Dear Editors:

We read with great interest the recent article by Emile SH. [1], published in Hernia. The authors present data from a systematic review and meta-analysis comparing tissue-based repair (Desarda’s technique) and Lichtenstein technique for inguinal hernia repair. Based on the analysis of six RCTs comprising 2159 patients [1], they concluded that both Descarda and Lichtenstein technique had similar low recurrence rate; furthermore, Desarda’s technique had lower complication rates compared with Lichtenstein technique.

We appreciate for the authors’ thorough analysis, and we also very pleased to see the favorable results of the tissue-based inguinal hernia repair technique. Furthermore, their results [1] offered a number of important points to comment, and provided the clues to some important questions in inguinal hernia repair, such as “the ideal layer” and the “ideal tissue” for inguinal hernia repair.

First, it is no doubt that the debate on the benefits of tissue-based repair or prosthetic repair of symptomatic inguinal hernias will continue for some time. Furthermore, the mesh position, either in preperitoneal space or in superficial as Lichtenstein, is still a dispute. Although Lichtenstein technique was strongly recommended by the Europe hernia society (EHS) [2], it is still not the ideal solution due to the consequence after mesh implantation, including stiffness, chronic pain, and foreign body sensation. Thus, the efforts of searching for non-prosthetic repair never stopped. Next, apart from mesh repair, what is the “ideal” tissue for repair? Most of the conventional tissue-based repairs aim to construct the posterior abdominal wall using patient’s deep abdominal wall muscular tissue and fascia, and especially, the transversalis fascia gained much attention [3], such as the Shouldice procedure. However, the Descarda’s technique uses the external oblique aponeurosis (EOA), we applauded for the fine and reasonable idea, since the EOA is not only strong, but more superficial and easy to manipulate, which makes the procedure simple. Furthermore, this new established layer, quite resemble the layer of the mesh placement in Lichtenstein procedure, which in part proved the reasonable layer for inguinal hernia repair. Third, most of the meshes for hernia repair are over-weight and much stronger than needed [4]. The use of patients’ own tissue of the EOA, although not as strong as a prosthetic mesh, but obviously stronger than the transversalis fascia, thus, the EOA may be a sound alterative tissue material in the majority of inguinal hernia cases, and provides a clue to the path to tissue repair.