissues. The consequences can be severe:
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Nerve entrapment causing persistent burning pain
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Pressure on the spermatic cord potentially affecting sexual function
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Tension on the bladder leading to urinary symptoms
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Pull on abdominal structures causing pain during exercise
Growing Athletes at Risk
For young, developing athletes, mesh implantation poses an additional concern. As the athlete grows several inches while the mesh simultaneously shrinks, the resulting tension creates conditions for long-term complications and performance limitations.
Foreign Body Reaction
All mesh materials trigger the body's natural defense mechanisms. Macrophages, lymphocytes, and specialized giant cells attack the foreign material with acids, free radicals, and enzymes. While the mesh typically withstands this assault, the ongoing inflammatory response often results in chronic pain and tissue irritation—a particularly problematic outcome for athletes requiring optimal tissue function.
This combination of factors explains why mesh-free hernia repair techniques are increasingly preferred for athletes and active individuals seeking to maintain peak performance without long-term complications.
Mesh Pain and Complications
Understanding, managing, and treating the challenges faced by patients experiencing adverse effects after mesh-based hernia repairs
Understanding Mesh-Related Pain
Approximately 15% of patients who undergo hernia repair with mesh develop chronic pain, typically manifesting several months after surgery. This pain results from multiple factors:
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Mesh shrinkage creating tension in surrounding tissues
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Sensitive structures becoming scarred to the mesh
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Ongoing foreign body reaction
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Formation of neuromas (damaged nerve tissue) and granulomas (inflammatory cells)
Microscopic examination of removed mesh reveals significant tissue damage, explaining why many patients continue to experience pain even after mesh removal. Current evidence consistently shows that non-mesh repairs result in lower rates of chronic pain across patient populations, with this advantage being particularly pronounced in athletes and young men.
Important: None of the surgical mesh products currently available are fully biocompatible with the body, which is why chronic pain remains a significant problem. For this reason, all specialized sports hernia experts avoid using mesh in their repairs.
Managing Pain After Mesh Hernia Repair
If you're experiencing pain following a mesh hernia repair, you're not alone. Many patients face similar challenges while seeking to return to normal activity levels.
Conservative Management First
Pain associated with mesh hernia repair often diminishes over time. We recommend:
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Waiting at least six months, ideally a full year, before considering surgical intervention
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Exploring non-surgical options during this period, including:
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Nerve blocks
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Steroid injections
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Heat therapy
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Appropriate rest
Though this waiting period can be frustrating, it allows time for potential natural improvement and helps determine if surgical intervention is truly necessary.
Surgical Treatment for Mesh Complications
When conservative management fails, surgical intervention may be required. This complex procedure addresses multiple aspects of mesh-related damage:
Surgical Approach
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Thorough review of previous operative notes, photos, and imaging studies
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Typical operative time of three hours to ensure careful technique
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Identification of key anatomical structures under magnification
Key Surgical Steps
Pain associated with mesh hernia repair often diminishes over time. We recommend:
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Spermatic Cord Dissection: The cord is often scarred to the mesh and must be carefully separated to preserve blood supply to the testicle.
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Vascular Considerations: Special attention is paid to:
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Nerve Treatment: Using magnification and specialized lighting to:
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Identify the ilioinguinal, genital, and iliohypogastric nerves
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Address nerve complications, often requiring nerve excision rather than simple cutting due to interconnections between nerves
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Spermatic Cord Skeletonization: Performed when testicular pain is a major component
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Mesh-Free Repair: Any hernia created by mesh removal is repaired without using additional mesh
Key Surgical Steps
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Complete healing typically takes nine months
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A 100% elimination of pain is rare
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An 80% improvement in symptoms is considered a good surgical outcome
Our practice is committed to helping patients experiencing mesh complications find relief through both conservative management and, when necessary, advanced surgical techniques that prioritize long-term well-being.
Hernia Repair: Why Choose No Mesh?
A Surgeon’s Perspective on Evidence-Based Hernia Treatment
At our practice, we base our surgical approach on both extensive clinical experience and careful analysis of outcome data. When comparing mesh and no-mesh hernia repair techniques, the evidence clearly supports Dr. Nguyen’s preference for suture-based, no-mesh repairs—particularly for athletes and active individuals.
Understanding the Two Approaches
There are two fundamental methods for hernia repair:
Suture-Based Repair (No Mesh)
Using specialized stitching techniques to close the hernia defect through an incision
Mesh-Based Repair
Placing synthetic material to patch the hernia, either laparoscopically from the inside or through an external incision
The Risk-Benefit Analysis
While many surgeons advocate for mesh-based repairs citing lower recurrence rates, this argument overlooks the complete risk profile that patients face:
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Recurrence Rates: Mesh repairs show approximately 3% recurrence versus 4% for non-mesh repairs
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Chronic Pain Risk: Approximately 15% of mesh repair patients develop lasting pain
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Risk-Benefit Imbalance: A marginal 1% improvement in recurrence rates comes with a significantly higher 16% risk of chronic pain
The Hidden Costs of Mesh
When mesh is implanted, the body's natural response creates complications that can severely impact quality of life:
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Fibrous scar tissue forms around the mesh, causing it to become rigid
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This rigidity creates shear stress during movement, leading to pain during bending and twisting
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Nerves and the spermatic cord can become entrapped in the mesh, resulting in:
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Exercise limitation or impossibility
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Severe burning sensations during physical activity
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Sexual dysfunction and testicular pain
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Need for additional surgery to remove mesh
Even After Mesh Removal
Many patients requiring mesh removal due to complications find that even after this secondary procedure, they only experience about 80% improvement in their symptoms, leaving them with residual issues that can affect their quality of life.
