Letter to the editor “Surgical expertise and long-term patient-reported outcomes following inguinal hernia mesh repair in Sweden”

Dear Editor, We read with great interest the recent study by de la Croix et al. titled “Surgical Expertise and Long-Term Patient-Reported Outcomes Following Inguinal Hernia Mesh Repair in Sweden” published in the International Journal of Surgery[1]. This is a pivotal research that addresses a critical question in surgical training and quality assurance. The study revealed a core finding: there was no significant difference existed between residents and specialists in terms of chronic pain, patient dissatisfaction, or reoperation rates after inguinal hernia mesh repair in Sweden. This result is both robust and thought-provoking. We would like to raise several points that may further enhance the interpretation of their findings and contribute to the ongoing discussion in this field. The principal concern lies in the inherent limitations of the observational design in addressing the research question[2,3]. A significant baseline imbalance in case complexity was observed between the cohorts. Specialists managed a substantially greater number of complex cases, including recurrent hernias (11% vs. 3%) and laparoscopic procedures (37% vs. 3%), a disparity that strongly suggests the presence of selection bias. Although multivariate adjustment was employed, it is methodologically uncertain whether statistical models can fully account for such extreme differences in case mix. The generalizability of the findings is also highly constrained. The results are inextricably linked to the specific context of the Swedish healthcare system, characterized by its high standardization, structured surgical training, and rigorous quality control. Extrapolating these results to healthcare systems with less standardized training protocols is not supported by the data. Finally, the data lacks technical details that are crucial determinants of outcomes in hernia surgery. Factors such as the type of mesh used (weight, structure, material), the method of fixation (glue, sutures), and the approach to nerve identification and handling are known to influence chronic pain and recurrence[4,5]. The failure to account for these technical variables represents a significant omission, as the observed outcomes may be affected by these choices. In conclusion, this study is valuable for surgical training and quality assurance. We hope our comments can help refine the interpretation of the findings and inspire more rigorous study designs in this field. Sincerely,