OBJECTIVE: The objective of this study was to determine the best treatment
 of incisional hernia, taking into account recurrence, complications,
 discomfort, cosmetic result, and patient satisfaction. BACKGROUND:
 Long-term results of incisional hernia repair are lacking. Retrospective
 studies and the midterm results of this study indicate that mesh repair is
 superior to suture repair. However, many surgeons are still performing
 suture repair. METHODS: Between 1992 and 1998, a multicenter trial was
 performed, in which 181 eligible patients with a primary or first-time
 recurrent midline incisional hernia were randomly assigned to suture or
 mesh repair. In 2003, follow-up was updated. RESULTS: Median follow-up was
 75 months for suture repair and 81 months for mesh repair patients. The
 10-year cumulative rate of recurrence was 63% for suture repair and 32%
 for mesh repair (P < 0.001). Abdominal aneurysm (P = 0.01) and wound
 infection (P = 0.02) were identified as independent risk factors for
 recurrence. In patients with small incisional hernias, the recurrence
 rates were 67% after suture repair and 17% after mesh repair (P = 0.003).
 One hundred twenty-six patients completed long-term follow-up (median
 follow-up 98 months). In the mesh repair group, 17% suffered a
 complication, compared with 8% in the suture repair group (P = 0.17).
 Abdominal pain was more frequent in suture repair patients (P = 0.01), but
 there was no difference in scar pain, cosmetic result, and patient
 satisfaction. CONCLUSIONS: Mesh repair results in a lower recurrence rate
 and less abdominal pain and does not result in more complications than
 suture repair. Suture repair of incisional hernia should be abandoned.

/pdf/long-term-follow-up-of-a-randomized-controlled-trial-of-1m0wy0j602.pdf

Long-term Follow-up of a Randomized Controlled Trial of Suture Versus Mesh Repair of Incisional Hernia

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.

/pdf/european-hernia-society-guidelines-on-the-treatment-of-3gpmvq0mxo.pdf

European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery. 
An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. 
The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. 
General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. 
An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients. 
The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

/pdf/international-guidelines-for-groin-hernia-management-3otlldvdxc.pdf

International guidelines for groin hernia management

http://www.chcs.org.cn/upload/2014-09/14091721577197.pdf

Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair

One result of the 2 million laparotomies performed in the United States each year is an incisional hernia rate of 3% to 20%,1 necessitating repair of approximately 90,000 ventral hernias annually. Factors associated with formation of an incisional hernia include wound infection, immunosuppression, morbid obesity, previous operations, prostatism, and surgery for aneurysmal disease. Abdominal wall defects are typically observed within the first 5 years after the surgical incision is made, but they may develop long afterward.2 These hernias contribute importantly to the long-term morbidity of conventional surgery. Until techniques for the prevention of hernias are established, repair of these defects will remain an important problem for all abdominal surgeons.

Many hernia repair methods have been described. Traditional primary repair entails a laparotomy with suture approximation of strong fascial tissue on each side of the defect. However, recurrence rates after this procedure range from 41% to 52% during long-term follow-up.2-4 Herniorrhaphies in which large prosthetic meshes are implanted appear to have lower failure rates (12-24%), but the required dissection of wide areas of soft tissue contributes to an increased incidence of wound infections and wound-related complications (12% or higher).3,5,6 These problems have stimulated a continuing search for new techniques for repairing ventral hernias.

The interest in less morbid herniorrhaphies and the appeal of minimally invasive surgery encouraged development of laparoscopic methods for repairing incisional hernias. These techniques are based on the same physical and surgical principles as the open underlay procedure described by Stoppa,3 Rives et al,7 and Wantz.8 Since the first report of laparoscopic ventral hernia repair (LVHR) in 1992,9 the operation has grown in popularity with the belief that it may offer shorter hospital stays, improved patient outcomes, and fewer complications than traditional open procedures. Several comparative studies are now available that support this assertion.10-14 Limiting factors in most of these and the noncomparative series that describe LVHR include limited sample size, varying techniques, and restricted follow-up.15-18

We here describe a study of outcomes achieved with LVHR performed by 4 attending surgeons using the same surgical technique and standardized perioperative regimens and follow-up protocols. The reported series includes every patient in whom the operation was performed or attempted. Data on most patients were collected prospectively, and the follow-up time extends to more than 8 years. The goal of the study was to assess the safety and efficacy of LVHR.

