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Pile suturing has always been used by surgeons to treat hemorrhoidal disease. We report a case of hemoperitoneum complicating a pile suture. Ultrasonography and computed tomography scan indicated the need for an emergency laparoscopic procedure and conservative management. As other authors have pointed out, we do not know how to prevent this type of complication. This case suggests the possibility of life-threatening complications following treatment procedures for hemorrhoids and underlines the importance of conservative treatment when this is possible.

We read with great interest the report by Symeonidis et al. on long-term results of a pilot study on plug and patch hernia repair using a fully absorbable mesh (polyglycolic acid/trimethylene carbonate—Gore BIO-A) [1], previously described [2]. At the 3-year follow-up, clinical examination revealed recurrence in three out of the eight patients (37.5 %). We agree with the authors when affirming that this result represents a crucial finding requiring appropriate critical interpretation. In 2009, we started a prospective multicentre study on the use of BIO-A plug and patch in groin hernia repair, as announced in a previous note [3]. In our study, the rationale for the use of BIO-A was the reduction of the potential risk of injury when a polypropylene (PP) mesh is placed in contact with the bare vas deferens, as in the case of plug and patch hernia repair; the goal was the evaluation of any higher long-term recurrence rate. On a pilot basis, we enrolled 15 young adults (\45 years), including only primary lateral (L-lateral according to EHS’s classification) hernias. At surgery, the hernia was classified as L1, L2 and L3 in 5, 8 and 2 cases, respectively. All patients underwent clinical examination 18 months after the procedure (medium term results). None of them presented any complication and all patients were totally satisfied. After 30 months (long-term follow-up), patients were contacted again. Two of them moved to a new address and for this reason were invited to a telephone interview. All the remaining patients were submitted to clinical examination. A recurrence was clinically diagnosed in two cases (2 patients aged 45, with L3 hernia), both revealing a medial (M) hernia at reoperation. No patient without recurrence complained foreign body sensation or pain, including the patients undergoing telephone inquiry. The recurrence rate in our study has proved to be three times lower than in Symeonidis et al.’s study (13 vs. 37.5 %). We believe that this might be due to two reasons. The first concerns the patients’ selection (different study design). In fact, Symeonidis et al. enrolled patients irrespective of the hernia type, lateral or medial, and of the age. Conversely in our study, we selected only patients aged\45, with lateral hernias. The second reason is related to the surgical technique. Symeonidis et al. finally restored the anatomy of the inguinal canal by closing the external oblique aponeurosis superficially to the spermatic cord. In our procedure, the external oblique aponeurosis was placed dorsally to the cord, as we routinely perform in all inguinal hernia repair. The adoption of these parameters by Symeonidis et al. could have probably reduced their recurrence rate to our values. Despite this, the incidence of 13 %, we have registered, appears unacceptable and requires a critical update. Based on the results of our pilot study, it seems that the polyglycolic acid/trimethylene carbonate absorbable mesh (Gore BIO-A Tissue Reinforcement ) patch cannot guarantee a solid reinforcement of the posterior wall of the inguinal canal, or prevent a medial hernia. Current data This comment refers to the article available at doi: 10.1007/s10029-012-1016-0.

