Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia...

Correspondence

The Editors welcome topical correspon-dence from readers relating to articlespublished in the Journal. Responses shouldbe sent electronically via the BJS website(www.bjs.co.uk). All letters will be reviewedand, if approved, appear on the website. Aselection of these will be edited and publishedin the Journal. Letters must be no morethan 250 words in length.

Risk factors for portal venousthrombosis after splenectomy inpatients with cirrhosis and portalhypertension (Br J Surg 2010; 97:910–916)

SirWe read with interest this manuscriptin which the authors demonstrated thatonly spleen diameter and consequentdecreased portal venous flow were riskfactors for the development of portalvein thrombosis (PVT) after splenec-tomy in patients with cirrhosis. Despitethis finding we believe that patients withcirrhosis are characterized by specificrisk factors for PVT after splenec-tomy owing to their peculiar prob-lems related to haemostasis. In fact,the incidence of 24 per cent of PVTafter splenectomy in patients with cir-rhosis is higher than that in patientswith underlying thrombophilic condi-tions (1·7–12·8 per cent)1. This couldbe due to the reset haemostatic balancewhich has been demonstrated recentlyto be shifted towards hypercoagulabilityin patients with Child’s grade C disease.In addition, patients with PVT havebeen shown to have increased levels offactor VIII, which can cause imbalancein haemostasis with a tendency towardsthrombosis. In fact, Kawanaka et al.2

recently showed that administrationof antithrombin III after splenectomywas likely to decrease the incidenceof PVT by restoring the equilibriumbetween procoagulant and anticoagu-lant factors.

Moreover, the rise in the plateletcount after splenectomy (not describedby the authors) could be an additionalrisk factor for PVT as demonstratedin a recent trial of the use of throm-bopoietin before invasive procedures inpatients with cirrhosis3. Finally, genetic

thrombophilic defects have been shownin up to 69 per cent of cases4. Thus,screening for thrombophilia could beuseful before surgical procedures, suchas splenectomy, in patients with a highrisk of thrombosis.

In conclusion, patients with livercirrhosis may stand even a greaterrisk of PVT after splenectomy thanpatients without cirrhosis and thiscould strongly suggest the need forthromboprophylaxis after surgery.

M. Senzolo, K. Rodriguez, E. Nadaland P. Burra

Department of Gastroenterology,University Hospital of Padua, Padua, Italy

(e-mail: [email protected])DOI: 10.1002/bjs.7239

1 Krauth MT, Lechner K,Neugebauer EA, Pabinger I. Thepostoperative splenic/portal veinthrombosis after splenectomy and itsprevention – an unresolved issue.Haematologica 2008; 93: 1227–1232.

2 Kawanaka H, Akahoshi T, Kinjo N,Konishi K, Yoshida D, Anegawa Get al. Impact of antithrombin IIIconcentrates on portal vein thrombosisafter splenectomy in patients with livercirrhosis and hypersplenism. Ann Surg2010; 251: 76–83.

3 Afdhal NH, Giannin E, Tayyab GN,Mohsin A, Lee JW, Andriulli A et al.Eltrombopag in chronic liver diseasepatients with thrombocytopeniaundergoing an elective invasiveprocedure: results from ELEVATE, arandomized controlled clinical trial.J Hepatol 2010; 52: S460.

4 Amitrano L, Brancaccio V,Guardascione MA, Margaglione M,Iannaccone L, D’Andrea G et al.Inherited coagulation disorders incirrhotic patients with portal veinthrombosis. Hepatology 2000; 31:345–348.

