1A. Systematic review of randomized clinical trials (RCTs) (with consistent results from individual studies) |
1B. RCTs (of good quality)
|
2A. Systematic review of 2B studies (with consistent results from individual studies) |
2B. Prospective and comparative studies (or RCTs of poorer quality) |
2C. Outcome studies (e.g., analyses of large registries, population-based data) |
3. Retrospective and comparative studies, case–control studies |
4. Case series (i.e., studies without a control group) |
5. Expert opinion, animal or lab experiments. |
A Consistent level 1 studies: strict recommendations (“standard,” “surgeons must do it”) |
B Consistent level 2 or 3 studies or extrapolations from level 1 studies: less strict wording (“recommended,” “surgeons should do it”) |
C Level 4 studies or extrapolations from level 2 or 3 studies: vague wording (“option,” “surgeons can do it”) |
D Level 5 evidence or worryingly inconsistent or inconclusive studies at any level (no recommendation at all, described options). |
Basics
How comparable are incisional and ventral hernias in terms of operative technique and outcomes?
Bruce Ramshaw
Statements
Level 4 | The level of complexity and variability for ventral/incisional hernia patients and repair techniques is high. |
Level 5 | The degree of complexity is growing higher at an increasing rate of change. The techniques and outcomes, therefore, cannot be considered comparable using current methods of analysis due to the many complex ever-changing variables as well as the relationships between variables, which are not controllable. |
Recommendations
Grade C | Due to the increasing pace of change and the complexity of ventral/incisional hernia patients and techniques, use of traditional human subjects clinical research, evidence-based methods and guidelines in health care should be considered a starting point rather than a goal. |
Grade C | The application of principles of complex adaptive systems science, particularly real-world clinical quality-improvement methods, likely will be required to improve the value of care (e.g., quality outcomes measures, satisfaction, patient experience, costs) for the patient with a ventral/incisional hernia. |
Research
Summary
Is the routine application of computed tomography (CT) and magnetic resonance imaging (MRI) recommended for the diagnosis of ventral hernias before laparoscopic ventral hernia repair?
R. Schrittwieser
Statements
Level 5 | The evidence for the use of CT/MRI in the daily routine is insufficient. In some cases, especially those involving posttraumatic hernias, obese patients, large hernias with loss of domain, or special rare entities such as lumbar hernias, a CT scan or MRI can be helpful. |
Recommendation
Grade D | In special cases, such as those involving posttraumatic hernias, rare entities such as lumbar hernias or Spieghelian hernias, and connections with obesity, a CT scan or MRI may be considered. |
How important are CT and MRI in postoperative diagnosis?
Statement
Level 2b | In the postoperative diagnosis of recurrent hernia, a CT scan is superior to a clinical examination. |
Recommendations
Grade B | A CT scan should be performed to find a recurrence or associated pathologies. |
Grade D | Functional cine MRI can be used to find postoperative adhesions. |
Classification
U. A. Dietz, F. Muysoms, M. Rohr
Statements
Level 5 | A consensus exists among experts that it is necessary to classify ventral and incisional hernias prospectively, to create a useful data set to improve understanding of the disease, to allow comparability of results, to substantiate patient counseling, and to optimize therapeutic algorithms. |
Recommendations
Grade D | It is recommended that ventral and incisional hernias be classified before surgical therapy. |
The European Hernia Society (EHS) classification for ventral and incisional hernias is recommended. |
Are the classification criteria included in the EHS classification consistent?
Statements
Level 2B | Numbers of previous repairs and reducibility have been demonstrated to increase the risk of postoperative seroma. |
Level 2C | Risk factors have been shown to influence the incidence of repeat recurrences. |
Level 3 | The incidence of SSI is increased in patients with recurrent incisional hernias and chronic steroid use as well as among smokers. |
The morphology and size of the hernia may influence the type of procedure. | |
Findings show the width of the hernia gap to be a predictive factor for postoperative complications and the length of the hernia to be an independent prognostic factor for repeat recurrences. | |
Level 4 | Risk factors, hernia gap size, and morphology can influence the time needed for the surgical procedure. |
Smoking, male gender, BMI, age, SSI, and postoperative wound complications are risk factors for the development of an incisional hernia. |
Recommendations
Grade B | Number of previous repairs, morphology, size of the hernia gap, risk factors and reducibility should be part of any classification system and should be recorded in the patient files. |
Grade C | Risk factors, hernia gap size, and morphology should be part of any classification. They should be considered in planning (tailoring) the surgical procedure. |
No known algorithm exists that reduces the incidence of SSI in patients with risk factors. These patients should be informed about the increased risk during preoperative counseling. |
Is it necessary to classify ventral and incisional hernias as well as which classification should be recommended?
