Laparoscopic Hernia Repair with Mesh: Recommendation
Laparoscopic hernia repair with mesh is strongly recommended for most hernia repairs, particularly for recurrent hernias, bilateral hernias, and complicated hernias, as it significantly reduces recurrence rates compared to tissue repair without increasing infection risk in clean and clean-contaminated surgical fields. 1
When to Use Laparoscopic Mesh Repair
Primary Indications (Strongest Evidence)
- Recurrent hernias - Laparoscopic total extraperitoneal (TEP) repair is the preferred approach, offering lower complication and recurrence rates 2
- Bilateral hernias - Laparoscopic approach allows simultaneous repair with evaluation of both sides 2, 3
- Incarcerated hernias without strangulation - Laparoscopic approach is safe and effective when there is no suspicion of bowel necrosis 1
- Defects >3 cm - Mesh reinforcement is essential as primary repair alone shows recurrence rates up to 42% 4
Surgical Field Classification Algorithm
Clean Fields (CDC Class I):
- Use synthetic mesh for all repairs - this is Grade 1A evidence 1
- Significantly lower recurrence rates versus tissue repair without increased wound infection 1
- Short-term antimicrobial prophylaxis only 4, 5
Clean-Contaminated Fields (CDC Class II):
- Synthetic mesh can be safely used even with intestinal strangulation and/or bowel resection without gross spillage - Grade 1A evidence 1
- No increase in 30-day wound-related morbidity 1
- 48-hour antimicrobial prophylaxis recommended 4, 5
Contaminated Fields (CDC Class III):
- Primary repair for defects <3 cm 1
- Biological mesh when direct suture not feasible for larger defects 1
- Avoid synthetic mesh - infection rates up to 21% 6, 4
- 48-hour antimicrobial prophylaxis 4, 5
Dirty Fields (CDC Class IV):
- Primary repair for small defects 1
- Biological mesh or open wound management with delayed repair for larger defects 1
- Full antimicrobial therapy required 4, 5
Laparoscopic Technique Selection
TEP (Total Extraperitoneal) - Preferred Method
- Lower complication and recurrence rates compared to TAPP 2
- Mesh placed in preperitoneal space without entering peritoneal cavity 6
- Best for patients without prior lower abdominal surgery 2
TAPP (Transabdominal Preperitoneal)
- Reserved for patients with prior lower abdominal wall incisions that make TEP dissection impossible 2
- Requires entering peritoneal cavity 6
When to Avoid Laparoscopic Approach
- Suspected bowel gangrene requiring intestinal resection - use open preperitoneal approach 1
- Peritonitis present 1
- Patients unable to tolerate general anesthesia 2
- Extensive prior lower abdominal surgery 2
- Unstable patients with severe sepsis or septic shock - open management required to prevent abdominal compartment syndrome 1
Clinical Outcomes and Benefits
Advantages of Laparoscopic Mesh Repair
- Reduced recurrence rates - 30-50% relative reduction compared to non-mesh repair 3
- Less chronic pain - significantly less persisting pain (Peto OR 0.54, p<0.0001) 3
- Less numbness - significantly less persisting numbness (Peto OR 0.38, p<0.0001) 3
- Faster recovery - return to usual activities approximately 7 days earlier 3
- Lower wound infection rates compared to open procedures 6, 7
- Shorter hospital stays 6, 7
Disadvantages to Consider
- Longer operative time - approximately 15 minutes longer (WMD 14.81 minutes, p<0.0001) 3
- Higher risk of visceral injuries - particularly bladder injuries (8/2315 vs 1/2599) 3
- Higher risk of vascular injuries (7/2498 vs 5/2758) 3
- Requires general anesthesia - not suitable for patients who cannot tolerate it 2
- Steeper learning curve - surgeons without advanced laparoscopic skills should refer complex cases 2
Critical Pitfalls to Avoid
- Do not avoid mesh in clean or clean-contaminated fields due to fear of infection - evidence shows it's safe and dramatically reduces recurrence 6, 5
- Do not use synthetic mesh in grossly contaminated fields (CDC Class III/IV) - infection rates can reach 21% 6, 4
- Do not perform laparoscopic repair when bowel resection is anticipated - open preperitoneal approach is preferable 1
- Do not use absorbable prosthetic materials - they lead to inevitable hernia recurrence due to complete dissolution 6
- Ensure adequate surgeon experience - complication and recurrence rates are significantly lower at centers experienced in laparoscopic techniques 2
Special Populations
Young Patients with Simple Unilateral Hernias
- Laparoscopic repair may be excessive surgery 2
- Consider repair under local anesthesia with open approach 2
- Avoid mesh if advantageous to do so in young patients 2