Authors’ reply: Risk factors forportal venous thrombosis aftersplenectomy in patients withcirrhosis and portal hypertension(Br J Surg 2010; 97: 910–916)

SirWe would like to thank Dr Marcoand colleagues for their interest in ourreport. We initially suspected that theincreased incidence of portal venousthrombosis (PVT) after splenectomyin patients with cirrhosis might be aresult of disturbed haemostasis1. How-ever, poor liver function (Child–Pughscore, Model for End-Stage Liver Dis-ease score, prothrombin time) was notfound to be a significant risk fac-tor for postoperative PVT in patientswith cirrhosis in this study (P = 0·061).Kawanaka and colleagues2 demon-strated that the incidence of PVT aftersplenectomy in patients with cirrhoticwas decreased by prophylactic adminis-tration of antithrombin III concentrates,suggesting that abnormal haemostasiscould be a risk factor for PVT in thesepatients. Prophylactic administration ofantithrombin III is routinely carried outwithin the first few days in patients athigh risk of PVT in our institution, andthe incidence of PVT after splenectomyin patients with cirrhosis thus remainslow. Further studies are needed to con-firm the involvement of the variousfactors (such as protein S and proteinC) that contribute to peculiar throm-bophilic conditions in the developmentof PVT after splenectomy in patientswith cirrhosis.

The purpose of this study was toclarify the incidence and characteristicsof PVT after splenectomy in patientswith cirrhosis. The associated risk fac-tors with regard to liver function, por-tal hypertension and splenectomy wereassessed in light of the need for prophy-lactic anticoagulation therapy for PVTwithin the first few days after splenec-tomy. The preoperative and operativeclinical factors were reviewed in thisstudy. Median(s.d.) platelet counts onpostoperative day 14 were higher inthe PVT group than in the non-PVTgroup (360(35) × 103 versus 201(13)/µlrespectively). However, the contribu-tion of the low platelet count to thehypercoagulability and subsequent for-mation of PVT after splenectomy wasnot determined.

N. Kinjo

Copyright 2010 British Journal of Surgery Society Ltd British Journal of Surgery 2010; 97: 1452–1457Published by John Wiley & Sons Ltd

Correspondence 1453

Department of Surgery and Science,Graduate school of Medical Sciences,

Kyushu University, 3-1-1 Higashi-ku,Fukuoka 812-8582, Japan

(e-mail:[email protected])

DOI: 10.1002/bjs.7240

1 Amitrano L, Guardascione MA,Brancaccio V, Margaglione M,Manguso F, Iannaccone L et al. Riskfactors and clinical presentation ofportal vein thrombosis in patients withliver cirrhosis. J Hepatol 2004; 40:736–741.

2 Kawanaka H, Akahoshi T, Kinjo N,Konishi K, Yoshida D, Anegawa Get al. Impact of antithrombin IIIconcentrates on portal vein thrombosisafter splenectomy in patients with livercirrhosis and hypersplenism. Ann Surg2010; 251: 76–83.

Chronic pain 5 years afterrandomized comparison oflaparoscopic and Lichtensteininguinal hernia repair (Br J Surg2010; 97: 600–608)

SirThis study reported the incidence ofpostoperative chronic groin pain as9·4 per cent at 5 years for the totallyextraperitoneal (TEP) technique. Wewould like to add our comments, whichare the result of our experience of 2431transabdominal preperitoneal inguinalhernia repairs.

Chronic pain can be reduced dra-matically by avoiding the use of tack-ers to fix the mesh, ensuring thatthe mesh is placed without creasesand, when necessary, employing twomeshes to cover the defect and weakpoints in order to prevent recurrence,which can be a cause of postopera-tive pain. When necessary we haveused a VicrylTM stitch to fix the meshat its upper border, to avoid usingthe tacker. Only six (0·3 per cent) ofour patients developed postoperativechronic groin pain.

The authors do not commentwhether patients with suspected recurrence

were subjected to further imaging (mag-netic resonance imaging, ultrasonogra-phy) to assess the cause of their pain andto exclude recurrence.

Despite being a randomized clinicaltrial, the operations were performed bydifferent surgeons with different lev-els of skills and experience, and withvariability of approach. The authorsreported that the technique describedby Voeller and Mangiante1 was used forTEP repairs and that of Amid et al.2

for Lichtenstein repairs. It might beimpossible to guarantee standardizationof approach for each case. The out-comes, including postoperative chronicgroin pain, would vary accordingly.

