LAUSR

Dear Editor, We would like to congratulate Sneiders et al. for their efforts in performing this study ‘‘Outcomes of Incisional Hernia Repair Surgery After Multiple Re-recurrences: A Propensity Score Matched Analysis’’ [1]. The authors compared the outcomes of primary incisional hernia repair and re-recurrent incisional hernia (IH) repair by using the propensity score matched method to balance covariates across groups and found that incidence of re-recurrence was similar between groups (re-recurrences: 25% vs. control 24%, p = 0.811). They concluded that further surgery in patients who already experienced multiple IH re-recurrences was a justifiable treatment and would result in a good outcome when they were performed by dedicated hernia surgeon. Although we consider these findings to be informative, we feel that several points deserve further comment. The study mentioned the qualifications of surgeons who repaired re-recurrence IH, but it did not clarify the qualifications of surgeons who treat primary IH because a dedicated hernia surgeon is the most important factor in inferring the results of this study. We wonder if the surgeons of the two groups get the same qualifications. Otherwise, surgeons of different qualifications who intervene in different groups will lead to a different outcome and also increase the unreliability of the results. Moreover, we have doubts about the qualification of a dedicated hernia surgeon. According to different working years and work experience, dedicated hernia surgeons are often classified as senior doctors and junior doctors. Everybody knows that senior doctors and junior doctors will have different surgical results sometimes. In the article, the authors recruited that the hernia surgeon was only required to perform at least 100 inguinal and 50 ventral hernia repairs annually, and they did not mention how many years they have served as a dedicated surgeon. This pre-inclusion selection bias may influence the reliability of the results. Furthermore, the treatment of IH is still challenging for abdominal wall surgeons. Even if all IH apply mesh repair, the incidence of recurrence is still up to between 25 and 32% [2]. The debate is focused on which method is more suitable for different re-recurrent IH repair [3]. Recent international guidelines recommend laparoscopic surgery for these re-recurrent IH which was primarily treated with open surgery. The main argument is whether the primarily laparoscopic treated re-recurrent IH should continue to be treated with laparoscopic surgery [4]. In this article, the most common surgical method for rerecurrent IH is sublay (49%), followed by IPOM (33%), which is not widely used by the latest guidelines. The article only compared and analyzed the treatment effects of all surgical methods in one group. Therefore, it concluded that there is no difference in the overall treatment results between the two groups. We are curious which surgery technic is superior. For this reason, we would like to ask whether Sneiders et al. can compare the two subgroups separately (sublay and IPOM) and analyze whether there is a significantly different outcome between the separated treatment method of re-recurrent IH. This can provide a good value of reference for the selection of the best treatment method in the future. & Xueyang Tang [email protected]