Fascial closure in IPOM repair: the case for long-term follow-up and clinical transparency

Correspondence to: Ming Wang (email: wm8383204@163.com; wangming2010@alumni.sjtu.edu.cn.)

Department of Gastrointestinal Surgery

Heze Municipal Hospital

Heze

Shandong

China

BJS, https://doi.org/10.1093/bjs/znaf169, published 02 September 2025

I read with great interest the PROSECO trial by Lindmark et al.1. This study provides high-quality evidence on whether primary fascial closure should be performed during laparoscopic intraperitoneal onlay mesh (IPOM) repair for midline ventral hernias. These findings are clinically meaningful and align with the current international consensus that anatomical restoration should be a priority in ventral hernia repair2.

However, I would like to raise two points for discussion in light of existing international guidelines.

First, the 12% incidence of mesh bulging in the bridging group highlights a complication that is often under-recognized due to its asymptomatic nature or reliance on clinical examination alone. More importantly, both recurrence and mesh bulging are typically delayed events, frequently manifesting 2-5 years after surgery, and are therefore easily missed with short-term follow-up3. Notably, mesh bulging is not always a static finding; in some patients, it may progress over time, leading to worsening abdominal wall biomechanical imbalance, symptom deterioration, and even what may be termed a "functional recurrence" requiring reoperation. Progressive mesh bulging can result in chronic pain, abdominal wall stiffness, or cosmetic deformity—factors that may ultimately prompt patients to undergo revision surgery. Whether such progression leads to increased reoperation rates warrants further investigation. Thus, a 1-year follow-up is insufficient to capture the true recurrence burden or assess the long-term protective effect of fascial closure against reoperation. I encourage future studies to continue long-term follow-up of the PROSECO cohort for at least 3-5 years, incorporating structured imaging, to determine the progression rate of mesh bulging and the proportion that ultimately require surgical reintervention. Such data would provide more clinically translatable evidence for decision-making.

Second, while the double-blind design enhances scientific rigour, the practice of withholding surgical details from patient records and follow-up clinicians raises practical and ethical concerns. Transparent documentation is essential for continuity of care, particularly if future interventions are required. As suggested by recent methodological consensus, alternative designs—such as single-blinding of outcome assessors or the use of independent endpoint adjudication committees—could preserve objectivity without compromising clinical transparency4.

In conclusion, the PROSECO trial offers compelling evidence supporting primary fascial closure as a standard component of IPOM repair when anatomically feasible. Its benefits in reducing mesh bulging and improving pain outcomes are clear. To maximize the impact of this important study, I urge the authors to pursue long-term follow-up of this cohort. Such data would not only validate current recommendations but also help refine future iterations of European and global hernia management guidelines.