A. Hussain and S. El-HasaniMinimal Access Unit, Princess RoyalUniversity Hospital, Orpington, UK(e-mail: [email protected])

DOI: 10.1002/bjs.7241

1 Voeller GR, Mangiante EC Jr. Totallypreperitoneal laparoscopic inguinalherniorrhaphy using balloondistention. Scand J Gastroenterol Suppl1995; 208: 67–73.

2 Amid PK, Shulman AG,Lichtenstein IL. Open ‘tension-free’repair of inguinal hernias: theLichtenstein technique. Eur J Surg1996; 162: 447–453.

Authors’ reply: Chronic pain 5 yearsafter randomized comparison oflaparoscopic and Lichtensteininguinal hernia repair (Br J Surg2010; 97: 600–608)

SirThank you for your comments concern-ing our article on chronic pain afterhernia repair. Your own result regardingchronic pain is excellent. Whether theuse of tackers for mesh fixation results inan increased frequency of chronic painis unclear according to the literature1,2;your suggestion to use sutures for meshfixation instead of tackers might, in ouropinion, also lead to chronic neurogenicpain.

Concerning patients with suspectedrecurrence or severe complaints, all

were examined clinically. If the inves-tigation was inconclusive, herniographywas performed to rule out a possiblerecurrence. This was not mentionedin the present article, but has beendescribed by us previously3. The pri-mary endpoint of the trial was recur-rence and there was no algorithm foraccessing severe complaints, besidesherniography.

We do believe that the operativetechnique used for both methods waswell standardized, as we have reportedpreviously4. In the laparoscopic group,the surgeons were required to haveperformed only 25 previous totallyextraperitoneal (TEP) repairs, whichis low compared with other trials5.We do believe that the learning curveinfluenced the outcome in the TEPgroup, especially regarding recurrence5.If the learning curve does influence thefrequency of chronic pain, our datado not permit any clear conclusionsregarding this.

A. Eklund and C. RudbergDepartment of Surgery, Central Hospital,

Vasteras, Sweden(e-mail: [email protected])

DOI: 10.1002/bjs.7242

1 Lau H. Fibrin sealant versus mechanicalstapling for mesh fixation duringendoscopic extraperitoneal inguinalhernioplasty: a randomized prospectivetrial. Ann Surg 2005; 242: 670–675.

2 Lovisetto F, Zonta S, Rota E,Mazzilli M, Bardone M, Bottero Let al. Use of human fibrin glue(Tissucol) versus staples for meshfixation in laparoscopic transabdominalpreperitoneal hernioplasty: aprospective, randomized study. AnnSurg 2007; 245: 222–231.

3 Eklund A, Montgomery A,Rasmussen I, Sandbue R, Bergkvist L,Rudberg C. Low recurrence rate afterlaparoscopic (TEP) and open(Lichtenstein) inguinal hernia repair, arandomized, multicenter trial with5-year follow-up. Ann Surg 2009; 249:33–38.

4 Eklund A, Rudberg C, Smedberg S,Enander L-K, Leijonmarck C-E,Osterberg J et al. Short-term results ofa randomized clinical trial comparing

Copyright 2010 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2010; 97: 1452–1457Published by John Wiley & Sons Ltd

1454 Correspondence

Lichtenstein open repair with totallyextraperitoneal laparoscopic inguinalhernia repair. Br J Surg 2006; 93:1060–1068.

5 Neumayer L, Giobbie-Hurder A,Jonasson O, Fitzgibbons R Jr,Dunlop D, Gibbs J et al. Open meshversus laparoscopic mesh repair ofinguinal hernia. N Engl J Med 2004;350: 1819–1827.

Case–control comparison ofprofundaplasty and femoropoplitealsupragenicular bypass for peripheralarterial disease (Br J Surg 2010; 97:344–348)

SirKoscielny and colleagues present acomparison of local groin procedurecompared with single segment bypassfor peripheral arterial occlusive disease(PAOD). They address an issue perti-nent to the practice of many vascularsurgeons, but fundamental questionsregarding local groin procedures remainunanswered by the current literature,including the present work.

