Association of Maternal Diabetes With Autism in Offspring.

In Reply Mesh reinforcement is almost always used in elective repair of an incisional hernia to minimize the risk of recurrence,1 as well as in repair of small umbilical and epigastric hernias.2 The expert consensus recommendation for the use of mesh was based on evidence from randomized trials from specialized hernia centers with high internal validity and from clinical nationwide prospective databases reporting “realworld” outcomes with high external validity. The fact that reoperation for clinical recurrence underestimates clinical recurrence by a factor of 3 to 4 makes the advantages of mesh reinforcement even larger. Additionally, laparoscopic or open repair carries a risk of approximately 10% for early surgical complications (5% severe),3 further emphasizing the need for mesh reinforcement to limit the risk of a later reoperation for recurrence. However, as shown in our study, the use of mesh reinforcement is not risk free. We found mesh-related complications in 5% of patients after 5 years. There are several limitations of using registry-based data, such as unmeasured confounding and selection bias. However, Dr Cherla and colleagues are not correct to state that we did not adjust for risk factors. Adjustment for hernia size and primary vs recurrent repair were performed for analyses on the use of mesh, as well as propensity score adjustment. The study outcomes may have been biased by use of ambiguous definitions of complications and unblinded assessment. We agree that nonblinded scoring is not optimal. However, in this study, nonblinded assessment was not practically possible because nonblinded access to the index incisional hernia operation was necessary simply to identify the type of operation. When doubt existed about the relatedness of complications, consensus was obtained between 2 investigators. Cherla and colleagues suggest that a composite outcome of several hernia-related complications would be superior to our 2 separate outcomes, recurrence and mesh-related complications. Using a composite outcome would make longterm results more difficult to interpret. The 2 outcome measures were assessed separately and results were not pooled, as indicated by Cherla and colleagues. Occurrence of either outcome led to ending the follow-up for that patient. Therefore, there was no overlap of patients. However, because wound infection is a risk factor for recurrence, further follow-up might show an increased recurrence rate in patients who had a meshrelated complication. The benefits outweigh the disadvantages when repairing incisional hernias with a foreign-body mesh material. However, it is remarkable that meshes, similar to other medical devices, are not subject to clinical quality monitoring before routine use is recommended. Clinical databases containing detailed intraoperative information may contribute to quality assessment in hernia surgery. For instance, databases may possess prospective intraoperative information, include longterm follow-up, and have sufficient numbers of patients and statistical power to track outcome measures such as meshrelated complications or reoperation rates for different types of mesh.