as surgeons gain experience caring for hernia repair patients , techniques continue to evolve and clinical outcomes continue to improve . surgical repair of hernias is one of the most common operative procedures performed , and there is no single gold - standard operative technique in hernia repair . the decisions about which techniques to use are not well defined , and instead the choice depends on tradition , context , and familiarity with the type of hernia . the debut of the first mesh indicated for hernia repair was in 1958 with the introduction of polyethylene mesh by usher et al . . the use of synthetic meshes was a milestone in hernia repair and led to the development of many other mesh products of various polymer types , densities , and elasticity . since the introduction of polyethylene mesh , there has been an increased reliance on the use of mesh in hernia repair , either for bridging the defect or for reinforcing the abdominal wall . meanwhile , identifying the right mesh for the right patient can be a difficult , if not impossible , task . at the 30th international congress of the european hernia society , nine international experts in hernia repair and experimental mesh evaluation participated in a roundtable discussion about today s unmet needs for hernia repair , including defining optimal hernia repair outcomes and the portfolio of  ideal  mesh prostheses . understanding the technical and general definition of  lightweight  and  heavyweight  mesh can be difficult as there are no official definitions or consensus on classifications . the panel evaluated connotations associated with existing lightweight hernia mesh nomenclature and discussed the technical aspects to approach a working definition . most surgeons in the united states have had few problems with heavyweight mesh , reporting few recurrences and complications . the use of heavyweight meshes is associated with increased complications and adverse events , such as fistula and adhesion formation and pain [ 4 , 5 ] . although these complications are mainly observed during intraperitoneal application , they have also been observed as a result of extraperitoneal placement . heavyweight meshes have an increased surface area and , therefore , produce a more intense foreign body reaction . they also tend to shrink more than lightweight meshes and are stiffer , which can make normal abdominal movements difficult or unnatural . the panel agreed that today the term  lightweight  is no more than a name alluding to the recent history of marketed meshes . the term  lightweight  is not always simply descriptive of the product being low in weight , nor can it be simply defined by a cutoff value of weight per square meter , filament , or specific pore size . lightweight typically refers more to meshes with a larger pore size , resulting in a smaller surface area . the lower amount of material present in lightweight meshes should lead to decreased foreign body reaction and fibrosis . conceptually , lightweight meshes are more flexible , both before and after tissue integration , which should improve physical properties , allowing a better activity profile post - surgery . this is most likely not at the expense of the strength of the repair , as the type of nonabsorbable synthetic mesh used for hernia repair is not related to recurrence rates . conversely , implant rigidity of heavyweight mesh has led to greater complications and adverse events , such as pain and foreign body reactions . although the panelists agreed that current lightweight meshes have a larger pore size with a smaller surface area and are more flexible than heavyweight mesh , they could not agree on the specifications for the characteristics . recently , hollinsky et al .   performed biomechanical studies on lightweight versus heavyweight mesh . thickness and weight were used to distinguish lightweight ( < 0.5  mm thick , < 1  g ) from heavyweight ( > 0.5  mm thick , > 1  g ) for mesh measuring 15    10  cm . however , the pore size overlapped between groups ( 1.243.0  mm for lightweight , < 12.0  mm for heavyweight ) . while the holinsky article presents a good basis for characterizing lightweight and heavyweight meshes , the panelists believed that pore size is the most important determinant . throughout this article it is recommended that the appropriate organizations determine the characteristics for each mesh . in other words , there is an urgent need for further standardization of mesh classification beyond that already available . looking beyond the features and benefits of meshes to discuss the key needs and expected results of hernia repair , it is necessary to understand the pathology of hernia . quality of collagen , for example , is important in the pathophysiology of hernias and plays an important role in repair . the purpose of surgical meshes in hernia repair is to reinforce and replace tissue for long - term stabilization of the abdominal wall . there are different requirements for inguinal repairs versus ventral repairs , small hernias compared with large hernias , and open approaches versus laparoscopic techniques . small hernias can be repaired with most mesh types , whereas it is much more difficult to find an effective mesh for larger hernias . for pelvic floor hernias , meshes that produce strong foreign body