Some patients do not want mesh for the repair of their hernia. This is a legitimate choice, recognised by international guidelines, and I perform all the techniques of repair without mesh, including the Shouldice and the McVay. The choice of technique is always a shared decision, made in the knowledge of its main drawback: a higher risk of recurrence than with mesh.
For inguinal hernia, the Shouldice technique remains the benchmark for repairs without mesh. Through an incision in the groin crease, the deep layer of the wall is opened and then reconstructed in several superimposed layers of sutures, leaving no foreign body other than the thread. The risk of recurrence is around 4% in randomised studies, that is, about twice as high as with mesh, with experienced teams achieving lower rates. In return, the risk of chronic pain is lower than with the open technique with mesh (Lichtenstein), according to several studies. It is a demanding technique, less suited to large hernias or fragile tissues.
The McVay technique involves suturing the deep muscle layer to Cooper’s ligament. It is particularly useful for crural (femoral) hernias, with a slightly higher risk of recurrence, of the order of 5 to 10% depending on the series.
For umbilical hernia, repair by simple suture is a reasonable option when the opening measures less than 1 cm. Beyond that, mesh is recommended: in the reference study of hernias measuring 1 to 4 cm, recurrence at 2 years was around 11% after suture, compared with 4% with mesh. Excess weight, smoking and diabetes also increase the risk of recurrence after suture.
We choose together, during the consultation, according to the size and type of your hernia, your profile and your preferences. For the laparoscopic route with mesh, I explain my approach in another article: Inguinal hernia: why I use the laparoscopic approach (TEP).
Dr Grégoire Deroide
Going further
To find out more about the different techniques of hernia repair, with or without mesh, see the dedicated page: Hernia surgery.
