A Commentary on “Laparoscopic Modified Percutaneous Internal Ring Suturing—a Mesh-free Alternative for Indirect Inguinal Hernia Repair in Adults: a Pilot Prospective Cohort Study.”

Dear Editor, We read with great interest the article by Gjessing et al, describing laparoscopic modified percutaneous internal ring suturing (mPIRS) as a mesh-free alternative for indirect inguinal hernia repair in adults[1]. In health systems where resources are constrained, an approach that avoids prosthetic mesh while preserving the advantages of laparoscopy is intuitively attractive. A technique such as mPIRS could reduce direct procedure-related costs and mitigate mesh-associated complications, including chronic groin pain and foreign body sensation. While we commend the authors for their innovative work and the impressive long-term follow-up, several issues warrant further consideration before mPIRS can be widely adopted in routine general surgical practice, particularly in non-specialized centers. First, the reported outcomes derive from a single, highly experienced center with a long-standing interest in laparoscopic pediatric and adult hernia surgery[1]. In daily practice, inguinal hernia case volumes and laparoscopic expertise vary substantially across institutions. The mPIRS technique fundamentally depends on precise high ligation of the sac at the internal ring without additional posterior wall reinforcement. Outside specialized hernia units, where surgeons may be less familiar with percutaneous internal ring suturing, tissue-based repairs are typically more operator dependent than standardized mesh techniques such as transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) repair. In the absence of real-world data from lower-volume centers, it is plausible that recurrence rates with mPIRS could be higher when the technique is disseminated more broadly. This concern is supported by recent data showing that outcomes of laparoscopic percutaneous internal ring suturing differ between pediatric and adult female patients, with recurrences clustering in adults[2]. Second, the strict exclusion criteria in the pilot cohort – such as the omission of patients with elevated body mass index, large scrotal hernias, previous groin surgery or emergency presentations – create a highly selected, “idealized” patient group[1]. In everyday practice, a substantial proportion of adults with inguinal hernias present with exactly these higher-risk features, which have been repeatedly implicated as patient-related risk factors for recurrence in observational studies[3]. In such patients, relying solely on high ligation of the sac without mesh-based reinforcement of the posterior wall may not fully align with the principle of tension-free repair. The efficacy and safety of mPIRS in a broader, unselected adult population therefore remain uncertain. Third, contemporary international guidelines continue to recommend mesh-based repairs as the standard of care for primary unilateral inguinal hernia in adults, based on large randomized trials and meta-analyses demonstrating lower recurrence rates with prosthetic reinforcement compared with non-mesh repair[4,5]. The rationale is that mesh strengthens the entire myopectineal orifice and addresses underlying connective tissue weakness, rather than merely closing the anatomical defect. Although reducing foreign material is an important goal – particularly in a disease with a recognized collagen and metabolic component – reintroducing a purely tissue-based approach for adult indirect inguinal hernia should be supported by robust comparative data before it is considered equivalent to established mesh-based techniques. Finally, although the median follow-up duration of almost 7 years reported by Gjessing et al is commendable[1], the assessment of recurrence appears to rely mainly on clinical review and patient-reported outcomes. Self-reporting may underestimate recurrence compared with systematic clinical examination supplemented by imaging, especially for small or minimally symptomatic defects. Furthermore, loss to follow-up over long time horizons may preferentially exclude patients with recurrence. Because current guidelines emphasize prevention of recurrence as a key endpoint for any non-mesh strategy[4,5], validation of mPIRS in adults should ideally incorporate rigorous, objective follow-up protocols to detect both overt and occult failures. In conclusion, mPIRS may represent a cost-effective option for selected adult patients with small, indirect inguinal hernias, particularly when performed by surgeons with substantial experience in percutaneous internal ring suturing[1,2]. However, in light of the existing evidence base and guideline recommendations[4,5], we believe that mPIRS should currently be regarded as an exploratory or adjunct technique rather than a replacement for standard mesh-based TAPP or TEP repair in routine practice. Future multicenter randomized controlled trials comparing mPIRS with established mesh-based laparoscopic approaches, using standardized definitions and objective long-term follow-up, will be essential to determine whether mPIRS can achieve true non-inferiority in terms of recurrence, chronic pain, and cost. Sincerely, The author