Why We Don't Use Mesh
What is Mesh?
Mesh is a sheet of cloth that looks like a fine fishing net. Mesh can be used to reinforce and repair hernias. Most Meshes are made with a monofilament fiber (like a fishing line) such as Polypropylene or Polyester.
- Pore Size: Pore size is a measure of the size of the holes in the mesh. If the pore size is too small, then the strands of the mesh are very close together. In that situation, the scar tissue that forms around one strand can bridge with scar tissue around the adjacent strand. When this happens, the strands get pulled together, and the mesh will shrink and get stiff.
- Elasticity: The abdominal wall stretches and contracts with every movement. In an ideal situation, the mesh should stretch and contracts with the body. Otherwise, when the abdominal stretches and contracts and the mesh do not, then there will be shear stresses where the abdominal wall and the mesh meet. Unfortunately, even the best mesh will stretch only half as well as the abdominal wall. Why use mesh when you know it can decrease the performance of an athlete?
- Shrinkage: In your mind, visualize a piece of mesh that has been used to repair a hernia. It is in between the muscle layers, and there are many sensitive structures nearby. Then imagine that mesh shrinking. As the mesh shrinks, it will pull on everything nearby. If the mesh pulls on a nerve, then there will be constant burning pain. If the mesh pulls on the spermatic cord, then sex will be a distant memory. If the mesh pulls on the bladder, then there will be spasms when you urinate. If the mesh pulls on the abdominal wall, then there will be pain when you exercise. Most meshes will shrink about 40%.
- Growing Athletes: Since all meshes shrink with time, it is unthinkable to put mesh in an athlete who has not finished growing. What is going to happen when the athlete grows 5 inches, and at the same time, the mesh shrinks? The surgeon is asking for a bad result.
- Foreign Body Reaction: All mesh illicit what is called a Foreign Body Reaction. The body attempts to get rid of what should not be there. (It is nice to know that the body is smarter than many surgeons). Macrophages, lymphocytes, and Giant Foreign Body Cells attack the mesh with acid, free radicals, and enzymes. Mesh usually survives this attack, but the attack does result in chronic inflammation and pain.
About 15% of patients after a hernia repair with mesh suffer chronic pain. The pain usually starts several months after the operation. As we discussed, the pain is caused by multiple factors: shrinkage of the mesh, sensitive structures becoming scarred to the mesh, and the result of the Foreign Body Reaction. When the mesh is removed and then examined under the microscope, there are multiple neuromas indicating nerve damage, and granulomas are indicating the body’s attempt to reject the mesh. Unfortunately, even after the mesh is removed, many athletes still suffer from pain.
None of the current meshes are compatible with the body. Because of this, chronic pain is a significant problem. If the benefits of mesh greatly outweighed the difficulties of mesh, then it might make sense to use mesh. But that is not the case! When you compare the results of a sports hernia repair with and without mesh in athletes, the long term results are much better without mesh. None of the Sports Hernia Experts use mesh. Also, when you compare the results of inguinal hernia repairs in young men, the results are better without mesh. In all other groups of patients, non-mesh hernia repairs have less pain than mesh hernia repairs.
Please do not let your surgeon use mesh.
Treating Pain After Mesh Hernia Repair
Your mesh hernia repair has left you with pain. You are not alone. If you’re like many people who’ve had a hernia repaired with mesh, then you’re looking for options and next steps so that you can get back to “normal.”
First and Foremost, a Word of Hope
Pain associated with mesh hernia repair often will lessen as time goes by. If the pain is manageable, Dr. Nguyen suggests that you wait at least six months, and preferably a year, before considering surgery as a treatment for pain after mesh hernia repair. Nerve blocks, steroids, heat, and rest can offer relief during this frustrating, yet highly recommended, waiting period.
Next, If Pain Continues to Affect Your Life
Many patients immediately want imaging tests such as a CAT scan or MRI ordered. Unfortunately, rarely do the imaging tests identify the problem. A detailed history and careful physical examination are much more informative.
Recurrent Hernia, Nerve Injury, Scarring of the Mesh, and damage of the Spermatic Cord are the most common causes of chronic pain.
