Table of Contents
Options in Hernia Surgery
The type of surgery you are offered depends on:
- The type of hernia you have - location, size, and previous hernia surgeries
- Your medical history - previous abdominal surgeries, general fitness and weight, other medical conditions
- Your surgeon – your surgeon’s expertise, experience, and preference
- What matters most to you
What are the different approaches to hernia surgery?
Open Surgery
Open surgery where your surgeon makes a traditional open cut to repair your hernia under direct view.
- May use mesh or non-mesh approaches
- Simple hernias can be performed with local anesthetic, whereas complex surgeries require general anesthetic
- Can be used to tackle almost all types of hernias, particularly large complex hernias
Laparoscopic Surgery
Laparoscopic surgery, or “keyhole surgery”, is where multiple small incisions (5mm - 15mm) are made and a thin camera is used to visualize the surgery.
- Generally requires mesh
- Requires general anesthesia
- Reduces pain and improves recovery time
- Might not be feasible for large complex hernias or previous abdominal surgery
Robotic Surgery
Robotic surgery is like laparoscopic “key-hole” surgery, but robotic arms are used to manipulate the instruments, providing more maneuverability.
- Generally requires mesh
- Requires general anesthesia
- Reduces pain and improves recovery time (compared to open surgery)
- Expands the capability to perform complex hernia surgery in a minimally invasive fashion
Mesh and Non-Mesh Approaches in Hernia Surgery
Hernias can be fixed with sutures (stitches), mesh, or both.
A mesh is a type of woven sheet using various types of synthetic or biosynthetic material. It is placed to reinforce a hernia repair by acting as a natural scaffold for your tissues to incorporate. Mesh is frequently used in hernia repairs and is used because it has been shown to significantly reduce the risk of hernia recurrence.
Most meshes are permanent synthetic meshes to provide strength for the rest of your life to ensure a hernia doesn’t recur.
There are absorbable meshes that are both synthetic and biologic (derived from animal/human tissue) that are used in unique situations where you can’t use a permanent mesh.
Some meshes have special shapes and coatings depending on where they are located in the body.
Mesh is used in the majority of hernia surgery to prevent recurrence.
For inguinal hernias, mesh is used in all laparoscopic and robotic surgeries, and the most common open surgeries.
For hernias elsewhere (incisional, epigastric, flank, umbilical, etc.) mesh is generally used except for very small umbilical hernias (<1cm).
Mesh is generally very safe. Similar to other medical devices (heart valves, stents, prosthetic joints, etc.), there are small risk of complications:
- The risk of a deep mesh infection is roughly 1 in 500 to 1 in 1000 (4). In the very rare case that mesh does get infected, it can be often treated with antibiotics. If this is not successful, then surgery to remove the mesh is required (5).
- The risk of chronic pain with and without mesh after inguinal hernia surgery is the same and is very low, roughly 1-5% (6).
- Other serious mesh related complications including erosions into other organs are very rare (<1%).
- The risk of needing an additional surgery to remove a mesh because of a mesh related complication (infection, pain, etc.) in groin hernias is <1% and in ventral/incisional hernias roughly 1-5% (7).
Non-mesh approaches are when the hernia is repaired using a combination of sutures and the patient’s own tissues.
This includes unique surgical techniques like the “Shouldice Repair” or the “Desarda Repair”, which are non-mesh approaches to inguinal hernias.
General surgeons will use non-mesh approaches for small umbilical hernias or when mesh cannot be used (e.g. contaminated wounds). Non-mesh approaches are also typically used for most hiatal hernia surgeries.
In inguinal hernias, specialized hernia surgeons or centers can offer non-mesh surgeries like the Shouldice technique or the Desarda technique. For certain eligible patients, this can give similar results to mesh-based techniques.
Your surgeon will review (1) the type of hernia you have; (2) your medical history; (3) their expertise and preference; (4) and what matters most to you and guide you into making a decision.
