What is the recommended approach for inguinal hernia repair, sutures or netting (mesh)?

Mesh is Superior to Sutures for Inguinal Hernia Repair

Prosthetic repair with synthetic mesh is strongly recommended over suture-only repair for inguinal hernia repair as it is associated with significantly lower recurrence rates without increasing wound infection risk. 1

Evidence-Based Recommendation

The 2017 World Society of Emergency Surgery (WSES) guidelines provide clear direction on this matter with a Grade 1A recommendation (highest level of evidence):

• Mesh repair is associated with significantly lower recurrence rates compared to tissue (suture) repair
• No increase in wound infection rates when using mesh in clean surgical fields
• Mesh repair should be the standard approach for all inguinal hernia repairs 1

Advantages of Mesh Repair

Reduced Recurrence Rates

• Suture-only repairs have historically high recurrence rates of 10-15% 2
• Mesh repair dramatically reduces recurrence rates to as low as 0.5% in some studies 2
• In a prospective randomized trial comparing mesh vs. tissue repair for para-umbilical hernias, recurrence rates were 0% vs. 19% respectively 1

Patient-Centered Outcomes

• Faster recovery and return to normal activities
• Most patients can return to previous jobs within 4 weeks after mesh repair 2
• Minimal postoperative pain with many patients requiring minimal or no analgesia 2
• Lower incidence of early chronic pain with mesh fixation compared to suture-only repair 3

Surgical Approach Considerations

Open vs. Laparoscopic Mesh Repair

Both approaches are acceptable with specific advantages:

• Laparoscopic approach:

  • Significantly lower wound infection rates (p<0.018) 1
  • No difference in recurrence rates compared to open approach (p<0.815) 1
  • Better for bilateral or recurrent hernias 4

• Open (Lichtenstein) approach:

  • Suitable for most primary inguinal hernias
  • Can be performed under local anesthesia 2
  • More cost-effective for unilateral hernias 4

Mesh Fixation Methods

• Glue fixation shows advantages over suture fixation:
  • Lower incidence of early chronic pain 3
  • Reduced hematoma formation 3
  • Shorter operative time 3
  • No increase in recurrence rates in long-term follow-up 3

Special Considerations

Patient Populations Who Especially Benefit from Mesh

• Elderly patients with weakened tissue
• Patients with connective tissue disorders (Ehlers-Danlos syndrome, Marfan syndrome)
• Recurrent hernias 5
• Patients with acquired absence of posterior wall fascia transversalis 5

Clean vs. Contaminated Fields

• In clean surgical fields (CDC wound class I), mesh is always recommended 1
• Even in clean-contaminated fields (CDC wound class II) with intestinal strangulation requiring bowel resection without gross spillage, synthetic mesh can still be safely used 1

Common Pitfalls to Avoid

1. Inadequate mesh size: Use appropriately sized mesh that extends well beyond the defect
2. Improper mesh placement: Ensure mesh is spread without wrinkles or folds
3. Mesh displacement: Consider fixation methods to prevent migration
4. Overlooking bilateral hernias: Laparoscopic approaches allow identification and repair of occult contralateral hernias (present in 11-50% of cases) 1

The evidence overwhelmingly supports the use of mesh for inguinal hernia repair as the standard of care, with significantly better outcomes in terms of recurrence rates, chronic pain, and quality of life compared to suture-only repairs.