reactions can result in a large number of complications , including fibrosis and pain . further , there tends to be an increased prevalence of nerve entrapment with the use of heavyweight mesh in inguinal repairs . an ideal portfolio of meshes would have the benefits of both heavyweight and lightweight meshes , such as the strength of a heavyweight mesh and the flexibility of a lightweight mesh with none of the adverse events . one aspect of all mesh repairs that needs improvement is attachment to the abdominal wall . current meshes on the market could be faster and easier to implant , whether deployed laparoscopically or through an open incision . this expediency would lead to shorter operating times , appealing to both the patient and the surgeon . the panelists agreed that more than one mesh type is required to accommodate the many possible patient / situation needs . mesh requirements depend on technique and mesh position with respect to the abdominal wall ( extraperitoneal versus intraperitoneal ) . the surgeon should have the ability to choose a mesh device suited to each patient s particular hernia condition . mesh development is an ongoing process , reflecting changes in polymer structure , biocompatibility , operative handling , and cost . ideal  portfolio of meshes resemble ? the panel s conversation began to distinguish the mesh characteristics according to different surgical needs , but generally the mesh features desired in four common surgical procedures ( open ventral , open inguinal , laparoscopic ventral , and laparoscopic inguinal hernia repairs ) were very similar . the topics discussed were pore size , geometry , active surface area , mesh memory , affinity for water , elasticity , and polymer type . according to the panel , a good mesh will have negligible foreign body reaction with no pathologic fibrosis . the panel pointed out that pore size can affect adhesions following intraabdominal placement , tissue integration , active surface area , elasticity , and memory . the heavyweight microporous meshes have a lower risk of tissue - to - mesh adhesion but carry a risk of encapsulation and foreign body reaction , resulting in decreased integration . lightweight macroporous mesh results in better tissue in - growth and lower foreign body reaction but may lead to a higher risk of adhesions . a larger pore size also provides optimal flexibility for improved physical properties , allowing a better activity profile post - surgery , but relinquishes memory , which is important for handling during the procedure . despite the absence of a formal approval on package inserts for many synthetic mesh products , the panel agreed that larger pore meshes seem to be safe to use in contaminated environments . the panel also agreed that a monofilament mesh with a pore size of > 2.5  mm seems ideal , although some authors recommended pore sizes as large as 3 and 6  mm . in all hernia repair techniques , a strong mesh is important for augmentation of the abdominal wall and to prevent recurrences . the panel agreed that a tensile strength of 16  n was probably more than sufficient to augment the abdominal wall ; for bridging of large defects , an increased tensile strength of 32  n may be necessary . the panel concluded that mesh should be flexible but also have a good memory , and it should have elasticity in more than one dimension , allowing it to stretch in more than one direction and then return to its original shape . in this way flexibility and memory , which make a mesh more adaptable , are also important to optimize the surgical handling of the mesh . the mesh should have an adequate adhesive quality that requires minimal or no additional fixation , even for large defects . in both laparoscopic inguinal and ventral procedures , the need for a mesh that is flexible with good memory was emphasized . in open inguinal lichtenstein repairs , a mesh with improved adhesive properties , especially at the ends , is seen as optimal . for laparoscopic ventral hernia repairs , the mesh composition needs to form an adequate barrier between the viscera and the mesh . although tissue separation properties are not required in other hernia repairs , the panel agreed that mesh used in intraabdominal mesh repair should have a solid absorbable barrier that prevents adhesion to the intestines . as adhesions begin to form immediately , the barrier should absorb slowly enough to prevent formation of adhesions . the panel also concluded that the parietal fraction of the mesh should have a good capacity for in - growth , and the construction should be strong enough for adequate bridging and augmentation . microporous materials with a strong affinity for water have been developed to reduce the risk of adhesion formation , but these materials lack adequate tissue integration and are more likely to cause recurrence . as a result , composite meshes were developed with a smooth microporous surface on one side for contact with the viscera , with the other side designed for appropriate tissue integration . according to the panel , an ideal mesh would be a monofilament mesh that would prevent adhesions yet still enable growth of the adjacent tissue for optimal augmentation . the desire for a transparent mesh for use in all hernia repair techniques was also discussed . transparency