Controversies in Abdominal Wall Reconstruction.

This article discuses current controversies in abdominal wall reconstruction, including the standardization of outcome reporting, mesh selection, the utility of robotic surgery in ventral hernia repair, and role for prophylactic stoma mesh at the time of permanent end colostomy formation. The current state of the literature pertaining to these topics is reviewed in detail.

The inguinal hernia management in Costa Rica according to a survey between surgeons: result comparison with 2018 International Groin Hernia Guidelines.

BACKGROUND: Inguinal hernia surgery is a frequent procedure among general surgeons in Costa Rica, but the management and technique are not uniform. The International Guideline for Groin Hernia management was published in 2018 to standardize the inguinal hernia surgery, but the diffusion of the guidelines and its adherence have been extremely varied. PURPOSE: Collect and analyze the current reality regarding groin hernia management in Costa Rica. Secondly evaluate the diffusion and development comparing it to the guideline's recommendations. METHOD: Questionnaire of 42 single and multiple answer questions according to the topics of the International Guideline directed to general surgeons. Diffusion of the inquiry through surgical and hernia association chats and email. Timeframe June-December 2019. RESULTS: 64 surveys were collected, which is a representative number of the general surgeons national college. The most frequent procedure between these was the abdominal wall surgery. Every surgeon did more than 52 groin hernia surgeries in one year, most of them outpatients. The epidural anesthesia was used the most and Lichtenstein's technique was the most frequently used (64%). 68% of the surgeons know how to perform a minimally invasive inguinal hernia surgery but with variable volumes. 38% of participants considered themselves experts in groin hernia management and 52% did not know the 2018 International Guideline. The recommendations of such guideline are followed only partially. CONCLUSIONS: The 2018 Hernia Surge International Guidelines have low diffusion among Costa Rican surgeons. The laparoscopic approach is widely accepted but there are no studies to assess the results and the quality. There should be protocols and studies adapted to Costa Rica's national situation.

Outcomes After Elective Inguinal Hernia Repair Performed by Associate Clinicians vs Medical Doctors in Sierra Leone: A Randomized Clinical Trial.

Importance: Task sharing of surgical duties with medical doctors (MDs) without formal surgical training and associate clinicians (ACs; health care workers corresponding to an educational level between that of a nurse and an MD) is practiced to provide surgical services to people in low-resource settings. The safety and effectiveness of this has not been fully evaluated through a randomized clinical trial. Objective: To determine whether task sharing with MDs and ACs is safe and effective in mesh hernia repair in Sierra Leone. Design, Setting, and Participants: This single-blind, noninferiority randomized clinical trial included adult, healthy men with primary inguinal hernia randomized to receiving surgical treatment from an MD or an AC. In Sierra Leone, ACs practicing surgery have received 2 years of surgical training and completed a 1-year internship. The study was conducted between October 2017 and February 2019. Patients were followed up at 2 weeks and 1 year after operations. Observers were blinded to the study arm of the patients. The study was carried out in a first-level hospital in rural Sierra Leone. Data were analyzed from March to June 2019. Interventions: All patients received an open mesh inguinal hernia repair under local anesthesia. The control group underwent operations performed by MDs, and the intervention group underwent operations performed by ACs. Main Outcomes and Measures: The primary end point was hernia recurrence at 1 year. Outcomes were assessed by blinded observers at 2 weeks and 1 year after operations. Results: A total of 230 patients were recruited (mean [SD] age, 43.0 [13.5] years), and all but 1 patient underwent inguinal hernia repair between October 23, 2017, and February 2, 2018, performed by 5 MDs and 6 ACs. A total of 114 patients were operated on by MDs, and 115 patients were operated on by ACs. There were no crossovers between the study arms. The follow-up rate was 100% at 2 weeks and 94.1% at 1 year. At 1 year, hernia recurrence occurred in 7 patients (6.9%) operated on by MDs and 1 patient (0.9%) operated on by ACs (absolute difference, -6.0 [95% CI, -11.2 to 0.7] percentage points; P < .001). Conclusions and Relevance: These findings demonstrate that task sharing of elective mesh inguinal hernia repair with ACs was safe and effective. The task sharing debate should progress to focus on optimizing surgical training programs for nonsurgeons and building capacity for elective surgical care in low- and middle-income countries. Trial Registration: isrctn.org Identifier: ISRCTN63478884.

Improving surgical education in East Africa with a standardized hernia training program.

INTRODUCTION: Inguinal hernias are among the most common surgical diseases in Africa. The current International HerniaSurge Guidelines recommend mesh-based surgical techniques in Low Resource Settings (LRS). This recommendation is currently unachievable in large parts of Africa due to the unaffordability of mesh and lack of appropriate training of the few available surgeons. There is, therefore, a need for formal training in mesh surgery. There is an experience in Hernia Repair for the Underserved in Central and South America, however, inadequate evidence of structured training in Africa. MATERIAL AND METHODS: Since 2016, the aid Organizations, Surgeons for Africa and Operation Hernia have developed and employed a structured hernia surgical training program for postgraduate surgical trainees and medical doctors in Rwanda. This course consists of lectures on relevant aspects of hernia surgery and hands-on training in operating theatres. The lectures emphasize anatomy and surgical technique. All parts of the training were evaluated. Formal pre-course evaluation was conducted to assess the personal surgical experience of the trainees. RESULTS: Over a 3-year period, a structured hernia training programme was employed to train a total of 36 surgical trainees in both mesh and also non mesh hernia surgery. The key principle in this course is the continuous competence assessment and feedback. Evidence is provided to demonstrate improvement in surgical skills as well as knowledge of surgical anatomy which is essential to acquiring surgical competency. With self-assessment, expressed on a Likert scale, the participants could improve the theoretical knowledge about hernias from median 4.4 (on a scale of 1-10) before training to 8.4 after the training. The specific knowledge about anatomy could be improved in the same assessment from 4.8 before training to 8.1. after the training. After training course 12 of the 36 participants (33.33%) were able to carry out both suture- and mesh-based operations of simple inguinal hernias completely and independently. 20 of the 36 participants (55.55%) required only minimal supervision and only four participants (11.11%) required surgical supervision even after the completion of the course. CONCLUSION: We have demonstrated that, medical personnel in Africa can be trained in mesh and non-mesh hernia surgery using a structured training programme.

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction.

BACKGROUND: Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common. DATA SOURCES: With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results. CONCLUSIONS: This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

A Practical Guideline for the Implementation of Shared Decision-making in Complex Ventral Incisional Hernia Repair.

BACKGROUND: Although obtaining preoperative procedural consent is required to meet legal and ethical obligations, consent is often relegated to a unidirectional conversation between surgeons and patients. In contrast, shared decision-making (SDM) is a collaborative dialog that elicits patient preferences. Despite emerging interest in SDM, there is a paucity of literature on its application to ventral incisional hernia repair (VIHR). The various surgical techniques and mesh types available, the potential impact on functional outcomes and quality of life, the largely elective nature of the operation, and the significant risk of perioperative patient complications render VIHR an ideal field for SDM implementation. METHODS: The authors reviewed the current literature and drew on their own practice experience to describe evidence-based practical guidelines for implementing the SDM into VIHR care. RESULTS: We summarized the evidence basis for SDM in surgery and discussed how this model can be applied to VIHR given the multiple, complex factors that influence surgical decision-making. We outlined an example of using an SDM framework, "SHARE," with a patient with a large, recurrent ventral hernia. CONCLUSIONS: SDM has the potential to improve patient-centered and preference-concordant care among individuals being considered for VIHR to ensure that treatment interventions meet a patient's goals, rather than solely treating the underlying disease process.

Can Intraoperative Video Recordings Contribute to Improving Laparoscopic Percutaneous Extraperitoneal Closure in Children with Inguinal Hernia and Prevent Recurrence? A Pilot Study.

