The use of mesh in hernia repair, risk management and the advantages of day surgery


Maurice Brygel,
"Hernia King"

Lecturer University of Melbourne,
General Surgeon,
Sir John Monash Hospital,
Masada Hospital,
Melbourne Hernia Centre
Author: Video Book of Surgery,
Office Procedures – Examination of lumps, tumours and masses (CD ROM);

Office procedures – Local anaesthesia (CD ROM)

Maurice Brygel
19 Merton Street
Phone: +61 (3) 9527 5145
Fax: +61 (3) 9527 1519

Key words: day surgery, hernia, mesh, local anaesthesia


This is the first in the series of articles on hernias and conditions of the scrotum and testes.

This article has been prepared for primary care physicians. The introduction is based on my experience with over 6000 hernia operations. It deals with the history, examination, terminology, basic anatomy, pathology and briefly the different surgical approaches. This is the first in a series dealing with all the common hernias, their differential diagnosis and then conditions of the scrotum and testis.

In Australia the patient must present to the GP to obtain a referral to a specialist – otherwise the government health system will not cover the cost of the consultation or surgical fees.

The adult patient usually notices discomfort or a bulge or both. The patient may relate it to a specific incident – especially at work, for repeated episodes. The swelling is often noticed in the shower whilst standing.

The doctor listens to the description of the onset of the symptoms – it instills confidence into the patient and actually saves time. The history can be important in making a positive diagnosis, and differentiating between hernias and other conditions. Occasionally a patient describes recurring swelling that cannot be demonstrated at the time of examination. The presence of the hernia cannot be found at examination, before careful and repeated evaluation.  

The use of mesh in hernia repair

The patient’s hernia region is then examined. The process should be explained to the patient as palpation of the adjacent scrotal region can cause embarrassment (this is part of risk management in Australia where soaring indemnity payments has become an issue).

The site is first inspected standing up at rest and then whilst coughing and straining. The hernia is usually apparent. During this process all possible sites for hernias should be inspected, including the opposite side for an inguinal or femoral hernia. It is surprising how often an additional femoral hernia or inguinal hernia can be detected in this manner. This avoids referring patients with an incomplete diagnosis. The hernia then may be palpated whilst standing. Then the hernia is palpated whilst the patient coughs and strains – looking for a cough impulse. Care must be taken not to hurt the patient by attempting to forcefully reduce an irreducible hernia.

The patient then lies down and is examined again.

The scrotal and testes region should also be examined whilst the patient is standing and then recumbent. Some conditions are only detected whilst the patient is standing. This includes a saphena varix, varicocele or communicating hydrocoele.

The scrotal contents and the testes and other structures are palpated carefully to exclude other conditions. The findings should be recorded – especially any abnormality. The patient should be advised, for example about the presence of a varicocele, so that following surgery it is not thought to be a complication of surgery (risk management).

Further general assessment firstly of the directly related areas and then other regions is required before giving comprehensive advice.