would assist proper placement of the mesh and possibly lead to a decrease in recurrence rates , pain , and other possible adverse effects , potentially leading to improved quality of life . in some institutions , surgeons seldom have their choice of mesh products available for use in hernia repairs . in these cases , the meshes stocked in the operating room reflect the least expensive options on the market . so , in order to complete the theoretical construction of the  ideal  mesh , prices should be reasonable . while mesh was the primary discussion topic , the panel addressed alternatives as well . myofascial transposition , in which lateral components are separated , is a technique popularized over the past 1015  years . this more functional repair tends to have high recurrence rates and is , therefore , primarily reserved for massive midline hernias in which currently available meshes are inadequate . absorbable biological and biosynthetic materials are not often used and have not lived up to initial expectations . these materials are also associated with high failure rates , not only in abdominal and inguinal hernia repair , but also in pelvic floor hernia repairs [ 15 , 16 ] . therefore , these materials are reserved for situations in which mesh is not appropriate , such as in septic conditions , and even then they might be prone to recurrence and graft - related complications . while the future of these biological materials looks hopeful , the currently available products are not yet adequate for successful hernia repair . the panel concluded that animal models resembling the human hernia are a useful tool for researchers to investigate hernia treatment options . the current animal models used to study hernia repair are not perfect , and panel members have had hands - on experience with a variety of these . from their experiences , the panelists agreed that artificially created hernias in animals are poor hernia models as they do not truly recreate the biological defects that cause hernias , such as collagen defects . furthermore , the defects that are created to test mesh products are not real - world defects that surgeons would encounter . in order to serve as a useful model , one factor when considering an animal model is similarities in the elasticity of the abdominal wall . although the panel did not reach a consensus for the most appropriate test or animal model , they agreed that animal models are useful when comparing different meshes in the same species either in vivo or ex vivo . studies in humans and large animals are the only way that most issues , such as elasticity , chronic pain , foreign body reaction , and adhesion , will be observed . what problems animal models can solve and which animals are the most appropriate for use will differ depending on the purpose of the study . animal models currently used include rodents , rabbits , pigs , and primates . small animals or even cell cultures are instructive for studying the inflammatory reaction and biocompatibility , but for abdominal wall function and elasticity , larger animals are more suitable . the panel agreed that although ineffective for other comparisons , pigs are useful to simulate mesh implantation within the human body as pigs have a similar body size to humans , and further work is being conducted to recreate human collagen problems in swine . sheep and rabbits are reasonable models to mimic vaginal operating conditions ; potentially , they are also useful models for pelvic floor damage due to pregnancy and birth , although the latter has not been formally studied yet . for these patients , it is difficult to imagine a more imperative issue . according to some studies the panel agreed that chronic pain , stiff abdomen , and foreign body sensation are least often observed with the use of a lightweight mesh and a laparoscopic approach [ 4 , 8 , 19 ] . a truly successful hernia repair requires effective bridging or augmentation that will prevent recurrence , but the panel agreed that complete avoidance of recurrence is unlikely . recurrence rates tend to be higher in patients who are obese , smoke , are older , have anemia , or are male [ 20 , 21 ] . if reoperation is required in the event of a recurrence , the incidence of chronic pain increases . there seem to be inconsistencies in the way recurrences are reported , especially in clinical trials , which affects the available clinical data . a recurrence may be anatomical but not functional , or it may be both . it is possible to have an asymptomatic or not visible recurrence , which may only be seen during ultrasound examinations ( subclinical ) . clinical trials that do not use ultrasound potentially miss some recurrences that are not clinically obvious . secondary to chronic pain and recurrence are foreign body reactions , seroma formation , quality of life with a return to normal activity , infection , comfort , and cosmesis with minimal scarring . a successful procedure is one in which a patient has no sensation of the foreign body , no stiffness , and can return quickly to normal activity . according to the panel , quality of life and comfort are influenced by many factors and should be measured before and after surgery . the carolina comfort scale and the swedish pain questionnaire are specifically used for patients