Prosthetic inguinal hernia repair is the gold standard because it has better outcomes than non-mesh repair. It reduces recurrence (0,8% vs 3,6%), is associated with less postoperative pain, shorter recovery, and shorter operative time. Nowadays, there is no justification for an elective non-prosthetic inguinal hernia repair. Even in contaminated cases (or with bowel resection) the use of a synthetic prosthesis is not fully contraindicated. There is a big industry (and lobby) and the are several types of prosthesis are available.
"First 100 Thoughts" - eBook
Get your free copy now
Do not have a iOS device?
The three main synthetic prosthetics used for inguinal hernia repair are polypropylene, polyester, and PTFE (polytetrafluoroethylene). Meshes must withstand at least 16N/cm strain to prevent disruption.
Polypropylene prosthesis is very common and resistant to biologic degradation, which has a positive impact on the recurrence rate. There is an ongoing debate between lightweight and heavyweight meshes. It seems that the former has lower postoperative pain and is associated with less awareness of the mesh. On the contrary, some studies report higher recurrence with lightweight meshes. Even though, results vary between different studies. Pore size is another important characteristic to be taken into account. Pores should be at least 75-100 µm to decrease infection.
The polyester prosthesis has the same recurrence rate as polypropylene. Some studies report less postoperative chronic pain and awareness of the prosthesis when a polyester mesh is used compared with polypropylene. However, there is no clear benefit of polyester, and the choice remains a surgeon’s preference. Even though, with polyester, there is the concern of biologic degradation over time and the potential failure of the graft.
PTFE is very common in vascular grafts. With the emergence of polypropylene and polyester, there was a decline in PTFE usage for inguinal hernia repair because of the higher recurrence rate. One big concern of PTFE is surgical site infection and seroma formation. When the pore is less than 10 µm macrophages and neutrophils are too large and cannot eliminate bacteria. In the case of a PTFE mesh infection, prosthesis removal is mandatory to manage the infection. This is an important drawback of this material.
There is also the barrier prosthesis for intraperitoneal placement that can prevent adhesions. The absorbable prosthesis is also available. However, this mesh stays intact for just a few weeks and therefore is associated with a high recurrence rate, and it should be used only in highly contaminated scenarios. Finally, the biological prosthesis is also a possibility. This mesh is extremely expensive and is usually used in infected surgical fields (some authors report no advantage comparing to synthetic mesh). High recurrence rates (80%) of the biological mesh, when used in a bridging manner for incisional hernia repair, is a big concern.
This is the scenario of the Western World. A lot of prostheses are available, and surgeons can choose the one they like the most and better fits each patient. However, this is not true in African countries. These countries have 10x’s more adult males with inguinal hernia than developed countries. In African countries, more than 50% of inguinal hernias are left untreated (increasing risk of incarceration, strangulation, and larger hernias over time) because they cannot support the cost, and most of them are repaired in emergencies (elective repairs in Africa vs Europe: 25-35% vs >90%). Additionally, only 5% of inguinal hernia repairs in Africa use a prosthesis because countries cannot buy a commercial mesh. Unbelievably, mesh price is even higher in Africa because there is no competition. Because African patients have larger hernias not suitable for non-mesh repairs, live far away from health facilities, and traveling is not easy, a mesh repair would be even better in Africa. How can this endemic situation be overwhelmed?
Mosquito-net mesh has similar outcomes.
A very interesting paper published in 2011 by Dr. J. Yang et al. from the Department of Surgery, Johns Hopkins University School of Medicine, presents a low-cost solution for inguinal hernia repair. A mosquito-net mesh has been used and outcomes are surprisingly good and similar to commercial mesh. I want to highlight three studies presented by the authors.
India (multicenter study 1996-2002)
Polyethylene and polypropylene mosquito-net mesh vs Prolene® Mesh
Autoclaved at the hospital
Price: 0,02 dollars vs 75 dollars
Complications: 6,9%
Recurrence: 0,27% (one patient)
No adverse events at 5 years of follow-up
Burkina Faso
Nylon mosquito-net mesh vs Ultrapro® Mesh
Autoclaved at the hospital
Price: <0,01 dollars vs 108 dollars (10x15 cm)
No complications
No recurrences
Ghana (2007)
Polyester mosquito-net mesh (7x15 cm)
Cleaning and sterilization by a UK hospital
1,50 dollars
Wound complications: 6,6%
No recurrence at 6 months
The authors conclude that if the mesh price is rendered negligible, a tension-free repair with a mesh can become the standard of care for inguinal hernias in African countries. Since inguinal hernia affects mostly young and highly productive males, this can benefit those countries a lot. What impressed me the most was the identical results reported with mosquito-net meshes, although more studies are necessary to validate them. Polypropylene is used for making some mosquito-nets and is one of the most commonly used materials in commercial meshes. However, a commercial prosthesis is not just a sterile polypropylene peace. A lot of variables are taken into account for making a mesh. Lightweight or heavyweight, pores size, quality control, etc. I believe using mosquito-net meshes in western societies is not even a remote possibility (there is also the lobby of the prosthesis’ companies), at least at the present day.
Imagine the surgery consultation:
Surgeon: I am going to use a mosquito-net to repair your inguinal hernia.
Patient: Not today. Not today…
Because we live in Portugal and the future is always unpredictable, the mosquito-net mesh is probably not such a crazy idea. With the Portuguese rulers and bosses, we never know what comes next...
"First 100 Thoughts" - eBook
Get your free copy now
Do not have a iOS device?
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon