Medium-Weight Mesh Fails to Reduce Chronic Pain and Other Complications of Ventral Hernia Repair

Miriam Davis, PhD

September 16, 2021

Chronic pain is a common and feared complication of ventral hernia repair. Pain affects up to 39% of the estimated 348,000 Americans who annually undergo ventral hernia repair. Pain may contribute to new, persistent opioid use, poorer quality of life, and emergency department visits — all of which may figure into the estimated $3.2 billion annual cost of ventral hernia repair in the United States.

A new study, published online September 15 in JAMA Surgery, sought to determine whether widely used heavy-weight polypropylene mesh, which is the surgical standard, might be contributing to patients' chronic pain. For ventral hernia repair, the mesh is sandwiched within the abdominal wall to reinforce the site of the breach. Mesh for ventral hernia repair is responsible for cutting recurrence rates by 50%. Would lighter-weight mesh successfully keep recurrence rates down while also reducing chronic pain?

Lighter-weight meshes have been introduced in recent years with that in mind. They are intended to decrease the overall amount of foreign body material, improve adherence to tissue, and thereby cut reactive scar formation, yielding less pain. But these benefits have not been put to rigorous test — until now.

Investigators at the Cleveland Clinic and at three other centers hypothesized that medium-weight mesh would improve pain 1 year postoperatively in comparison to heavy-weight mesh. But the results of their randomized clinical trial were unequivocal and unexpected: the medium-weight mesh failed to improve pain, quality of life, and other patient-reported and clinical outcomes.

The study recruited a total of 350 adult patients who required open retromuscular ventral hernia repair with a width of ≥20 cm. The median age of participants was 59.2 years. The single-blind study prevented patients from knowing whether they were receiving the heavy- or medium-weight mesh. The surgeons, on the other hand, could not be blinded. The primary outcome was pain at 1 year, as assessed by the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity Short Form 3a.

Secondary outcomes included pain and quality of life 30 days postoperatively, quality of life at 1 year, patients' awareness of the mesh, and 1-year hernia recurrence, among others. Quality of life was assessed by the abdominal-wall-specific, hernia-specific quality of life (HerQLes) questionnaire. Recurrence rates at 1 year were determined on the basis of a composite of three measures: physical exam, the Hernia Recurrence Index, and CT scan.

No differences were found between the medium-weight mesh group and the heavy-weight mesh group on all primary and secondary outcomes.

  • There were no differences in pain at 30 days and 1 year.

  • There were no differences in quality of life at 30 days and 1 year.

  • There were no differences in the composite 1-year recurrence rate (8% in the heavy-weight vs 7% in the medium-weight group; P = .79).

Dr David Krpata

Patients were asked, "Do you feel your mesh?" Despite the differences in mesh weight, patients' perception of mesh within their abdominal wall was about the same across groups (19.1% of the heavy-weight vs 18.1% of the medium-weight mesh group; P = .93). On a positive note, both groups experienced an improvement in quality of life from baseline to 1 year. HerQLes scores for both groups shot up from around 35 at baseline to about 90 out of 100 at the 1-year point.

Dr Brent Matthews

"The study concluded that medium-weight mesh does not provide benefit over heavy-weight mesh for pain and other outcomes. Based on our trial of clean cases of [retromuscular ventral hernia repair], we advise others to feel comfortable with either mesh. But longer-term data are needed on the question of durability of the medium-weight mesh," said first author David Krpata, MD, director, Cleveland Clinic Center for Chronic Groin Pain and General Surgeon at the Cleveland Clinic, in an interview with Medscape Medical News.

Brent D. Matthews, MD, surgeon-in-chief and chair, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina, who was not involved with the study, sees the study's bottom line somewhat differently. "Innovation [with the medium-weight mesh] is not providing the benefit you would think from its biomechanical properties," he told Medscape Medical News. "Based on the available evidence, I would continue to use the heavy-weight polypropylene mesh for open retromuscular ventral hernia repair until longer-term follow-up [to 5 years] is completed on recurrence rates."

Krpata and Matthews report no relevant financial relationships

JAMA Surg.Published online September 15, 2021. Full text

Miriam Davis, MD, is an award-winning freelance medical writer of more than 1000 articles over a 25-year career.

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