The Most Important Clinical Trial in the Last 10 Years in Inguinal and Incisional Hernia Surgery

Abstract

Introduction: Despite an uninterrupted accumulation of scientific evidence within hernia surgery, only few results have proven exceptional originality through sustained clinical impact on decision-making and optimized surgical practice. From a surgical academic point of view, we found it worthy to outpoint one inguinal and one incisional hernia trial with outstanding international penetrance for hernia surgery and quality of treatment. Methods: Based on our personal opinion and consensus, we selected two papers published within the last 10 years. Our choice was based on exceptional originality, creativity, outstanding potential for clinical change of surgical practice to improve patient treatment, and cost-effectiveness rather than scientific methodology or journal impact factor. Results: Löfgren J et al. A randomized trial of low-cost mesh in groin hernia repair. N Engl J Med 2016;374:146–53. Motivation: Inguinal hernia disease is highly prevalent and often life-threatening condition in the third world where a conventional mesh repair is often impossible. The authors demonstrated in a randomized setting with an almost 100% 1-year follow-up for the first time safety, efficacy in terms of low recurrence, and enormous cost reduction in the use of sterilized mosquito net-based mesh compared with commercially available mesh material. Millbourn D et al. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg 2009;144:1056–9. Motivation: Between 10% and 30% of patients develop an incisional hernia after open laparotomy. However, results after incisional hernia repair still leave much for improvement such as recurrence, morbidity, chronic pain, and socioeconomic costs. There are various surgical approaches to minimize the incidence of incisional hernia, but the presented small stitch technique for linea alba closure is perhaps the most simple and effective in this respect. Interestingly, this pioneer report has succeedingly been externally proven for its efficacy and cost-effectiveness in a large-scale randomized controlled trial. Conclusion: The two examples of pioneer studies represent original and cost-effective surgical groundbreaking scientific milestones for the benefit of surgical patients. Moreover, they serve as an example for academic surgeons that randomized evaluation of even simple surgical procedures may have scientific merit.