Are the classification criteria included in the EHS classification consistent?
Author | Years | Type of study | Oxford | New classification | Use of a classification | Recurrence rating | Morphology | Size | Risk factors | Surgical procedure |
---|---|---|---|---|---|---|---|---|---|---|
Ammaturo and Bassi [51] | 2005 | Case series | 4 | X | X | X | ||||
Chevrel and Rath [52] | 2000 | Expert opinion | 5 | X | ||||||
Chowbey et al. [53] | 2006 | Expert opinion | 5 | X | ||||||
Conze et al. [54] | 2005 | Experimental | 5 | X | X | |||||
Conze et al. [55] | 2007 | Case series | 4 | X | X | |||||
Dietz et al. [56] | 2007 | Expert opinion | 5 | X | ||||||
Dietz et al. [57] | 2012 | Retrospective case–control | 3 | X | X | X | X | X | ||
Hadeed et al. [58] | 2011 | Case series | 4 | X | ||||||
Höer et al. [59] | 2002 | Outcome study | 2c | X | ||||||
Jenkins et al. [14] | 2010 | Case series | 4 | X | X | X | ||||
Kaafarani et al. [60] | 2009 | RCT | 2B | X | ||||||
Kaafarani et al. [21] | 2010 | RCT | 2B | X | X | |||||
Kingsnorth [61] | 2006 | Review | 5 | X | ||||||
Klinge et al. [62] | 2001 | Experimental | 5 | X | ||||||
Korenkov et al. [63] | 2001 | Expert opinion | 5 | X | ||||||
Leblanc et al. [64] | 2001 | Retrospective cohort | 4 | X | ||||||
Licheri et al. [65] | 2008 | Case series | 4 | X | X | |||||
Losanoff et al. [66] | 2007 | Review | 5 | X | X | |||||
Martínez-Serrano et al. [67] | 2010 | Retrospective cohort | 3 | X | ||||||
Moreno-Egea et al. [68] | 2007 | Review | 5 | X | ||||||
Moreno-Egea et al. [69] | 2008 | NR-controlled trial | 3 | X | ||||||
Muysoms et al. [70] | 2009 | Expert opinion | 5 | X | X | X | X | X | X | |
Muysoms et al. [71] | 2012 | Expert opinion | 5 | X | X | |||||
Parker et al. [72] | 2011 | Retrospective cohort | 4 | X | ||||||
Piardi et al. [73] | 2010 | Retrospective cohort | 4 | X | X | X | ||||
Sanchez et al. [74] | 2011 | Review | 5 | X | ||||||
Sørensen et al. [75] | 2005 | Retrospective cohort | 3 | X | ||||||
Varnell et al. [15] | 2008 | Case series | 4 | X | X | X | ||||
Veljkovic et al. [76] | 2009 | Case series | 4 | X | ||||||
Winkler et al. [77] | 2008 | Review | 5 | X | X | X | X | X |
Indication for surgery
Indications for treatment: dependence on size of defect or hernia sac, hernia type, symptoms, and age
Thomas Simon
Statements
Level 4 | Symptoms develop for 33–78 % of patients with a ventral or incisional hernia. |
Level 4 | Surgery is performed for 5–15 % of patients with a ventral or incisional hernia because of an acute complication (obstruction/strangulation). |
Emergency repairs are associated with high morbidity. | |
Umbilical hernias obstruct five times more often than other ventral and incisional hernias. | |
Level 4 | The defect size of incisional hernias predicts recurrence rates. |
Level 4 | Findings seem to indicate no difference in terms of morbidity or mortality regarding laparoscopic surgery for ventral hernias in advanced age. |
The reduced risk of SSI in laparoscopic techniques has an impact especially for elderly patients. |
Recommendations
Grade D | Symptomatic ventral and incisional hernias should be treated surgically. |
Grade D | The laparoscopic technique for ventral and incisional hernias should preferably be reserved for defect sizes smaller than 10 cm in diameter. |
Grade D | The laparoscopic technique for ventral and incisional hernia repair can be used even for patients advanced in age. |
Symptoms
Acute hernia
Age
Indication related to size
Asymptomatic hernias
Is there still a place for open suture repair depending on defect size?
