Laparoscopic / Robotic with Mesh Repair vs. Open Shouldice Repair
A Technical Deep Dive
There is a lot of confusion out there. After years of performing surgery, here is our definitive take and a deep dive into the nitty-gritty of how these two approaches actually work.
Think of a hernia like a hole in the wall. When a hernia repair is performed laparoscopically or robotically, that hole never actually gets closed. Instead, a patch of mesh is merely placed over it.
While the mesh is strong, the repair itself isn't completely structurally solid, allowing it to potentially buckle through the hole. It is like the classic cartoon where someone lays a jacket over a puddle for a lady to walk across—only for her to sink right through because the jacket doesn't have the underlying structural strength to hold her up.
You might ask: Why don't you just suture the hole closed first, and then put the mesh on top laparoscopically?
To understand why, think of the abdominal wall like a book:
Because of the anatomy at the "back cover," there is simply no pliable tissue to stitch together. The gap cannot be safely or durably closed. While a few surgeons describe suturing it closed, doing so carries a high risk because major nerves and blood vessels sit right there. The risk-to-reward ratio is unacceptably high, which is why it is not routinely performed during laparoscopic/robotic surgery.
When undergoing laparoscopic/robotic hernia repair, the surgeon must gently peel back a thin layer of tissue called the peritoneum (back cover) to place the mesh. While this heals beautifully for the hernia, the process naturally triggers the body to form thick, dense scar tissue (fibrosis) in that deep pelvic space. If you ever need surgery down the road in that area, ie prostatectomy (prostate removal), this scar tissue acts like a physical barrier, making the area very difficult for a surgeon to navigate. Because the normal, clean surgical paths are blocked by scarring, subsequent surgeries become far more complex. Studies show that in up to 15% of prostatectomy cases, scar tissue is so severe that a surgeon may have to stop the procedure altogether.
At the very least, it introduces significant technical challenges, including longer operating times and an increased risk of bleeding. Most importantly, this thick tissue can block access to the nearby lymph nodes, meaning the surgeon may not be able to safely remove or clear them during an operation.
When performing an open Shouldice repair, the entire defect is sewn closed. This allows the abdominal wall to heal using its own natural tissue. It works just like a skin cut that is sutured together—eventually, the stitches are removed, and the tissue stays together on its own.
We are also performing the surgery on the “front cover” of the book, well away from any abdominal organs. Any scar tissue created is outside the abdomen.
However, the Shouldice repair does have one limitation: if the hernia gap is too large, it cannot be closed without tension. For any hernia repair to be successful and secure, the tissue must be stitched together without being pulled too tight.
Because of this, for a select 10% of patients, a mesh must be added to reinforce the Shouldice repair. The upside to this scenario is that you get a "double repair"—the hole is fully closed, and the mesh is there for extra reinforcement. Contrast this with standard laparoscopic/robotic mesh repairs, which only cover the hole while leaving the defect entirely wide open.
Fortunately, for 90% of patients undergoing a Shouldice repair, the hernia can be completely closed without using any mesh at all.
On face value, using an absorbable mesh that eventually disappears sounds like a great idea. The theory is that the mesh will trigger your body to create scar tissue, and when the mesh dissolves, that scar tissue will bridge the gap. Think of it like building a bridge over a river out of materials that melt away. It might get you across the river the first time, but you still need that bridge to be there when you want to return.
While absorbable mesh sounds nice in theory, it does not work well in the real world. Countless clinical studies show an incredibly high hernia recurrence rate when absorbable mesh is used. Because of this, the only true indication for using an absorbable mesh is an acute surgical emergency where an active infection is present inside the abdomen.