Aim: We reviewed intraoperative video recordings (IVRs) of laparoscopic percutaneous extraperitoneal closure (LPEC) for inguinal hernia in children blindly to assess performance. Methods: IVRs of 183 LPEC performed between April 2013 and March 2016, graded by the operating surgeon as difficult (D; n = 8), straightforward (S; n = 96), or easy (E; n = 79), were scored by a panel of reviewers with advanced (group A; >400 LPEC cases; n = 5), intermediate (group I; 50-150 cases; n = 5), and basic (group B; <10 cases; n = 5) experience, according to suturing, dissection plane, vas/vessel dissection, bleeding, and peritoneal injury. They also allocated a recurrence risk rank (RRR; highest = 6; lowest = 1) for each IVR. Mean score variance for each IVR was also compared between reviewers. Results: There was one recurrence (R; 4-year-old male; level E). RRR were: 1, 2, and 2 for reviewers A, I, and B, respectively. Reviewer A scores for "suturing" and "bleeding," and reviewer I scores for "dissection plane" and "peritoneal injury" correlated significantly with RRR. No reviewer B scores correlated with RRR. Score variance between A and I and A and B for cases D1 and D2 were statistically significant. Conclusion: Advanced reviewers showed greatest variance, questioning the validity of whether experience alone improves surgical technique.

Laparoscopic Toupet fundoplication for gastroesophageal reflux disease and hiatus hernia: proposal for standardization using the "critical view" concept.

Laparoscopic Toupet fundoplication has gained progressive consideration in the management of patients with gastroesophageal reflux disease and hiatus hernia. Previous studies showed equivalent results in terms of reflux control with lower rate of side effects compared to the Nissen fundoplication. However, multiple technical variations may account for the long-lasting reputation of decreased durability and poor long-term reflux control. Inspired by the "critical view" concept, a step-by-step laparoscopic Toupet fundoplication is described and illustrated. During the study period, 2012-2017, 348 consecutive patients underwent laparoscopic Toupet fundoplication according to a standardized procedure. A large hiatus hernia was present in 39% of patients, and 14% had volvulus of the intrathoracic stomach. Sixty-four (18.4%) patients had one or more previously failed antireflux procedures. The median follow-up was 37 months (range 12-61). The Gastroesophageal Reflux Disease Health-Related Quality of Life score significantly improved compared to baseline (p < 0.001), and 77% of patients were off proton-pump inhibitors. The proposed standardization of the Toupet fundoplication based on a "critical-view" concept may help to improve reproducibility, clinical outcomes, and teaching of this procedure.

Single-incision approach for bilateral inguinal hernia repair in children: A retrospective study.

To introduce the use of a new surgical approach named single-incision bilateral inguinal herniorrhaphy (SBIH) in pediatric surgical population.This was a STROBE-compliant retrospective cohort study using data from 101 patients who had undergone bilateral inguinal herniorrhaphy in our institution. Children with bilateral inguinal hernias without contraindications for surgery, ranging in age from 6 months to 12 years, were included. Fifty-six children with bilateral inguinal hernias underwent SBIH (SBIH group) and 45 patients underwent laparoscopic bilateral inguinal herniorrhaphy (LBIH) (LBIH group). Differences in operative time, postoperative pain, recurrence, and complications between the 2 groups were analyzed. Patient satisfaction with cosmetic result was also investigated using questionnaires.There were no statistically significant differences in operative time (P = .2257), postoperative pain (P = .0607), recurrence (P = .8756), and complications (P = .7467) between the 2 groups. Interestingly, the operation time of girls in SBIH group was significantly shorter than that of the boys in this group (P < .0001), but also shorter than that of girls in LBIH group (P = .0038). Postoperative pain for boys was lower in SBIH group than in the LBIH group (P = .0340). No ascending testis, testicular atrophy, and hydrocele occurred in either group. According to the questionnaire, both procedures had equally high levels of satisfaction for cosmetic results (P = .7531).Initial results show that SBIH for pediatric patients, regardless of gender, is a safe and feasible procedure compared with LBIH with an equally low recurrence rate, few complication, and satisfactory cosmetic outcomes.

Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide.

