The use of mesh and collagen in incisional hernias

Abstract

Dear Editor We read with much interest the article by Vidovic et al., titled “Factors aVecting recurrence after incisional hernia repair [1]”. We fully agree with the authors’ conclusion that it is important to become familiar with the risk factors for recurrence of incisional hernia to eliminate or decrease recurrence, but we have a few remarks concerning the article. The authors claim that the routine use of synthetic mesh is not justiWed because of its potential for complications, and that the results of sutured repair of small to medium-sized hernias are satisfactory. However, according to a well-conducted randomized controlled trial that compared suture versus mesh repair of incisional hernia in patients with a primary or Wrst-time recurrent incisional hernia, the conclusion was that the routine use of mesh is superior to suture repair for both small and large incisional hernias, and the use of mesh repair results in lower recurrence rates. Mesh reduces the morbidity and costs associated with incisional hernias. In patients with small incisional hernias, the recurrence rates were 67% after suture repair and 17% after mesh repair (P = 0.003). Hence, concerning the potential for complications in the mesh repair group, 17% had a complication, compared with 8% in the suture repair group (P = 0.17), not a statistically signiWcant diVerence [2]. The authors also did not discuss collagen metabolism disorders in hernia patients. Collagen disorders play an important role in the development of inguinal hernia [3]; impaired proportions result in tissue alterations, and are one of the factors that lead to hernia formation. Collagen plays an important role in the pathogenesis of incisional hernias and is not mentioned. A recent study, conducted in our department, comparing the qualitative and quantitative aspects of total and types I and III collagen samples of linea alba aponeurosis in patients with hernias on the anterior abdominal wall, including incisional ones, and from cadavers without hernias, showed that individuals with hernia have a small amount of total and type I collagen. The amount of total collagen was 18.05% smaller and type I collagen was 20.50% smaller in patients with hernias (P < 0.05) [4]. The results of these and other studies [5] indicate a relationship between incisional hernias and collagen disorder. In the evaluations of incisional hernia repair we should never forget the important role of collagen imbalance in the pathophysiology of hernia formation. The use of mesh should be increasingly encouraged to avoid unnecessarily high rates of recurrence.