Specifically, does a local groin proce-dure (defined as improving flow throughan occluded/severely stenotic segmentof the common, superficial or profundafemoris arteries) alter the natural historyof symptomatic PAOD? Will claudica-tion distance improve or will criticallimb ischaemia be reversed?

If patch closure is required, isit desirable or necessary to preservethe long saphenous vein for futurebypass? What is the likely rate ofwound infection to inform decisions onprosthetic patch use?

Variation in practice suggests aspectrum of opinion on the value ofthis procedure. It is easy to presupposethat some use the technique to treatclaudicants insisting on a procedure,and at the other end of the spectrumperform groin reconstruction in thepatient unattractive for distal bypass asa ‘last ditch’ salvage manoeuvre. Betterunderstanding of the likely benefits inboth scenarios is desirable.

A systematic approach is needed,defining which parts of the femoral

artery bifurcation in the groin are dis-eased and to what extent, as well as dataon distal vessels. Furthermore, defin-ing outcome in a comparable fashion tothat used in bypass/angioplasty trials isdesirable.

Ultimately, a randomized controlledtrial may become possible once theprecise area of equipoise has beendefined.

K. HusseyDepartment of Vascular Surgery,

Southern General Hospital, Glasgow, UK(e-mail: [email protected])

DOI: 10.1002/bjs.7243

Authors’ reply: Case–controlcomparison of profundaplasty andfemoropopliteal supragenicularbypass for peripheral arterial disease(Br J Surg 2010; 97: 344–348)

SirMr Hussey is correct that few dataregarding the groin procedure areavailable in the current literature.This was the reason for initiatingthe presented comparison, which wasdesigned as a retrospective matched-pair study in patients with an occludedsuperficial femoral artery (Table 1). Wecompared only patients with similarrisk profiles, identical indications forintervention and similar angiographiccharacteristics (Table 2) to determinewhich procedure gave better results.Within the limits of a retrospectivestudy we tried to provide a systematicapproach, defining diseased parts of thefemoral artery bifurcation, deliveringdata on distal vessels (Tables 1 and 2) anddefining the outcome in a comparablefashion.

We found a significantly better walk-ing distance in patients with claudica-tion, significantly reduced rest pain incritical limb ischaemia, and a significantimprovement of the ankle–arm indexafter profundaplasty. Similar resultshave been obtained by other authors1 – 3,suggesting that the ‘natural history ofsymptomatic PAOD’ can be altered bythis procedure, as shown in retrospec-tive studies.

For patch closure we preferreda segment of the most distal longsaphenous vein harvested from the ankleregion to preserve the more proximallong saphenous vein for future bypass.We used alloplastic patches only whenthe saphenous veins were not availablebecause of removal or venous disease.

We observed only one infection inthe 28 patients in the profundaplastygroup (4 per cent). In this patient wehad used an alloplastic patch. Nodata regarding infection rates in groinprocedure were given by other citedauthors.

We perform profundaplasty as first-step procedure both in patients withclaudication and in patients with restpain and at least two patent cruralarteries. There is the advantage thatthe option of a later distal revascular-ization remains possible if symptomsare not improved4. The performingvascular surgeons were familiar withthe profundaplasty and supragenicularfemoropopliteal bypass operations, andperformed them frequently.

We agree completely that random-ized multicentre trials are needed toachieve a systematic approach to theprofundaplasty versus bypass surgeryversus angioplasty.

A. KoscielnyDepartment of Vascular Surgery, Klinik

und Poliklinik fur Allgemein-, Viszeral-,Thorax- und Gefasschirurgie, Bonn,

Germany(e-mail: [email protected])

DOI: 10.1002/bjs.7244

1 Cotton LT, Roberts VC. Extendeddeep femoral angioplasty: analternative to femoropopliteal bypass.Br J Surg 1975; 62: 340–343.