BACKGROUND: Although laparoscopic inguinal hernia repair was described about 30 years ago and advantages of the technique have been demonstrated, the utilization of this approach has not been what we would expect. Some reasons may be the need for surgeons to understand the posterior anatomy of the groin from a new vantage point, as well as to acquire advanced laparoscopic skills. Recently, however, the introduction of a robotic approach has dramatically increased the adoption of minimally invasive techniques for inguinal hernia repair. METHODS: Important recent contributions to this evolution have been the establishment of a new concept known as the critical view of the Myopectineal Orifice (MPO) and the description of a new way of understanding the posterior view of the antomy of the groin (inverted Y and the five triangles). In this paper, we describe 10 rules for a safe MIS inguinal hernia repair (TAPP, TEP, ETEP, RTAPP) that combines these two new concepts in a unique way. CONCLUSIONS: As the critical view of safety has made laparoscopic cholecystectomy safer, we feel that following our ten rules based on understanding the anatomy of the posterior groin as defined by zones and essential triangles and the technical steps to achieve the critical view of the MPO will foster the goal of safe MIS hernia repair, no matter which minimally invasive technique is employed.

Abdominal wall hernia surgery in The Netherlands: a national survey.

PURPOSE: In The Netherlands, the quality of abdominal wall hernia surgery is largely unknown due to the lack of a hernia registry. This study was designed to assess the current state of abdominal wall hernia surgery in The Netherlands, to create a starting point for future evaluation of new quality measures. METHODS: Dutch hernia management indicators and recently proposed European Hernia Society (EHS) requirements for accredited/certified hernia centers were used. The number of Dutch hospitals that meet the four main EHS requirements (on volume, experience, use of a registry and quality control) was assessed by analyzing governmental information and the results of a survey amongst all 1.554 Dutch general surgeons. RESULTS: The survey was representative with 426 respondents (27%) from all 75 hospitals. Fifty-one percent of the hospitals had a median inguinal repair volume of more than 290 (14-1.238) per year. An open or laparo-endoscopic inguinal repair technique was not related to hospital volume. Experienced hernia surgeons, use of a registry and a structured quality control were reported to be present in, respectively, 97%, 39%, and 15% of the hospitals. Consensus in answers between the respondents per hospital was low (< 20%). Two hospitals (3%) met all four requirements for accreditation. CONCLUSION: This descriptive analysis demonstrates that hernia surgery in the Netherlands is performed in every hospital, by all types of surgeons, using many different techniques. If the suggested EHS requirements are used as a measuring rod, only 3% of the Dutch hospitals could be accredited as a hernia center.

Population-based rates of hernia surgery in Ghana.

PURPOSE: To estimate the population-based annual rate of hernia surgery in Ghana, so as to better define the met and unmet need and to identify opportunities to decrease the unmet need. METHODS: Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 of 5 tertiary hospitals, and scaled-up to nationwide estimates. Rates of hernia surgery were compared to previously published annual incidence of symptomatic hernia in Ghana (210/100,000 population) and to published annual rates of hernia surgery in high-income countries (120-275/100,000). RESULTS: Estimated 17,418 [95% uncertainty interval (UI) 8154-26,683] hernia operations were performed nationally. The annual rate of hernia operations was 65 operations/100,000 population (95% UI 30.2-99.0). The rate was considerably less than the annual incidence of new symptomatic hernia or rates of hernia surgery in high-income countries. Hernia operations represented 7.5% of all operations. Most hernia operations (74%) were performed at district hospitals. Most district hospitals (54%) did not have fully trained surgeons, but nonetheless performed 38% of district-level hernia operations. CONCLUSIONS: The rate of hernia operations fell short of estimated need. Most hernia repairs were performed at district hospitals, many without fully trained surgeons. Future global surgery benchmarking needs to address both overall surgical rates as well as rates for specific highly important operations. Countries can strengthen their planning for surgical care by defining their total, met, and unmet need for hernia surgery.

Learning curve in open inguinal hernia repair: a quality improvement multicentre study about Lichtenstein technique.