J. Kukleta, Th. Simon, S. Morales-Conde
Statements
Level 1B | Suture herniorrhaphy is the simplest procedure among the open repair techniques. |
Suture repair is associated with a high recurrence rate. | |
Suture repair is accomplished in a shorter operative time than mesh repair. | |
Mesh repair reduces the recurrence rate significantly compared with suture repair. | |
Mesh repair seems to be a safe method even in the presence of nonviable bowel loops in an incarcerated umbilical hernia. | |
Wound complication rates can be slightly higher in mesh repair or similar in the two groups. | |
Level 3 | Independent risk factors for recurrence of small hernias are not clearly defined. Hernia size, BMI, or wound infection in one study, and smoking, obesity, size of hernia, type of repair, and COPD in another study do not seem to predict recurrence in small hernia repair. |
Level 4 | Not every “small hernia” requires mesh repair. |
Suture repair of hernias smaller than 2 cm shows an acceptable recurrence rate and low wound morbidity. | |
Level 5 | Despite the existing evidence, suture repair still is very popular in the surgical community |
Recommendations
Grade A | For repair of primary defects larger than 2 cm or recurrent hernias of any size, mesh repair should be considered as the first choice. |
Grade C | Suture repair should be used only for very small primary defects of the abdominal wall in the absence of any possible recurrence risk factors. |
Grade D | In terms of recurrence, the available evidence is sufficiently strong to recommend that all defects of the abdominal wall, whether inguinal, incisional, or umbilical hernias, and of whatever size should be repaired with the use of prosthetic mesh. |
Risk factors
Author | Study | No. of patients | OM/Rec n (%) | LM/Rec n (%) | ONM/Rec n (%) | Wound infection OM/LM/ONM (%) |
---|---|---|---|---|---|---|
Abdel-Baki | RCT | 42 | 21 (0) | 21 (19) | ||
Arroyo | RCT | 200 | (1) | (11) | Similar | |
Polat | RCT | 50 | 17 PHS | 15 Onlay | 18 Mayo | |
Aslani | Sys rev | (1) | (11) | |||
Asolati | Retrosp | 229 | 132 (3) | 97 (7.7) | ||
Bowley | 473 | 80 (2.5) | 393 (4) | |||
Ergul | Case series | 10 + Lapchol | (0) | |||
Eryilmaz | Prosp | 111 | 48 (2) | 63 (14) | ||
Farrow | Retrosp | 152 | (1.5) | (9.2) | 19 | |
Gonzales | Retrosp | 76 | 20 (20) | 32 (0) | 24 (8) | 15/0/0 |
Halm | Retrosp | 131 | 12 (0) | 119 (13) | ||
Kamer | Retrosp | 64 | 14 | 50 | ||
Lau | Retrosp | 102 | 9 (0) | 26 (0) | 43 + 24 (8.7) | |
Malik | Retrosp | 236 | (7.4) | (22.7) | ||
Solomon | Retrosp | 724 | 227 (1.8) | 301 (1.0) | 146 (30) | 1.3/2.2/5.5 |
Sanjay | Retrosp | 100 | 39 (0.0) | 61 (11.5) | 0.0/11.5 | |
Stabilini | Retrosp | 98 | 64 (3.1) | 34 (14.7) | 1.4 | |
Venclauskas | Retrosp | 97 | 5 | 92 | ||
Wright | Retrosp | 116 | 20 | 30 | 66 |
Limitations of laparoscopic intraperitoneal onlay mesh (IPOM) repair in relation to defect size or body habitus
J. Bingener, M. Rohr
Feasibility with regard to obesity: statements
Level 3 | Laparoscopic IPOM is feasible for obese patients (BMI > 30 kg/m2). |
Level 3 | Laparoscopic IPOM is feasible for morbidly obese patients (BMI > 40 kg/m2). |
Level 3 | Laparoscopic IPOM is feasible for super morbidly obese patients (BMI > 50 kg/m2). |
Level 4 | Laparoscopic IPOM is feasible for patients with a BMI up to 82 kg/m2. |
IPOM feasibility in relation to hernia size: statements
Level 3 | Laparoscopic IPOM is feasible for defects larger than 15 cm. |
