LAUSR

Dear Editors, We read with great interest the recently published article by Fischer et al. [1]; the authors reported 56 cases of parastomal hernia (PSH) repaired with 3D funnel mesh in IPOM technique, and demonstrated that it is a safe, efficient and easy procedure compared to other techniques. We are very interested in this clinical trial; however, in our opinion, several points need further discussion. First, actually, parastomal hernia is a special kind of ‘‘incisional hernia,’’ with the functional intestine passing through the incision site (stoma), which prevents the complete closure of the weakness, and renders the high incidence/recurrence of the PSH and the challenge of all kinds of repair. Second, it is conceivable that, in the repair of any kind of hernia, when a method focusing on repairing the ‘‘hole’’ itself, it usually leads to poor results, one example is the using of plug itself (without patch) in inguinal hernia repair. Therefore, it has been reported that most of the PSH recurrence after ‘‘keyhole’’ technique was in the central hole (72.7%) [2], which highlights the ‘‘drawback’’ of this ‘‘keyhole-repair’’ technique. Furthermore, when interpreting the mechanism of occurrence or recurrence of PSH, we believe that it is not the weakness of any layer of the fascia-muscular tissue or the mesh, but the presence of the artificial ‘‘hole,’’ which is gradually enlarged beyond of the adjacent healthy abdominal. Thus, it is obvious that we could not successfully repair a ‘‘hole’’ with another artificial mesh ‘‘hole.’’ Although the present 3D funnel mesh technique could partially overcome the problem associated with a flat ‘‘keyhole’’ mesh, it is still a modified ‘‘keyhole’’ technique in nature, and the same recurrence developing mechanism of PSH is still present, which attributes to the recurrence rate of 12.5% in the present study. Third, we would also like to point out another two concerns with the 3D funnel mesh technique. One concern is the removal and reconstruction of the stoma, which was associated with the incidence of stoma necrosis and stoma retraction, as reported in the author’s study. Another concern is the relatively rigid 3D configuration of the mesh structure itself, which was in close relation with the soft and flexible abdominal contents, such as small intestine, and furthermore, we feel uncomfortable to encapsulate the functional sigmoid colon within it in the long run. Both of the concerns could be obviated with other alterative procedures, such as by placing the mesh outside of abdominal cavity, in the retromuscular space [3]. Again, PSH repair is a challenging procedure, until now, no ideal technique exists, and we appreciate very much for the author’s study and expecting for the longterm results of the study.