PURPOSE: Inguinal hernia repair is one of the most performed procedure all over the world with more than 20 million procedures performed each year. Due to the lack of data in literature about the learning curve of the Lichtenstein procedure, we decided to reproduce a research on learning curves with the same methodology proposed in our previous study about laparoscopic hernia repair. The aim of this multicentre study was to analyse how many cases are required to achieve the learning curve for a Lichtenstein procedure. METHODS: We performed a retrospective analysis of the first 100 Lichtenstein procedures performed by 4 trainees from three different institutions and compared them with the same number of procedures performed by 3 senior surgeons from the same institutions. The data about the achieving of learning curve were evaluated with CUSUM and KPSS test. RESULTS: No differences about biometrical features were found between the seven groups of patients. CUSUM analysis showed that the trainees achieve the learning curve after 37-42 procedures, reaching an operative time similar to that one of the senior surgeons. CONCLUSIONS: In conclusion, we have shown that the number of procedures required to reach the learning curve from the beginning of surgical residency is around 40 hernia repairs. This number, produced in a controlled environment under strict supervision, could be the minimum requirement to start the procedure of accreditation and specialization in hernia surgery and is higher and steeper than previously reported.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery.

INTRODUCTION: The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature. METHODS: A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated. RESULTS: All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures. CONCLUSION: A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

Not a Routine Case, Why Expect the Routine Outcome? Quantifying the Infectious Burden of Emergency General Surgery Using the NSQIP.

Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3% vs 3.6% for any SSI). Postoperative sepsis (5.8% vs 1.5%), septic shock (4.7% vs 0.6%), length of stay (8.1 vs 2.9 days), and mortality (3.6% vs 0.4%) were increased in emergent surgery; P < 0.001 for all. When controlling for age, gender, BMI, diabetes, smoking, wound classification, comorbidities, functional status, and procedure on multivariate analysis, emergency surgery (odds ratio 1.15, 95% confidence interval 1.11-1.19) was independently associated with the development of SSI. Patients undergoing emergency general surgery experience increased rates of SSI. Patients and their families should be appropriately counseled regarding these elevated risks when consenting for emergency surgery.

Guidelines of the Brazilian Hernia Society (BHS) for the management of inguinocrural hernias in adults. / Orientações da Sociedade Brasileira de Hérnia (SBH) para o manejo das hérnias inguinocrurais em adultos.

Inguinal hernias are a frequent problem and their repair is the most commonly performed procedure by general surgeons. In the last years, new principles, products and techniques have changed the routine of surgeons, who need to recycle knowledge and perfect new skills. In addition, old concepts regarding surgical indication and risk of complications have been reevaluated. In order to create a guideline for the management of inguinal hernias in adult patients, the Brazilian Hernia Society assembled a group of experts to review various topics, such as surgical indication, perioperative management, surgical techniques, complications and postoperative guidance.

As hérnias inguinais são um problema frequente e o seu reparo representa a cirurgia mais comumente realizada por cirurgiões gerais. Nos últimos anos, novos princípios, produtos e técnicas têm mudado a rotina dos cirurgiões que precisam reciclar conhecimentos e aperfeiçoar novas habilidades. Além disso, antigos conceitos sobre indicação cirúrgica e riscos de complicações vêm sendo reavaliados. Visando criar um guia de orientações sobre o manejo das hérnias inguinais em pacientes adultos, a Sociedade Brasileira de Hérnias reuniu um grupo de experts com objetivo de revisar diversos tópicos, como indicação cirúrgica, manejo perioperatório, técnicas cirúrgicas, complicações e orientações pós-operatórias.

Variation in outcomes and use of laparoscopy in elective inguinal hernia repair.

Background: The early outcomes of inguinal hernia repair in routine practice and the extent to which the laparoscopic approach is used are unknown. The aims of this study were to identify national benchmarks for early reoperation and readmission rates, to identify the degree to which the laparoscopic approach is used for elective hernia surgery in England, and to identify whether there is any variation nationally. Methods: All adults who underwent publically funded elective inguinal hernia repair in England during the six financial years from 2011-2012 to 2016-2017 were identified in the Surgeon's Workload Outcomes and Research Database (SWORD). Patients were grouped according to whether they had a primary, recurrent or bilateral hernia, and according to sex. Overall rates of readmission, reoperation and laparoscopic approach were calculated, and variation was assessed using funnel plots. Results: Some 390 777 patients were included. Overall, 11 448 patients (2·9 per cent) were readmitted to hospital as an emergency within 30 days of surgery and 2872 (0·7 per cent) had a further operation. Laparoscopic repair was performed for 65·5 per cent of bilateral inguinal hernias compared with 17·1 per cent of primary unilateral inguinal hernias, 31·3 per cent of recurrent hernia repairs and 14·0 per cent of primary unilateral hernias in women. The unadjusted readmission, reoperation and laparoscopy rates varied significantly between hospitals. Conclusion: The likelihood of a patient being readmitted to hospital, having an emergency reoperation or undergoing laparoscopic inguinal hernia repair varies significantly depending on the hospital to which they are referred. Hospitals and service commissioners should use this data to drive service improvement and reduce this variation.