Background: A wide variety of meshes are available for surgical treatment of abdominal wall defects. These meshes are constructed with different materials with different biological properties. Methods: A prospective database was instituted (January 2009-December 2010) to register biological prostheses (BPs) implanted in Italy. Results: A total of 193 cases were registered. The mean age of the patients was 53.1 years (SD ±7.4). The ratio of males to females was 1.3 to 1. The mean body mass index was 28.2 (SD ±4.1). The breakdown of American Society of Anesthesiologists (ASA) scores was as follows: ASA I, 35.7%; ASA II, 27.5%; ASA III, 31.6%, and ASA IV, 5.2%. For ventral-incisional hernias, the mean duration of surgery was 101.1 min (SD ±25.3), while for inguinal-femoral hernias it was 49.2 min (SD ±19.1). The rate of urgent procedures was 36.7%. The surgical field was clean in 57.4% of cases, clean-contaminated in 21.3%, contaminated in 12.3% and dirty in 9%. Techniques used for inguinal-femoral hernias were as follows: Lichtenstein in 66.7%, plug and mesh in 3.8%, transabdominal-preperitoneal in 25.7% and intraperitoneal onlay mesh in 3.8%. The following prostheses were used: swine intestinal submucosa in 54.9%, porcine dermal collagen in 39.9% and bovine pericardium in 5.2%. In 45.1% of cases the prostheses were cross-linked. Techniques used for ventral-incisional hernias were as follows: onlay in 3.6%, inlay in 5.5%, sublay in 62.7% and underlay via laparoscopy in 28.2%. The mean overlap was 4.1 cm (SD ±1.2). No intestinal anastomosis was necessary in 65.3% of cases; however, small/large bowel resection and anastomoses were necessary in 22.3 and 12.4% of cases, respectively. Intraoperative blood transfusion was necessary in 10.4% of procedures. The skin was completely closed in 84% of procedures. At the 1-month follow-up, there were no complications in 54.4% of cases. Among the cases with complications, 10 patients (5.8%) experienced recurrence, and the postoperative readmission rate was 12.9%. The average visual analog scale (VAS) score for pain was 2.9 (SD ±1.2) at rest. At the 1-year follow-up, there were no complications in 96.4% of cases. Two patients experienced recurrence, and the postoperative readmission rate was 3.6%. The average VAS score for pain was 1.8 (SD ±0.8) at rest. Conclusions: This register shows that BPs are highly versatile and can be used in either open or laparoscopic surgery in all kinds of patients and in contaminated surgical fields. However, due to the very good outcomes of synthetic meshes and the high costs of BPs, the latter should only be used in selected cases.

We read with great interest the report by Efthimiou et al. [1] on plug and patch hernia repair using a polyglycolic acid-trimethylene carbonate mesh. The purpose of this pilot study (ten patients with direct and indirect inguinal hernia with a mean age of 65.6 years) was to evaluate the efficacy of using a totally absorbable device (Gore BIO-A Tissue Reinforcement patch and Gore BIO-A plug), looking primarily at recurrence and chronic pain assessed 1 year after the operation. The authors stress, and we agree with, that an ideal mesh for inguinal hernia repair should cause the minimum foreign body reaction. Moreover, the excessive local inflammatory reaction that occurs when a polypropylene (PP) mesh, especially heavyweight PP, is implanted, may cause prosthetic shrinkage and chronic pain. For these reasons, surgeons would consider the use of PP with different characteristics (low-weight large porous PP, PP/polyglactine composite, PP with polytetrafluorethylene surface) or other materials as polyvinyliden fluoride (PVDF). Gore BIO-A mesh is made of a biocompatible synthetic polymer. Its design structure (with open highly interconnected pores) creates a scaffold that facilitates tissue generation, mimicking native collagen fibres. This material is fully absorbed in approximately 6 months. At 1 year follow-up, none of the patients from Efthimiou’s study had clinical signs of recurrence. Only one patient experienced intermittent pain without the need for any medication. On the other hand, the authors do not highlight any protective role on the vas deferens that could possibly be played by Gore BIO-A plug and patch repair, probably because all patients in their study were elderly. Many experimental studies in animals have shown that PP mesh can adversely affect spermatic cord structure and/ or function [2–5]. On the contrary, little clinical information is available regarding the long-term effects of PP mesh on the vas deferens. One possible reason is that most men undergoing hernia repair tend to be elderly, and thus not so concerned about maintaining their reproductive potential. However, a multiinstitutional experiment and some casereports [6–8] have confirmed the potential risk of injury when a PP mesh is placed in contact with the bare vas deferens, as in the case of plug and patch repair. PP herniorraphy is being offered to young adults whose fertility status will be an issue in the future. At present, we are unable to determine whether PP mesh will result in an higher incidence of inguinal vasal obstruction and infertility. In 2009, we began a prospective multicentre study on the use of BIO-A prosthesis in young adults (maximum age 45 years) to try to answer these questions, and to offer a safer repair to patients. Only primary indirect (L, lateral, according to EHS’s classification) hernias were included in the study. All patients underwent open plug and patch repair. C-reactive protein (CRP) samples were collected to estimate the inflammatory response. Pain was evaluated using VAS score, and quality of life status by the SF-36 system. Mid-term results (at 2 years) will be published soon. In the meantime, we wish to point out that, at 18-month follow-up, none of the 15 patients enrolled by our Centre had any complications and all patients were totally satisfied. We can also assume that no adverse events affected the cord structure. P. Negro (&) F. Gossetti M. R. Dassatti J. Andreuccetti L. D’Amore Department of General Surgery ‘‘P. Stefanini’’, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy e-mail: pal.negro@libero.it