A new tear or hernia can be the source of your pain. This might be the case if:
- The pain is minimal when you are resting.
- Long periods of standing and sitting aggravates the pain.
- The pain is usually not severe.
- There will often be a bulge, which disappears when you lie on your back.
A recurrent hernia can usually be identified during the physical examination, and an ultrasound can be helpful. The treatment is to repair the hernia.
Injury to a nerve is another possible source of your pain, especially if:
- There is usually some pain all the time.
- The pain will suddenly worsen with even slight movement or pressure.
- The pain is often debilitating.
- The pain is usually in the area of skin normally innervated by the nerve.
- On examination, there is often allodynia in the area of skin innervated by the nerve.
- Direct pressure on the nerve will often reproduce the pain (Tinel’s Sign).
Imaging tests and nerve conduction tests are usually not helpful in determining nerve injury. What Dr. Nguyen has found to be most helpful are diagnostic nerve blocks. For example, if you have pain in the distribution of the ilioinguinal nerve, then Dr. Nguyen anesthetizes the ilioinguinal nerve with local anesthetic. If this provides significant relief, then that is strong evidence that the ilioinguinal nerve is the source of the problem.
There are several treatment options. Pain will sometimes improve if a steroid is injected around the nerve. Often a second or third injection is required. But each injection usually lasts a longer period of time.
Oral medications such as gabapentin or pregabalin can be tried, but Dr. Nguyen has noticed that they seldom are helpful and most patients do not like the side effects.
TENS units are occasionally helpful, as they use an electric current to confuse the nerve, which alleviates pain.
Nerve ablation is a procedure that involves placing the tip of a needle near the nerve. A radio frequency current then heats and destroys the nerve. But it can be difficult to see the nerve with ultrasound, and thus getting the needle in the right place can be challenging.
If conservative measures fail, then the damaged nerve can be excised. The nerve should be cut as high as possible and the nerve should be removed as far distally as possible. This will leave an area of skin numbness that decreases with time. Most of the nerves are purely sensory, so that there is no muscle weakness after neurectomy. Also, in men, the neurectomy does not affect the penile sensation nor erectile function and women will still have normal sensation of the clitoris and of the vagina; so intercourse will not be affected. Most patients report that sex is enjoyable again after surgery, because they can do it without worrying about pain.
Mesh used to repair the hernia is often a source of pain. This might be the source of your pain if:
- The pain is usually constant and worsens with exercise.
- The pain is often difficult to localize.
- The pain is usually not debilitating.
If you are thin, the mesh can often be palpated (felt) and it will be hard. Imaging tests are usually not helpful in determining whether or not the mesh is the pain source. To help with the diagnosis, Dr. Nguyen often will inject the mesh with a local anesthetic such as lidocaine. If you experience significant relief, then that confirms that mesh is a component of the pain.
Steroids injected around the mesh will sometimes provide long-term relief, but repeated injections are usually required.
If conservative measures fail, then the mesh should be removed.
The spermatic cord can become scarred to the mesh. Within the spermatic cord there are multiple, very important and sensitive structures: the genital nerve that innervates the testicle, the genital artery and veins that supply blood for the testicle, the vas deferens that transports the sperm, and the cremasteric muscle that retracts the testicle.
If the genital nerve is injured or damaged, you will have pain in the testicle (not the scrotum), and:
- The pain is constant and gets worse with activity or pressure.
- The pain can be debilitating, and sex is often impossible.
- There is severe pain in the testicle.
If the blood supply to the testicle is damaged:
- There is severe pain in the testicle.
- The patient is debilitated
- The testicle slowly shrinks and dies.
- An ultrasound can help confirm the diagnosis.
- The testicle may have to be removed.
If the vas deferens is damaged, then sperm cannot get out of the testicle. There will be:
- An ache and a swelling of the testicle.
- Intercourse is painful.
- The sperm count may be low.
- A steroid injection may help.
If the cremaster muscles become attached to the mesh, then the testicle will no longer retract upward in response to cold and sex. Surgery can help.
Learn more about Dr. Nguyen’s approach to hernia repair without mesh. Contact Dr. Nguyen today.
