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Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Hernia repair is a cornerstone of general surgery—accounting for up to 1.5 million repairs annually in the US—yet certain patient factors introduce complexities that transcend routine practice and require specialized expertise.1,2
These challenging scenarios include managing patients with chronic illnesses such as liver failure, treating individuals with traumatic hernias, determining appropriateness of mesh use in contaminated fields, and offering elective tissue-based inguinal hernia repairs for a specific subset of patients.
Although mesh-based hernia repair is typically recognized as the gold standard for both inguinal (groin) and ventral (abdominal) operations, no hernia repair method is completely free of risk. Consequently, the surgeon must apply a tailored approach with each patient assessment in order to reduce the risk of recurrence, minimize risks of complications and chronic pain, and optimize recovery.
Hernia Surgery in High-Risk Patients
Hernia specialists typically follow evidence-based algorithms that prioritize patient safety when managing complex scenarios. For example, patients with cirrhosis, heart disease, transplant history, or critical illness will each have a different treatment algorithm tailored to their needs. This customized approach helps mitigate risks of postoperative complications, which may vary or be amplified in each special patient group.
In the case of a cirrhotic patient with a hernia, guidelines published jointly by the American and European Hernia Societies suggest optimizing liver function before elective repair, unless strangulation poses immediate risk to life.3 “Managing complex hernia repairs means tweaking what is your standard of care for a patient in an evidenced-based approach in order to effectively treat those really difficult scenarios,” said Shirin Towfigh, MD, FACS, president and founder of Beverly Hills Hernia Center in California, and a general surgeon who specializes in the treatment of hernias and hernia-related complications.
In high-risk patients presenting with a life-threatening problem associated with a hernia, the dictums of acute care surgery demand that the primary focus of the surgeon should be saving the life of that patient. “The one message that we give, which is not often found in textbooks, is that you don’t need to fix everyone’s hernias,” explained Dr. Towfigh.
“For example, if you’re in surgery for a hernia-related complication like a strangulated femoral hernia with septic shock, you don’t necessarily have to fix that hernia during the first operative session.” In fact, Dr. Towfigh shared a valuable surgical pearl to manage these cases: plug the femoral hernia with an absorbable hemostatic agent at the time of the initial operation. “This simple step allows the surgeon to focus on addressing the dead bowel and getting the septic patient off the OR table. Once the patient is clinically more stable, then you can return to the OR and perform a definitive femoral hernia repair in a more controlled setting,” she explained.
As with all surgical procedures, including hernia repair, the first goal for the surgeon is to address what is killing the patient, and the second goal is to do no harm.
In trauma settings, abdominal wall hernias are commonly accompanied by life-threatening injuries and qualify as situations where the surgeon would prioritize “life over hernia,” noted Dr. Towfigh. A traumatic wall hernia could occur during a motor vehicle collision, fall from a significant height, or via a direct impact blow. Unsurprisingly, the same patient-centered approach for hernia repairs in critically ill patients also applies to trauma patients.
“Usually, if you have someone with a traumatic hernia, they’re going to have not just the abdominal wall ripped off its bony insertion, but maybe also a spleen injury or a bowel injury or broken pelvis or some other distracting injury that is more important than the hernia,” she explained. “It is advisable to avoid addressing the traumatic hernia at that time and focus on saving the life.”
With initial trauma management focused on survival, delaying repair of the traumatic hernia by 6 months can allow for resolution of local soft tissue bleeding and edema, improved compliance of tissue planes, and safer, more effective reconstructive repair. “By delaying the repair of the traumatic hernia, you have a fluid status that is more normal, the massive bleeding from this torn muscle is resolved, and now you’re working in a more fibrotic space,” she said.
Nevertheless, early repair may still be appropriate for patients with massive hernias causing severe quality of life impairment.
“There will be patients who have a massive traumatic hernia that is humongous—as if they’re carrying a baby on their side. So, the quality of life decline from delaying surgery in that patient may not be worth the wait,” noted Dr. Towfigh. “Early treatment, once they’re healed from their acute problems, may be a better choice in a subset of patients.”
It is also important to stress that, no matter the case scenario, the surgeon should not aim for perfection for every individual hernia repair. “Whatever intervention the surgeon decides to pursue, it should consider balancing the patient’s quality of life and the benefit of repairing the hernia in a timely fashion.”
Could Strict Adherence to BMI Thresholds Delay Necessary Care?
