Indications for Pure Tissue Repairs

  • A. Koch
  • R. Bendavid
  • J. Morrisson
  • C. Hill
  • K. Petersen
  • V. Iakovlev


“Indications for pure tissue repairs” is a timely and relevant chapter in a modern textbook on the art of hernia surgery. While the introduction of synthetic polypropylene meshes seemed a boon at first in the management of the tenacious hernia recurrence, it fell short as a panacea. Mesh in any shape, form, weight, configuration, and combination with resorbable and non-resorbable addenda is still a foreign body with its expected flaws and limitations. Unfortunately, the most germane predicament has been the chronic post-herniorrhaphy pain syndrome which has become a major obstacle to a patient’s well-being.

Hernia as a surgical specialty has become a complex art which needs and calls upon allied disciplines such as pathology, materials experts, and statisticians to enlighten the surgeons who are beginning to feel hounded by a savvy patient population.

While recurrence rates may have come down for the average general surgeon who performs less than 50 operations a year, those rates have not come down for the hernia specialists who have always had good results.

Recent evidence, as we shall see within the chapter, has proven that for primary hernias which make up 90–95% of all hernia surgery, pure tissue repairs, in the proper hands and proper training in the majority of cases, can provide an excellent mainstay of hernia surgery. Let us hope that our present dedication will serve as an apology for the turbulent past and a promise of a bias-free future!


