Yes. In fact, inguinal hernia surgery in our modern era goes back about 150 years, and for almost a century, was based on reconstructing the patient's own tissues (i.e. no mesh). In the past 70 years or so, mesh has become increasingly the standard in repair of the groin hernia due to more reproducible results (i.e. more surgeons are able to achieve good results). Having said that, the Shouldice Clinic in Canada has been consistently producing excellent results (recurrence rates around 1% or less) for decades, and a handful of surgeons experienced in the technique also offer it. There has also been an ongoing interest in other non-mesh techniques, such as the Desarda repair (first described in 2001) and the Kang repair (a modification of the Marcy repair), and a combination of techniques.

Dr. Cober's Take:
Yes, in properly selected patients, non-mesh repairs should give comparable outcomes in terms of recurrence rate, and probably may be slightly improved in terms of pain and long-term overall outcomes.

The short answer is that we are not yet sure. Most in the surgical community would answer that the Shouldice operation is the best non-mesh inguinal hernia repair. But some advocate the Desarda repair or the Kang repair. Furthermore, many experienced surgeons do hybrid techniques based on patients' individual factors and anatomy. Having said that here are some of the pros and cons of Shouldice and Desarda:

1. Shouldice:
PRO: 

• longer history and presence in the surgical literature with lower recurrence rates

CONS: 

• theoretically the tissue tension is moderate

• more surgeon skill / experience required

2. Desarda:

PROS:

• tissue tension is low

• technically easier / more reproducible for surgeons

CONS:

• theoretically more of a concern with a weak inguinal floor

• newer than Shouldice with less experience in the surgical community

Dr. Cober's Take:
I like to tailor things. I think repairing the floor is best done with some of the principles from the first two layers of the Shouldice. The Desarda flap is excellent to keep tension on the repair down. The Kang repair seems interesting, I personally don't have much experience with it, so I would combine it with other repairs.

Most experts agree that having a skilled and experienced surgeon is most important with surgical success long-term. Having said that, published rates of recurrence in general for inguinal hernias range usually from 1 to 10%, with non-mesh repairs having a slightly higher recurrence.

Dr. Cober's Take:
In patients who are good candidates for non-mesh and who follow the activity restrictions for the first month after surgery, we should see a recurrence rate no higher than 1-3%.

1. MYTH: All hernias must be repaired as soon as possible

Many small and asymptomatic hernias are safe to observe ("watchful waiting") and have a low risk of serious complication (probably less than 1% per year). Hernias that are painful or growing would more likely warrant repair.

2. MYTH: Open surgery is much more painful than robotic surgery

Hernia surgery performed by expert surgeons is generally well-tolerated regardless of the technique. Many of our patients with open repairs do not use strong pain medicines for more than a day, and some do not even use any strong pain medicines.

3. MYTH: Robotic surgery is always best

Different hernia surgery techniques have pros and cons which are unique to each patient and their situation. We do not only do one technique, but rather seek to employ the best, least invasive, and safest technique based on a patient's particular anatomy and physiology.

The open repair is the classic approach to the inguinal hernia, having been performed for over a century. It has had excellent results over the years and in the US has slightly fallen out of favor with many surgeons as new technologies with laparoscopy have been adopted. The open approach allows an operative field which can address femoral hernias, mesh and non-mesh repairs. Another benefit of the open repair is that it can be done under light sedation and local anesthesia.

Dr. Cober's Take:
I have a lot to say about open inguinal hernia repairs. I hear many surgeons comment about how the new laparoscopic techniques are much better and less painful. But I question if we are talking about the same open operation. While I agree there is a place for laparoscopic and robotic repairs, I believe that open repairs are excellent. When done using careful technique, the post-op pain is similar, and any differences are even more negligible with the use of exparel (long-acting local anesthetic). Furthermore the risk of major complications from open hernia repair is extremely low and I consider it to be very often the best balance of safety and reliability. 

Dr. Cober's Technical Tips To Reduce Pain:
- Clearly identify the three named nerves (iliohypogastric, ilioinguinal, and the genital branch of the genitofemoral nerves) and avoid them with any sutures.
- Do not skeletonize the ilioinguinal nerve.
- Any small branches from the ilioinguinal and genital banch nerves that must be divided can be divided deliberately (and sparingly).
- Do not skeletonize the cord, simply reduce/ligate the sac and any cord lipoma.
- Repair the floor by double breasting the transversalis fascia rather than performing a Bassini.
- The superior sutures to the conjoint tendon should not be too tight to prevent long-term cutting through the muscle like a seton.
- Use liposomal marcaine.
- For the Lockwood repair: if using a small plug, remove the inner petals, and use the anatomy such that the plug is effectively a flat mesh with small overlap -- place the knots inside the plug, and get the Cooper's ligament stitches low down on the plug, and the inguinal ligament stitches "higher up" on the plug.

