Coskun repair of inguinal hernia: is it really new?

Abstract

We read with interest, the recent prospective study by Coskun et al. [1] describing a method of open inguinal hernia repair using endogenous tissues and a comparison with anterior (Lichtenstein) and preperitoneal mesh repairs. Dr. Coskun discussed placation of the transversalis fascia with a single row of sutures followed by a second layer of sutures between the inguinal ligament and the conjoint tendon, a technique that has been dismissed as ‘‘corrupted Bassini’’. The series’ cumulative recurrence rate was 1.6% and did not affect the endogenous repair patients which had a median follow-up of 36 months. Dr.Coskun and his colleagues concluded that the method was as effective as mesh repair [1], despite level A evidence demonstrating superiority of mesh repair over Shouldice repair (the best of non-mesh repairs) [2–4]. Fifty percent of inguinal hernia recurrences first appear 5 years after surgery [5]; many patients are lost of follow-up including those who seek care from other surgeons when their hernias recur. A 10-year follow-up is considered a truly reliable measure of a repair’s durability [5]. The follow-up in Dr. Coskun’s series is too short to allow any firm conclusions about the ultimate durability of the repair described. The telephone interviews used for those who did not attend the clinic must be considered as not very reliable [6, 7] because recurrences are best diagnosed by physical examination [5]. Coskun et al. claim superiority of their endogenous repair over mesh techniques but do not discuss disorders of collagen metabolism in patients with hernia, a lifelong risk factor. Morphologic and molecular investigations in hernia patients underscore the significance of impaired wound healing, suggesting that the use of prosthetic mesh can influence hernia recurrence [8]. Coskun notes no other technique utilizing a two-layer repair consisting of plication of the transversalis fascia with a first row of sutures followed by approximation of the conjoint tendon and the inguinal ligament [1]. We are aware of two published repair methods that are very similar to the one used by Dr.Coskun: (1) the wellknown Ponka approach includes closure of the transversalis fascia followed by approximation of the transverses abdominis arch medially and the iliopubic tract and inguinal ligament laterally [9]. (2) the Gilmore groin repair which is typically used to repair the so-called ‘‘sportsman’s hernia’’ consists of a layer of interrupted sutures in the transversalis fascia, and a second suture line between the conjoint tendon and the inguinal ligament [10]. These publications suggest that the repair principles proposed by Dr. Coskun are not new. The length and method of follow-up in the series of Coskun et al. [1] do not support the conclusion that the two-layer endogenous repair they describe carries a recurrence risk equal or better than the Lichtenstein and preperitoneal mesh repairs. The current understanding about collagen deficiencies in patients with hernia [8] suggests that alloplastic rather than endogenous repairs should be preferred.