Guy Voller, MD, has performed hernia surgeries for over 30 years. Writing in GeneralSurgeryNews.com, Dr. Voller was asked by the president of the American Hernia Society to share his observations about hernia repair, comparing the techniques of yesteryear and today. 

In the early 1980s, Voller describes his residency training days, practicing techniques based on the dissection of 500 cadavers. Voller credits the 19th-century Italian doctor, Edoardo Bassini, as being the godfather of modern hernia surgery (this writer’s words, not Voller’s). Bassini published his “radical cure of inguinal hernia,” in 1887. “This elegant operation,” as Voller calls it, reconstructs the inguinal floor by sewing the triple layer of musculature in the abdominal wall (the internal oblique muscle, transversus abdominis muscle and transversal fascia). The incision is performed above the inguinal (groin) ligament and below the iliopubic tract. 

Voller suggests that in decades past, there was a problem with this technique: to properly execute the technique, the posterior wall of the inguinal floor has to be cut, and that, it seems, is no easy task, perhaps because of the precarious location: the cremasteric muscle, which is located in the inguinal canal and scrotum. The main function of this pelvic muscle is to protect the testes. To perform the procedure correctly, the cremasteric muscle has to be cut out. “Both of these steps were often not done in the United States,” says Voller, adding that when it was done, the technique was often botched because of an overlapping of tissue layers in the surgical closure of a wound. 

The consequence for the hernia patient of this: high recurrence rates.

Hernia Surgery Major Fail Rate Sparks Innovation

When Voller began his residency, a paper was published showing that the failure rate for primary inguinal hernia repair was 10% in the USA. The paper received a lot of attention in the medical community, and served as a catalyst for improving inguinal hernia repair techniques. 

Shortly after, Voller learned the so-called Lichtenstein tension-free mesh hernia repair technique. Named after a pioneering doctor in the art of surgical mesh hernia repair, Dr. Irving Lichtenstein, the technique is still considered the gold standard of hernia repair by the American College of Surgeons, says UCLA Health, which describes the procedure as “Covering the opening of the hernia with a patch of mesh, instead of sewing the edge of the hole together. The surgical mesh acts as a bridge or scaffolding for ingrowth of new tissue to reinforce the abdominal wall.”

Of course, mesh repair is far from perfect. Thousands of faulty mesh lawsuits have been filed against makers of the devices. 

The Roots of Hernia Mesh Repair

Lichtenstein wasn’t actually the inventor of the mesh hernia repair technique. Prior to Lichtenstein, one Dr. Richard Newman began experimenting with the procedure. Newman, Voller suggests, never received the recognition for the technique because he had trouble getting published. Newman began experimenting with hernia mesh repair back in the 1970s, roughly a decade before Lichtenstein would be introduced to the procedure by none other than Newman. 

Newman is reported to have performed 1,600 mesh repairs in the ‘70s. But Newman isn’t the inventor of the mesh hernia repair technique either. Credit for that goes to Dr. Francis Usher, who experimented with tension-free hernia mesh in 1960. 

It is believed that the first hernia mesh repair was performed by Dr. Don Acquaviva in France, in 1944. Acquaviva used a nylon mesh prosthesis. The design for these key-hole meshes with tails are still in use today, says Voller. 

But it was Lichtenstein who popularized the term, “tension-free”. Thus, he is often erroneously believed to be the pioneer of the technique. Lichtenstein does deserve much of the credit for minimizing the recovery time associated with the procedure. Prior to his evolutionary work on the procedure, people would spend several days after getting hernia surgery. A few decades later, Lichtenstein’s techniques are still employed, and as a result, the recurrence rate, claims Voller, has been reduced to no more than 2% from 10%. 

The Rise of Elmiron Recurrence Repair

Lichtenstein did in fact pioneer one hernia surgical technique: the plug repair for femoral and recurrent surgeries. With this type of surgery, only a small repair is needed while the rest of the repair remains intact. Thus, for those in need of recurrence surgery, the procedure is much less invasive. To fix the small repair, Lichtenstein invented the technique of “plugging” the defect with a small piece of rolled mesh. By 1990, Lichtenstein had successfully performed 1,400 of these procedures, which ultimately led to the plug and patch technique innovation as well as Ethicon’s Prolene Hernia System. 

To date, the Lichtenstein technique, plug and patch repair and Elmiron’s Prolene remain the three most common types of open inguinal hernia repair. Lichtenstein’s method is the most popular of the three (25%), followed by plug and patch (18%) and Elmiron’s Prolene (6%). 

Are there any differences between these three techniques in terms of complications, pain, the length of time it takes a patient to return to activity or recurrence? According to Voller, the clinical trials that have been published show no difference in outcomes between the different techniques. Voller says, “The key is for a surgeon to learn one of these techniques properly and [the] patients can do well.”

Robots That Fix Hernias 

Voller goes on to discuss the advent of laparoscopic hernia repair in the early 1990s, which involves four critical components: 

• General anesthesia 
• A breathing tube
• Three smaller incisions in the lower part of the abdomen
• A tiny camera inserted into the abdomen

When done properly, Voller says laparoscopic surgery is equal “with respect to recurrence compared with the open mesh-based repairs.”

Despite not having a better recurrence rate, laparoscopic surgery seems to offer benefits, including:

• Less postoperative pain 
• Less impairment in sensibility 
• Faster return to daily activities
• Less chronic pain 

The cherry on top for this type of surgery, suggests Voller: it costs the same as the other approaches. 

But the downside to laparoscopic is the steep learning curve required to master the technique. This is why less laparoscopic hernia repairs were being performed. However, with the advent of robotics, the procedure has become more popular. Known as “lap-robotic” surgery, the technique is now performed in approximately half of all inguinal hernia repairs. 

Mesh vs. Tissue Repair: Final Verdict

Voller argues for mesh-based repairs, owing to the fact they “always have statistically significantly fewer recurrences with a risk reduction of 75.” Furthermore, Voller says  complication rates are the same for mesh and non-mesh repairs. And, most importantly, he says, “The incidence of chronic groin pain is the same for mesh and non-mesh repairs.” Voller gives the final word to the Danish Hernia Database a compilation of over 10,000 inguinal repairs a year. The Database recommends the use of mesh for primary inguinal hernia repair and laparoscopic or open depending on the surgeon’s expertise. Laparoscopic has less acute and chronic pain, and tissue-based repair is not recommended.

But those that have experienced serious mesh hernia side effects should also factor in  Voller’s conclusions. And indeed, Voller addresses this issue. He writes, “I think with the issues around mesh that are common today, it is critical that surgeons learn an open autogenous repair so they can offer patients a non-mesh option.”

Voller continues: “The patient may want to take on a slightly higher chance of recurrence in exchange for avoiding mesh use for whatever reason.”