Well after the point it was thought to be a settled matter, the use of surgical mesh in hernioplasty is now up for debate. In making sense of the situation, why not look to the person who literally wrote the book on laparoscopic hernia repair?
Michael Kavic, MD, is the professor emeritus of surgery at Northeast Ohio Medical University and a founding member of both the Society of Laparoendoscopic Surgeons (SLS) and the American Hernia Society. He is also the editor-in-chief of the SLS journals JSLS and CRSLS.
To understand where things are at now, Kavic says it’s useful to examine the history of hernioplasty.
For most of the 20th century, the methodology behind hernia repair was basically the same. It was based on the pioneering work of Italian surgeon Edoardo Bassini, who developed a procedure that reconstructed the inguinal wall with a triple layer of the patient’s own tissues.
In the early 1970s, Irving Lichtenstein developed a new approach, changing hernia repair into a procedure that could be performed under local anesthesia. In contrast to closing the hernia defect with layers of tissue he simply employed synthetic mesh to cover the hernia defect after the herniated content was placed back into the abdomen. Recurrences, previously the most nettlesome problem following an open hernia repair procedure, dropped significantly. As with any innovation, it took some time before Lichtenstein’s variation caught on, but it eventually became the standard for hernia repair.
(Image credit: screen grab from YouTube/Dr. Gamal Sakr)
Some 30 years later, a new problem emerged. According to tracking data, anywhere from 11 to 16 percent of patients were reporting chronic, disabling abdominal pain beginning several months after the procedure.
Kavic says inherent qualities of surgical mesh might be the culprit, calling attention to research conducted by Robert Bendavid, MD.
“What Bendavid found out by looking at explanted mesh — removed — was that it became distorted,” Kavic says. “We knew that. It shrunk, we knew that. We knew that mesh has little interstices.”
The problem arises when, in open surgery, tissue is cut for the mesh to be placed in position. The body has to go through its natural healing process. In that process, small nerves that have been cut, regenerate and grow in the interstices.
“Also what Bendavid showed was that in these spaces, nerves grow into the mesh, along with capillaries.,” explains Kavic. “What happens to those capillaries when that space shrinks? The mesh becomes distorted. Mesh shrinkage and distortion contribute to an environment — a micro-environment — of decreased oxygen and increased pressure on the ingrown capillaries and nerves. So is it any wonder that these patients may get pain?”
The pain, Kavic says, can become intractable.
Kavic cautions that the evidence might be compelling, but it’s not conclusive. He and others are calling attention to the issue as a first step, arguing that the time has come to assemble problem-solving groups comprised of physicians, educators, device manufacturers, and surgical ethicists.
“It’s easy to claim like Chicken Little, ‘The sky is falling,’ and I hope it doesn’t sound like that,” Kavic says. “I don’t mean it that way. It’s very early in the game–in the process of studying the disabling pain from the use of mesh. However, there’s enough solid evidence out there that maybe we’d better get together and think about it. That’s what this is all about.”
