Imagine a tire with an inner tube inside. The tire is your abdominal wall and the inner tube is your intestine. If the tire develops a hole, the tube pokes through. A patch on the inside of the tire is the strongest fix, because the tire's own pressure holds the patch against the hole. Putting the mesh behind the abdominal wall uses the same physics, and it keeps the mesh away from two of the three groin nerves that cause most chronic pain.

In our published ACHQC registry data, this repair had better patient-reported outcomes than the on-top-of-the-muscle Lichtenstein repair over 10 years [2]. Compared with laparoscopic and robotic repair, recurrence was the same, early quality of life was slightly better, and 18% of patients used opioids at 30 days versus 45% [3]. And no general anesthesia.

We do about 100 Shouldice repairs a year. Dr. Reinhorn trained with the team at Shouldice Hospital in Toronto, and we have offered it since 2015. The hernia is repaired by sewing the layers of the abdominal wall together in four separate layers, with no mesh. The best candidates are thin, healthy patients with small to moderate hernias.

Done at high volume, tissue repair works well. Recurrence at the dedicated Shouldice Hospital is near 1.2% [4]. In our own matched comparison, the mesh repair gave less pain and better quality of life through one year, with no difference in recurrence [5]. We go through both options at your consult, and you choose.

Fear of mesh is legitimate, and we take it seriously. Mesh goes into more than one million people a year with few complications. The real problem is chronic pain, which affects roughly 10 to 12% of patients across all techniques, severe in a smaller group [6]. In our opinion the main driver is mesh or fixation sitting near the groin nerves in on-top repairs. Behind the muscle, the mesh stays away from two of the three nerves. That is a large part of why we do it this way, and why chronic pain is rare in our patients.

There are two options. The first is a mesh repair: through a small incision at the navel, the tissue is reduced, a small mesh is placed under the abdominal wall, and the hole is sewn closed over it in a durable two-layer repair. The second is a suture-only repair, reserved for thin, healthy patients, especially women with hernias from pregnancy.

For hernias 1 to 4 cm, a randomized trial found mesh cut recurrence from about 12% to about 4% [7], and international guidelines recommend a flat preperitoneal mesh for most patients [8]. For a small hernia in a thin patient, especially after pregnancy, sutures alone are reasonable.

Yes. Women more often have femoral hernias. A femoral hernia sits lower in the groin, where tissue pushes through the femoral canal alongside the femoral blood vessels and nerve. The wider shape of the female pelvis makes them more common in women: more than 30% of groin hernias in women are femoral, versus 2 to 3% in men. Because the opening is small, a femoral hernia is more likely to become incarcerated or strangulated, and that is why guidelines advise timely repair rather than waiting [1].

This video covers what women should know.