with hernias , and the 36-item short form ( sf-36 ) is used as a measure of general well - being [ 22 , 23 ] . although these tests are useful , the panel agreed that a better questionnaire is needed . foreign body reactions , such as seromas , can present more than 1  year after surgery . tissue mobilization is important to prevent seroma formation , and binders may help reduce fluid formation . seroma formations are common in laparoscopic procedures , and the panelists agreed , based on their own experiences ( and from published data ) , that lightweight meshes result in fewer seromas [ 25 , 26 ] . the hernia repair process should begin with informing the patient about the procedure , signs and symptoms of infection , and recurrence , and how to distinguish between normal or abnormal pain and discomfort . following patient education , technique should be considered , which is the most important factor of success . most surgeons are hesitant to modify their surgical methodology but understand that technical advances , such as mesh repair , are important to include into practice . the panelists agreed that in the groin , the right technique can minimize or completely prevent pain . the ideal technique includes a high - quality dissection , maximum visualization , maximum coverage of the anatomical defect using wide overlap , and minimum fixation . the procedure should consider both the physiology of the hernia region and the integrity of the spermatic cord . in order to eliminate chronic pain and stiffness , optimal mesh flexibility and elasticity ensure a quick return to function , and heavyweight mesh should be avoided as it can cause chronic pain due to retraction and tends to reduce the ability of the abdominal wall to move in a normal fashion . good cosmesis with no seroma formation and minimal scarring are ideal for both the patient and the surgeon . the optimal hernia repair will result in minimal adverse events , such as pain , foreign body reaction , and seroma formations . the panel concluded that an optimal clinical outcome is a repair that is free from recurrence , pain , and infection , with minimal scarring and with improvement in patient s quality of life . the role and responsibilities of the surgeon with regard to training , experience , and interaction with the patient are important to understand if outcomes are to be optimized . surgical residency training with mentors who are experienced in hernia repair or in hospitals that perform large numbers of herniorrhaphies even with experience and good operative technique , there will still be issues that the surgeon can not control . residency training today is insufficient , and residents should be exposed to more cases to enhance their education . fellowships for minimally invasive surgery can improve the skills of commonly performed surgeries , including hernia repair , and are a good option for surgeons who are leaving residency programs . the prevalence of pelvic floor prolapse problems is increasing , and more gynecologic surgeons are needed with the skills to perform these repairs . due to the increasing number of pelvic floor hernias most hernia repairs are performed by general surgeons and have good results , but there are still improvements that can be made to address the unmet educational needs of surgeons . while the number of hernia repair centers is increasing in the united states , the constructs of socialized medicine often preclude other countries from creating such arrangements . deciding whether or not to use mesh for hernia repair can be a difficult task . with the advent of laparoscopy , the use of mesh has become commonplace for hernia repair and is increasingly popular for use even in young patients . furthermore , in open repair of incisional hernias , the use of mesh is recommended . even using surgical mesh with a lichtenstein repair is a technique gaining in popularity in less developed countries . according to the swedish hernia registry , high recurrence rates have been reported in hernia operations performed without mesh , suggesting that mesh should always be used . patient involvement is encouraged if the patient is properly educated and can help inform the decision of using mesh . ultimately , the choice of whether or not to use a surgical mesh is the surgeon s prerogative . age , smoking status , pre - existing medical conditions , and patient activity level are all factors that need to be considered when making this determination . understanding the technical and general definition of  lightweight  and  heavyweight  mesh can be difficult as there are no official definitions or consensus on classifications . the panel evaluated connotations associated with existing lightweight hernia mesh nomenclature and discussed the technical aspects to approach a working definition . most surgeons in the united states have had few problems with heavyweight mesh , reporting few recurrences and complications . the use of heavyweight meshes is associated with increased complications and adverse events , such as fistula and adhesion formation and pain [ 4 , 5 ] . although these complications are mainly observed during intraperitoneal application , they have also been observed as a result of extraperitoneal placement . heavyweight meshes have an increased surface area and , therefore , produce a more intense foreign body reaction . they also tend to shrink more than lightweight meshes and are stiffer , which can make normal abdominal movements difficult or unnatural . the panel agreed that today the term  lightweight  is no more than a name alluding to the recent history of marketed meshes . the term  lightweight  is not always simply descriptive of the product being low in weight , nor can it be simply defined by a cutoff value of weight per square meter , filament , or specific pore size . lightweight typically refers more to meshes with a larger pore size , resulting in a smaller surface area . the lower amount of material present in lightweight meshes should lead to decreased foreign body reaction and fibrosis . conceptually , lightweight meshes are more flexible , both before and after tissue integration , which should improve physical properties , allowing a better activity profile post - surgery . this is most likely not at the expense of the strength of the repair , as the type of nonabsorbable synthetic mesh used for hernia repair is not related to recurrence rates . conversely , implant rigidity of heavyweight mesh has led to greater complications and adverse events , such as pain and foreign body reactions . although the panelists agreed that current lightweight meshes have a larger pore size with a smaller surface area and are more flexible than heavyweight mesh , they could not agree on the specifications for the characteristics . recently , hollinsky et al .   performed biomechanical studies on lightweight versus heavyweight mesh . thickness and weight were used to distinguish lightweight ( < 0.5  mm thick , < 1  g ) from heavyweight ( > 0.5  mm thick , > 1  g ) for mesh measuring 15    10  cm . however , the pore size overlapped between groups ( 1.243.0  mm for lightweight , < 12.0  mm for heavyweight ) . while the holinsky article presents a good basis for characterizing lightweight and heavyweight meshes , the panelists believed that pore size is the most important determinant . throughout this article it is recommended that the appropriate organizations determine the characteristics for each mesh . in other words , there is an urgent need for further standardization of mesh classification beyond that already available . looking beyond the features and benefits of meshes to discuss the key needs and expected results of hernia repair , it is necessary to understand the pathology of hernia . quality of collagen , for example , is important in the pathophysiology of hernias and plays an important role in repair . the purpose of surgical meshes in hernia repair is to reinforce and replace tissue for long - term stabilization of the abdominal wall . there are different requirements for inguinal repairs versus ventral repairs , small hernias compared with large hernias , and open approaches versus laparoscopic techniques . small hernias can be repaired with most mesh types , whereas it is much more difficult to find an effective mesh for larger hernias . for pelvic floor hernias , meshes that produce strong foreign body reactions can result in a large number of complications , including fibrosis and pain . further , there tends to be an increased prevalence of nerve entrapment with the use of heavyweight mesh in inguinal repairs . an ideal portfolio of meshes would have the benefits of both heavyweight and lightweight meshes , such as the strength of a heavyweight mesh and the flexibility of a lightweight mesh with none of the adverse events . one aspect of all mesh repairs that needs improvement is attachment to the abdominal wall . current meshes on the market could be faster and easier to implant , whether deployed laparoscopically or through an open incision . this expediency would lead to shorter operating times , appealing to both the patient and the surgeon . the panelists agreed that more than one mesh type is required to accommodate the many possible patient / situation needs . mesh requirements depend on technique and mesh position with respect to the abdominal wall ( extraperitoneal versus intraperitoneal ) . the surgeon should have the ability to choose a mesh device suited to each patient s particular hernia condition . mesh development is an ongoing process , reflecting changes in polymer structure , biocompatibility , operative handling , and cost . the panel s conversation began to distinguish the mesh characteristics according to different surgical needs , but generally the mesh features desired in four common surgical procedures ( open ventral , open inguinal , laparoscopic ventral , and laparoscopic inguinal hernia repairs ) were very similar . the topics discussed were pore size , geometry , active surface area , mesh memory , affinity for water , elasticity , and polymer type . according to the panel , a good mesh will have negligible foreign body reaction with no pathologic fibrosis . the panel pointed out that pore size can affect adhesions following intraabdominal placement , tissue integration , active surface area , elasticity , and memory . for open ventral hernia repair , the heavyweight microporous meshes have a lower risk of tissue - to - mesh adhesion but carry a risk of encapsulation and foreign body reaction , resulting in decreased integration . lightweight macroporous mesh results in