Response to the Comment on “Heavyweight Mesh is Superior to Lightweight Mesh in Laparo-endoscopic Inguinal Hernia Repair: A Systematic Review and Meta-analysis”

Abstract

randomized control trials studies, however, we want to look into the underlying mechanism of the author's present findings, and furthermore, we aim to provide the possible and definite resolution to this problem, therefore, several comments on this topic were addressed.First, about the recurrence mechanism. Unlike the recurrence after incisional hernias, which may be associated with the enlargement of defect, the mesh-fascia disruption, or multiple defects, the mechanism of inguinal hernia recurrence after laparo-endoscopic repair with LWM is largely due to mesh dislocation or mesh protrusion, 2,5 as it is more likely that a less strong LWM will protrude if the primary direct or indirect defect is large, which may occur in the early postoperative period, before the fibrotic response and subsequent fixation of mesh just stared, or occur gradually several months later. Consequently, the recurrent inguinal hernia was usually present with the same size as nonoperated, which indicates a technique failure.Second, about the mesh fixation. The authors reported that the increased recurrence using LWM disappeared when mesh fixation used. However, the efficacy and necessary of mesh fixation in laparo-endoscopic inguinal hernia repair are still debatable. Theoretically, the purpose of mesh fixation in laparo-endoscopic inguinal hernia repair is different from that of laparoscopic ventral/incisional hernia repair. In case of laparoscopic intraoperitoneal onlay mesh repair, fixation is mandatory to hold the mesh in place, while, the purpose of fixation in laparo-endoscopic inguinal hernia repair is rather to position the mesh in the proper place, to prevent mesh curling, than to permanently fix the mesh from dislocation. According to the guideline, mesh fixation is not mandatory in the majority of laparo-endoscopic inguinal hernia repair. 1 Furthermore, there are studies with large volume (11,228 male patients) clearly showing that mesh fixation did not reduce the recurrence rate. 6,7 Third, narrowing the defect before mesh placement. Since the increase recurrence was attributed to the mesh dislocation or protrusion into the defect cavity, 2,5 which is prone to occur in either direct hernia or large indirect hernia. Although LWM is more prone to migrate, the HWM can also protrude or slide into the large defect cavity as well, and result in hernia recurrence. Therefore, we routinely close the large direct hernia defect by suture the transversalis fascia with barbed suture instead of fixation the mesh, 8 in not only LWM, but also in the use of HWM. In case of large and scrotal indirect hernia with a wide defect orifice, we proposed dividing the distal hernia sac, and close the distal sac, 9 or simply narrowing the defect by suture the lower edge of the divided distal sac to the Junsheng Li have no conflicts of interest or financial ties to disclose.