A Real-World Example
I recently examined a 16-year-old male soccer player with an indirect inguinal hernia. His mother told me the first surgeon advised him to have hernia repair with mesh. She was concerned about the hazards of mesh.
The young athlete’s hernia was small and would require only a few absorbable sutures to repair. I told his mother that I agreed with her that mesh was the wrong choice. (I have found that mothers are always right.) I explained that mesh has a significant risk for chronic pain, especially for a young man who is still growing. Also, if he did have trouble after the mesh repair, the mesh is difficult to remove.
I called the first surgeon at his mother’s request. That surgeon was kind enough to talk with me. He said that he would like to do a non-mesh hernia repair, but it was not part of his training. He did not know how to do a non-mesh repair and so could not offer that operation to his patients. Most of the younger surgeons have not been trained in how to repair hernias without mesh. They are not familiar with the anatomy, nor the various techniques. Thus, most patients are never given the option for one of the classic suture repairs.
I think this is a terrible situation when patients are suffering from complications due to mesh, simply because their surgeons have not had training in non-mesh repair. It’s even more unfortunate that many patients are unaware that non-mesh hernia repairs are an option. Never has getting a second opinion, and doing your research been more important than it is when it comes to hernia repair.
Surgery to Treat Mesh Complications
Most patients who need surgery are experiencing damage to the nerves, shrinkage of the mesh, and scarring of the spermatic cord. All these components of the disaster have to be treated to provide full relief.
The operative notes and photographs from all previous operations are studied. All imaging tests are reviewed. The operation cannot be rushed. Dr. Nguyen routinely plans on an operating time of three hours.
Knowing the type of mesh and the location of the mesh is beneficial information. The first step of the operation is to find the spermatic cord. Gentle tugging down on the testicle will often help to find the spermatic cord as it passes over the pubic bone. Once the cord is identified, it is followed to the internal inguinal ring. The spermatic cord will be scarred to the mesh. Separating the cord from the mesh without causing damage to the testicle’s blood supply is complicated and is best done with magnification. If not done carefully, the testicle will die. The inferior epigastric vessels will be adhered to the mesh and are very easy to tear. So, these vessels need to be isolated to prevent significant hemorrhage. To avoid damage to the femoral artery and vein, it is sometimes wiser to leave some mesh behind rather than risk damaging those vessels. Bleeding from a tear of the femoral vein is especially difficult to stop. The nerves can be difficult to find, so Dr. Nguyen uses magnification and special lighting. The ilioinguinal nerve usually runs along the superior anterior aspect of the spermatic cord. The genital nerve usually runs along the posterior aspect of the spermatic cord. The iliohypogastric nerve runs deep to the external oblique aponeurosis about 2 cm above the internal inguinal ring. The nerves have multiple interconnections, so if only one nerve is cut, the pain sensation will still get back to the brain. Therefore it is better to excise the nerve rather than cut the nerves.
If the major component of the patient’s pain is the testicle, then Dr. Nguyen also advises the skeletonization of the spermatic cord.
Finally, any hernia that is caused by removing the mesh should be repaired without mesh.
Preparing for a Long Recovery
The healing will take nine months. A 100% reduction of pain is rare. An 80% improvement is a good result.
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Note: discusses the incidence of pain after mesh hernia repair
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Note: Dr. Fishcer (Harvard Medical School) makes a strong argument against the use of mesh.
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Note: Compares injection therapy to neurectomy to treat pain after mesh hernia repair.
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Note: Discusses the use of nerve blocks to treat pain after mesh hernia repair
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Note: Discusses skeletonization of the spermatic cord to treat testicular pain.
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Note: discusses the treatment of sexual dysfunction after hernia repair.
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Note: Contains more detailed information about meshes.
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Note: Discusses nerve damage by mesh.
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Note: damage to bladder and colon from mesh
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Int J Surg. 2017 Mar;39:150-155. doi: 10.1016/j.ijsu.2017.01.083. Epub 2017 Jan 25.
Note: discusses the excellent results of a non mesh repair.
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Note: Excellent results in younger patients for tissue repairs.
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BMC Surg. 2015 May 17;15:64. doi: 10.1186/s12893-015-0046-9.
Note: Femoral nerve injury after mesh hernia repair.
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