For all hernia repair patients, particularly for critically ill and traumatic cases, enhanced recovery after surgery (ERAS) protocols help drive successful hernia surgery outcomes by emphasizing glycemic control, nutritional optimization, nonopioid multimodal pain control, and weight management.
However, Dr. Towfigh and other hernia surgeon specialists support challenging rigid adherence to elective surgery cutoffs for specific patients, particularly individuals living with obesity. “If you strictly follow the ERAS protocol and never offer elective surgery to anyone for a ventral hernia repair with a body mass index (BMI) over 40—what are you actually doing? Are you helping the patient because you can get a great majority of them to lose the weight and then come back to you for elective surgery, or are you punting what could have been a less-than-ideal elective repair into an emergency situation where now you have the on-call doctor who’s not a specialist struggling with a small bowel obstruction, wound complication, or strangulation and unable to provide any reasonable type of hernia repair?” asked Dr. Towfigh.
This is an example of a umbilical incisional hernia, which typically appears as a bulge near the navel.
Elective hernia repair in morbidly obese patients—while imperfect—has the ability to prevent recurrent hospitalizations, bowel obstruction, and emergency surgery with significantly higher complication rates and resource use. Notably, while laparoscopic or robotic-assisted repairs are common approaches for the average hernia patient, open surgery may be necessary in complex scenarios, including in cases with obese patients, in order to enhance visualization of organs and tissue mobilization.
“There is an ongoing discussion in our hernia world that it may be a more humane decision to perform a less-than-perfect hernia repair electively in someone who is morbidly obese and accept the fact that if you do a good-enough repair electively, it could positively impact their quality of life and help them avoid ending up in the emergency room,” explained Dr. Towfigh. “Surgeons need to be able to translate what the research shows with ERAS protocols versus the reality, especially in communities where there is a high obesity rate.”
Long-Term Data Optimize Mesh Repair Decision-Making
Current research reinforces the assertion that mesh-based hernia repair is the standard of care for reducing the risk of recurrence, a practice pattern sparked by a pair of foundational, longitudinal studies that evaluated ventral hernia repair versus primary suture repair. The initial study, published in 2000, described 3-year outcomes revealing a substantial reduction in recurrence with mesh (24% with mesh compared to 43% with suture repair).4
An open abdomen for surgical repair involves a large, vertical incision through the midline of the abdomen.
“Researchers then examined the same cohort of patients and followed them out for a total of 10 years with more or less the same results,” said Arielle J. Perez, MD, MPH, FACS, a general surgeon with PeaceHealth in Springfield, Oregon, specializing in abdominal wall reconstruction and hernia repair. “So, after a decade, 32% of patients with a mesh repair had a hernia recurrence, while 62% of patients with a primary suture repair had a hernia recurrence.”5
Three primary categories of mesh are used in hernia repair surgery: permanent synthetic mesh, biologic mesh, and the newest category—absorbable synthetic mesh.
“Permanent synthetic mesh is the most commonly used mesh and was the first type introduced into clinical practice,” said Dr. Perez.
These meshes—commonly made of polypropylene, polyester, or ePTFE (GORE-TEX)—are designed to provide durable, long-term structural support. Permanent synthetics have the strongest evidence base, particularly in “clean cases,” supported by randomized controlled trials and long-term follow-up. A clean case in mesh hernia repair refers to patients with no signs of infection, inflammation, or strangulation, providing an optimal setting for safe placement of mesh with minimal risk of postoperative infection.
Biologic meshes are derived from human (allograft) or animal (xenograft) tissue, including porcine, bovine, or other sources. The tissues undergo decellularization to remove immunogenic elements, leaving a collagen-rich scaffold that supports tissue remodeling. These meshes were marketed to provide a theoretically safer alternative to treat repairs in contaminated or infected fields. However, they are an expensive option, may stretch over time, and have a higher recurrence rate, particularly when used as a bridge rather than with primary fascial closure, according to Dr. Perez.
“Absorbable synthetic meshes are the newer options on the market, meant to be a cheaper alternative to biologic mesh. Although they are not permanent, these materials are intended to provide safer support in an infected or contaminated field,” she said, noting that these meshes are marketed to reduce long-term complications like chronic infection or pain by degrading over time. “The caveat to this option is that the surgeon should check with their hospitals to determine the true pricing of each product.”
