Comment to: intestinal erosions following inguinal hernia repair: a systematic review

Abstract

We read with great interest the paper “Intestinal erosions following inguinal hernia repair: a systematic review” by Koliakos et al. [1]. Mesh-related visceral complications (MRVCs) represent an emerging topic indeed and some authors recently overhauled data from international medical literature, inspired by the presentation of personal cases [2, 3]. We first published a review, splitting MRVCs following groin hernia repair from those involving ventral/incisional hernia surgery [4]. In that study, we already included clinical cases related to small and large bowel lesions, stratified by technique of primary operation. Data reported by Koliakos cannot be different as they come largely from the same data of the literature we reviewed. All prosthetic inguinal hernia repairs can be followed by MRVCs but we observed that the rate of MRVCs after laparoscopic approach was almost double than after mesh-plug technique (51% vs. 41%). Our data are quite similar to those reported by Koliakos (47% vs. 28%), though the paucity of numbers does not allow any further consideration. In our study, latency time between primary hernia repair and the diagnosis of visceral lesions resulted longer in open than in laparoscopic approach. For Koliakos also, early presentation (< 6 months) of intestinal complications is more common after minimally invasive procedures while an open primary repair is more often associated with late presenting cases. We do not completely agree with the explanation given by Koliakos that patients in early group were more likely to have been subject to technical failures during the primary hernia operation. In our opinion, even though fixation methods may play a role, the low incidence of visceral erosion after open repair, particularly when the Lichtenstein technique is performed, compared to higher rates following laparoscopic approach suggests that the distance between the mesh and peritoneum could represent the most relevant factor. Fixation devices seem rather significant in cases involving mainly the urinary bladder [5]. Pathogenesis of mesh erosion is complex and depends not only on technical detail but also on the characteristics of the prosthetic material, the orientation and composition of the host tissue and the applied forces [6].