Hernia | 2021
Comment to: Prophylactic retromuscular mesh placement for parastomal hernia prevention. Author’s reply
Abstract
We would like to thank Li for his interest in our recent article [1] and we appreciate the opportunity given by the Journal to respond to his comments [2]. First, our main findings were that parastomal prophylactic mesh reduces the incidence of parastomal hernia (PSH) for permanent colostomy but increases the rate of PSH for permanent ileostomy. Li suggests that this finding would indicate the general lack of efficiency of a prophylactic mesh as a preventive measure, rather than a difference resulting from the type of stoma created. As stated in our article, we agree that there is a growing body of evidence that questions the use of prophylactic prothesis, particularly for end colostomy [3]. However, we believe that the studies assessing the use of this preventive technique for end ileostomies are still too few to be able to draw definitive conclusions. Furthermore, we would like to clarify that the small sample size of our cohort was suggested as a potential reason for the quite large confidence interval of the observed hazard ratio rather than the direction of the treatment effect itself, as suggested in the comment. Our data indeed suggested a statistically significant increased likelihood of PSH occurrence following the use of prophylactic mesh for end ileostomies, but we believe that this subgroup size might be too small to allow for an adequate estimation of the size of this risk. Second, we agree with Li that the keyhole technique is frequently described in articles evaluating prophylactic meshes, as in our work, even though the modified Sugarbaker technique represents the most effective technique for PSH repair. As explained in our article, we chose this technique as it is time efficient, and can be used for both open and laparoscopic surgeries. Patients in our prophylactic mesh group had a higher BMI, a known risk factor for PSH occurrence, and we believe that the keyhole technique described was easier to perform in patients with increasing obesity. For a preventive measure to be used frequently by many surgeons, it must be technically efficient, and the keyhole technique certainly fulfilled this criterion. Finally, the third element of Li’s comment regarding the etiology of PSH is interesting, and appropriately illustrates the surgical challenge that represents PSH prevention. We are thankful for this opportunity to share our position on their comment and hope we clarify the conclusions of our work.