Reply to the Editorial and Reviewers Comments

Reply to the Editorial and Reviewers’ comments

REVIEWER 1

Minor concerns:

1st comment: is it even necessary to call it "Acquired" because the main concerning part is the integrity of diaphragm which may be lost even in post traumatic acquired hernias?

Reply: as you can see in the section Literature search, we excluded from our review those intercostal hernias which were part of congenital diseases, such as Poland Syndrome and lumbocostovertebral syndrome. For this reason, to avoid any type of confusion or ambiguity, we considered it appropriate to specify the acquired origin of this hernia within the descriptive term.

2nd comment: in their case report, it may be useful to elaborate on as to how they followed up with their patient at 2 years - Clinical exam only or a CT scan too since a subtle recurrence can be missed on a clinical exam.

Reply: we apologize for this oversight. We added this information in the text. We checked our patient by clinical examination and ultrasound. In our Institution, a CT scan is usually employed only to resolve any diagnostic doubts after first line examinations or as part of preoperative assessment in case of complex hernia recurrence which needs surgical repair.

3rd comment: the range of duration of symptoms (1d - 96 months) and the time between the trauma and hospital admission (1d-120 months) do not match to the table 2.

Reply: we apologize for the mistake. The new correct data were introduced in the text. Mean duration of symptoms was 8.3 months (range: a few hours - 48 months); mean time between the trauma and hospital admission was 24.4 months (range: same day - 20 years).

MAJOR CONCERNS:

1st comment: with the advent of newer tacks and advances in laparoscopic surgery, it may be safer and better than thoracotomy since it does not involve working near the intercostal nerves. It would also be helpful to get the thoughts on combined laparoscopic and open approach for reducing the incidence of recurrence for such hernias? Reply: Given the lack of evidence on this specific issue, we confined ourselves to describing the available surgical options and to merely expressing our opinion on which could be the best depending on the situation. The intercostal hernia defect is always close to the diaphragm and bordered by ribs with intercostal neurovascular pedicles, thus mesh fixation may be a challenge both by open and laparoscopic approach. A type of combined approach was used only by two authors who chose to perform rib approximation during laparoscopic hernia repair. Bobbio passed 3 sutures through small-skin incisions with the help of a Reverdin needle to fix the flail segment of broken ribs [17]; Bendinelli used this approach to treat a recurrent intercostal hernia following previous laparoscopic repair. He reduced the hernia content, sutured the mesh applying further stitches and partially re-approximated the intercostal space by means of 3 sutures through an accessory 5 cm thoracotomy [14]. It should be emphasised that the hernia defect was very large (12 x 9 cm). However, following your suggestion we have edited the text adding a short description of this surgical approach.

2nd comment: The author insists on the repair of the hernia but states that the rib approximation should be avoided to prevent discomfort and chronic pain. This statement needs further support by literature since majority of the papers have been recommending rib approximation for a stronger repair of hernia.

Reply: We stated that the general principles of modern hernia surgery should also apply to AAIH.

Rib approximation may not allow a true tension-free repair and so it should be avoided unless strictly necessary. We think that an attempt at soft tissue reconstruction and/or rib approximation could be justified in the case of particularly widened intercostal space or very large defect, provided that this procedure does not create excessive tension or intercostal nerve damage. However, we have seen fit to introduce a more detailed explanation on this issue in the text.

3rd comment: Was there any difference in the hernia sac size in the patients who had rib fixation / approximation as compared to those who did not have it? Reply: Paradoxically the mean maximum diameter of the hernia orifice was higher in those cases treated without rib approximation, although the difference was not significant (7.8 cm ± 2.7 DS

[range 5-12 cm] vs 8.6 cm ± 3.4 DS [range 3.5-12 cm]; P= 0.661*). Obviously, given the very small number of cases, we considered it unnecessary to include such information in the text.

* Student’s t-test

4th comment: The mean duration of follow up is 8.6 months whereas all the recurrences have been seen within 12 month of follow up. So is the rate of recurrence actually higher than the one mentioned i.e. 28.6% - are we missing a few recurrences?

Reply: We absolutely agree with the referee on this issue. Cumulative incidence of recurrence after hernia repair does tend to increase over time and 2 years is probably the minimum follow up to achieve a reliable recurrence rate and to assess the effectiveness of various treatments [Haapaniemi

S et al. Ann Surg 2001; 234:122-126, Flum DR et al. Ann Surg 2003;237:129-135, Neumayer L et al. N Engl J Med 2004;350:1819-1927]. In our review, we found only two cases, including the one reported by us, with a follow-up time of at least 2 years. Following your comment, we have introduced a brief remark on this topic in the text.

REVIEWER 3

Comment: Excellent

Reply: Thank you