better tissue in - growth and lower foreign body reaction but may lead to a higher risk of adhesions . a larger pore size also provides optimal flexibility for improved physical properties , allowing a better activity profile post - surgery , but relinquishes memory , which is important for handling during the procedure . despite the absence of a formal approval on package inserts for many synthetic mesh products , the panel agreed that larger pore meshes seem to be safe to use in contaminated environments . the panel also agreed that a monofilament mesh with a pore size of > 2.5  mm seems ideal , although some authors recommended pore sizes as large as 3 and 6  mm . in all hernia repair techniques , a strong mesh is important for augmentation of the abdominal wall and to prevent recurrences . the panel agreed that a tensile strength of 16  n was probably more than sufficient to augment the abdominal wall ; for bridging of large defects , an increased tensile strength of 32  n may be necessary . the panel concluded that mesh should be flexible but also have a good memory , and it should have elasticity in more than one dimension , allowing it to stretch in more than one direction and then return to its original shape . in this way flexibility and memory , which make a mesh more adaptable , are also important to optimize the surgical handling of the mesh . the mesh should have an adequate adhesive quality that requires minimal or no additional fixation , even for large defects . in both laparoscopic inguinal and ventral procedures , in open inguinal lichtenstein repairs , a mesh with improved adhesive properties , especially at the ends , is seen as optimal . for laparoscopic ventral hernia repairs , the mesh composition needs to form an adequate barrier between the viscera and the mesh . although tissue separation properties are not required in other hernia repairs , the panel agreed that mesh used in intraabdominal mesh repair should have a solid absorbable barrier that prevents adhesion to the intestines . as adhesions begin to form immediately , the barrier should absorb slowly enough to prevent formation of adhesions . the panel also concluded that the parietal fraction of the mesh should have a good capacity for in - growth , and the construction should be strong enough for adequate bridging and augmentation . microporous materials with a strong affinity for water have been developed to reduce the risk of adhesion formation , but these materials lack adequate tissue integration and are more likely to cause recurrence . as a result , composite meshes were developed with a smooth microporous surface on one side for contact with the viscera , with the other side designed for appropriate tissue integration . according to the panel , an ideal mesh would be a monofilament mesh that would prevent adhesions yet still enable growth of the adjacent tissue for optimal augmentation . the desire for a transparent mesh for use in all hernia repair techniques was also discussed . transparency would assist proper placement of the mesh and possibly lead to a decrease in recurrence rates , pain , and other possible adverse effects , potentially leading to improved quality of life . in some institutions , surgeons seldom have their choice of mesh products available for use in hernia repairs . in these cases , the meshes stocked in the operating room reflect the least expensive options on the market . so , in order to complete the theoretical construction of the  ideal  mesh , prices should be reasonable . myofascial transposition , in which lateral components are separated , is a technique popularized over the past 1015  years . this more functional repair tends to have high recurrence rates and is , therefore , primarily reserved for massive midline hernias in which currently available meshes are inadequate . absorbable biological and biosynthetic materials are not often used and have not lived up to initial expectations . these materials are also associated with high failure rates , not only in abdominal and inguinal hernia repair , but also in pelvic floor hernia repairs [ 15 , 16 ] . therefore , these materials are reserved for situations in which mesh is not appropriate , such as in septic conditions , and even then they might be prone to recurrence and graft - related complications . while the future of these biological materials looks hopeful , the currently available products are not yet adequate for successful hernia repair . the panel concluded that animal models resembling the human hernia are a useful tool for researchers to investigate hernia treatment options . the current animal models used to study hernia repair are not perfect , and panel members have had hands - on experience with a variety of these . from their experiences , the panelists agreed that artificially created hernias in animals are poor hernia models as they do not truly recreate the biological defects that cause hernias , such as collagen defects . furthermore , the defects that are created to test mesh products are not real - world defects that surgeons would encounter . in order to serve as a useful model , one factor when considering an animal model is similarities in the elasticity of the abdominal wall . although the panel did not reach a consensus for the most appropriate test or