Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

32. Chronic Groin Pain: Mesh or No Mesh
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Perceptions
Perceptions about mesh use for inguinal hernia repair can vary
greatly; trying to understand the thoughts and biases of surgeons,
patients, and research data can be challenging. Some believe the use of
mesh in and of itself is the cause for the apparent increase in CGP. Others
believe there has not been an objective increase in CGP due to mesh, but
at the same time they recognize that mesh can play a role in the development
of CGP postoperatively.
Fischer recently wrote a commentary on the continued use of mesh for
inguinal hernia repair despite the “human toll of inguinodynia” [ 4 ]. He
comments that “conventional” tissue repairs had sound results, including
acceptable recurrence rates of 4–6 % and CGP in 2–4 % of patients. Along
the way, mesh repairs became more popular and with it his personal perception
of increased incidence of inguinodynia . These complications were
superimposed with issues of pending litigation, potential malingering by
patients for secondary gain, and “ruined lives.” After evaluating the data,
including mesh use and nerve management, he concludes that there has
been little gained by the use of mesh in inguinal hernia repair due to the
risk of chronic debilitating pain and really no improvement of recurrence
rates. He contributes the etiology of CGP to the inflammatory response of
mesh as it involves the three inguinal nerves (ilioinguinal, iliohypogastric,
and genital branch of the genitofemoral nerve). His recommendation is
that it would be better to learn to do tissue repairs, similar to the Shouldice
repair, so as to not “create” inguinodynia in patients, as it has significant
societal and economic implications. He also notes that the U.S. Food and
Drug Administration has become increasingly concerned about the issue
of CGP and the use of mesh.
The opposite view was expressed by Gilbert, a hernia surgeon specialist
and originator of a commonly used mesh prosthesis for inguinal
hernia repair. He wrote a response to Fischer’s article with a perception
that was strikingly different, starting with the issue of inflammation due
to a foreign body [ 5 ]. He states, “Ordinarily reactions to inert mesh are
minimal and short lived.” He goes on to interpret the existing data that
incriminate mesh to have bias, as they are not the result of randomized
controlled trials. His personal experience includes both Shouldice tissue-based
repairs and thousands of mesh-based repairs. His perceptions
of CGP were that it occurred in his patients with recurrences and not
necessarily in those with mesh. He further states that the mesh repair
decreases the incidence of recurrence. His feeling is that CGP is due to
inadequate knowledge of the groin and is directly related to surgical