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

Update of guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-Part A

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 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 initial guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before

INDEPENDENT PATIENT DATA META-ANALYSIS OF PROPHYLACTIC MESH PLACEMENT FOR INCISIONAL HERNIA PREVENTION (AFTER ABDOMINAL AORTIC ANEURYSM SURGERY): A COLLABORATIVE EUROPEAN HERNIA SOCIETY PROJECT (I-PREVENT-AAA)

peer reviewedAbstract Introduction Incisional hernia (IH) is a prevalent and potentially dangerous complication after abdominal surgery, especially in high-risk groups. Prophylactic mesh augmentation (PMA) of the abdominal wall has been studied as a preventive measure for IH-formation, but strong recommendations are lacking. Our primary aim was to evaluate the effectiveness of the use of PMA after open abdominal aortic aneurysm (AAA)-surgery for the prevention of IH by performing an individual patient-data meta-analysis (IPDMA). Secondary aims include evaluation of postoperative complications, and identification of subgroups that benefit most from PMA. Methods A systematic literature search to identify Randomized-Controlled Trials (RCTs) that compare PMA after open AAA surgery to primary suturing (PS), was conducted. Lead authors of eligible studies were asked to share individual participant-data. A one-stage analysis was performed and Cox-regression analyses were used to assess time-to-event outcomes. Results Five RCTs were included in our IPDMA, which resulted in 488 analysed patients. PMA resulted in a Hazard Ratio (HR) of 0.25 (95%CI 0.12–0.50) for the reduction of IH occurrence. No significant differences were present when comparing onlay with sublay mesh (HR 0.56, 95%CI 0.24–1.28). Patients treated with an onlay mesh had significantly more seroma formation in comparison to PS (OR 22.1,95%CI 1.88–259.58) and patients with a sublay mesh had fewer re-operations than those treated with PS (OR 0.47,95%CI 0.43–0.51). Subgroup analyses showed the effectiveness of PMA in various subgroups (e.g., high BMI patients). Conclusion PMA after open AAA surgery is an effective measure to reduce IH formation in a wide variety of patients

Technical aspects of inguino scrotal hernia surgery in developing countries

Purpose: Technical aspects of inguinoscrotal herniorrhaphy performed in low to middle income countries (LMICs) are described here to help surgeons who will operate on these challenging hernias in austere settings. Methods: Technical considerations related to operative repair were delineated with the consensus of 7 surgeons with extensive experience in inguinoscrotal hernia repair in LMICs. Important steps and illustrations were prepared accordingly. The anatomical and pathologic differences and technical implications of operating in limited resource settings are emphasized with suggestions to approach anticipated challenges. Pre-operative evaluation, anesthetic considerations, and technical guidelines are offered in context. Results: The authors have cumulatively performed over 1775 inguinoscrotal Lichtenstein operations in LMICs. While dedicated, reliable, long-term follow-up is unavailable from LMICs, one author reports outcomes with 5 year follow-up from the HerniaMed registry using the identical technique in similarly classed hernias. In 90 inguinoscrotal Lichtenstein repair patients (78.3% follow-up), there was one recurrence, low rates of chronic pain (2.2% at rest, 4.4% with activity), and low rates of reintervention (1.1%). Conclusion: There is a difference between inguinal hernias found in LMICs and those seen in high-income countries with larger, chronic, and more technically challenging pathology. The consequences of intra-operative complications can be catastrophic in a LMIC. Technical measures are offered to improve outcomes, avoid and manage complications, and provide optimal care to this important population