Priv.-Doz. Dr. med. Joachim Conze is a leading specialist in the field of hernia surgery, heads the UM Hernia Center Dr. Conze in Munich, and is also a member of the executive board of the German Hernia Society. With over 30 years of experience, particularly in the treatment of inguinal and abdominal wall hernias, he is highly regarded both nationally and internationally. Dr. Conze has made a name for himself through innovative treatment methods and his ability to develop customized therapies for complex hernia cases. The Hernia Center, which he has successfully led on his own since 2017, offers comprehensive surgical solutions for a wide range of hernias, including inguinal hernias, umbilical and incisional hernias, as well as sports-related inguinal hernias and chronic inguinal pain.
A particular focus is placed on individualized patient care. Following a thorough examination, a specific treatment plan is developed for each patient. The decision regarding whether surgery is necessary and whether a synthetic mesh should be used is made in close consultation with the patient and based on their personal risk profile. Dr. Conze prefers open surgical procedures, which allow for an intraoperative decision regarding the use of a mesh based on the patient’s individual needs—a process known as intraoperative “mesh tailoring.”
In addition to the surgical treatment of hernias, another area of focus is the treatment of chronic groin pain, often resulting from previous surgeries involving mesh implants. Here, Dr. Conze employs modern techniques such as intraoperative nerve response testing (IONR) to precisely locate pain and treat it in a targeted manner. For elite athletes, the Hernia Center offers a specialized, mesh-free “minimal repair technique” for treating sports hernias, which has gained worldwide recognition. Surgeries are primarily performed under local anesthesia to minimize the burden on the patient and can be conducted either on an outpatient basis at the Hernia Center or in collaboration with the Paracelsus Clinic in Munich.
Dr. Conze’s expertise, his individualized treatment approach, and his focus on patient-centered solutions make him one of Europe’s leading hernia surgeons. The editorial team of the Leading Medicine Guide spoke with Dr. Conze to learn more about the broad spectrum of hernia surgery.
Hernias occur due to a weakness or opening in the abdominal wall through which internal organs, such as sections of the intestine, can protrude. These weaknesses may be congenital or develop over time, for example due to obesity, heavy physical strain, or following surgery. Common types include inguinal hernias, umbilical hernias, and incisional hernias. Symptoms include swelling and pain in the affected area, particularly during physical exertion. Treatment options range from conservative therapy, such as wearing a hernia truss, to surgical procedures.
Hernia Surgery: Open Versus Minimally Invasive Techniques
“Fundamentally, there has long been a ‘battle’ between hernia surgeons who perform open surgery and those who perform laparoscopic surgery. It’s certainly true that, generally speaking, people say everyone should be able to do everything. Personally, I say that just as someone who can knit doesn’t necessarily have to know how to crochet—and vice versa. After all, when it comes to choosing a surgical method, everyone has their own personal preference. At the end of the day, we surgeons are simply craftsmen shaped by what we do. This makes it all the more important to engage in continuous professional development, to critically evaluate the techniques we use, and to practice quality assurance—including self-assessment,” emphasizes Dr. Conze at the start of our conversation, before going on to discuss the options of laparoscopic and open hernia surgery in more detail:
“There are fundamentally different approaches here. I, too, used to perform a lot of laparoscopic surgeries—today I only perform open surgeries because I believe that others are better at laparoscopic surgery than I am. However, I opted for the open technique primarily because I believe it’s the better approach for many patients. It’s commonly said today that laparoscopy causes less difficulty for patients who are particularly overweight. But if a patient has a somewhat thicker abdominal wall, it can be difficult at the end of the operation—after removing the trocars, i.e., the surgical instruments—to close the newly created fascial defect, resulting in a trocar scar hernia. So while an inguinal hernia has been successfully repaired, a new hernia has been created. The guidelines state that for a patient who has previously undergone open surgery and has a recurrent hernia, a second laparoscopic procedure is more advisable because it avoids the need to dissect through the scarred area. Personally, I remain skeptical, as it is usually impossible to determine with certainty exactly where the patient’s pain is coming from. Is the pain caused by the recurrence or by local irritations such as nerve injuries? And if the nerve is the problem, I usually cannot resolve it using a laparoscopic technique. That’s why I personally rarely see an indication for a minimally invasive procedure. And if a patient explicitly requests it, they should see a doctor who truly has expertise in this area, because more things go wrong than people would like to admit.”