Level 2B | Hernia recurrence is more likely with defects wider than 10 cm. |
Level 3 | The operating time is longer with defects larger than 15 cm. |
Level 2B | Mesh sizes up to 1,250 cm2 can be used. |
Level 4 | Mesh sizes up to 2,400 cm2 can be used. |
Level 4 | LVHR is feasible for defects of up to 880 cm2. |
Morbidity and obesity: statements
Level 3 | Complication rates in patients with a BMI ≥ 40 kg/m2 undergoing LVHR are higher than for patients with a BMI < 40 kg/m2. |
Level 2B | The recurrence rate is increased with BMI > 30 kg/m2. |
Recommendations
Grade B | Obese patients should be informed that LVHR is feasible. |
Grade B | Patients should be informed that the risk of complications and hernia recurrence increases with BMI. |
Grade B | Patients should be informed that complications and wound infections are less likely with LVHR for obese patients than with the open approach. |
LVHR versus open repair for large hernia: statements
Level 2B | LVHR requires the use of larger mesh sizes than open hernia repair. |
Level 2B | LVHR results in fewer superficial SSIs than open repair of large hernias. |
Level 2B | LVHR results in less blood loss than open repair of large hernias. |
Level 3 | LVHR is associated with less use of postoperative narcotics than open repair. |
Level 3 | LVHR is associated with a shorter hospital stay than open repair. |
Level 3 | LVHR of large hernias is associated with less ileus than open repair. |
Recommendations
Grade B | Patients should be informed that LVHR for large hernia defects is feasible. |
Grade B | Patients should be informed that LVHR for large hernias reduces the incidence of superficial SSIs compared with open repair. |
Grade B | Patients should be informed that LVHR for large hernias is accompanied by less blood loss than open repair. |
Grade B | Patients should be informed that LVHR for large hernias results in a shorter hospital stay than open repair. |
Obese patients and incisional hernia
F. Köckerling, P. Chowbey
Statements
Level 1A | Laparoscopic ventral and incisional hernia repair is associated with fewer wound infections. |
Level 2A | Laparoscopic ventral and incisional hernia repair is associated with significantly fewer wound complications. |
Level 2B | Obese patients (BMI > 30 kg/m2) have significantly larger defect sizes in laparoscopic incisional hernia repair. |
Level 3 | A BMI higher than 30 kg/m2 or a defect larger than 8–10 cm significantly increases the risk of recurrence. |
The early outcome of LVHR does not differ significantly between non-morbidly obese (BMI < 35 kg/m2) and morbidly obese (BMI ≥ 35 kg/m2) patients. |
Recommendations
Grade A | For obese patients presenting with a ventral or incisional hernia, the laparoscopic approach is preferred because it reduces the wound infection rate and complications. |
Grade B | For patients with a BMI of 35 kg/m2 or higher, laparoscopic ventral and incisional hernia repairs may be preferred. |
In obese patients, the defect sizes are significantly larger, something that must be considered when the laparoscopic approach is advised. | |
For obese patients (BMI ≥ 30 kg/m2) with a defect size greater than 8–10 cm, there may be a need for additional technical steps (greater mesh fixation, more overlap, suture closure of the defect) when the laparoscopic approach is indicated. |
Recurrence after open surgery: redo better laparoscopically?
