Can an Open Pre-peritoneal Inguinal Hernia Repair Be Done with a Biological Mesh or Only with a Synthetic One?

There are currently several studies and trials involving the use of biological mesh for inguinal hernias. If you aggregate all the data, it's clear that both biological and synthetic meshes are utilized. In an open approach, any biomesh can be used, especially when it's in direct contact with vascularized tissue, giving it a better chance for a successful repair.

I would recommend considering bovine mesh, such as SurgiMesh, for its efficacy. Additionally, there is a novel hybrid sheep rumen collagen with a permanent or dissolvable plastic layer designed for ease of handling. However, the key factor is the surgeon. The success of the procedure greatly depends on the surgeon's knowledge and willingness to use these innovative products or be open to new research.

The popularity of synthetic meshes can be attributed to years of use. Initial guinea pigs were used during the initial phase, leading to better outcomes over time. If you are paying out-of-pocket and the mesh is relatively safe and well-studied, there is no reason not to use it, especially if it is the only option to alleviate your discomfort or pain.

Biological Mesh vs. Synthetic Mesh

Biological mesh is generally used in situations where a synthetic mesh is contraindicated, such as in cases of infection. For an open pre-peritoneal approach to an inguinal hernia, a synthetic mesh is the preferred choice. In cases of infection, a primary closure without a mesh may be appropriate.

The cost of a biological mesh is significantly higher—5-1 times more expensive—without providing any additional benefits in terms of mesh strength or flexibility. I learned open pre-peritoneal mesh repair during my training and alongside laparoscopic intraperitoneal and preperitoneal repairs. In practice, I exclusively use laparoscopic approaches due to the superior visualization and workspace, ensuring that an adequate and correctly positioned mesh is inserted and secured.

Foreign body reactions are necessary for the mesh to be incorporated into the surrounding tissue. Using biological mesh in a non-infected elective situation would unnecessarily complicate the procedure and increase costs without offering any advantages.

It's important to remember that biological meshes are still foreign materials derived from pigs or human cadavers, and they will either be encapsulated rather than incorporated or completely replaced by scar tissue as the body forms it. This scar tissue, being weaker than synthetic mesh, can stretch over time, leading to hernia recurrence. This is based on my experience, but other hernia surgeons may have a different perspective.

Final word: While the choice between biological and synthetic mesh is subjective, the decision should be backed by research, cost considerations, and the surgeon's expertise.