Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100 hernia repairs over 15 years

Abstract

Dear Editor, I congratulate Dulucq et al. [1] for their large study and very impressive results. Their retrospective series deserves, however, some comments regarding the materials and the results. Firstly I was surprised by the rate of bilateral hernias (almost one-third of patients), while in large epidemiologic studies and registers this rate does not exceed 10% in Europe [2] and 14% in the USA [3]. A further large study also showed that the rate of occult contralateral hernias is as low as 8% [4]. The reported rate of bilateral hernia is surprisingly high and led us to assume that a number of occult contralateral hernias have been repaired during the study period. Such an aggressive attitude remains controversial. Two randomized trials [5, 6] have shown that there is no evidence that routinely operating asymptomatic hernias could be beneficial for all patients. The results were also impressive, with a mean operative duration not exceeding 17 min for unilateral hernias and 24 min for bilateral ones, and a late recurrence rate of 0.3%. One can say that this is too much of a good thing, since in the American multicenter trials using the same technique, the results were far less favorable [7]. Beside this trial, the Cochrane meta-analysis [8] showed a 2.7% recurrence rate, which is significantly higher than the 0.3% reported in the present paper. One can assume that, in contrast with the results of the Veterans Affair study or of ‘‘heterogeneous’’ meta-analyses, those of the present study come from an expert team, but the authors did not give results (for example) regarding the outcome ‘‘recurrence’’ nor the number of evaluable patients nor the length of follow-up. As presented in the paper, the results suggest that all patients have been assessed for recurrence (a very rare situation in hernia surgery, all the more so given that the study period was over 15 years). We all know that the follow-up of patients operated on for inguinal hernia is a very hard task. Furthermore, one of the main flaws of every retrospective study is definitely the loss of data. After reading the paper, and despite the huge number of patients and hernia repairs, several questions remained unanswered: how many patients have actually been reviewed? How many were lost to follow-up? How have they been evaluated, by their general practitioner or by the surgeon or by telephone interview? What was the followup duration or at least to provide an actuarial recurrence curve? On the other hand, the authors stated that their technique has changed during the study period but they did not do any subgroup analysis (regarding type of mesh, technique with fixation or not, etc.). Providing all these data (occult contralateral hernia, details on recurrence, subgroup analyses) would allow us to assess the results from this major study more accurately and would increase both the external validity of the study and the reproducibility of the reported results.