  1. 1.
    de Beauvoir. Simone. “All Said and Done” 1972. p. 16.Google Scholar
  2. 2.
    John I. Why most published research findings are false. PLoS Med. 2005;2(8):e124. Accessed 19 Oct 2010.
  3. 3.
    Barbour V et al. An unbiased scientific record should be everyone’s agenda. PLoS Med. 2009;6(2). 1000038. Accessed 19 Oct 2010.
  4. 4.
    Steen RG. Retractions in the scientific literature: do authors deliberately commit research fraud? Medical Ethics. Accessed 15 Nov 2010.
  5. 5.
    Jung K, Rosch R, Klinge U, et al. Risk factors related to recurrence in inguinal hernia repair: a retrospective analysis. Hernia. 2006;10:309–15.CrossRefGoogle Scholar
  6. 6.
    Burger JW, Luidendijk RW, Hop WC, et al. Long term follow-up of a randomized control trial of suture vs mesh repair for incisional hernia. N Engl J Med. 343:392–8.Google Scholar
  7. 7.
    Iakovlev V, Koch A, Petersen K, et al. A pathology of mesh and time. Dysejaculation, sexual pain, and orchialgia resulting from polypropylene mesh erosion into the spermatic cord. Ann Surg. 2016.
  8. 8.
    Bendavid R. A femoral “umbrella” for femoral hernia repair. Surg Gynecol Obstet. 1987;165:153–6.PubMedGoogle Scholar
  9. 9.
    Bassini E. Sulla cura radicale dell’ernia inguinale. Arch Soc Ital Chir. 1887;380:4–30.Google Scholar
  10. 10.
    Iason HA. Hernia. Philadelphia: The Blakiston; 1940.Google Scholar
  11. 11.
    Malik A, Bell CM, Stukel TA, Urbach DR. Recurrence of inguinal hernias repaired in a large hernia surgical specialty hospital and general hospitals in Ontario, Canada.Google Scholar
  12. 12.
    Lange JFM, Meyer VM, Voropai DA, et al. The role of surgical expertise with regards to chronic postoperative inguinal pain (CPIP) after Lichtenstein correction of inguinal hernia: a systematic review. Hernia. 2016;20:349–56. Scholar
  13. 13.
    Bendavid R. Prosthetics in hernia surgery: a confirmation. Post-graduate general surgery. 1992. p. 166–7.Google Scholar
  14. 14.
  15. 15.
    Probst P, Knebel P, Grummich K, Tenckhoff S, Ulrich A, Buchler MW, Diener MK. Industry bias in randomized controlled trials in general and abdominal surgery: an empirical study. Ann Surg. 2016;264(1):87–92.CrossRefPubMedGoogle Scholar
  16. 16.
    Amato B, Moja L, Panico S, Persico G, Rispoli C, Rocco N, Moschetti I. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Data Base Syst Rev. 2012;(4):CD001543.Google Scholar
  17. 17.
    Olavarria OA, Holihan JL, Cherla D, Perez CA, Kao LS, Ko TC, Liang MK. Comparison of conflicts of interest among published hernia researchers self reported with the centers for medicare and medicaid services open payment database. J Am Coll Surg. 2017;224(5):800–4.CrossRefPubMedGoogle Scholar
  18. 18.
    Koch A. The “Tailored approach” to inguinal hernias. The current statistical realities. AHS 18th Annual Repair. Cancun, Mexico. Accessed 8 Mar 2017.Google Scholar
  19. 19.
    Werner MU, Kehlet H. Management of patients with persistent pain following groin hernia repair. Ugeskr Laeger. 2014; pii:V061130349.Google Scholar
  20. 20.
    Petersen K. 1st World Conference on Abdominal Wall Hernia Surgery. Milan, Italy, April 25-29, 2015, Program page 46.Google Scholar
  21. 21.
    Latremoliere A, Wolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain. 2009;10(9):895–926.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Chen DC, Hiatt JR, Amid P. Operative of refractory neuropathic inguinodynia by a laparoscopic retro-peritoneal approach. JAMA Surg. 2013;148(10):962–7. Scholar
  23. 23.
    Kumar V, Abbas A, Fausto N, Aster J. Robbins and cotran pathological basis of disease, 7th and 8th editions. Elsevier, Imprint: W.B. Saunders; 2004 and 2010.Google Scholar
  24. 24.
    Hallab NJ, Jacobs JJ. Biologic effects of implant debris. Bull NYU Hosp Jt Dis. 2009;67(2):182–8.PubMedGoogle Scholar
  25. 25.
    Anderson JM. Exploiting the inflammatory response on biomaterials research and development. J Mater Sci Mater Med. 2015;3:121.CrossRefGoogle Scholar
  26. 26.
    Klinge U, Klosterhalfen B, Müller M, Schumpelick V. Foreign body reaction to meshes used for the repair of abdominal wall hernias. Eur J Surg. 1999;165(7):665–73.CrossRefPubMedGoogle Scholar