The Herniamed Registry is a comprehensive database developed specifically for documenting hernia surgeries. It enables the collection and analysis of patient data, treatment procedures, and outcomes to improve the quality of care and gain scientific insights. It is used by surgeons to compare treatment outcomes and develop best-practice methods. The registry supports the continuous improvement of hernia surgery and provides an evidence-based foundation for clinical decisions.
“Data on hernia patients has been systematically collected in this registry for over ten years. And we’ve observed that about 12% of patients continue to experience pain even a year after laparoscopic surgery, and one in ten patients requires a second operation. That really makes you question the quality of care we’re providing,” criticizes Dr. Conze.
Sutures or mesh?
There are three procedures in hernia surgery: open and laparoscopic methods, with open procedures further divided into suture and mesh techniques. In open procedures, the goal is anatomical reconstruction of the posterior wall, either through an overlapping suture technique (Shouldice procedure) or a mesh technique (Lichtenstein mesh), where the posterior wall is repaired and a mesh is inserted for reinforcement. Laparoscopic procedures are all mesh-based, whereby the defect is not directly closed but is covered with a larger mesh.
“Open surgery—and suture techniques in particular—has fallen out of favor because most of the data on this topic dates from the 1970s through the 1990s, when all hernias were treated with suture techniques. Today we know that not every inguinal hernia is suitable for a suture technique. These are particularly indicated for lateral, mostly congenital hernias. When assessing a hernia, we distinguish based on the location of the defect: whether the hernia is located more in the area of the internal inguinal ring, where the spermatic cord enters the canal, or whether the hernia has developed through the medial posterior wall. Lateral hernias, which are usually congenital, are well-suited for suture repair, especially in young patients. If the medial posterior wall is severely weakened, a mesh procedure makes more sense. It is not always possible to make this distinction preoperatively, even with ultrasound. One advantage of the open technique is intraoperative flexibility, as the surgeon can choose between suturing and mesh during the procedure based on the intraoperative findings. This is not possible with laparoscopy, since mesh is always used in that approach, and thus the decision to use mesh is made prior to surgery. General anesthesia is also always required for laparoscopic procedures involving mesh. “With all procedures, one should always bear in mind that complications can arise that are difficult to treat, and it is particularly hernias treated laparoscopically whose complications are harder to manage,” states Dr. Conze, adding with a critical eye:
“Incidentally, I don’t understand why the same mesh size is used for everyone in a mesh procedure, regardless of whether the patient is young or old, tall or short, male or female. The meshes are always the same size: 15x10 cm. Personally, I cannot understand this standard. It’s good that the meshes aren’t located in the abdominal cavity but are placed between the peritoneum and the abdominal wall—but if they cause problems, it can be extremely difficult to remove them partially or completely if necessary.”
A patient’s individual risk factors, such as age, preexisting conditions, or overall health, also play a major role in choosing the surgical approach and deciding between mesh and suture techniques.
These factors influence both the stability of the abdominal wall and the risk of complications, which determines the choice of the optimal surgical technique. “Older patients or those with weak connective tissue are more likely to develop larger and more complex hernias. In these cases, the mesh technique is often preferred, as the patient’s own tissue is frequently not strong enough to repair the defect with sutures alone. A mesh provides additional stability and reduces tension on the tissue, which lowers the risk of a hernia recurrence. We see this in contrast to infants, in whom we use only a small suture because their healing potential is enormous. With increasing age, however, blood flow and fascial healing deteriorate, which is why the mesh technique is used more liberally in older patients. Personally, however, I tend to follow the approach used for younger patients and decide intraoperatively between “mesh or suture,” depending on the findings. “If I see that it is a lateral, congenital hernia and the medial posterior wall is stable, I see no compelling reason to use a mesh, even in older patients. One should base the decision on the individual risk profile,” explains Dr. Conze.
To prevent potential complications such as infections or chronic pain following hernia surgery, there are preventive measures and comprehensive postoperative management.
