The debate on the benefits of an open or laparoscopic repair of symptomatic inguinal hernias will continue for some time. However, when using open mesh techniques [1], the dispute centers on different issues and the question that really needs answering is “which prosthetic repair is superior?” [2]. Indeed, is there one or is it all to do with the “comfort zone” that only surgeons can empathize with and which is actually quite difficult to quantify?

Synthetic mesh repairs have been around for some time with the concept of a tension-free repair well established. Patients, especially those with co-morbidities, wish for speedy rehabilitation in the short term and a later acceptable recurrence rate (<1 %). General surgeons yearn for a short learning curve with an easily reproducible technique that yields results comparable to so-called hernia zealots. Indeed, Lichtenstein and co-workers advocated minimalist plug repairs in recurrent groin herniation almost 40 years ago [3, 4]. In this edition of Hernia, Li et al. present data from a systematic review and meta-analysis looking at the available evidence comparing repairs with a flat mesh (Lichtenstein repair) or a 3D mesh-plug augmented with an overlying patch. By carefully scrutinizing the literature, they identified 8 randomized controlled trials with 2,912 patients to review. This may seem a small number given that mesh-plugs have been around for so long. However, as not all studies in their review accrued all the information that they hoped to analyze, they are to be congratulated for their perseverance in contacting the authors of the original publications to robustly obtain further useful information.

Their results have established a number of important points. First, all the patients were deemed to have identical outcomes in the early postoperative period (wound complications, convalescence and pain). Second, there is no difference in recurrence rates. Overall, this systematic review and meta-analysis provides for the surgical truism: “it’s all in the dissection.” The type of prosthesis used is not the most important issue. Individual surgeons should use the prosthesis with which they have the most experience and confidence, and fortunately mesh repairs are associated with a more tolerable learning curve when compared with that required in performing good-quality sutured repairs [5].