  27. 27.
    Klosterhalfen B, Klinge U. Retrieval study at 623 human mesh explants made of polypropylene—impact of mesh class and indication for mesh removal on tissue reaction. J Biomed Mater Res B Appl Biomater. 2013;101(8):1393–9.CrossRefPubMedGoogle Scholar
  28. 28.
    Klosterhalfen B, Junge K, Hermanns B, Klinge U. Influence of implantation interval on the long-term biocompatibility of surgical mesh. Br J Surg. 2002;89(8):1043–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Klinge U, Klosterhalfen B, Birkenhauer V, Junge K, Conze J, Schumpelick V. Impact of polymer pore size on the interface scar formation in a rat model. J Surg Res. 2002;103:208–14.CrossRefPubMedGoogle Scholar
  30. 30.
    Klinge U, Klosterhalfen B. Modified classification of surgical meshes for hernia repair based on the analyses of 1,000 explanted meshes. Hernia. 2012;16(3):251–8.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Klosterhalfen B, Junge K, Klinge U. The lightweight and large porous mesh concept for hernia repair. Expert Rev Med Devices. 2005;2(1):103–17.CrossRefPubMedGoogle Scholar
  32. 32.
    Klinge U, Klosterhalfen B, Müller M, Ottinger AP, Schumpelick V. Shrinking of polypropylene mesh in vivo: an experimental study in dogs. Eur J Surg. 1998;164(12):965–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Zogbi L, Trindade EN, Trindade MR. Comparative study of shrinkage, inflammatory response and fibroplasia in heavyweight and lightweight meshes. Hernia. 2013;17(6):765–72.CrossRefPubMedGoogle Scholar
  34. 34.
    Tunn R, Picot A, Marschke J, Gauruder-Burmester A. Sonomorphological evaluation of polypropylene mesh implants after vaginal mesh repair in women with cystocele or rectocele. Ultrasound Obstet Gynecol. 2007;29(4):449–52.CrossRefGoogle Scholar
  35. 35.
    Svabík K, Martan A, Masata J, El-Haddad R, Hubka P, Pavlikova M. Ultrasound appearances after mesh implantation—evidence of mesh contraction or folding? Int Urogynecol J. 2011;22(5):529–33.CrossRefPubMedGoogle Scholar
  36. 36.
    Jerabek J, Novotny T, Vesely K, Cagas J, Jedlicka V, Vlcek P, Capov I. Evaluation of three purely polypropylene meshes of different pore sizes in an onlay position in a New Zealand white rabbit model. Hernia. 2014;18(6):855–64.CrossRefPubMedGoogle Scholar
  37. 37.
    Weyhe D, Cobb W, Lecuivre J, Alves A, Ladet S, Lomanto D, Bayon Y. Large pore size and controlled mesh elongation are relevant predictors for mesh integration quality and low shrinkage—systematic analysis of key parameters of meshes in a novel mini pig hernia model. Int J Surg. 2015;22:46–53.CrossRefPubMedGoogle Scholar
  38. 38.
    Bendavid R, Lou W, Koch A, Iakovlev V. Mesh-related SIN syndrome. A surreptitious irreversible neuralgia and its morphologic background in the aetiology of post-herniorrhaphy pain. Int J Clin Med. 2014;5:799–810.CrossRefGoogle Scholar
  39. 39.
    Bendavid R, Lou W, Grischkan D, Koch A, Petersen K, Morrison J, Iakovlev V. A mechanism of mesh-related post-herniorrhaphy neuralgia. Hernia. 2016;20(3):357–65.CrossRefPubMedGoogle Scholar
  40. 40.
    Massaron S, Bona S, Fumagalli U, Battafarano F, Elmore U, Rosati R. Analysis of post-surgical pain after inguinal hernia repair: a prospective study of 1,440 operations. Hernia. 2007;11(6):517–25.CrossRefPubMedGoogle Scholar
  41. 41.
    Huerta S, Patel PM, Mokdad AA, Chang J. Predictors of inguinodynia, recurrence, and metachronous hernias after inguinal herniorrhaphy in veteran patients. Am J Surg. 2016;212(3):391–8.CrossRefPubMedGoogle Scholar
  42. 42.
    Hallén M, Sevonius D, Westerdahl J, Gunnarsson U, Sandblom G. Risk factors for reoperation due to chronic groin postherniorrhaphy pain. Hernia. 2015;19(6):863–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Hamouda A, Kennedy J, Grant N, Nigam A, Karanjia N. Mesh erosion into the urinary bladder following laparoscopic inguinal hernia repair; is this the tip of the iceberg? Hernia. 2010;14(3):317–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Agrawal A, Avill R. Mesh migration following repair of inguinal hernia: a case report and review of literature. Hernia. 2006;10(1):79–82.CrossRefPubMedGoogle Scholar