R. Schrittwieser
Statement
Level 4 | Some evidence indicates that reoperation for recurrence after open repair is better performed laparoscopically. |
Recommendation
Grade C | Some cases of recurrence after open repair are better managed laparoscopically provided the surgeon has sufficient experience in laparoscopic ventral hernia repair. |
Perioperative management
Evidence for antibiotic and thromboembolic prophylaxis in laparoscopic ventral hernia surgery
Rudolf Schrittwieser
Statements
Level 2b | Antibiotic prophylaxis in ventral hernia repair is associated with significantly fewer local infections. |
Level 5 | The evidence for routine thromboembolic prophylaxis in laparoscopic ventral hernia repair is insufficient. |
Recommendations
Grade B | Routine antibiotic prophylaxis in ventral hernia repair is recommended. |
Grade D | Thromboembolic prophylaxis should be given in accordance with the presence of risk factors for the individual patient. |
Antibiotic prophylaxis
Thromboembolic prophylaxis
Key-points of the technique
Positioning of the trocars and creating the capnopneumoperitoneum
M. Rohr, Y. Trommer
Statements
Level 4 | A safe area for Veress needle insertion usually is in the right or left upper quadrant. However, most surgeons prefer an open access (Hasson) in the left or right subcostal region but modify the insertion site depending on previous surgery and expected adhesions. |
The location of the trocars is influenced by the location of the hernia defect or defects. | |
The use of 30° and 45° scopes provides better visualization of the inner aspect of the abdominal wall. |
Recommendations
Grade D | The left or right upper quadrant subcostally is recommended for the first access port to the peritoneal cavity. |
The use of a 30° laparoscope is recommended. | |
The trocar entry points should be as far as possible from the site of expected adhesions and the size, site, and number of wall defects, and they should be placed to achieve triangulation of the hernia site. |
Port type, positions, and number in laparoscopic ventral hernia repair
Sean Rim, Danny Yakoub, George Ferzli
Statements
Level 2 | Visually guided insertion of trocars can minimize the size of the entry wound but does not decrease the incidence of visceral or vascular injury. |
Level 4 | Placement of trocars is dictated by the size and location of the defect. |
Placement of additional trocars may be necessary. |
Recommendations
Grade B | Visually guided entry of trocars is recommended because these decrease the size of the wound. |
Grade D | When additional trocars are needed, the principles of triangulation and maintenance of optimal distance should be taken into consideration. |
Port type
Port positions and number
Principles of adhesiolysis
M. Rohr, J. Lang
Statements
Level 1b | Adhesiolysis offers no additional benefit in itself. |
Level 3 | Adhesiolysis increases the risk of iatrogenic enterotomy, which increases mortality. |
Level 4 | Greater age and number of previous operations increase the risk of iatrogenic enterotomy during adhesiolysis. |
Level 5 | Monopolar coagulation has a larger collateral damage zone surrounding the coagulated tissue and produces higher temperatures. |
Currently, there is no reliable prevention of adhesions in abdominal surgery. | |
Use of monopolar electrocoaguation increases the risk of enterotomy. |
Recommendations
Grade B | Adhesiolysis should be limited to freeing the abdominal wall to enable adequate overlapping of the defect by the mesh. |
Grade C | Cold and sharp adhesiolysis is preferred to ultrasonic dissection. |
Bipolar coagulation is allowed, but monopolar coagulation should be avoided. | |
Grade D | Adhesiolysis should be performed near the abdominal wall away from the adherent bowel. |
Laparoscopic ventral or incisional hernia repair: importance of defining hernia defect margins and gauging the size of the hernia pre- and postoperatively
P. Chowbey
Statements
Level 2B | Size of the hernia defect is a significant risk factor for recurrence in laparoscopic ventral/incisional hernia repair. |
Level 3 | Accurate measurement of the hernia defect size is important to the choice of an appropriate surgical technique. |
Level 3 | Accurate measurement of the defect is important to the choice of an appropriate-sized mesh. |
Level 3 | The laparoscopic approach affords the surgeon the ability to define the margins of the hernia defect clearly and definitively and to identify additional defects that may not have been clinically apparent preoperatively. |
