Selective use of bioabsorbable Gore BIO-A plug and patch for groin hernia repair

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.