  45. 45.
    Klinge U, Park JK, Klosterhalfen B. The ideal mesh? Pathobiology. 2013;80(4):169–75.CrossRefPubMedGoogle Scholar
  46. 46.
    Nikhil K, Rishi N, Rajeev S. Bladder erosion and stone as rare late complication of laparoscopic hernia meshplasty: is endoscopic management an option? Indian J Surg. 2013;75(3):232–4.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Riaz AA, Ismail M, Barsam A, Bunce CJ. Mesh erosion into the bladder: a late complication of incisional hernia repair. A case report and review of the literature. Hernia. 2004;8(2):158–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Liebert TC, Chartoff RP, Cosgrove SL, McCuskey RS. Subcutaneous implants of polypropylene filaments. J Biomed Mater Res A. 1976;10:939–51.CrossRefGoogle Scholar
  49. 49.
    Iakovlev VV, Guelcher SA, Bendavid R. Degradation of polypropylene in vivo: a microscopic analysis of meshes explanted from patients. J Biomed Mater Res B Appl Biomater. 2017;105(2):237–48.CrossRefPubMedGoogle Scholar
  50. 50.
    Mary C, Marois Y, King MW, Laroche G, Douville Y, Martin L, Guidoin R. Comparison of the in vivo behavior of polyvinylidene fluoride and polypropylene sutures used in vascular surgery. ASAIO J. 1998;44(3):199–206.CrossRefPubMedGoogle Scholar
  51. 51.
    Miklos JR, Chinthakanan O, Moore RD, Mitchell GK, Favors S, Karp DR, Northington GM, Nogueiras GM, Davila GW. The IUGA/ICS classification of synthetic mesh complications in female pelvic floor reconstructive surgery: a multicenter study. Int Urogynecol J. 2016;27(6):933–8.CrossRefPubMedGoogle Scholar
  52. 52.
    Kaza AK, Pigula FA. Are bioprosthetic valves appropriate for aortic valve replacement in young patients? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2016;19(1):63–7.CrossRefPubMedGoogle Scholar
  53. 53.
    Rosu C, Soltesz EG. Selection of valve prostheses. Semin Thorac Cardiovasc Surg. 2015;27(2):152–8.CrossRefPubMedGoogle Scholar
  54. 54.
    Zahar A, Webb J, Gehrke T, Kendoff D. One-stage exchange for prosthetic joint infection of the hip. Hip Int. 2015;25(4):301–7.CrossRefPubMedGoogle Scholar
  55. 55.
    Pospischill M, Knahr K. Strategies for head and inlay exchange in revision hip arthroplasty. Int Orthop. 2011;35(2):261–5.CrossRefPubMedGoogle Scholar
  56. 56.
    Shearburn EW, Myers RN. Shouldice repair for inguinal hernia. Surgery. 1969;66:450–9.PubMedGoogle Scholar
  57. 57.
    Volpe L, Galli T. The shouldice repair-our experience. Congress in General and Gastro-Intestinal Surgery, Hospital San CarloBorromeo, Milan, Italy; 1991.Google Scholar
  58. 58.
    Wantz G. The Canadian repair of inguinal hernia. In: Nyhus L, Condon R, editors. Hernia III. Philadelphia: JB Lippincott; 1989. p. 236–52.Google Scholar
  59. 59.
    Myers RN, Shearburn EW. The problem of the recurrent inguinal hernia. Surg Clin North Am. 1973;53:555–8.CrossRefPubMedGoogle Scholar
  60. 60.
    Devlin HB, Gillen PHT, Waxman BP. Short stay surgery for inguinal hernia. Clinical outcome of the Shouldice operation. Lancet. 1977;1:847–9.CrossRefPubMedGoogle Scholar
  61. 61.
    Flament JB. Personal Communication.Google Scholar
  62. 62.
    Wantz G. Hernia III. In: Nyhus L, Condon R, editors. Philadelphia: JB Lippincott; 1989. p. 245.Google Scholar
  63. 63.
    Shouldice Hospital in Bendavid R. The Shouldice method of inguinal herniorrhaphy. In Nyhus L, Baker RJ, editors. Mastery of surgery, 2nd ed. Boston: Little Brown; 1992.Google Scholar
  64. 64.
    Moran MR, Bliek M, Collura M. Double layer of transversalis fascia for repair of inguinal hernia. Surgery. 1968;63:424–9.Google Scholar
  65. 65.
    Berliner S, Burson L, Kate P. An anterior transversalis fascia repair for adult inguinal hernias. Am J Surg. 1978;135:633–6.CrossRefPubMedGoogle Scholar
  66. 66.
    Simons MP, Aufenacker T, Bay-Nielsen M, et al. European hernia society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343–403.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • A. Koch
    • 1
  • R. Bendavid
    • 1
  • J. Morrisson
    • 1
  • C. Hill
    • 1
  • K. Petersen
    • 1
  • V. Iakovlev
    • 1
  1. 1.Tel Aviv UniversityTel AvivIsrael

Personalised recommendations