Mesh has routinely been used in hernia repairs in the last 20 years for all groin hernias as well as hernias in the abdominal wall that are more than 2 cm in diameter.
Lately, there is lots of controversy with regards to the use of mesh in the abdominal surgery.
Recent Controversies With Use of Mesh
In the last 2-3 years, there has been increased reporting of complications of mesh use. Most of these have been in the newspapers. Most of the problems with the use of mesh has been as part of gynaecological procedures, mostly to treat prolapse or incontinence.
There are 2 problems that I as a general surgeon can see with regards to the use of mesh in these procedures. The first reason is that this mash is placed under the organ (usually bladder or womb). When a woman is standing, these organs are by gravity being pulled down and the mesh is holding them in place and tension is placed onto the mesh from the organs above. This mesh can slowly cheese-wire into these organs and cause problems.
The second reason is that this mesh is placed into the abdominal cavity and will cause scarring inside. This scarring can cause twisting of the bowel and bowel obstruction.
The second reason also occurs in general surgical procedures where the mesh is placed within the abdominal cavity.
Why Do We Surgeons Use Mesh in Hernia Operation?Mesh is used to minimise the risk of hernia recurrence. This risk is different in different hernia operations. For groin hernias, the risk of recurrence can be up to 30-40% if the mesh is not used. The only place in the world that has low rates of recurrence for repair of groin hernias without mesh is Shouldice Hernia Hospital in Canada. No other hospital has managed to achieve these low levels of risk of recurrence in the world. The recurrence rates following groin hernia repair with mesh are less than 5%. The recurrences following abdominal groin hernia repairs are around 10-20% depending on the size of a hernia (those that are more than 10cm have higher recurrence rates) and patients obesity.
Mesh was developed to strengthen the area and cause ingrowth of the tissue into the mesh. These meshes do not resorb with time, although some do partially reabsorb.
The mesh placement is different for different types of surgery and where a hernia is.
Placements of the mesh:
• Abdominal wall hernia (umbilical and ventral)
○ Laparoscopic (keyhole repair) - the mesh is placed inside the abdominal cavity
○ Open repair - mesh can be placed outside or inside the abdominal cavity. This is influenced by the size of a hernia and surgeon preference.
• An inguinal hernia (groin)
○ Laparoscopic repair - the mesh is placed behind the abdominal wall muscles, but in front of the peritoneum (the smooth lining of the abdominal cavity). Mesh is not within the abdominal cavity and is not exposed to abdominal organs unless the hole in the peritoneum was made during repair of a hernia
○ Open repair - the mesh is placed over the abdominal wall muscles, just behind the tough sheath called external oblique fascia. Mesh is not exposed to the abdominal cavity unless plug mesh used (this technique is not commonly used by surgeons in New Zealand)
• A femoral hernia (groin) - mesh not used all the time.
○ Laparoscopic repair - same as for an inguinal hernia above.
○ Open repair - mesh placed next to femoral vein, outside of the abdominal cavity.
Problems with mesh
Adhesions or scarring inside the abdominal cavity. In this situation, abdominal organs close to the repair site get stuck to themselves or to the mesh. These symptoms can be caused:
○ Bowel obstruction - pain, abdominal distention and vomiting
○ Bowel twisting - extreme pain, bowel rupture, nausea, vomiting and rarely distention
• Scarring outside abdominal cavity
○ Being able to feel the scar/mesh - usually only in skinny people
○ Pain - due to injury to sensory nerves in the groin - either during the surgery or being pulled into scarring by the mesh.
Why are hernias being repaired?
Hernias should only be repaired if they cause you significant problems. If hernias are not symptomatic, they should not be repaired. The risks of hernia repair surgery always need to be taken into account.
The problems that hernias may cause are a pain, bowel obstruction (blockage) and bowel perforation. On average, they will slowly increase in size.
You should always discuss both the risks and benefits of any surgical procedure with your surgeon. At the end of the day, the benefits of surgery need to outweigh the risks.
Always discuss the risks and benefits of hernia surgery with your surgeon. Ask any question that you may have, of your surgeon. In the end, you are the only one who can make the decision whether or not to have surgery and is it worth it or not.
Never let anyone push you into having an operation that you do not want to have.
I have often been asked by patients if they are a candidate for breast conservation surgery or should they have a mastectomy. So is there a right answer?
Both you as a patient and your surgeon have a say in this decision, but ultimately the choice is yours.
The breast surgeon will decide whether it is possible to perform the breast conserving surgery or if the mastectomy is required. How do we as surgeons do this?
This decision will depend on the amount of breast tissue that will need to be removed and in which part of the breast the cancer is vs the amount of breast tissue (size of the breast) that the woman has.
When we are talking about the outside half of the breast (towards the armpit), we can remove up to 20% of breast tissue. In the middle half of the breast, you can only remove 15% of the whole breast tissue. This is, so we prevent deformity of the breast following surgery and likely radiation afterwards.
As surgeons, we aim to remove cancer or the calcifications (usually DCIS) and 1 cm of normal breast tissue around a tumour. So if a tumour is 1 cm in diameter, approximately 3 cm in diameter of breast tissue will be removed. If a tumour is 3 cm in diameter, then 5 cm in diameter of breast tissue will be removed.
After the cancer is removed, the breast tissue around the cavity is moved to fill in the cavity. If tissue from a different part of the body is used - this is called a flap.
So please talk to your surgeon whether or not she or he is able to perform breast conserving surgery.
Your surgeon will let you know if she or he can technically perform breast conserving surgery. If this is possible, then it's your decision whether or not you would like to have breast conserving surgery.
The risk of cancer coming back over time in the same breast is similar whether you have a mastectomy (removal of the whole breast) or breast conserving surgery followed by radiation. The risks associated with mastectomy and breast conserving surgery are similar (apart from the risk of positive margins) and not very high at all. But do discuss these risks with your surgeon, as these do differ between different surgeons. If you do have breast reconstruction at the same time as mastectomy, then the surgical risks are much higher.
In women with low risk of breast cancer (general population), there is no need to remove other breast to prevent cancer on that side. The risk of cancer in the other breast causing risks to your life is less than 1%. The risks of surgery are higher.
You and your surgeon need to have a discussion whether the breast conserving surgery is technically possible. Risks of both surgeries, as well as recurrence, need to discuss so you can make an informed decision with regards to the operation. In the end, it's your decision which surgery you will have.
Please do not rush with this decision, take your time. Short delays do not have any impact on your survival, but making a decision that you are not happy with will have an impact on you forever.
I am Breast, Endocrine and General Surgeon.
Wakefield Specialist Medical Centre
99 Rintoul St, Newtown
Waikanae Specialist Centre
Boulcott Specialist Centre
666 High Street, Boulcott