Laparoscopic hernia repair without the use of staples or knotting manoeuvres

Sir Thank you for giving me the opportunity to respond to the letter from Drs Baragwanath and Harding. I agree with their principle of primum non nocere. I had anticipated that a surgeon would be more circumspect when considering investigations or treatmt nt in a patient who has, or is suspected t N3 have, a factitious disorder but it is a point worth emphasizing. A common problem with factitious presentation is uncertainty about the nature of the disorder. Drs Baragwanath and Harding do not seem to encounter this dubiety in their population of chronic wound patients. Nevertheless their prevalence of 0.5 per cent and their conviction that factilious disorders are rare in general surgical practice ought to be qualified as ‘recognized’ cases. It is unhelpful to demarcate the surgeon’s contribution tc a few technical issues. Success requires collaboration among the physical specialists, psychiatrist and general practitioner a team that may expand to involve the paediatrician and the occupational health physician in the event of proxy disorders being suspected.