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Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.

Andresen K, Burcharth J, Fonnes S, et al. Sexual dysfunction after inguinal hernia repair with the Onstep versus Lichtenstein technique: A randomized clinical trial. Surgery. 2017;161(6):1690-1695.

Commentary by: Robert J. Fitzgibbons Jr., MD, FACS

Two of the authors of this manuscript recently published a systematic review of open preperitoneal groin hernia repairs with mesh, which concentrated on nine different preperitoneal operations, including a transrectus sheath preperitoneal technique (TREPP), a transinguinal preperitoneal technique (TPT), the Kugel repair, and the procedure used in the present study, Onstep.1 These four operations have in common small skin incisions and a very similar blunt, blind dissection of the preperitoneal space and the use of one of several commercially available prostheses that are made rigid by a memory ring at the edges. This allows these devices to be deployed in the preperitoneal space without the need for fixation. The theoretical value is that nerves in the anterior space are avoided by being in the preperitoneal space; the lack of the need for fixation results in less postoperative pain, including that related to sexual activity. However, the review concluded by stating that further randomized clinical trials were needed to determine if this was actually so.

The Onstep procedure is a modification of the TPT technique introduced by Pélissier et al and then popularized by Lourenc and da Costa with a series of 693 patients.2 Since then, the literature regarding the Onstep operation has been dominated by the present Danish authors; one need only type “Onstep” into the PubMed search engine to confirm this considerable reflection of their enthusiasm for the procedure. The difference between Onstep and the other three small-incision procedures is that the latter are entirely preperitoneal, while Onstep is a hybrid procedure (mesh is placed obliquely with the medial aspect preperitoneal, but the lateral side is placed between the external oblique aponeurosis and the internal oblique muscle encircling the internal ring). This has been a source of criticism of the procedure: some say bridging the preperitoneal space to the conventional anterior space is physiologically unsound.3

Regardless, all four small-incision procedures have technical nuances which need to be mastered if the same results as the proponents are to be obtained. Indeed, the authors of the present manuscript have several publications describing step-by-step training methods necessary to properly train surgeons.4 In my opinion, none of these procedures should be performed until a formal training course has been completed followed by proctoring.

The current study uses the same 290 patients from a previously published randomized controlled trial that showed no difference in short-term pain or complications when comparing Onstep to Lichtenstein.5 The present analysis of these patients dealt only with the effect of an inguinal hernia and the repair of the same on pain. The study appeared to show convincing evidence that more patients are relieved of their preoperative pain and less patients have postoperative pain with the Onstep technique when compared to the Lichtenstein operation. However, given the fact that authors are strong proponents of the procedure, it is essential that confirmation come from other investigators.


  1. Andresen K, Rosenberg J. Open preperitoneal groin hernia repair with mesh: A qualitative systematic review. Am J Surg. 2016;213(6):1153-1159.
  2. Lourenço A, da Costa RS. The ONSTEP inguinal hernia repair technique: Initial clinical experience of 693 patients, in two institutions. Hernia. 2013. 17(3):357-64.
  3. Koning GG, Vriens PWHE, Berrevoet F. Comment to: Recurrence mechanisms after inguinal hernia repair by the Onstep technique: a case series. Hernia. 2017;21(4):661-662.
  4. Andresen K, Laursen J, Rosenberg J. Difficulties and Problematic Steps in Teaching the Onstep Technique for Inguinal Hernia Repair, Results from a Focus Group Interview. Surg Res Pract. 2016;2016:1-6. Free Full Text
  5. Andresen K, Burcharth J, Fonnes S, et al. Short-term outcome after Onstep versus Lichtenstein technique for inguinal hernia repair: results from a randomized clinical trial. Hernia. 2015;19(6):871-877.