animal model , they agreed that animal models are useful when comparing different meshes in the same species either in vivo or ex vivo . studies in humans and large animals are the only way that most issues , such as elasticity , chronic pain , foreign body reaction , and adhesion , will be observed . what problems animal models can solve and which animals are the most appropriate for use will differ depending on the purpose of the study . small animals or even cell cultures are instructive for studying the inflammatory reaction and biocompatibility , but for abdominal wall function and elasticity , larger animals are more suitable . the panel agreed that although ineffective for other comparisons , pigs are useful to simulate mesh implantation within the human body as pigs have a similar body size to humans , and further work is being conducted to recreate human collagen problems in swine . sheep and rabbits are reasonable models to mimic vaginal operating conditions ; potentially , they are also useful models for pelvic floor damage due to pregnancy and birth , although the latter has not been formally studied yet . chronic pain is an issue that primarily affects patient quality of life . for these patients , it is difficult to imagine a more imperative issue . according to some studies , chronic pain can occur in up to 40% of hernia surgeries . the panel agreed that chronic pain , stiff abdomen , and foreign body sensation are least often observed with the use of a lightweight mesh and a laparoscopic approach [ 4 , 8 , 19 ] . a truly successful hernia repair requires effective bridging or augmentation that will prevent recurrence , but the panel agreed that complete avoidance of recurrence is unlikely . recurrence rates tend to be higher in patients who are obese , smoke , are older , have anemia , or are male [ 20 , 21 ] . if reoperation is required in the event of a recurrence , the incidence of chronic pain increases . there seem to be inconsistencies in the way recurrences are reported , especially in clinical trials , which affects the available clinical data . a recurrence may be anatomical but not functional , or it may be both . it is possible to have an asymptomatic or not visible recurrence , which may only be seen during ultrasound examinations ( subclinical ) . clinical trials that do not use ultrasound potentially miss some recurrences that are not clinically obvious . secondary to chronic pain and recurrence are foreign body reactions , seroma formation , quality of life with a return to normal activity , infection , comfort , and cosmesis with minimal scarring . a successful procedure is one in which a patient has no sensation of the foreign body , no stiffness , and can return quickly to normal activity . according to the panel , quality of life and comfort are influenced by many factors and should be measured before and after surgery . the carolina comfort scale and the swedish pain questionnaire are specifically used for patients with hernias , and the 36-item short form ( sf-36 ) is used as a measure of general well - being [ 22 , 23 ] . although these tests are useful , the panel agreed that a better questionnaire is needed . foreign body reactions , such as seromas , can present more than 1  year after surgery . tissue mobilization is important to prevent seroma formation , and binders may help reduce fluid formation . seroma formations are common in laparoscopic procedures , and the panelists agreed , based on their own experiences ( and from published data ) , that lightweight meshes result in fewer seromas [ 25 , 26 ] . the hernia repair process should begin with informing the patient about the procedure , signs and symptoms of infection , and recurrence , and how to distinguish between normal or abnormal pain and discomfort . following patient education , technique should be considered , which is the most important factor of success . most surgeons are hesitant to modify their surgical methodology but understand that technical advances , such as mesh repair , are important to include into practice . the panelists agreed that in the groin , the right technique can minimize or completely prevent pain . the ideal technique includes a high - quality dissection , maximum visualization , maximum coverage of the anatomical defect using wide overlap , and minimum fixation . the procedure should consider both the physiology of the hernia region and the integrity of the spermatic cord . in order to eliminate chronic pain and stiffness , permanent fixation should ideally be avoided or at least be as minimal as possible . optimal mesh flexibility and elasticity ensure a quick return to function , and heavyweight mesh should be avoided as it can cause chronic pain due to retraction and tends to reduce the ability of the abdominal wall to move in a normal fashion . good cosmesis with no seroma formation and minimal scarring are ideal for both the patient and the surgeon . the optimal hernia repair will result in minimal adverse events , such as pain , foreign body reaction , and seroma formations . the panel concluded that an optimal clinical outcome is a repair that is free from recurrence , pain , and infection , with minimal scarring and with improvement in patient s quality of life . the role and responsibilities of the surgeon with regard to