“With laparoscopic techniques, I’m concerned that too much is simply lumped together under the ‘one size fits all’ approach. In my opinion, this doesn’t always do justice to the hernia. After all, our findings and symptoms vary too widely, which is why we need to be very cautious here. It’s also important to approach hernias in women differently than in men (and vice versa). Young men with acute pain should also be managed more cautiously than older men who, for example, have been living with a visible bulge for years. Ultimately, the greatest danger with unclear groin symptoms is doing too much too soon. The right decision for the patient must be made before surgery—that is, preventively,” advises Dr. Conze, adding further details:
“Patients who undergo laparoscopic surgery generally have an easier time in the first few days after the procedure, while those who undergo open surgery take a little longer to heal. From the third day after surgery onward, however, recovery usually proceeds at the same rate. The necessary anesthesia methods must also be considered. All minimally invasive procedures are performed under general anesthesia, while all open procedures can be performed under local anesthesia, with twilight sedation if desired. I am not at all a fan of spinal anesthesia, as I consider it a very invasive procedure that can often lead to delayed mobility and urinary retention. My patients walk to the operating table, undergo surgery, and can be picked up one hour after the procedure. At home, they can apply cold compresses to the surgical site and receive preventive pain management. It is important that they do not wait until it hurts, but take the medication as a preventive measure. Personally, I like to introduce myself to patients as a ‘travel companion’ on their journey toward hernia repair and explain the anatomy as well as the planned procedure. In doing so, I place particular emphasis on the postoperative recovery process. After all, an informed patient is ultimately better equipped to cope with everything.”
Priv.-Doz. Dr. Conze has been performing surgery at the Munich Hernia Center for 13 years, treating approximately 450–500 hernias per year (inguinal, incisional, and abdominal wall hernias). At the Munich Hernia Center, every patient receives one-on-one care, so that Dr. Conze always sees his patients before, during, and after surgery.
Regarding postoperative care, Dr. Conze adds: “I see my patients again on the 5th or 6th day after surgery for a follow-up and routinely perform an ultrasound on all of them, not only to check the superficial wound condition but also to rule out any possible deep wound fluid accumulations, known as seromas,” says Dr. Conze.
Precision and Pain Management in Hernia Surgery: Advantages of the Open Technique.
“As I mentioned earlier, complication management begins even before surgery with a careful assessment of the indication. After that, it is above all a meticulous and standardized surgical technique that ensures the success of hernia repair. And here I would like to once again highlight the open technique, which makes it possible to assess the course of sensitive nerve pathways intraoperatively, so that they can then be spared or otherwise managed as appropriate—and all under local anesthesia! This technique cannot be called “minimally invasive,” but I consider our approach to be “minimally traumatic.” This is because, thanks to local anesthesia combined with light twilight sleep (analgosedation), I have a lower anesthesia risk; I make a small, cosmetically inconspicuous incision of about 5 cm in the lower abdominal skin fold without the risk of trocar hernias; and I can often avoid the use of synthetic mesh. The recommendation that patients should take it easy after surgery—and, for example, not lift anything weighing more than five kilograms—is no longer justifiable today. Even a single sneeze puts more strain on the repair than any form of physical exertion. The only limiting factor is pain, which can be particularly noticeable in the first 2–3 days. “The whole thing should be more or less over by the end of the first week,” Dr. Conze explains optimistically, adding:
“What strikes me is the high number of patients with chronic pain who come to see me at the hernia center. Someone with chronic groin pain—whether following open or laparoscopic surgery—is ultimately often left to deal with their problem on their own. This is because the surgeon tells the patient that there is no visible issue, and another surgeon is rarely willing to take another look at the case. I see patients here from all over the country—sometimes young, strong men who sit before me exhausted and in great pain, most of whom have already been through a veritable medical odyssey. Nearly 20% of my work now consists of what I call ‘cleanup work.’ And if another surgery is necessary, it’s of course particularly advantageous to be able to operate under local anesthesia. Because if I suspect that a sensitive nerve is responsible for the patient’s pain, I can elicit a pain response intraoperatively. When I reach the scarred area and the area of the affected nerve during surgery, I can let the patient wake up a little, take the forceps, and manipulate the structures to locate the nerve within the scar and then treat it selectively. This is only possible under local anesthesia, which, unfortunately, isn’t really favored in our healthcare system, since the reimbursement for local anesthesia is significantly lower than for general anesthesia. But the sad issue of financial reimbursement and hernia surgery doesn’t belong here.” And with that, we conclude our conversation.
Thank you very much, Dr. Conze, for this insightful and very critical explanation regarding hernia surgery!
