Commentary on “Open inguinal hernia repair in women: is mesh necessary?” by N. M. Thairu, B. P. Heather, J. J. Earnshaw

Excerpt

This proposed study is an interesting and accurate microcosm of what is happening in the larger sphere of hernia surgery. In terms of incidence of hernias in women, percentage of indirect to direct hernias, the values match the much larger studies of the past. It is also a most significant study, in view of the fact that the 52 female patients that were examined did not include any with femoral hernias. The latter group can wreak havoc on the interpretation of statistics on groin hernias, in general, and, more particularly, in women! The references have also identified and pinned what is substantially overlooked by the profession, namely that open techniques still account for 85% of hernia surgery, despite aggressive and flamboyant attempts by laparoscopists. However, the use of non-mesh repairs seems to have gravitated from 9% to 5%, and these values would presage the inevitable demise of pure tissue repairs. The authors have been able to project, and here again accurately, despite the small series, a truism that has all too often been overlooked, if not forgotten by some…that mesh is not necessary in ALL hernia repairs. Women, children, and young adults form a notable group for whom surgeons can do away with mesh, and, I may add, patients with indirect inguinal hernias, where the defect of the deep inguinal ring is minimal or insignificant. This paper reminds us that indirect inguinal hernias account for at least 73% of inguinal hernias in women, where the challenge is one of sac identification and removal. The women with direct inguinal hernias, 15% in this series, should be considered to manifest a defect in collagen metabolism and are the patients for whom mesh must be considered. The Shouldice Hospital surgeons may, likely successfully, if statistically, argue this last issue! But logic and out-of-Shouldice statistics will strongly support the use of mesh, not only for some female patients but also for all patients with femoral hernias, primary and recurrent direct inguinal hernias, and some recurrent indirect inguinal hernias. …