training , experience , and interaction with the patient are important to understand if outcomes are to be optimized . surgical residency training with mentors who are experienced in hernia repair or in hospitals that perform large numbers of herniorrhaphies is necessary to ensure a comprehensive understanding of the anatomy and proper technique . even with experience and good operative technique , there will still be issues that the surgeon can not control . residency training today is insufficient , and residents should be exposed to more cases to enhance their education . fellowships for minimally invasive surgery can improve the skills of commonly performed surgeries , including hernia repair , and are a good option for surgeons who are leaving residency programs . the prevalence of pelvic floor prolapse problems is increasing , and more gynecologic surgeons are needed with the skills to perform these repairs . due to the increasing number of pelvic floor hernias being performed , the procedure is becoming more standardized . most hernia repairs are performed by general surgeons and have good results , but there are still improvements that can be made to address the unmet educational needs of surgeons . while the number of hernia repair centers is increasing in the united states , the constructs of socialized medicine often preclude other countries from creating such arrangements . deciding whether or not to use mesh for hernia repair can be a difficult task . with the advent of laparoscopy , the use of mesh has become commonplace for hernia repair and is increasingly popular for use even in young patients . furthermore , in open repair of incisional hernias , the use of mesh is recommended . even using surgical mesh with a lichtenstein repair is a technique gaining in popularity in less developed countries . according to the swedish hernia registry , high recurrence rates have been reported in hernia operations performed without mesh , suggesting that mesh should always be used . patient involvement is encouraged if the patient is properly educated and can help inform the decision of using mesh . ultimately , the choice of whether or not to use a surgical mesh is the surgeon s prerogative . age , smoking status , pre - existing medical conditions , and patient activity level are all factors that need to be considered when making this determination . the development of mesh prosthetics for successful hernia repair has proven to be an intricate and difficult task . many important lessons have been learned from both successful and unsuccessful herniorrhaphies . to move forward into a new era of hernia mesh prosthetics , the panel agreed that new technologies and novel approaches must be investigated and designed . the portfolio of meshes should be cost effective ; have no adhesion potential , excellent tissue integration , minimal shrinkage , good memory ; and be easy to use . ideal meshes should not promote infection , fistula , or seroma formation and should not limit or negatively affect a patient s normal activity . the panel concluded that a new quality - of - life survey should be developed . additionally , present - day teaching and awareness programs should be further expanded , including enhanced professional education for surgical residents as well as education of patients . the use of animal testing in hernia repair clinical trials is presently inadequate , and better animal models should be developed to advance today s methodologies . certain topics for future roundtable discussions were identified , such as mesh properties and fixation , disseminating information to hernia patients , training in hernia surgery , and quality - of - life scales for evaluating hernia surgery . roundtable meetings on these topics are important , and outcomes of such meetings would be of interest to many hernia surgeons . these proceedings provided insight into the features and benefits of innovation for the portfolio of ideal hernia repair prostheses and into how such attributes translate into better clinical patient outcomes . there is optimism that continued discussion can lead to the development of new and  ideal  hernia mesh prostheses , which would improve the outcomes of hernia repair procedures .
backgroundeffective repair of hernia is a difficult task . 
 there have been many advances in hernia repair techniques over the past 50  years , but new strategies must be considered to enhance the success of herniorrhaphy.discussionat the 30th international congress of the european hernia society , nine experts in hernia repair and experimental mesh evaluation participated in a roundtable discussion about today s unmet needs in hernia repair , including what constitutes an  ideal  hernia repair and the portfolio of  ideal  mesh prostheses . defining characteristics of lightweight mesh , 
 mesh alternatives , the surgeon s role in hernia repair , adverse events , the unmet requirements for today s hernia repair , and optimized animal models were among the topics discussed.conclusionthe ideal mesh s construction is still in progress , but greater understanding of its critical characteristics was explored . 
 it is hoped that these suggestions will lead to the development of improved hernia treatments and a maximally effective portfolio of hernia mesh prostheses .