Laparoscopic repair of ventral hernias: nine years' experience with 850 consecutive hernias.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(03)14746-0.pdf

Hernias: inguinal and incisional

Laparoscopic techniques were used in five cases to repair incisional abdominal hernias ranging in size from 1.5 to 6 cm2. Four to five trocars were used in each case, one in the upper midline and three or four placed laterally. All repairs were made using 1-mm-thick expanded polytetrafluoroethylene patches inserted intraperitoneally and stapled to the anterior abdominal wall over the defects, making use of intra-abdominal pressure to secure the repair. The surgical technique is an extension of our current laparoscopic techniques for repairing inguinal hernias and potentially offers a significant decrease in morbidity.

Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings.

Guidelines are increasingly determining the decision process in day-to-day clinical work. Guidelines describe the current best possible standard in diagnostics and therapy. They should be developed by an international panel of experts, whereby alongside individual experience, above all, the results of comparative studies are decisive. According to the results of high-ranking scientific studies published in peer-reviewed journals, statements and recommendations are formulated, and these are graded strictly according to the criteria of evidence-based medicine. Guidelines can therefore be valuable in helping particularly the young surgeon in his or her day-to-day work to find the best decision for the patient when confronted with a wide and confusing range of options. However, even experienced surgeons benefit because by virtue of a heavy workload and commitment, they often find it difficult to keep up with the ever-increasing published literature. All guidelines require regular updating, usually every 3 years, in line with progress in the field. The current Guidelines focus on technique and perioperative management of laparoscopic ventral hernia repair and constitute the first comprehensive guidelines on this topic. In this issue of Surgical Endoscopy, the first part of the Guidelines is published including sections on basics, indication for surgery, perioperative management, and key points of technique. The next part (Part 2) of the Guidelines will address complications and comparisons between open and laparoscopic techniques. Part 3 will cover mesh technology, hernia prophylaxis, technique-related issues, new technologic developments, lumbar and other unusual hernias, and training/education.

/pdf/guidelines-for-laparoscopic-treatment-of-ventral-and-4iywt9vvsy.pdf

Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)—Part 1

Our first 100 patients and our second 100 patients who underwent a laparoscopic repair of incisional and ventral hernias were compared and evaluated This analysis revealed that the second group was approximately 9 years older with more comorbid medical conditions In all, 15% were incarcerated hernias, and 21% were recurrent Seven operations were converted to the open repair because of adhesions in five patients and either a small or large bowel injury in two patients There were no complications related to enterotomy Older and more infirm patients in the second group did not significantly affect outcomes The average size of the hernia defects was 111 cm2 The average size of the prosthesis was 2575 cm2 Larger prostheses were used in the second group With more experience, the recurrence rates have declined from 9% to 4% The etiology of these recurrences differed in these two groups of patients Removal of the prosthetic due to infection was a predictable recurrence in two patients A new hernia below the original hernia has caused us to repair the entire incision that had the initial hernia Only one technical failure was noted, due to fracture of the suture during transfascial placement and clamping of the suture It is not recommended to grasp any suture that remains in the patient during this hernioplasty Recurrences were reduced because of the use of an increased overlap of the biomaterial and the use of dual methods of fixation (tacks and transfascial sutures)

Laparoscopic incisional and ventral hernioplasty: lessons learned from 200 patients.

Laparoscopic incisional and ventral hernia (LVIH) repair is becoming more popular throughout the world. Although individual series have presented their own information, few data have been collected to identify the risk of the most serious complication, enterotomy. A literature review has identified this to occur in 1.78% of patients who undergo this procedure. Large bowel injury represents only 8.3% of these injuries. Eighty-two percent of the time, these injuries will be recognized and repaired. In the majority of published series in which this occurred, the hernia repair was completed with a laparoscopically placed prosthesis, as only 43% were converted to the open procedure. Complications related to this approach are infrequent. The mortality rate of this operation was noted to be 0.05%. However, if an enterotomy occurred, it increased to 2.8%. A recognized enterotomy was associated with a mortality rate of 1.7%, but an unrecognized enterotomy had a rate of 7.7%. Careful technique and close inspection of the intestine at the completion of the adhesiolysis and the herniorrhaphy is recommended. If the hernia repair proceeds as planned following repair of enterotomy, continuation of antibiotics and the placement of an antimicrobial impregnated prosthesis are recommended. More study is necessary before firm recommendations can be made, as the majority of these events are most likely unreported. Safety concerns may require postponement of the hernia repair if an enterotomy occurs.

Karl A. LeBlanc

Papers

Hernias: inguinal and incisional

Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings.

Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)—Part 1

Laparoscopic incisional and ventral hernioplasty: lessons learned from 200 patients.

Enterotomy and mortality rates of laparoscopic incisional and ventral hernia repair: a review of the literature.