2 Towne JB, Rollins DL.Profundaplasty: its role in limb salvage.Surg Clin North Am 1986; 66: 403–414.

3 Diehm N, Savolainen H, Mahler F,Schmidli J, Do DD, Baumgartner I.Does deep femoral arteryrevascularization as an isolatedprocedure play a role in chronic criticallimb ischemia? J Endovasc Ther 2004;11: 119–124.

4 Kalman PG, Johnston KW,Walker PM. The current role of


Correspondence 1455

isolated profundaplasty. J CardiovascSurg (Torino) 1990; 31: 107–111.

Endoscopic resection of early gastriccancer treated by guideline andexpanded National Cancer Centrecriteria (Br J Surg 2010; 97:868–871)

SirI would like to congratulate the authorson a well written analysis, whichdemonstrated similar long-term survivaland outcomes when using expandedNational Cancer Centre criteria com-pared with those obtained with thepopular Japanese Gastric Cancer Asso-ciation guideline. However, some pointsshould be discussed.

Early gastric cancer is defined as alesion confined to the mucosa or submu-cosa regardless of the lymph node status.In general, lymph node metastasis isthe most important factor in determin-ing the prognosis of patients with earlygastric cancer and is associated sig-nificantly with submucosal invasion ofneoplastic cells1,2. However, the accu-racy of preoperative computed tomog-raphy and endoscopic ultrasonographyin the detection of lymph node metas-tasis is between 50 and 70 per cent3.Other clinical and pathological factorsneed to be used in the assessment of riskof nodal metastasis, such as ulceratedlesions, tumour size, differentiation anddepth of invasion3,4.

Among these factors, depth oftumour invasion is most importantbecause it shows a positive correlationwith the possibility of submucosal lym-phovascular invasion. In addition, itsevaluation is very challenging in clinicalpractice.

First, greater endoscopic skills areneeded to avoid possible complications,such as bleeding or perforation dur-ing the time-consuming procedure ofendoscopic mucosal resection (EMR)or endoscopic submucosal dissection(ESD). Moreover, endoscopists shouldhave the ability to perform success-ful ‘one-piece’ resection rather than‘piecemeal’ resections, to resect a larger

tumour and obtain a more reliablepathological specimen.

Second, experienced pathologists arealso required. They should have thecapability to identify incomplete resec-tion of tumour. They should have theknowledge that the deepest point of sub-mucosal invasion is not always in thecentral area of the lesion5 and thus thenecessity for assessing the entire lesionwith thin sections. Only with these isaccurate assessment of depth of inva-sion possible, which is critical in thedecision-making process for surgery, toprevent residual disease and local recur-rence.

Expansion of the indications forEMR and ESD means that morepatients could have their stomach pre-served and an improved quality of life.However, besides skilful endoscopistsand experienced pathologists, success oftreatment also demands highly selected,cooperative patients and a strict follow-up protocol.

C.-C. ChiuDepartment of General Surgery, Chi MeiMedical Centre, Tainan County, Taiwan


1 Jee YS, Hwang SH, Rao J, Park DJ,Kim HH, Lee HJ et al. Safety ofextended endoscopic mucosal resectionand endoscopic submucosal dissectionfollowing the Japanese Gastric CancerAssociation treatment guidelines. Br JSurg 2009; 96: 1157–1161.

2 Son HJ, Song SY, Kim S, Noh JH,Sohn TS, Kim DS et al. Characteristicsof submucosal gastric carcinoma withlymph node metastatic disease.Histopathology 2005; 46: 158–165.

3 Lee JH, Choi IJ, Kook MC, Nam BH,Kim YW, Ryu KW. Risk factors forlymph node metastasis in patients withearly gastric cancer and signet ring cellhistology. Br J Surg 2010; 97:732–736.

4 Tajima Y, Murakami M, Yamazaki K,Masuda Y, Aoki S, Kato M et al. Riskfactors for lymph node metastasis fromgastric cancers with submucosalinvasion. Ann Surg Oncol 2010; 17:1597–1604.

