Alex G. Shulman, M.D. ,Lichtenstein Hernia Institute Los Angeles, California
Just over one century ago, Eduardo Bassini, an Italian surgeon, first
described the classic hernia repair that is still in vogue today. The
recurrence rate of that operation has consistently remained
approximately 10% for the past century.
Causes of Early and Late Recurrence of Hernias
There is a weak area in the groin, the floor of the inguinal canal,
which is covered by the fascia transversalis, a flimsy structure of
little strength. This is the only area of the abdominal wall not
supported by muscle layers, and is extremely vulnerable to injury.
Hernial protrusions commonly result.
Clearly, the canal floor requires reinforcement, to correct what nature has failed to do.
This weak area, in which the strong transversus
abdominis tendon is widely separated from the inguinal ligament
(iliopubic tract), is present in at least 15% of males. Forced surgical
approximation of these semirigid structures to close this gap as is
commonly done to correct a hernial defect inevitably creates tension on
tissues or on suture lines and can result in early hernia recurrence.
It is at this site that 50% of hernia failures are found. Another 40%
of recurrences appear initially at the internal ring, along side the
site of emergence of the spermatic cord. Here, secure surgical closure
is prevented by the presence of the spermatic cord.
Late recurrence of hernia repairs can be explained by
the steady deterioration of tissue with age. Defective collagen
metabolism (either decreased formation or increased degradation) has
been shown to result in weakening of tissue with time. This, in
addition to a familial predisposition, explains the increasing
incidence of hernia in persons over 50 years of age. Thus, despite the
many books and countless articles on the subject in the past century,
there has been little improvement in results. Why?
As early as 1890, Billroth, the most famous surgeon of
his day, suggested that the ideal way to repair hernias was to use a
prosthetic material to close the hernial gap. Many materials were
tried, but they all fell victim to the triple headed monster of
infection, rejection and recurrence and proved to be unacceptable.
Compounding the dilemma, was the use of unsuitable multifilamented
suture material, which caused their own special problems. Surgeons
became disenchanted with the popular cotton and silk sutures because of
the frequently tiresome rejection syndrome and the endless recurring
infections that often resulted. The use of such sutures to secure mesh
in place undoubtedly contributed to and aggravated the existing bias
Polypropylene mesh (Marlex) to repair going hernia was introduced by
Francis Usher in 1962, and its early use was not associated with the
complications previously associated with other prosthetics. This record
has been maintained for three decades.
Polypropylene mesh is unique in many respects. It is
monofilamented and thus cannot harbor infection. (Indeed, it is more
resistant to infection than is human tissue.) It is neither allergenic
nor oncogenic (able to cause the growth of cancer). It cannot be felt
by either patient or physician when placed beneath muscle and is not
radiopaque (able to stop the passage of x-rays). It is readily
available, permanent, and will not break, shred, or tear with time.
Perhaps its most valuable feature is that it stimulates fibroblasts to
grow into its interstices, thereby producing an impenetrable
collagenous structure that resembles strong, normal tissue.
Today, many surgeons agree that use of a prosthetic
mesh is the preferred way to repair most recurrent hernias. But why not
prevent such recurrences by using the mesh for the treatment of all
primary repairs? Surgeons who piously insist that no foreign material
should ever be used for hernia repair often select nonabsorbable
monofilamented polypropylene (Prolene) as their preferred suture for
many kinds of operations. Because the Marlex mesh and the Prolene
suture are both made of polypropylene, objections to using the mesh
because it is a foreign body, become pointless.
It should be emphasized that the hernia repair depends on the strength
and permanency of the mesh itself, not on the degree of scar tissue
which subsequently develops in and around the mesh.
Use of the "Patch"
There is an inherent disadvantage of forcibly bringing together the two
sides of a hernia defect. With distorted muscle fibers and later
contraction of muscles, as they normally tense the abdominal wall,
stress can result in the tearing of tissue and the beginning of a
recurrence. However, a simple patch can be expeditiously placed over
the defect thereby correcting the hernia in this way, with no tension
Employing this principle, we began in 1984 to use a
tension-free repair, suturing a polypropylene mesh patch over the
defect without attempting to close the hernial hole. Only 4 failures
have occurred in more than 2,975 primary hernia repairs. Upon analysis,
these failures were readily explained by our use of too small a patch
in the early days of our experience, an error which we quickly
corrected. Since reporting our own success with the polypropylene
patch, we have investigated the results obtained by surgeons in four
other different geographical areas who are now using the same
technique. Less than 1% of wound infections has been reported in
approximately 5,000 operations, and there have been no instances of
The advantages of using the polypropylene mesh
prosthesis are self-evident. The operation is simple to perform and can
be done rapidly. Since it does not create tension on tissues, there is
no post-operative restriction of activity on the part of patients after
operation. It produces permanent repairs with a success rate
approaching 100%, and is virtually free of complications.
The problem with the standard methods of hernia surgery
in patients with Ehlers-Danlos syndrome is the slow and often
inadequate healing of tissues forcibly held together by sutures. It is
this failing which has produced a long saga of repeated recurrences
following hernia operations.
In June of 1992, a woman with EDS, with a troublesome
hernia had been turned down for surgical operation by six surgeons in
her home area in another state. She was referred to us because we are
known for popularizing the tension-free repair of applying mesh and not
sewing together the hernial defect.
Using this approach, she sustained a successful and uneventful repair,
the operation having been carried out on an outpatient basis, under
local anesthetic. She was able to fly back to her home on the second
day after surgery, and has remained well.
While this represents only one patient, it seems
logical that the method should be applicable to others with the same
problem or even to those with recurrent hernias. Should this continue
to be successful when used for other such patients, it may represent a
breakthrough in the ability to offer some help to people with the
1. Lichtenstein IL, Shulman AG, Amid PK, Monttlor MM. The tension-free hernioplasty. Am J Surgery 1989;157:188-93
2. Lichtenstein IL, Shulman AG, Amid PK Twenty questions about hemioplasty Am Surg 1991;57:730-3.
3. Shulman AG, Amid PK, Lichtenstein IL. The safety of
mesh repair for primary inguinal hernias - results of 3,019 operations
from five diverse surgical sources. Am Surg 1992;58.-255-7.
4. Shulman AG, Amid PK, Lichtenstein IL. The "plug" repair of 1,402 recurrent inguinal hernia. Arch Surg 1990;125.265-7
5. Shulman AG, Amid PK Lichtenstein IL. Plug repair of recurrent inguinal hernias. Cont Surg 1992;40:30-
6. Shulman AG, Amid PK, Lichtenstein IL. Prosthetic
mesh repair of femoral and recurrent inguinal hernias: the American
experience. Ann R Coll Surg Engl 1992;74:97-9.