Comparing apples and oranges will not guide treatment the right way in umbilical hernia repair: Use either level-1 evidence or guidelines

R. Kaufmann*, J. A. Halm, J. F. Lange

*Corresponding author for this work

Research output: Contribution to journalComment/Letter to the editorAcademicpeer-review


Dear Sir,

We write in response to the recently published study by Mitura et al. entitled “Is mesh always necessary in every small umbilical hernia repair? Comparison of standardized primary sutured versus patch repair: retrospective cohort study”. The authors investigated 161 patients: 104 patch repairs and 57 suture repairs and concluded that for the smallest umbilical hernias, the use of suture repair may be an effective alternative to patch repair techniques in patients with no additional risk factors for recurrence. They found that patch repair was associated with a significantly higher risk of postsurgical pain. The follow-up was performed by a telephone interview.

Some initial statements in the manuscript are incorrect. For example, the study by Arroyo et al. is introduced suggesting that small hernias in that study were treated with a flat mesh and that it was not reported that the orifice was widened to place the mesh. Arroyo treated hernia defects up to 3 cm with a mesh plug repair, whereas a mesh sheet was inserted for larger hernias only. Thereafter, suture techniques are mentioned referring to an article on open repair of predominantly incisional hernia and another paper on laparoscopic ventral hernia repair, not comparable to the research presented in this study.

In short, from a large randomized controlled trial, there is strong evidence in favour of flat mesh for hernia diameters ≥ 1 cm. In a large database study with similar patient characteristics as in the current study, there is also good evidence for mesh in case of hernia diameters smaller than 1 cm. We, therefore, consider the comparison between patch repair (known for more postoperative complications including postoperative pain from randomized investigation) and suture repair a comparison between two “inferior” techniques and would like to emphasize that flat mesh reinforcement outperforms suture repair (and patches) even in small umbilical hernias in all studies. Ignoring this evidence and the current American and European Hernia Society guidelines is a disservice to patients with an umbilical hernia. Suture repair should be used as “second best” in selected patients with small umbilical hernia defects (< 1 cm) without diastasis recti, in patients that refuse mesh, and in women of childbearing age that wish to become pregnant.
Original languageEnglish
Pages (from-to)821-822
Number of pages2
Issue number3
Early online date22 Apr 2020
Publication statusPublished - Jun 2021


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