Recommendations
Grade B | Accurate measurement of the hernia defect size should be performed. |
Grade B | The intracorporeal method of measuring the size of the hernia defect should be used. |
Bridging, augmentation, and reconstruction of the linea alba: closure of the defect before IPOM
J. F. Kukleta, E. Chelala, P. Chowbey
Statements
Level 3 | Reconstruction of the linea alba in laparoscopic incisional hernia repair improves the functionality of the abdominal wall. |
Reconstruction of the midline (even using open procedure) and laparoscopic reinforcement through IPOM decrease the rate of wound complications. | |
Laparoscopically assisted transfascial repair of the midline defects often is feasible under “physiologic tension.” | |
Although not “tension free,” the augmentation repair causes less pain in the early postoperative period than bridging repair. | |
Augmentation repair (due to combined defect closure and extended mesh overlap) is a stronger repair than bridging repair if technically feasible. The usual overlap of 5 cm can be extended to 8 cm, for example, without an increase of technical difficulty. | |
The IPOM-Plus technique reduces the recurrence rate compared with classical IPOM. | |
Level 4 | Closing hernia defects in IPOM-Plus repair minimizes seroma incidence and prevents bulging, thus reducing the patient’s discomfort. |
The augmentation repair decreases the recurrence rate and the incidence of chronic pain. | |
Reconstruction of the linea alba without mesh reinforcement leads to high recurrence rates. |
Recommendations
Grade B | The suture material for defect closure in IPOM-Plus should be nonabsorbable. |
Grade C | Reconstruction of the linea alba (or any defect closure) in laparoscopic ventral or incisional hernia repair combined with IPOM is recommended for hernias of limited size. Additional components separation facilitates the closure and should be used for larger defects. |
Grade D | The anterior transfascial suture technique should involve the hernia sac to obliterate the dead space as much as possible with the aim of preventing seroma formation. |
How much overlap is necessary?
Salvador Morales-Conde
Statements
Level 3 | Recurrence is increased if overlap of the fascial defect by the prosthesis is inadequate. |
Large meshes with substantial overlap are associated with a low recurrence rate. | |
Level 4 | Structures such as the falciform ligament, the ligamentum teres, and the prevesical fatty tissue require dissection to enable proper fixation and incorporation of the mesh in the area that has mesh overlap of the fascial defect. |
A larger overlap of the prosthesis (5 vs 3 cm) is necessary if sutures are not used and is more important for securing the overlap than the use of transfascial sutures for fixation of the mesh. | |
Recurrence after incisional hernia repair appears to be due primarily to disregard for the principle that the whole incision (not only the hernia) must be repaired. |
Recommendations
Grade B
| The mesh used for laparoscopic repair of a ventral hernia should overlap the hernia defect by at least 3 to 4 cm in all directions |
Grade C
| For proper fixation and incorporation of the mesh dissection of anatomic structures such as the falciform ligament, the ligamentum teres and the prevesical fatty tissue should be done. |
A large overlap of the defect by mesh is necessary, with a minimum of 5 cm if the mesh is fixed without transfascial sutures. | |
A larger overlap is recommended for larger hernias than the overlap used for small hernias. | |
To avoid recurrences, the entire incisional scar should be covered by the mesh, even if the defect is overlapped 3 to 5 cm in all directions. |
Fixation
R. H. Fortelny, M. Misra, F. Köckerling, J. Kukleta
Statements
Level 1B | The method used for mesh fixation (sutures and/or tacks) has no influence on acute postoperative pain. |
Suture fixation of the mesh incurs a significantly longer operation time than fixation by tacks. | |
The absorbability of the suture material used for mesh fixation is not related to the incidence of postoperative pain. | |
Tacks-only fixation is associated with a significantly higher grade of mesh shrinkage in the horizontal direction than transfascial suture fixation. | |
In umbilical hernias with a defect size up to 5 cm, mesh fixation by glue results in less acute postoperative pain than fixation by tacks. | |