Incisional hernia recurrence after open elective repair: expertise in abdominal wall surgery matters.

BACKGROUND: Recurrence after incisional hernia repair is one of the major problems related with this operation. Our objective is to analyze the influence of abdominal wall surgery expertise in the results of the open elective repair of incisional hernia. METHODS: We have compiled the data of a cohort of patients who received surgery for an incisional hernia from July 2012 to December 2015 in a University Hospital. Data were collected prospectively and registered in the Spanish Register of Incisional Hernia (EVEREG). The short- and long-term complications between the groups of patients operated on by the Abdominal Wall Surgery (AWS) unit and groups operated on by surgeons outside of the specialized abdominal wall group (GS) were compared. RESULTS: During the study period, a total of 237 patients were operated on by the open approach (114 AWS; 123 GS). One hundred seventy-five patients completed a median follow-up of 36.6 months [standard deviation (SD) = 6]. Groups were comparable in terms of age, sex, body mass index (BMI), comorbidities, and complexity of hernia. Complications were similar in both groups. Patients in the AWS group presented fewer recurrences (12.0% vs. 28.9%; P = 0.005). The cumulative incidence of recurrence was higher in the GS group [log rank 13.370; P < 0.001; odds ratio (OR) = 37.8; 95% confidence interval (CI) = 30.3-45.4]. In the multivariate analysis, surgery performed by the AWS unit was related to fewer recurrences (OR = 0.19; 95%CI = 0.07-0.58; P < 0.001). CONCLUSION: Incisional hernia surgery is associated with better results in terms of recurrence when it is performed in a specialized abdominal wall unit.

Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)): Part B.

In 2014 the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias". Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. METHODS: For the development of the original guidelines all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based-Medicine. For the present update all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne) the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. RESULTS: Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques-minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite still insufficient evidence with respect to these new techniques it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. CONCLUSION: Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initially guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

A systematic methodological review of non-randomised interventional studies of elective ventral hernia repair: clear definitions and a standardised minimum dataset are needed.

BACKGROUND: Ventral hernias (VHs) often recur after surgical repair and subsequent attempts at repair are especially challenging. Rigorous research to reduce recurrence is required but such studies must be well-designed and report representative and comprehensive outcomes. OBJECTIVE: We aimed to assesses methodological quality of non-randomised interventional studies of VH repair by systematic review. METHODS: We searched the indexed literature for non-randomised studies of interventions for VH repair, January 1995 to December 2017 inclusive. Each prospective study was coupled with a corresponding retrospective study using pre-specified criteria to provide matched, comparable groups. We applied a bespoke methodological tool for hernia trials by combining relevant items from existing published tools. Study introduction and rationale, design, participant inclusion criteria, reported outcomes, and statistical methods were assessed. RESULTS: Fifty studies (17,608 patients) were identified: 25 prospective and 25 retrospective. Overall, prospective studies scored marginally higher than retrospective studies for methodological quality, median score 17 (IQR: 14-18) versus 15 (IQR 12-18), respectively. For the sub-categories investigated, prospective studies achieved higher median scores for their, 'introduction', 'study design' and 'participants'. Surprisingly, no study stated that a protocol had been written in advance. Only 18 (36%) studies defined a primary outcome, and only 2 studies (4%) described a power calculation. No study referenced a standardised definition for VH recurrence and detection methods for recurrence varied widely. Methodological quality did not improve with publication year or increasing journal impact factor. CONCLUSION: Currently, non-randomised interventional studies of VH repair are methodologically poor. Clear outcome definitions and a standardised minimum dataset are needed.