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Re: Recurrence after inguinal hernia repair at ten years by open darn, open mesh and TEP – no advantage with mesh
the surgeon 8 (2010) 122
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Letter to the Editor
Re: Recurrence after inguinal hernia repair at ten years by open darn, open mesh and TEP – no advantage with mesh Dear Sir We were interested to read the findings of the Lothian Surgical Audit. This well established audit provides an excellent insight into a hernia service over 20 years and demonstrates the difficulty in evaluating long term surgical outcomes. We note however the 4% recurrence rate of open mesh repair compared to the 1–2% widely quoted for primary inguinal hernia repair (Nice Guidance). We accept that 12% of open mesh repairs in this cohort were performed on recurrent hernias. It would have been more helpful to show long term data for recurrence in the primary and recurrent groups separately. We question the authors’ conclusion that open mesh repair provides no advantage over TEP given their 7% recurrence rate. Of most interest, is the variance in recurrence rates for open mesh repair between surgeons. Although nine consultants contributed to these data, 4 contributed 96% of all cases. Their recurrence rate varied from 2.4 to 6.4%. Moreover the 5
consultants performing 4% of operations had 16% of all recurrences. The Lichtenstein technique is well described, however inguinal hernia repair is a procedure often performed by trainees and may vary in its execution in terms of mesh type, size, number of sutures etc. The Lothian results show a peak of recurrences after mesh was introduced and support our hypothesis that open mesh repair is in fact intolerant of less than perfect technique, requires standardised training and should not be performed by unsupervised trainees. Ashok Handa and Mary Weisters John Radcliffe Hospital, Oxford 1479-666X/$ – see front matter ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2009.10.027
Reply Dear Sir Thank you for your interest in our paper. Our recurrence rate of 4% at 10 years compares very favourably with the finding of NICE who found that, even when working in the context of a randomised trial, the Lichtenstein operation had a recurrence rate of 2.3% at two years. The largest trial of laparscopic versus Lichtenstein repair from the USA reported by Neumayer et al. in fact had a 4.5% recurrence rate at two years after open mesh repair. In my view, the ‘‘widely quoted’’ recurrence rate of 1–2% for Lichtenstein is ‘‘wildly optimistic’’ when one looks, at reported series other than those from the Lichtenstein clinic. I agree that differentiation of primary and recurrent repairs would be ideal, but, in reality only 10% of our cases were performed for recurrent hernia and there would have only been approximately 30 recurrent cases in each group from which no valid conclusions could have been drawn. I am not sure how the observation that ‘‘Lothian results show a peak of recurrences after mesh was introduced’’ was made as our data did not look at the results of mesh repair over time. It may be that the Lichtenstein repair does have a learning curve and later results from this type of repair may improve over time. We will have to revisit this question when more recent 10 year follow
up data become available. We have already reported that supervised trainees have excellent results with the open mesh repair whereas unsupervised trainees do not. Finally, I apologise if we gave the impression that ‘‘open mesh repair provides no advantage over TEP’’. We did clearly report the high early failure rate after TEP due we believe to the learning curve. Again we have previously reported this finding. Overall, the disease of recurrent inguinal hernia seems to be as common today as in the 1980s, well before mesh became popular. I am sure we all agree that long term follow up data are needed but whilst industry has gained enormous financial benefit from our use of mesh, we are finding it difficult to prove that our patients have also benefitted.
Steve Nixon, Edinburgh Royal Infirmary 1479-666X/$ – see front matter ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2009.10.028
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Letter to the Editor
Re: Recurrence after inguinal hernia repair at ten years by open darn, open mesh and TEP – no advantage with mesh Dear Sir We were interested to read the findings of the Lothian Surgical Audit. This well established audit provides an excellent insight into a hernia service over 20 years and demonstrates the difficulty in evaluating long term surgical outcomes. We note however the 4% recurrence rate of open mesh repair compared to the 1–2% widely quoted for primary inguinal hernia repair (Nice Guidance). We accept that 12% of open mesh repairs in this cohort were performed on recurrent hernias. It would have been more helpful to show long term data for recurrence in the primary and recurrent groups separately. We question the authors’ conclusion that open mesh repair provides no advantage over TEP given their 7% recurrence rate. Of most interest, is the variance in recurrence rates for open mesh repair between surgeons. Although nine consultants contributed to these data, 4 contributed 96% of all cases. Their recurrence rate varied from 2.4 to 6.4%. Moreover the 5
consultants performing 4% of operations had 16% of all recurrences. The Lichtenstein technique is well described, however inguinal hernia repair is a procedure often performed by trainees and may vary in its execution in terms of mesh type, size, number of sutures etc. The Lothian results show a peak of recurrences after mesh was introduced and support our hypothesis that open mesh repair is in fact intolerant of less than perfect technique, requires standardised training and should not be performed by unsupervised trainees. Ashok Handa and Mary Weisters John Radcliffe Hospital, Oxford 1479-666X/$ – see front matter ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2009.10.027
Reply Dear Sir Thank you for your interest in our paper. Our recurrence rate of 4% at 10 years compares very favourably with the finding of NICE who found that, even when working in the context of a randomised trial, the Lichtenstein operation had a recurrence rate of 2.3% at two years. The largest trial of laparscopic versus Lichtenstein repair from the USA reported by Neumayer et al. in fact had a 4.5% recurrence rate at two years after open mesh repair. In my view, the ‘‘widely quoted’’ recurrence rate of 1–2% for Lichtenstein is ‘‘wildly optimistic’’ when one looks, at reported series other than those from the Lichtenstein clinic. I agree that differentiation of primary and recurrent repairs would be ideal, but, in reality only 10% of our cases were performed for recurrent hernia and there would have only been approximately 30 recurrent cases in each group from which no valid conclusions could have been drawn. I am not sure how the observation that ‘‘Lothian results show a peak of recurrences after mesh was introduced’’ was made as our data did not look at the results of mesh repair over time. It may be that the Lichtenstein repair does have a learning curve and later results from this type of repair may improve over time. We will have to revisit this question when more recent 10 year follow
up data become available. We have already reported that supervised trainees have excellent results with the open mesh repair whereas unsupervised trainees do not. Finally, I apologise if we gave the impression that ‘‘open mesh repair provides no advantage over TEP’’. We did clearly report the high early failure rate after TEP due we believe to the learning curve. Again we have previously reported this finding. Overall, the disease of recurrent inguinal hernia seems to be as common today as in the 1980s, well before mesh became popular. I am sure we all agree that long term follow up data are needed but whilst industry has gained enormous financial benefit from our use of mesh, we are finding it difficult to prove that our patients have also benefitted.
Steve Nixon, Edinburgh Royal Infirmary 1479-666X/$ – see front matter ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2009.10.028