Is it really worth it? Reply to: Selective use of bioabsorbable Gore BIO-A plug and patch for groin hernia repair. Negro P, Campanelli G, Ipponi PL, Gossetti F, Dassatti MR, Manto O, D'Amore L. Hernia. 2013, 17(6):795-6.

Abstract

It is a great pleasure for us to realize that what started as a heretic idea in our department found supporters or, better, in order to be more precise, colleagues sharing the same research ideas and dilemmas within the hernia repair surgical society. So, ‘‘we are not alone’’. Indeed, we continue to believe that chronic pain and, generally, the interactions of the different mesh type’s materials with the host tissues are still the most ill-investigated field in inguinal hernia repair with great perspectives for future development and progress. We would like to start this response by stating right from the outset that our response probably entails bias as in many instances there are no unequivocal evidences to be supported from. We read with great interest the report by Negro et al. [1] dealing with their experience out of the use of the Bio A totally absorbable material as the sole mesh for inguinal hernia repair. The authors have used the Shumbelick classification of inguinal hernias in order to sub-classify patients with lateral inguinal hernias according to the magnitude of the defect [1]. In addition, they have adopted a modified repair technique altering the normal anatomy by placing the external oblique aponeurosis dorsally to the spermatic cord [1]. Although the authors report a significantly better recurrence rate than the one reported in our recent report [2], we would rather avoid entering into a discussion relevant to the actual causes of this finding. We do believe that Negro et al. [1] have supplied adequate arguments on the subject and we tend to agree with the majority of them. However, to our opinion, it is still a result that requires proper interpretation. Negro et al. [1] have concluded that this certain mesh type can indeed have an indication for inguinal hernia repair. Young (\45 years) patients with small inguinal hernias (L1 and L2) without a notable defect in the transversalis fascia verified with the intra-operative stress test could be the ideal candidates for having their hernia repaired with the use of this totally absorbable mesh [1]. The reproducibly of this test though, could be quite problematic, as by definition, general anesthetic, currently the mainstream anesthesia for inguinal hernia repair in the majority of Northern European countries [3], is precluded as a valid alternative for the procedure from the anesthetic viewpoint. Furthermore, we would consider the above modification of the textbook tension-free technique as an alternative repair on its own, although not properly validated, especially if a small lateral inguinal hernia is the case. Although this maneuver can indeed aid in lowering the recurrence rate, can prove especially misleading if the evaluation of the efficacy of the mesh used is the actual challenge. In L1 and L2 patients, i.e., the patients group ‘‘suitable’’ for this type of mesh according to Negro et al., the benefits in terms of recurrence rate reduction of the use of a prosthetic mesh are not as obvious as in patients with large defects [4]. Negro et al. have witnessed a total failure of the followed repair in all (2 patients) L3 hernia patient, the patient group definitely in need of a repair reinforcement, i.e., a mesh. Within this context, the almost axiomatic adage that a large hernia needs a mesh in order to lower to an acceptable range the recurrence rate, does not seem to be fulfilled by This reply refers to the article available at doi:10.1007/s10029-013-1117-4.