A biological mesh for hernia repair, which can be ideal for complex cases, is designed to reinforce weak abdominal walls while reducing risk of infection.
While permanent synthetic mesh offers the most durable support and strongest long-term data, especially in clean cases, the evidence is more sparse in clean-contaminated and contaminated settings, where infection risk complicates decision-making.
“The difficult—and important—thing to do is find good studies that look at contaminated cases and clean-contaminated cases—findings that are essential for surgeons when performing hernia repairs in settings that are not straightforward,” Dr. Perez said.
The Centers for Disease Control and Prevention (CDC) wound classification system stratifies cases from clean to dirty/infected to assist healthcare providers in assessing degree of contamination and determine risk of surgical site infection. CDC wound classification for mesh repair includes:
Class I (Clean): Elective, no inflammation, no entry into respiratory/alimentary tracts. Low risk; synthetic mesh is appropriate.
Class II (Clean-Contaminated): Controlled entry into respiratory/alimentary/genital/urinary tract. Moderate risk; synthetic or biologic meshes are used.
Class III (Contaminated): Open, fresh, accidental wounds or major breaks in sterile technique. High risk; biologic or bioabsorbable mesh is often preferred to reduce infection.
Class IV (Dirty/Infected): Perforated viscera, clinical infection, or devitalized tissue. Highest infection risk; generally avoid permanent mesh.
While synthetic mesh is standard for clean (Class I) wounds, clean-contaminated (Class II) or contaminated (Class III) scenarios have historically been cases where use of permanent synthetic mesh was anathema and biologic, or absorbable synthetic mesh was used due to concern of complications such as infection, mesh erosion, or fistula formation.
A pivotal multicenter randomized controlled trial study, published in 2022 in JAMA Surgery, examined mesh selection in contaminated settings. Researchers found that in CDC Class II and III cases, synthetic mesh placed in a retromuscular position resulted in significantly lower hernia recurrence than biologic mesh at 2 years (5.6% vs. 20.5%) without increasing the risk of dreaded complications.6
A 5- to 10-year follow-up study, published in 2025 in the Annals of Surgery examining the same patient cohort, revealed similar findings, with recurrence rates of 11.8% for synthetic mesh versus 23.6% for biologic mesh, and no increase in long-term mesh-related complications.7
“You still saw a reduction of hernia recurrence using a synthetic mesh over biologic mesh, and there were no differences in terms of patients requiring any sort of mesh excision. In fact, the only mesh excision in this study came from a biologic mesh,” explained Dr. Perez.
CT scan shows an incarcerated femoral hernia with small bowel obstruction.
The key takeaway from these studies suggests that even in contaminated or clean-contaminated cases, prudent use of permanent synthetic mesh—when placed appropriately—can outperform biologic mesh in long-term outcomes.
Despite these findings, Dr. Perez emphasized the fact that a “perfect mesh for contaminated settings simply does not exist.”
“What we’re worried about with any patient are the potential complications that they may have to endure after surgery, including hernia recurrence, infections, sometimes surgical site occurrences, seromas, and hematomas,” she said. “The more serious complications that we should be considering are related to requiring further surgery and the need to excise the mesh. No mesh is perfect in any sort of clean, clean-contaminated, contaminated, dirty/infected case. It behooves the surgeon to weigh the risk-benefit, think about why they are using the mesh, and what the goal is for that surgery.”
While the data show that the best outcomes are associated with permanent synthetic meshes, how should a surgeon respond if conditions change intraoperatively?
Adaptability is critical in these scenarios, and surgeons should not hesitate to change course regarding mesh type, technique, or staging the repair.
“Having a surgeon who knows the benefits and risks associated with each mesh category is important, especially since some patient factors cannot be defined preoperatively—some of it may be determined by intraoperative factors, requiring a game-time decision,” said Dr. Perez.
Mesh Is Not Always the Answer
For ventral hernia defects measuring larger than 1 cm, mesh repair continues to be the preferred approach to prevent recurrence, although a subset of patients may experience inflammatory or autoimmune responses to these materials, signaling the need for a tissue-based approach.
“When you look at autoimmune diseases, we know that these patients have weaker immune systems, so they may be more prone to infections,” said Samer Sbayi, MD, MBA, FACS, chair of surgery at Glen Cove Hospital in New York, and assistant professor of surgery at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Uniondale, New York. “We also know that people who have a history of asthma, and skin and other allergies may be at a higher level of sensitivity to implanted products.”