Prior to the introduction of the surgery robot, most progressive surgeons were utilizing the TEP technique. Sometimes referred to as a "laparascopic inguinal hernia repair," the technique actually keeps the surgical instruments out of the peritoneal cavity, thereby keeping a layer of protection (the peritoneum) between the surgical field and the bowels. The downsides of this approach are that it is technically difficult and requires a fair amount of expertise as the working space is limited. The upsides are that it is a very efficient operation and there is no peritoneal flap that could be a source of adhesions later in life.

Dr. Cober's Take:
The TEP approach is my preferred approach for posterior repairs when mesh is desired or to address femoral hernias.

Dr. Cober's Technical Tips To Reduce Pain:
- Use cautery sparingly but do try to keep the field dry for visualization.
- Do not skeletonize the vas and the gonadal vessels.
- Keep a layer of fascia and fat on the sidewall laterally to protect the nerves from the mesh.

Many surgeons nationwide now prefer to do inguinal hernias robotically with the surgery robot. Note that while it is called a robot, it is not autonomous, rather it is an elaborate piece of equipment that transmits directly the surgeon's movements at a control console to the instruments which are inside the abdomen. One of the reasons why this technique is becoming more widely adopted is that the robotic platform provides very high-definition visualization and precise movements of the instruments. In short, it makes laparoscopic surgery much easier to perform. The downsides of this approach are that it requires general anesthesa, and is most often done by entering the peritoneal cavity and creating a peritoneal flap which is then sutured closed at the end of the procedure -- while this usually has no noticeable downside, there have been times when patients have had bowel obstructions or herniation through failures of the peritoneal flap closure.

Dr. Cober's Take:
The robotic approach I think gives us the most bang for our buck in overweight patients when the other techniques are technically more challenging -- however it is always best to get down to a good weight prior to the operation, not only for the hernia outcome, but for overall health and well-being.

Dr. Cober's Technical Tips To Reduce Pain:
- Use cautery sparingly but do try to keep the field dry for visualization.
- Do not skeletonize the vas and the gonadal vessels.
- Keep a layer of fascia and fat on the sidewall laterally to protect the nerves from the mesh.

The following are principles of "prehab" (preconditioning and optimization prior to surgery) for hernia surgery:

1. Get to goal weight -- a rough guide would be BMI 25 or under (BMI calculator site).

• This is very important with decreasing recurrence rates, especially with no-mesh repairs. 

• Achieve this with:
  i. Diet
  ii. Healthy lifestyle
  iii. Exercise (cardio + strength) 

2. Core strength: 

• Strengthening the muscles improves the tissue quality at time of surgery. 

• Muscles to focus on in the core:
  i. Rectus abdominis
  ii. Obliques
  iii. Balance the above with the erector spinae 

• Stretching is good to do after exercises. 

• We recommend doing 5-10 minutes of core exercises daily (more is better, but this is quite sustainable in the long-term). 

To help achieve these goals, please refer to our healthy lifestyle page, other resources such as healthy diets, and core exercise plans such as pilates. Also of note, the Hernia Coach is available to help patients and has a very informative website.

Here are links to interesting reading:

• The history of inguinal hernia surgery

Inguinal hernia papers:

• Long Term Outcomes after Surgery for Inguinal Hernia: a Retrospective Cohort Study Comparing Outcomes of Desarda and Lichtenstein Repairs with Three Years of Follow-Up
  Desarda versus Lichtenstein inguinal hernia repair: A meta-analysis of randomized controlled trials

• Novel modification of Marcy operation for indirect inguinal hernia reconstituting deep inguinal ring shutter action

• Shouldice technique versus other open techniques for inguinal hernia repair

• Shouldice Versus TAPP for Inguinal Hernia Repair: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

• Shouldice versus Lichtenstein inguinal hernia repair: A meta-analysis of randomized controlled trials

• Mesh versus non-mesh for inguinal and femoral hernia repair

• Is Shouldice the best NON-MESH inguinal hernia repair technique? A systematic review and network metanalysis of randomized controlled trials comparing Shouldice and Desarda