Comment on: Is the self-adhesive mesh a solution for chronic postoperative inguinal pain after TAPP: A single centre preliminary experience?

Dear Editor, Chronic post-operative inguinal pain (CPIP) is a well-recognised complication of inguinal hernia surgery, affecting 10%–12% of patients, with a lower incidence in those undergoing laparoscopic surgery.[1] We read with interest the article by Kirov et al.,[2] which advocates for the use of Parietex ProGrip™ self-adhesive mesh in reducing CPIP. While the study presents valuable insights, several factors warrant further discussion and closer examination. Published research, including multivariable analysis of a large registry database, has shown that CPIP is significantly influenced by younger age (P < 0.001).[1] Given the mean age in this study is 59.9 years, a demographic already at lower risk for CPIP, attributing the lack of CPIP solely to the type of mesh used, is challenging. Similarly, literature indicated that female gender increases the risk of CPIP,[1] yet the present study’s cohort was predominantly male (96.2%).[2] The authors did not collect data on the presence of pre-operative pain, hernia defect size or body mass index (BMI), all of which significantly increase the risk of CPIP postoperatively (pre-operative pain, P < 0.001; smaller hernia defect, P < 0.001 and higher BMI, P < 0.001).[1] These omissions in patient selection undermine the generalisability of the findings to a more diverse population. It is also important to note the 21.2% loss to follow-up in this study.[2] Given that the expected incidence of CPIP is less than this and the overall small total case numbers (n = 52), even a few of these patients having undetected/unreported CPIP would drastically change the study’s results and conclusions. The pathophysiology behind CPIP is not fully understood. A recent meta-analysis concluded that the current evidence is ‘very uncertain’ regarding the impact of mesh fixation on CPIP incidence,[3] suggesting that similarly whether the mesh is self-adhesive or not is unlikely to have a significant impact. Furthermore, CPIP exists regardless of the mesh fixation method, pointing to the dissection and/or the mesh-induced inflammation itself as potential causes of CPIP. Claiming that self-adhesive mesh provides superior outcomes compared to cheaper, established meshes and fixation methods is not well supported and neglects other important surgical factors. In conclusion, while the use of self-adhesive mesh in laparoscopic transabdominal preperitoneal repair shows some promise, it is imperative to consider patient demographics and pre-operative conditions, which play critical roles in the development of CPIP. The lack of substantial evidence favouring self-adhesive mesh over more cost-effective options, particularly given the lack of consideration of established patient-related risk factors, suggests that routine use of expensive self-adhesive mesh may not be justified. We recommend readers weigh the wider body of evidence and the study’s limitations before adopting self-adhesive mesh as standard practice. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.