This view shows a biological mesh repair.
The autoimmune/inflammatory syndrome induced by adjuvants (ASIA) covers a spectrum of immune-mediated diseases triggered by a variety of factors, including the presence of foreign bodies such as mesh.
“All patients do not react equally to mesh, with some individuals presenting symptoms that could include fatigue, fever, chronic pain, and even some cognitive deficits. We have found that the removal of mesh in these patients can actually relieve them of these symptoms,” he said.
Consensus guidelines from the American and European Hernia Societies support primary tissue repair for patients with primary umbilical or ventral hernias of 1 cm or less with no high-risk underlying conditions, including diabetes, nicotine use, morbid obesity, and chronic steroid use.
As the field of hernia repair continues to evolve, it is important for surgeons to consider the full spectrum of treatment options available, including tissue-based repair.
“Tissue repair is kind of a tricky subject because there is an understanding in the surgical community that tissue repairs don’t work,” said Dr. Sbayi. “Regardless, there are patients who may benefit from this approach, and surgeons should be prepared to address the fact that some patients may want to move away from implantables. As a profession, we need to figure out a better way to have that discussion and actually dig deeper into it. In the end, we are trying to serve our patients in the best way possible.”
The Shouldice technique, a specialized tissue-based approach for inguinal hernia repair, is a highly effective option for patients who are concerned about possible long-term mesh-related complications or prefer a more natural, non-prosthetic solution. Using permanent sutures to overlap four layers of abdominal tissue, the Shouldice technique has a notable recurrence rate of less than 1% and is associated with low infection rates and minimal chronic pain.8
A strangulated hernia is a life-threatening medical emergency where a portion of the intestine becomes trapped in a hernia, cutting off its own blood supply.
Developed in the 1940s at the Shouldice Hernia Hospital in Ontario, Canada, the technique was originally devised during World War II to aid men who were unable to enlist in the military due to their hernias. Dr. Sbayi trained at the Shouldice Hospital (reportedly the only hospital in the world dedicated to this approach) for nearly 2 years before returning to the US as a general surgeon. (Dr. Sbayi performs both Shouldice and mesh-based repairs.)9
“I am from the generation that trained with laparoscopy, with the robotic-assisted approach and mesh—and I had to figure out how to include tissue-based repair into my practice, because for some patients, it is a good procedure, and some of them are actually asking for it,” he said, adding that for patients with a BMI of less than 30, the data show there is a reduced risk of surgical site infections and occurrences.
“I think surgeons have a shared agreement that we do not have a perfect solution for hernia repairs. I just want surgeons to put themselves in their patient’s shoes in order to better understand them when they start asking about what you can do other than a mesh repair,” Dr. Sbayi explained. “The good news is that the profession is definitely better at how we do hernia repairs overall, and mesh has really come a long way. The current macroporous monofilament nature of mesh has seen greater tissue ingrowth, lower bacterial adherence, and decreased biofilm formation, allowing for higher mesh salvage rates and lower recurrence rates.”
As the practice of hernia repair continues to evolve, surgeons are encouraged to remain open to learning both new and established techniques, engage colleagues with specialized experience, and prioritize patient-centered discussions.
Video
Tailored Hernia Repair for Complex Cases
Shirin Towfigh, MD, FACS, offers her perspectives for navigating specialized operative complexities in hernia repair, with a focus on underlying conditions, such as obesity.
Henriksen NA, Kaufmann R, Simons MP, Berrevoet F, et al (on behalf of the European Hernia Society and the Americas Hernia Society). EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances, BJS Open, 2020;4(2):342-353.
Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343(6):392-398.
Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg. 2004;240(4):578-583.
Rosen MJ, Krpata DM, Petro CC, Carbonell A, et al. Biologic vs synthetic mesh for single-stage repair of contaminated ventral hernias: A randomized clinical trial. JAMA Surg. 2022;157(4):293-301.
Remulla D, Carvalho A, Birrell AM, Fafaj A, et al. Mesh-related outcomes of biologic versus synthetic mesh for single-stage repair of contaminated ventral hernias: A five to ten-year analysis of a randomized controlled trial. Ann Surg. 2025; August 2025. Epub ahead of print.
Chan CK, Chan G. The Shouldice technique for the treatment of inguinal hernia. J Minim Access Surg. 2006;2(3):124-128.