If you are eligible and interested in a non-mesh approach, your surgeon might refer you to a specialized surgeon and/or center to discuss the risks and benefits.
Facts and Myths with Mesh and Non-Mesh Approaches
The major problems and lawsuits related to mesh are not related to hernia surgery and are for use of different types of mesh in other parts of the body (urology/gynecology). Like other medical devices (prosthetic joints, heart valves, pacemakers), only a handful of meshes have been recalled from the market and there are tight regulations to ensure that the devices are safe and that complications are rare.
Most non-mesh techniques require permanent material, either permanent suture or very thin wire (8, 9).
Non-mesh techniques can still have infection, chronic pain, and other complications. One analysis looking at 23 randomized controlled trials with 5444 patients with inguinal hernia surgery showed no difference in chronic pain between non-mesh and mesh repairs (6).
These are broad studies of many patients from many countries, and this data may not necessarily apply to you.
In inguinal hernias, international hernia societies recommend mesh based approaches for the majority of patients, reserving non-mesh base approaches to a select group of healthy patients with low risk of recurrence and who strongly prefer not having a mesh (11 – 13).
Mesh-based approaches are used for incisional hernias, ventral hernias, and recurrent hernias.
Non-mesh based approaches are strongly recommended when there is a high risk for infection or a contaminated wound.
What's the bottom line on mesh vs. non-mesh surgery?
Mesh is a core part of hernia surgery and is very safe. While you can read lots on the internet about best techniques, quoted recurrence rates, and patient testimonials, that data might not be up to date and may not apply to you and your hernia. International hernia societies all agree that the surgery needs to be tailored to the patient with mesh and non-mesh techniques. Talk to your surgeon about your options and they will guide you in making an informed decision.
Preparing for my Hernia Surgery
What should I be doing before my hernia surgery?
Surgery is a huge stress to the body, so it is essential to optimize your health and physical fitness.
- Exercise and physical activity are NOT prohibited before hernia surgery. Physical activity pre-operatively, including light weights and walking/running, has been shown to improve surgical outcomes. Improving your cardiovascular health is key to preparing your body for surgery. You are encouraged to exercise so long as (1) it doesn’t cause excessive discomfort; or (2) your surgeon has not explicitly prohibited it.
- Weight loss. Obesity is major risk factor for post-operative complications and hernia recurrence. You can find more information about weight loss strategies and weight loss surgery here.
- Diabetes management and strict blood sugar control is essential to prevent wound infections. Talk to your family doctor or endocrinologist if your diabetes is poorly controlled before your hernia surgery.
- Quitting smoking is highly recommended if not mandatory prior to having a hernia surgery. Smoking negatively affects wound healing in several ways. Smoking cessation is very hard, and especially hard to do by yourself. The use of smoking cessation programs can increase success of quitting from 3% to 30%(14). To find out more about smoking cessation, click here.
By quitting smoking, being physically active, and controlling your diabetes, you improve your chance of the best surgical outcome and you improve your overall health.
What should I do for my postoperative care?
The majority of common hernia surgeries, including umbilical or groin hernias, are done as day surgeries and admission into hospital is not required. If you have a large complex hernia, you may require an admission in hospital.
Every surgeon will have specific instructions for your post operative care that you should follow. In general, these are some guidelines we suggest:
Discomfort and pain over your incision is normal. We recommend ice/cold compresses over your incision and this can reduce the amount of medications required.
The following oral pain medications may be recommended by your physician:
- Acetaminophen (Tylenol) – you get this over the counter (OTC) at your pharmacy. Follow the instructions on the label. If you require pain medications, this is your foundational first-line choice, and can be taken on a scheduled basis. Additional medications can be layered on top of this foundation. Be aware that certain forms of Tylenol (Tylenol #1/2/3, Tylenol Arthritis) have additional ingredients that can interact with your other medications and limit your maximum dose. Speak to your pharmacist or doctor.
