Invited commentary on “Improved Outcomes in the Management of High‐Risk Incisional Hernias Utilizing Biological Mesh and Soft‐Tissue Reconstruction: A Single‐Center Experience”

Abstract

Improved outcome—isn’t this our ultimate goal in surgery? So how can we further improve outcome in repairing incisional hernias? The question is especially tricky when dealing with those problematic, huge, and complex hernias that many surgeons shy away from, regarding them as too difficult to repair, with too much associated morbidity, too high failure rate, and too little glory. First, let’s define again the problems in this specific group of ‘complex incisional hernias’. • Overall results are unsatisfactory Early outcome is hampered by a high infection rate (prominent among other kinds of morbidity), and late outcome is associated with significant failure rate and hernia recurrence. • Too many techniques are described, and variability in tissue dissection, mobilization, and approximation makes comparison a difficult task. The modern debate concerns the need for defect closure and midline reconstruction, made possible by component separation and other tissue transfer techniques. Let us leave alone, for once, the issue of laparoscopic versus open repair, which is less relevant in the management of these complex hernias… • Too many reinforcement materials are available on the market, and the selection is difficult, based on many different parameters: theoretical qualities, personal preferences and beliefs, cost, and even industry pressure, and ‘surgical fashion’ and hype—with insufficient hard data to give us a definitive and final winner. The modern debate is between synthetic and biologic materials, but it seems that we are not much closer to a clear conclusion. Even the exact location to place the mesh is still a matter of heated debate, ‘inlay’ and ‘sublay’ currently being the finalists. Against this background noise, in this issue of the World Journal of Surgery, Skipworth et al. [1] give us their view on this subject. In a series of 58 patients, they report overall ‘‘good’’ results—a relatively low rate of surgical site infections (15 %), reoperations (4 %), and readmissions (7 %), zero mesh explanations, and 5 % asymptomatic recurrence at a median follow-up of 17 months. So let’s skip, this time, the obvious questions about methodology (non-comparative retrospective cohort, relatively small size of the group, short duration of follow-up, etc.), and analyze the factors that possibly made a difference in achieving such good results.