Dear Editor,

We thank Dr. Wang and colleagues for their interest in our recently published article [1]. Two main questions concerning the surgical technique and surgical team were formulated. Regarding the surgical team, potential impact of surgical experience on outcomes in the compared groups was questioned. Concerning the surgical technique, additional data were requested regarding outcomes for different surgical techniques among patients with multiple previous incisional hernia (IH) recurrences.

In the present data-set, all patients, including patients operated on primary IH, were operated by a dedicated hernia surgeon. However, in the recurrent hernia group, previous surgery might have been performed by a surgeon not affiliated to the Hernia-club registry, who may not necessarily be a dedicated hernia surgeon. Although within the Hernia-club registry, all patients have been operated by dedicated hernia surgeons, it is conceivable that patients with multiple previous recurrences have been referred to a more experienced surgeon. Therefore, selection bias could have contributed to more favorable results in the recurrent IH group. Nevertheless, this selection of patients and physician reflects the patient work up in daily clinical practice.

Concerning the preferred technique for surgical IH repair after multiple re-recurrences, no conclusions can be drawn based on current data. In contrast to the first IH repair, the chosen technique in patients with multiple previous recurrences will depend on the previously used techniques and remaining integrity of the anatomical planes in the abdominal wall. Often a different anatomical plane is chosen compared to the initial repair procedures. Therefore, the technique used in recurrent hernia repair may sometimes be a necessity rather than evidence-based choice.

The percentage of re-recurrence at 12-month follow-up among patients with multiple previous re-recurrences was 25.7% for sublay mesh reinforcement (n = 35), 16.7% for intra-peritoneal onlay mesh reinforcement (n = 24), and 50% for patients without mesh reinforcement (n = 12). However, we would like to stress that no conclusion on superiority of either technique for this indication can be drawn. Why twelve patients were operated without placement of a mesh remains unclear from current data. Potentially, a non-resorbable mesh was still in situ or patients may have refused placement of a new mesh prosthesis due to previous mesh-related problems. However, the latter remains speculative. Importantly, regardless of the technique used, IH repair in patients with multiple previous recurrences is not necessarily futile and may result in acceptable outcomes.