Recommendation for NHSScotland

The evidence supports the continued availability of surgical mesh as an option for elective repair of primary ventral hernias, incisional hernias, and primary inguinal hernias, in adults in Scotland.

Patient preference may be for a non-mesh (suture) hernia repair and access to alternative hernia management options should be available to accommodate this.

All elective hernia repairs should be preceded by a detailed discussion between the patient and the surgeon as part of an informed consent process. Points for discussion include:

• the benefits and risks of surgical and non-surgical approaches to hernia management, including the fact that neither mesh nor non-mesh repair are risk-free procedures
• the risk of developing chronic pain following hernia repair, especially for patients with pain as their main presenting symptom, and
• the uncertainty around long-term outcomes from hernia surgery, using mesh or non-mesh repair, given the few studies that followed up with patients beyond 1 year.

Patients should be provided with detailed information on hernia repair in a variety of accessible formats, including verbal and written.

The decision to use laparoscopic or open mesh repair should be based on the patient’s medical history, the characteristics of their hernia, and surgical expertise. The decision on which mesh fixation technique to use in elective hernia repair should be based on surgical expertise, the type and size of hernia, laparoscopic or open repair, and the type of mesh used.

It is important that data on long-term outcomes from hernia repair in Scotland are recorded at a national level to inform future decision-making. This should be aligned with the UK Medical Device Information System and include collection of patient reported outcomes.

NHSScotland is required to consider the Scottish Health Technologies Group (SHTG) advice.

What were we asked to look at?

SHTG was asked by the Scottish Government to explore a series of questions relating to the use of surgical mesh in the elective repair of abdominal and groin hernias in all adults. The research questions included a series of comparisons: mesh versus suture repair, laparoscopic versus open repair, and synthetic mesh versus biological mesh. We were also asked to compare mesh fixation techniques, to assess potential sex-specific differences in outcomes, and to explore patient experiences. Primary ventral hernias, incisional ventral hernias, umbilical hernias, inguinal hernias, and femoral hernias, were selected as being representative of the majority of hernias treated in NHSScotland.

Why is this important?

The use of surgical mesh has become an important topic in the last few years following women’s experiences of severe, chronic pain after mesh was used to treat pelvic organ prolapse. Hernia repairs are one of the most common surgical procedures performed globally, with an estimated 20 million hernia repair procedures each year. Following the impact on women of using mesh for prolapse repair, there is a need to consider the evidence in relation to using mesh to repair hernias in both men and women.

What happened after our advice was published?

• Scottish Government continues to use our advice to inform the provision of mesh and alternatives across all NHSScotland health boards.

• Our advice has been used to informed debate within the Scottish Parliament Public Petitions Committee on the use of mesh across Scotland. On numerous occasions our advice has been quoted in verbal and written responses to parliamentary questions relating to mesh.

• Based on a framework developed by the International Network of Agencies for Health Technology Assessment (INAHTA), our advice is deemed to have achieved a major impact through informing policy and the use of mesh at a local, regional and national level.