- NSAIDs or anti-inflammatory pain medications (ibuprofen – Advil, naproxen – Aleve, aspirin, celecoxib – Celebrex, etc.) – there are over-the-counter and prescription forms of this medication. This class of medication can be added on top of acetaminophen and can reduce the amount of opioid-based medications you need for pain control. This medication is often not prescribed to older adults or those with a history of kidney issues, heart attack or stroke, or stomach problems.
- Opioid based medications (morphine – Kadian, Statex; codeine – Tylenol No. 3; hydromorphine – Dilaudid; oxycodone – OxyNeo, Percocet; tramadol – Ralivia, Tridural, Zytram) – these are prescription, opioid based medications that are used for moderate or severe pain not controlled by above options. Opioid medications are generally safe to manage short term surgical pain but should not be taken for long-term pain issues. Do not operate machinery or make important decisions if you have taken opioids. If you are taking opioids, taking an over-the-counter laxative like PEG (Restoralax) is important to prevent constipation.
Most patients with simple hernia surgeries just require cold compresses and acetaminophen (Tylenol) for pain control.
In general, dressings can be removed 48 hours after surgery. A dry dressing or bandage can be applied to prevent soiling of your clothes, but isn’t necessary.
You may shower 48 hours after surgery. Let the soap and water run over your incisions and pat dry. Avoid soaking in water (baths, pools, hot-tubs) for at least two weeks.
Most of the time, you will have absorbable sutures. If you have staples or non-absorbable sutures, your surgeon will give you instructions for removal.
Your activity restrictions will depend on what type of work you do and what type of surgery you had.
Return to normal activity and work
Listen to your body. You should return to normal day to day activity as soon as you feel able, typically in the first few days. Most people can return to desk work after laparoscopic surgery within a few days and after open surgery within a week.
Return to exercise and heavy lifting
Light aerobic exercise (walking, swimming, cycling) can be resumed if you can tolerate it, typically after a week or so. In general, we suggest avoiding heavy lifting (>10 lbs) for 2 weeks after laparoscopic surgery and for 4-6 weeks after open surgery. Speak to your surgeon about this.
There are no specific dietary restrictions. Eat a normal balanced diet as you can tolerate after your surgery.
It is important not to gain significant weight after your hernia surgery to prevent recurrence.
Complications of Hernia Surgery
These are some of the complications to be aware of after a hernia surgery.
A seroma is a very common and normal finding after a hernia surgery and looks like a soft bulge at the site of your hernia surgery. It is caused by a build-up of physiological fluid in the space where your hernia was previous. Your body will typically resolve this on its own, but sometimes it needs to be aspirated (removed with a needle) by your surgeon. If it is not causing significant discomfort, you can typically wait until your follow up appointment. However if you are having pain or discomfort, call your surgeon’s office.
A hematoma is a build-up of clotted blood, effectively a large bruise, that can occur at your hernia site and causes a mild amount of discomfort. It is often caused by very minor pinpoint bleeding while the body is clotting and healing. This is a very common finding after surgery and is not dangerous and will go away as your body breaks down and absorbs the hematoma. This is often found after inguinal hernia surgery with bruising in the scrotum.
If you have a very large and rapidly growing bruise (over minutes), then you need to go to the nearest emergency department or call 911.
A surgical site infection causes pain, worsening tenderness, redness, and swelling at the incision site. You can sometimes have pus draining from your incision, or fevers and malaise. ff you are having these symptoms, call your surgeon’s office or go to the nearest emergency department.
Mild pain managed with ice, cold compresses, and oral pain medications is normal and expected after hernia surgery and should last a few days to a few weeks. Numbness over your scar is expected and can be long term.
Some patients can develop chronic pain, discomfort, or a large area of numbness/tingling. Chronic pain is typically defined as pain that last for >3 months. This is one of the complications that can come after inguinal hernia surgery due to the proximity of important nerves in the groin. The risk of chronic pain is around ~1-5% and is not different between mesh vs. non-mesh approaches.
