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Our mission in publishing The Hernia Letter is to provide a rational and objective view of hernia surgery free from the influence of the industry and its “collaborative faculties”. Where the industry has had a hand, through financing, sponsorship, cooperation in publication, direction of research, presentations at conferences, presence at society boards, transparency and accountability must be the rule.

The need for “The Hernia Letter” became evident and imperative as soon as the EHS-Herniasurge International Guidelines for Adult Hernias were being proposed. At first, pure tissue repairs were proscribed by the steering and working committees. This was followed by prevarications which were prompted by a session at the Vienna EHS meeting. Recommendations, as they stand presently in the Guidelines are not convincing nor are they in line with major publications listed in articles elsewhere in this issue.

The Hernia Letter, first of all, is not an anti-mesh site! Mesh has been used consistently but judiciously by the surgeons listed on the banner page. Dr Bendavid was credited with having designed the first two mesh devices in the 1980s (the Umbrella and the Fletching) and was instrumental in introducing mesh at the Shouldice Hospital where it is still being used, albeit far less often than everywhere else.

It is distressing to anatomists and older surgeons alike that within a single generation, the art of a pure tissue repair has been lost. There are young heads of departments of surgery who have never seen a groin dissection as bequeathed by Bassini! Our late teacher, friend and colleague John Skandalakis, decried and deplored the fact that the teaching of anatomy was being abandoned by many medical schools.

I remember Ira Rutkow who promoted his Bard plug by stating that: “With a plug, you do not need to know anatomy”! Time, the harshest but fairest of critics has proven otherwise.

Now, more than ever, a return to basics with simpler instruments should be the order of the day. A pure tissue repair is essentially a safer, superficial operation without the demands of rigid, long training necessary for laparoscopic approaches which have never established themselves solidly in 25 years of existence except in certain, well recognized pockets.

Pure tissue repairs, properly performed, established a gold standard barely 20 years ago with our most respectable colleagues … Stoppa, Flament, Wantz and many others throughout Europe and North America. Recurrence rates were no higher than reported today with mesh. Further evidence as shown in the additional articles in this “The Hernia Letter” has confirmed that mesh has promoted a “laisser-aller” attitude, meaning a reliance on mesh regardless of hernia type as the answer to the problem! The series by the Mayo Clinic, Urbach, Herniamed have proven that indeed, pure tissue repairs are here to stay.

The nature and shortcomings of polypropylene meshes in a significant portion of the patient population (12% and +) has imposed a new look and reconsideration of pure tissue repairs. A body of literature has now confirmed that indeed, the majority of patients with a groin hernia can be safely treated with a pure tissue repair thus saving mesh for failure.

The experience of our recent past colleagues and teachers have proven, and recent publications are reconfirming that indeed, an open pure tissue repair is a valuable tool which must never be lost as we have lost the ability to make violins and Caucasian rugs!

The problem at present, and we are meeting it, is who will teach the world?

Patients have learned to study the offerings on the net and more than ever, patients are demanding mesh free repairs! It has been interesting to see also the many surgeons who are now scrambling to learn a basic, anatomical, mesh free repair!

As always, there will be a need for mesh in certain cases and they should not be denied. The reduction of mesh from 95% to less than 5% will without doubt, reduce its known complications which can take place up to 30 years later.


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