No-mesh Inguinal Hernia Repair with Continuous Absorbable Sutures : Is it a Step Forward or Backward ?

As regard to the surgical technique, the author states that a thin filmy layer superficial to the external oblique muscle was left undisturbed. The author fails to describe the significance of this maneuver. Furthermore, the surgical technique lacks the benefit of the tension-free repair. In fact, there is contradiction in the discussion of the procedure, as the author denies the absence of tension on the suture line (paragraph 4) while elsewhere (paragraph 6) he mentions that contraction of the muscles makes tension on the muscle strip.


Sir,
The no-mesh inguinal hernia repair, with its many different modifications, is considered in the current surgical practice as the tension repair.The tension inhibits full and effective healing of the edges.As a result, the muscle edges may pull apart causing a higher failure rate with recurrent (often larger and more complex) hernia. [1]sarda, [2] in the study involving 229 patients, revived the subject of nonmesh hernia repair.He used a new surgical technique using absorbable suture material for the inguinal hernia repair.The author claims a less recurrence rate and less postoperative complications with this new technique.
There are some concerns regarding this new surgical technique that need to be addressed.
There is a wide range of the duration of the follow-up for this number of patients from 6-42 months.In previous studies [Table 1] for the nonmesh inguinal hernia repair, longer periods of follow-up were used for larger numbers of patients to properly assess these procedures.
As regard to the surgical technique, the author states that a thin filmy layer superficial to the external oblique muscle was left undisturbed.The author fails to describe the significance of this maneuver.Furthermore, the surgical technique lacks the benefit of the tension-free repair.In fact, there is contradiction in the discussion of the procedure, as the author denies the absence of tension on the suture line (paragraph 4) while elsewhere (paragraph 6) he mentions that contraction of the muscles makes tension on the muscle strip.
The repair depends on the aponeurotic sheath of the external oblique as the only posterior layer but the original weak posterior wall has not been repaired.Suturing the edge of the upper flap to the posterior wall does not strengthen the posterior wall muscles as claimed.On the contrary, it disturbs the physiology of the abdominal wall muscles by suturing them together.So, it is not a physiological repair as claimed as the muscles run in different directions even in the inguinal canal region.
The author states that 209 patients preferred to stay back even though they were allowed to go home the same day; the author fails to give an explanation for this preference.He defined a scoring system for pain but there is no definition of the discomfort despite being experienced by most patients.
The study mentions the cost effectiveness of this outpatient technique, while there was no single patient who went home the same day.On the contrary, there is unexplained hospital stay of 8.74% patients for more than a day increasing the monetary burden for a simple procedure as hernia repair.
The author needs to be queried for the following: (1) Why should there be a long learning curve for general surgeons in other techniques and not for this one?(2) What are the risks of the dissection of inguinal canal floor that are not present in the mentioned technique?Finally, it should be noted that it is not true that all the nonmesh repair techniques use interrupted stitches.
However, it appears that the authors misunderstand the concept between the tension present at rest and the tension present during contraction of any normal muscle.As is well understood, the muscles of the human body are relaxed at rest and the tension (increased tone) is created only during contractions.The strip of the external oblique aponeurosis in our operation is also relaxed (without tension) at rest and the tension (increased tone) is created only during contractions.This is a normal physiological phenomenon.Therefore, our surgical technique is a tension-free inguinal hernia repair.This does not occur in the other described techniques of the pure tissue hernia repairs since the muscles are pulled down from their normal location to suture to the inguinal ligament.This creates tension on the suture line even at rest and, moreover, is aggravated in multiples during the contractions of those muscles.
Additionally, in my study, it is clearly stated that there was no recurrence or groin pain following the surgery.Therefore, it is misleading on the part of Naguib, et al. to state that we made a claim of a low recurrence rate.In a recent article dealing with a series of 860 patients having 920 inguinal hernias [2] with a follow-up period of more than 7 years, I have demonstrated that these results compared well with other international publications.Continuous non absorbable sutures were used in all my previous surgeries.
The thin fascia covering the external oblique aponeurosis helps to keep the fibers together, if at all there is any chance of separation.This basic property of the fascia is generally known to the readers.
Finally, with regard to the claim by the authors that the repair depends on the aponeurotic sheath of the external oblique as the only posterior layer and that the original weak posterior wall has been left repaired is incorrect.They also state that suturing the edge of the upper flap to the posterior wall does not strengthen the posterior wall muscles.However, the posterior wall is not formed by only transversalis fascia, as is generally described, but it is composed of two layers.
Transversalis fascia forms the posterior layer and is papery thin without any strength except at some places where it is thickened to form the iliopubic tract.The second layer is in front and that is formed by the aponeurotic extensions from the transversus abdominis aponeurotic arch. [3,4]There is no muscle in the posterior wall, as claimed by the authors, therefore, the question of strengthening the muscle does not arise.The sutured strip in the new technique replaces the absent or deficient aponeurotic element to form the new posterior wall.As such, their comment that the posterior wall is not repaired is incorrect.The statement by the author Naguib et al. that muscles run in different directions even in the inguinal canal region is also inaccurate and should be supported by evidence.
The new concepts of the physiology of the inguinal canal based on surgical anatomy has been previously demonstrated in a series of 200 patients undergoing hernial repair surgery. [5]nally, issues like definition of discomfort was meant heavy feeling without pain and risk of inguinal floor dissection was meant trauma to iliac vessels or ilio-pubic vein or any aberrant vessel causing troublesome bleeding.Observations pertaining to "learning curve" or "interrupted sutures" in other no-mesh techniques are unwarranted since the article in question does not aim to compare this technique with another.