Inguinal hernia repair is among the most frequently performed operations worldwide, with over 20 million procedures undertaken annually. Despite this ubiquity, few topics in general surgery have generated as much sustained debate as the question: mesh or no mesh? What once appeared settled by the widespread adoption of tension-free mesh repair has reemerged as a contentious issue, fueled by patient advocacy, litigation, evolving evidence, and a renewed emphasis on individualized care. Historical Evolution: From Tissue Repair to Mesh Dominance The history of inguinal hernia repair mirrors the broader evolution of surgery itself. Early techniques, including those described by Bassini in the late 19th century, emphasized meticulous anatomical reconstruction of the posterior wall of the inguinal canal. Bassini’s repair dramatically reduced recurrence rates and became the gold standard for decades. However, tissue-based repairs were inherently tension repairs. The latter half of the 20th century witnessed a paradigm shift with the introduction of synthetic mesh, culminating in Lichtenstein’s description of the tension-free mesh repair in the 1980s. Mesh repair offered technical simplicity, reproducibility, rapid recovery, and reduced recurrence rates. The Evidence Base: Recurrence versus Morbidity Multiple randomized controlled trials and meta-analyses have consistently demonstrated lower recurrence rates with mesh repairs compared to traditional tissue repairs, particularly when performed outside specialized centers. This evidence established mesh repair as the standard of care in most clinical settings. However, recurrence is no longer the sole determinant of surgical success. Expert-performed nonmesh repairs, particularly the Shouldice technique, have demonstrated comparable outcomes in selected settings, highlighting the importance of surgical expertise and patient selection. Chronic Pain and Quality of Life Chronic postherniorrhaphy pain has emerged as a critical outcome measure, affecting a significant minority of patients. Mesh implantation may contribute to chronic pain through mechanisms such as nerve entrapment, foreign body reaction, and fibrosis. While most cases are mild, a subset of patients experience persistent pain that significantly impacts quality of life. Emerging evidence suggests that nonmesh repairs may be associated with lower rates of chronic pain in selected patients, particularly when meticulous surgical technique is employed. This has shifted the focus from purely anatomical success to patient-reported outcomes. Mesh-related Complications Mesh-related complications, although uncommon, can be severe and include infection, erosion, migration, and chronic inflammatory reactions. These issues have gained prominence due to litigation and media attention. Resurgence of Nonmesh Repair Rather than being obsolete, nonmesh repair has evolved into a selective, indication-based strategy. Its resurgence is driven by multiple factors, including patient preference to avoid implants, suitability in young individuals, concerns regarding long-term mesh complications, and relevance in resource-limited settings. However, nonmesh repair demands meticulous technique, sound anatomical knowledge, and appropriate patient selection, limiting its universal applicability. Techniques of Nonmesh Repair The principal nonmesh techniques include the Shouldice repair, which involves multilayered reconstruction of the posterior wall of the inguinal canal using continuous sutures and offers the lowest recurrence rates among tissue repairs when performed by experienced surgeons. The Bassini repair approximates the conjoint tendon to the inguinal ligament, representing a classical tension-based method with historical significance but higher recurrence in general practice. More recently, the Desarda repair utilizes a strip of external oblique aponeurosis to reinforce the posterior wall in a tension-free manner, gaining popularity as a physiological and mesh-free alternative. Laparoscopic Era The advent of laparoscopic hernia repair has further strengthened the role of mesh, as minimally invasive approaches are inherently mesh-based. Laparoscopic repair offers clear advantages in bilateral and recurrent hernias, including reduced postoperative pain and faster recovery. In these scenarios, the role of mesh remains largely uncontested. Guidelines and the Risk of Dogma International guidelines uniformly endorse mesh repair as the standard of care for inguinal hernia. However, rigid adherence to guidelines without consideration of individual patient factors risks oversimplification. Surgical decision-making must remain flexible, incorporating clinical judgment rather than dogmatic application of protocols. Ethical and Medicolegal Considerations In the current era, informed consent must include a balanced discussion of both mesh and nonmesh options, including their risks and benefits. Transparency regarding surgeon expertise and institutional outcomes is equally important. Patient autonomy and shared decision-making are central to ethical surgical practice. Toward a Patient-centered Algorithm The choice between mesh and nonmesh repair should be individualized, taking into account patient age, hernia characteristics, tissue quality, comorbidities, occupational demands, and patient preference. While nonmesh (tissue) repair offers advantages such as avoidance of foreign body implantation, reduced risk of mesh-related complications, lower chronic inflammatory response, and cost-effectiveness – particularly in resource-limited settings – it is not without limitations. The outcomes of tissue repair are highly operator-dependent, with recurrence rates closely linked to surgical expertise. These techniques are technically demanding and associated with a significant learning curve. Furthermore, tissue repairs may be less suitable in large direct hernias, recurrent hernias, and in patients with poor tissue quality, necessitating careful selection. Future directions Advances in biomaterials, including lightweight and biologic meshes, improved fixation techniques, and enhanced understanding of pain mechanisms, are likely to refine mesh-based repairs. Concurrently, renewed emphasis on training in tissue repair techniques will help preserve surgical versatility. Future research should focus on risk stratification and personalized surgical approaches. Conclusion Mesh repair remains a cornerstone of modern inguinal hernia surgery due to its reproducibility and low recurrence rates. However, nonmesh repair retains a valid and important role in selected patients. The debate should not be framed as mesh versus no mesh, but rather as choosing the right operation for the right patient. The future of hernia surgery lies in a balanced, patient-centered, and evidence-informed approach that transcends surgical dogma.
Jagdish Gupta (Thu,) studied this question.