5 Nunobe S, Gotoda T, Oda I, Katai H,Sano T, Shimoda T et al. Distributionof the deepest penetrating point ofminute submucosal gastric cancer. JpnJ Clin Oncol 2005; 35: 587–590.

Authors’ reply: Endoscopicresection of early gastric cancertreated by guideline and expandedNational Cancer Centre criteria(Br J Surg 2010; 97: 868–871)

SirWe thank Dr Chiu for his interest inour study as well as his reasonable anduseful comments, which support thegoals behind our leading article in theJournal.

Our case–control study demon-strated an equivalent long-term survivalrate in patients with either early gastriccancer (EGC) that fulfils the expandedNational Cancer Centre (NCC) crite-ria or EGC classified as a guidelinelesion. Guideline lesions were defined assmall EGCs less than 2 cm in diameter,with intestinal-type histology, no fibro-sis and invasion only intramucosally.These strict criteria have been definitelyregulated by the Gastric Cancer Treat-ment Guidelines of the Japanese GastricCancer Association1 in the era of endo-scopic mucosal resection (EMR).

With the advent of endoscopic sub-mucosal dissection (ESD) in 1999,larger EGCs, regardless of the presenceof fibrosis, were able to be removed.On the other hand, as Dr Chiu com-mented, the accuracy of preoperativeevaluation such as depth of tumourinvasion, lymphatic–vascular involve-ment and/or histological differentia-tion strongly related to lymph nodemetastasis2 is not yet reliable, evenusing computed tomography and endo-scopic ultrasonography3. This has ledus to consider whether ESD is a ther-apeutic procedure or whether it shouldultimately be considered a diagnos-tic method. Regardless, curability afterendoscopic resection should be obtainedonly through precise histological assess-ment of en bloc material by ESD.


1456 Correspondence

ESD still requires greater endoscopicskills to avoid the complications associ-ated with EMR. However, ESD, whichdirectly dissects the submucosal layer,was developed as a completely differ-ent concept from standard EMR, whichpulls or sucks the mucosa. Therefore, webelieve that ESD is not an extension ofEMR and should be assessed as a sepa-rate surgical procedure. We realize thatthe time-consuming nature of ESD is asignificant problem, resulting in hesita-tion to perform this procedure in manyinstitutions. In addition, laparoscopicresection under general anaesthesia canbe a much easier procedure to performthan ESD. Therefore, we should discusswhether to choose ESD or laparoscopicsurgery as the better and safer curativetreatment for EGC.

Even in Japan there are not enoughexperienced pathologists specializing inthe gastrointestinal tract. To improvediagnostic capability, it is importantto hold joint conferences with endo-scopists, pathologists and surgeons inattendance. It is through such forumsthat we are able to share informationand reach a consensus regarding thediagnostic process and/or curability ofspecific procedures.

As described above, ESD is a form ofminimally invasive surgery and is not aneasy endoscopic technique. Moreover,endoscopists should encourage self-awareness in order to increase the treat-ment of neoplastic lesions. Therefore,reasonable decision-making regardingthe best treatment option to perform, aswell as a strict surveillance programme,should be mandatory4, especially whenexpanding the indications for endo-scopic procedures in the era of ESD.

T. GotodaDepartment of Gastroenterology and

Hepatology, National Centre for GlobalHealth and Medicine, Shinjuku-ku-,

Tokyo, Japan(e-mail: [email protected])

DOI: 10.1002/bjs.7246

1 Japanese Gastric Cancer Association.Japanese classification of gastriccarcinoma – 2nd English edition.Gastric Cancer 1998; 1: 10–24.

2 Gotoda T, Sasako M, Ono H, Katai H,Sano T, Shimoda T. Evaluation of thenecessity of gastrectomy with lymphnode dissection for patients withsubmucosal invasive gastric cancer. BrJ Surg 2001; 88: 444–449.

3 Yanai H, Noguchi T, Mizumachi S,Tokiyama H, Nakamura H, Tada Met al. A blind comparison of theeffectiveness of endoscopicultrasonography and endoscopy instaging early gastric cancer. Gut 1999;44: 361–365.

