What are the guidelines for hernia repair with mesh?

Guidelines for Hernia Repair with Mesh

Mesh repair is recommended for hernia defects, particularly for defects larger than 3 cm, as it is associated with a significantly lower recurrence rate compared to tissue repair without increasing wound infection rates. 1

Surgical Approach Based on Wound Classification

The World Journal of Emergency Surgery guidelines provide clear recommendations based on the CDC wound classification:

Clean Surgical Field (CDC Class I)

• Prosthetic repair with synthetic mesh is recommended for patients with intestinal incarceration without signs of strangulation 1
• Benefits include lower recurrence rates without increased infection risk
• Both open and laparoscopic approaches are viable options

Clean-Contaminated Field (CDC Class II)

• Emergent prosthetic repair with synthetic mesh is recommended for patients with intestinal strangulation and/or concomitant bowel resection without gross enteric spillage 1
• This approach is associated with lower recurrence risk regardless of hernia defect size
• No significant increase in 30-day wound-related morbidity has been observed

Contaminated/Dirty Field (CDC Classes III and IV)

• For small defects (<3 cm): Primary repair is recommended 1
• For larger defects where direct suture isn't feasible: Biological mesh may be used 1
• Choice between cross-linked and non-cross-linked biological mesh should be based on defect size and contamination degree
• If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives

Special Considerations

Unstable Patients

• Open management is recommended to prevent abdominal compartment syndrome 1
• Intra-abdominal pressure should be measured intraoperatively
• After stabilization, early definitive closure should be attempted
• When early fascial closure isn't possible, progressive closure can be attempted during surgical wound revisions

Anesthesia Considerations

• Local anesthesia shows advantages in terms of shorter operative time and hospital stay, lower cost, and faster recovery compared to general anesthesia 1
• However, general anesthesia should be preferred when bowel gangrene is suspected or in cases of peritonitis

Specific Patient Populations

Cirrhotic Patients

• Approximately 20% develop umbilical hernias due to increased abdominal pressure from ascites 2
• Repair is not contraindicated but requires careful risk-benefit assessment
• Optimal fluid control and appropriate nutrition may minimize hernia progression 2

Pregnant Women

• Emergency repair is indicated for incarcerated/strangulated hernias
• Elective repair for symptomatic hernias
• Asymptomatic hernias should have repair postponed until after childbirth 2

Postoperative Management

Monitoring

• Patients should be monitored for at least 24 hours, focusing on:
  • Hemodynamic stability
  • Surgical site complications
  • Respiratory function 2

Pain Management

• First-line: Acetaminophen 500-1000 mg every 6 hours (maximum 4000 mg/day)
• Second-line: Tramadol 50-100 mg every 6-8 hours (maximum 400 mg/day)
• NSAIDs should be avoided due to increased bleeding risk 2

Follow-up Care

• Monitor for recurrence and complications
• 5-year recurrence rates are approximately 10.6-12.3% with mesh repair compared to 17.1% without mesh 2
• Patient education on signs of hernia strangulation is essential

Potential Complications

Mesh-related complications may include:

• Infection (42%)
• Mechanical failure (18%)
• Pain (9%)
• Reaction (8%)
• Intestinal complications (7%)
• Adhesions (6%) 3

Evidence Quality and Considerations

The evidence supporting mesh use in hernia repair is strong for clean and clean-contaminated cases. A landmark study in the New England Journal of Medicine demonstrated three-year cumulative recurrence rates of 43% for suture repair versus 24% for mesh repair in primary hernias 4.

However, for contaminated and dirty surgical fields, the evidence is less robust. A recent Cochrane review (2023) found very low-certainty evidence regarding mesh versus non-mesh repair in emergency groin hernia surgery, particularly regarding surgical site infections and mortality 5.