European Hernia Society guidelines on the closure


Background

Incisional hernias are a frequent complication of abdominal wall incisions, but a wide range of incisional hernia rates are reported [1–6]. The weighted mean incisional hernia rate at 23.8 months was 12.8 % in a systematic review and meta-regression study [7], but incidence rates up to 69 % have been reported in high-risk patients with prospective long-term follow-up [8]. The reported incidence is determined by several factors: the patient population studied, the type of abdominal wall incision, the length of follow-up and the method of incisional hernia diagnosis. Risk factors for incisional hernias include postoperative surgical site infection, obesity and abdominal aortic aneurysm [9–11]. Neverthe- less, it seems that the suture material and the surgical tech- nique used to close an abdominal wall incision, are the most important determinants of the risk of developing an inci- sional hernia [1, 12]. The development of an incisional hernia has an important impact on the patients' quality of life and body image [13]. Furthermore, the repair of incisional hernias still has a high failure rate with long term recurrence rates above 30 %, even when mesh repair is performed [14– 16]. Optimising the surgical technique to close abdominal wall incisions using evidence based principles, holds a potential to prevent patients suffering from incisional hernias and the potential sequelae of incisional hernia repairs [17]. The mean direct and indirect costs for the repair of an average incisional hernia in an average patient in France in 2011 was € 7,089 [18]. Thus, reducing the incisional hernia rate by optimising the closure of abdominal wall incisions holds a great potential for costs savings in the use of health care facilities and in reducing postoperative disability.

The European Hernia Society (EHS) originated from the "Groupe de la recherche de la paroi abdominal" (GREPA), which was founded in 1979 with the aim: "The promotion of abdominal wall surgery, the study of anatomic, physiologic and therapeutic problems related to the pathology of the abdominal wall, the creation of associated groups which will promote research and teaching in this field, and the development of interdisciplinary relations". During the autumn board meeting of the EHS in September 2013 in Italy it was decided to extend our mission to actively pro- mote the prevention of incisional hernias by the Sperlonga statement: "Maybe we should first learn and teach how to prevent incisional hernias, rather than how to treat them?".

Objective

The objective is to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the optimal materials and methods used to close the abdominal wall. The goal is to decrease the occurrence of both burst abdomen and incisional hernia. The guidelines refer to patients undergoing any kind of abdominal wall incision, including visceral surgery, gynaecological surgery, aortic vascular surgery, urological surgery or orthopaedic surgery. Both open and laparoscopic surgeries are included in these guidelines.


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