Chronic pain and discomfort can be caused by multiple reasons including seromas/hematomas, recurrence, nerve entrapment/injury, mesh migration, etc. In the majority of patients, the chronic pain resolves with time and oral medication as the sutures used in the surgery are absorbed by the body. If the pain persists, a multi-modal approach will be used to determine the cause and treat the pain. This could include medications, injections, or additional surgery.
A dehiscence is when your hernia repair comes apart in the period immediately after your hernia surgery. This often happens with coughing or heavy lifting leading to sudden pain and/or a bulge. If this occurs, go to the emergency department or call 911.
A recurrence is when your hernia comes back after your hernia surgery. This often takes months to years to develop. The risk of hernia recurrence depends on the type of hernia and your individual risk factors. For inguinal hernias, the average risk is roughly 1-3%. The risk factors that lead to a hernia recurrence include having a large complex hernia, smoking, diabetes, and obesity. Addressing these issues minimize your risk of having a recurrence.
Like knee/shoulder joint replacements, some hernia surgeries have a lifetime and hernias are expected to come back with time – such as parastomal hernias.
Other complications that can occur after hernia surgery include:
- Urinary retention – very common and typically resolves without intervention
- Injury to surrounding organs (e.g. bowel injury, blood supply to the testes, etc.)
- Mesh migration or folding
- Sexual dysfunction – pain or ejaculatory dysfunction (very rare)
- Mesh erosion into other organs (very rare)
- Male infertility (very rare)
References
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- Bedewi M, El-Sharkawy M, Al Boukai A, Al-Nakshabandi N. Prevalence of adult paraumbilical hernia. Assessment by high-resolution sonography: a hospital-based study. Hernia. 2012;16:59-62.
- Nachiappan S, Markar S, Karthikesaligam A, Ziprin P, Faiz O. Prophylactic mesh placement in high-risk patients undergoing elective laparotomy: a systematic review. World journal of surgery. 2013;37:1861-71.
- Moon V, Chaudry GA, Choy C, Ferzli GS. Mesh infection in the era of laparoscopy. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2004;14(6):349-52.
- Kuo Y-C, Mondschein JI, Soulen MC, Patel AA, Nemeth A, Stavropoulos SW, et al. Drainage of collections associated with hernia mesh: is it worthwhile? Journal of Vascular and Interventional Radiology. 2010;21(3):362-6.
- Öberg S, Andresen K, Klausen TW, Rosenberg J. Chronic pain after mesh versus nonmesh repair of inguinal hernias: a systematic review and a network meta-analysis of randomized controlled trials. Surgery. 2018;163(5):1151-9.
- Itani KM. New findings in ventral incisional hernia repair. JAMA. 2016;316(15):1551-2.
- Lorenz R, Arlt G, Conze J, Fortelny R, Gorjanc J, Koch A, et al. Shouldice standard 2020: review of the current literature and results of an international consensus meeting. Hernia. 2021:1-9.
- Desarda MP. New method of inguinal hernia repair: A new solution. ANZ journal of surgery. 2001;71(4):241-4.
- Lockhart K, Dunn D, Teo S, Ng JY, Dhillon M, Teo E, et al. Mesh versus non‐mesh for inguinal and femoral hernia repair. Cochrane Database of Systematic Reviews. 2018(9).
- Stabilini C, van Veenendaal N, Aasvang E, Agresta F, Aufenacker T, Berrevoet F, et al. Update of the international HerniaSurge guidelines for groin hernia management. BJS open. 2023;7(5):zrad080.
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- Simons M, Aufenacker T, Bay-Nielsen M, Bouillot J, Campanelli G, Conze J, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Springer; 2009. p. 343-403.
- Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, Lawrence D, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. The Lancet. 2016;387(10037):2507-20.