4 Kodera Y, Yamamura Y, Torii A,Uesaka K, Hirai T, Yasui K et al.Incidence, diagnosis and significance ofmultiple gastric cancer. Br J Surg 1995;82: 1540–1543.

Adverse effects of polyvinylidenefluoride-coated polypropylene meshused for laparoscopic intraperitonealonlay repair of incisional hernia(Br J Surg 2010; 97: 1140–1145)

SirWe read with interest the experienceof Fortelny and colleagues with the useof DynaMesh. In their series of 29patients, ileus and adhesion formationwas the main problem resulting in theremoval of three meshes, and a furthertwo patients had surgery for small bowelobstruction.

The increased popularity of compos-ite meshes compared with biologicalsis mainly due to cost, ease of han-dling and advantages associated with themicroporosity. A number of compos-ite meshes are available, but there areno randomized controlled trials prov-ing the effectiveness of one over theother.

We have performed 38 laparoscopicincisional and ventral abdominal wallhernias over the past 30 months. Fourpatients were operated on for obstructedincisional hernias. The male to femaleratio was 14 : 24, with an age rangeof 30–78 years. DynaMesh – IPOMwas employed for all these repairs,with a standard double crowning tech-nique using a ProTackTM . In terms ofsymptoms associated with small bowel

obstruction, only one patient returnedwith an ileus and had normal findingson computed tomography. He was dis-charged after conservative treatment.To date, we have had no reoperationsor complications associated with smallbowel adhesions or obstruction.

Berger and colleagues1 reportedon 340 patients who had repairof incisional/parastomal hernias usingDynaMesh. These authors observedno direct complications that wererelated to small bowel adhesions orobstruction. They provided a listof other complications, all of whichoccurred in less than 1 per cent of thepatients.

Laparoscopic repair of abdominalwall hernia has a clear advantage overthe open methods. Only a random-ized controlled trial of the differentmeshes, with long-term follow-up, candetermine the true incidence of compli-cations.

S. AnwarDepartment of Surgery, Huddersfield

Royal Infirmary, Huddersfield, UK(e-mail: [email protected])

DOI: 10.1002/bjs.7247

1 Berger D, Bientzle M. Polyvinylidenefluoride: a suitable mesh material forlaparoscopic incisional and parastomalhernia repair! A prospective,observational study with 344 patients.Hernia 2009; 13: 167–172.

Authors’ reply: Adverse effects ofpolyvinylidene fluoride-coatedpolypropylene mesh used forlaparoscopic intraperitoneal onlayrepair of incisional hernia (Br J Surg2010; 97: 1140–1145)

SirWe thank you for your interest inour study and congratulate on yourresults. As you have commented,reports of positive experiences withDynaMesh – IPOM do exist1,2. Weencourage you to add your expertiseto the body of knowledge by publish-ing them in a peer-reviewed journal.We cannot explain why our results have


Correspondence 1457

been so disappointing, and a thoroughanalysis did not reveal common char-acteristics in the affected patients. Asdiscussed in the paper, many adhesionsremain (almost) asymptomatic or can betreated conservatively. The true inci-dence of adhesions is simply not known,and neither is the mechanism of devel-opment and individual factors that makethem symptomatic. We suggest that ourresults are viewed in this light, ratherthan making a final verdict on a specificproduct.

A. H. Petter-PuchnerLudwig Boltzmann Institute for

Experimental and Clinical Traumatology,Vienna, Austria


1 Berger D, Bientzle M. Polyvinylidenefluoride: a suitable mesh material forlaparoscopic incisional and parastomalhernia repair! A prospective,observational study with 344 patients.Hernia 2009; 13: 167–172.

2 Junge K, Binnebosel M, Rosch R,Jansen M, Kammer D, Otto J et al.Adhesion formation of apolyvinylidenfluoride/polypropylenemesh for intra-abdominal placement ina rodent animal model. Surg Endosc2009; 23: 327–333.


Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia...

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