Our Recommendation: Suture Repair
Based on these considerations, we strongly believe that suture-based, no-mesh hernia repairs represent the superior approach, particularly for:
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Athletes at all levels
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Young, active individuals
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Patients prioritizing long-term mobility and pain-free performance
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Anyone concerned about foreign body reactions
The marginal improvement in recurrence rates with mesh does not justify exposing patients to a substantially higher risk of chronic pain and its associated functional limitations. Our practice is committed to techniques that prioritize your long-term well-being and return to full activity, which is why we specialize in advanced no-mesh repair approaches.
The Types of Non-Mesh Hernia Repairs
There are several proven techniques for pure tissue repair that avoid the use of synthetic mesh. Each offers unique advantages for specific hernia types and patient needs.
Bassini
The Bassini is a classic approach perfected over the last century with excellent results. This technique repairs the inguinal floor by directly suturing the transversalis fascia to the inguinal ligament. The external oblique is then repaired over the spermatic cord, creating a strong, durable repair using only the patient's natural tissues.
Shouldice
The Shouldice method creates a sophisticated four-layer repair using running sutures. First, a continuous suture plicates and strengthens the inguinal floor. A second running suture then plicates the oblique muscles. This technique distributes tension evenly with minimal strain on any single point. The Shouldice repair achieves recurrence rates equal to or better than mesh repairs, making it an excellent option for durable results without synthetic materials.
Marcy
Particularly effective for indirect hernias, the Marcy repair involves carefully separating the hernia sac from the spermatic cord. The sac is then either tied off or inverted into the retroperitoneal space. The internal ring is subsequently tightened with several precise sutures, and the external oblique aponeurosis is closed to complete the repair. This tension-free approach results in minimal post-operative pain, quick recovery, and excellent long-term outcomes.
Desarda
The innovative Desarda repair uses the patient's own external oblique aponeurosis as a natural patch to reinforce the inguinal floor. This provides similar structural support to mesh but uses the patient's own tissue instead of synthetic material. The remaining sections of the external oblique aponeurosis are closed over the spermatic cord to complete the repair. This technique delivers excellent results with low recurrence rates and minimal tension.
McVay
Surgeons have relied on the McVay technique for over 50 years, particularly in specialized cases. Unlike other repairs that use the inguinal ligament, the McVay uniquely attaches the transversalis fascia to Cooper's ligament medially and then to the inguinal ligament laterally. This approach is especially valuable when the inguinal ligament is weak or absent, and is the preferred method when addressing femoral hernias. While it may involve moderate tension on the repair, often requiring a relaxing incision, it provides excellent structural support in challenging cases.
Matching Techniques to Hernia Types
Each hernia repair requires a tailored approach based on the patient's specific anatomy, activity level, and type of hernia. The ideal surgeon should be skilled in all non-mesh techniques, allowing them to select the most appropriate method for your unique situation.
For Young Athletes with Indirect Inguinal Hernias
The Marcy repair with ringplasty offers exceptional results with minimal tissue disruption, reduced post-operative pain, and faster return to activity.
For Direct Inguinal Hernias
Several excellent options exist, each with specific advantages:
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Bassini Technique: Particularly effective when the inguinal canal floor is weakened but not completely torn. This classic approach creates a strong repair by securing the transversalis fascia to the inguinal ligament shelf.
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Desarda Approach: Provides excellent results with minimal tension on the repair. This technique requires a healthy external oblique aponeurosis to serve as a natural patch, making it unsuitable if this tissue is torn or weakened.
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Shouldice Method: Creates a remarkably solid four-layer repair with minimal tension. While highly effective, this technique depends on an intact inguinal ligament and may not be possible in all cases.
For Complex Cases
The McVay repair utilizes Cooper's ligament instead of the inguinal ligament to reconstruct the inguinal floor. This approach is particularly valuable when the inguinal ligament is damaged or when addressing a concurrent femoral hernia. Patients should be aware that this technique involves more tension on the repair and may require additional recovery time.
The Value of Surgical Versatility: A truly skilled hernia surgeon should be proficient in all these techniques. In many cases, the best results come from hybrid approaches that combine elements from different methods, customized to address your specific anatomical needs. This versatility ensures you receive the most appropriate repair for your unique situation rather than a one-size-fits-all approach.
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