Level 3 | The incidence of acute postoperative pain correlates significantly with the number of tacks used for mesh fixation. |
Level 4 | The recurrence rates do not differ between the different fixation techniques. |
Application intervals of 1.5 cm for the staples/tacks in the single- or double-crown technique are associated with a low recurrence rate. | |
The type of mesh fixation technique does not influence the incidence of postoperative chronic pain. | |
The use of resorbable penetrating fixation devices achieves sufficient tensile strength and low recurrence rates. | |
The use of additional glue fixation increases the efficacy of fixation and postoperative pain. | |
Level 5 | Penetrating fixation devices (e.g., transfascial sutures, protruding tacks) can cause incisional hernias and in the pericardial region may result in a cardiac tamponade. |
Recommendations
Grade B | Suture fixation alone or a combination with tacks should be performed. |
Grade C | The tacks-only fixation can be considered the technique of choice, taking into account the increased risk of postoperative pain due to the number of devices and the need for an additional overlap of mesh (at least 5 cm) to prevent recurrence caused by shrinkage. |
Additional glue fixation reduces the need for penetrating fixation devices and hence decreases postoperative pain and device-induced hernia. |
Recurrences related to fixation techniques
Type of fixation | No. of studies | Total no. of patients | Recurrence rate median % (IQR) | Chronic pain follow-up median %/month (IQR) |
---|---|---|---|---|
Sutures+tacks | 10 | 2,211 | 3.65 (2.45–5.75)a,b
| 2.75 (1.72–13.22)a,b
|
31.5 (27.75–38.25) | ||||
Sutures only | 2 | 1,121 | 1.05 (0.82–1.27)a,b
| 3.75 (3.12–4.37)a,b
|
39 (33.5–44.5) | ||||
Tacks only | 11 | 2,473 | 4.5 (2.4–6.17)a,b
| 6,35 (2.17–13.22)a,b
|
40 (30.5–49.5) |
Acute postoperative pain
Authors | Study | Total patients (groups) | Type of fixation | Assessment (weeks or daysa) | Acute pain Sut/FS/tack |
p Value | Level of evidence |
---|---|---|---|---|---|---|---|
Wassenaar et al. [286] | RCT | 172 (56/60/56) | SR+T vs T vs SN+T | 2/6/18 | NS/NS/NS | >0.05 | 1b |
Bansal et al. [181] | RCT | 68 (32/36) | SN vs T | 1a/1/12 | S/S/S | <0.05 | 1b |
Beldi et al. [254] | RCT | 40 (20/20) | SN vs T | 6/24 | S/NS | 0.020 | 1b |
Eriksen et al. [287] | RCT | 38 (19/19) | FS vs T | 2a/10a
| S/S | 0.025 | 1b |
Nguyen et al. [288] | Prospective comparative. | 50 (29/21) | SN vs T | 1/4/8 | NS/NS/NS | >0.05 | 2b |
Chronic postoperative pain
Number of tacks and postoperative pain
Intervals of tacker fixation
Operation time: suture fixation versus tacks fixation
Type of suture used for fixation and pain
Fixation-associated complications
New fixation devices
Glue fixation
Fixation in suprapubic and subxiphoidal hernia repair
R. H. Fortelny, M. Misra, F. Köckerling
Statements
Level 4 | A retropubic dissection is necessary to achieve sufficient and safe mesh overlap of the suprapubic defect as well as an effective fixation. |
A combination of mesh fixation by sutures and tacks, including fixation at Cooper’s ligament and a sufficient mesh overlap, is associated with a low recurrence rate. |
Recommendations
Grade C | For safe positioning and sufficient overlap of mesh, the retropubic space should be dissected. |
The mesh fixation should include Cooper’s ligament, preferably by penetrating devices. |
Fixation in suprapubic hernia
Fixation in subxiphoid hernia
Statements
Level 4 | Dissection of the extended retroxiphoidal space up to 5 cm behind the xiphoid process is mandatory for appropriate mesh positioning and overlap. |
Fixation in the cephalad portion of the mesh carries a high risk of injury to the pericardium. |
Recommendations
Grade C | The overlap of the mesh should be sufficient, especially in the proximal retroxiphoidal space. The proximal part of the mesh should not be fixed. |
Mesh insertion
M. C. Misra, V. K. Bansal, Pradeep Prakash, D. Babu, P. Singhal, R. Fortelny
Rolling techniques and mesh introduction
Statements
Level 3 | Mesh insertion (up to 30 × 30 cm) through a 10- to 12-mm port is possible in the majority of laparoscopic incisional/ventral hernia repairs of varying sizes. |
Mesh insertion through a 2- to 3-cm skin incision at the center of the defect directly (inside a plastic sleeve) or through a 15-mm port may be a viable alternative for larger defects requiring larger meshes (>30 cm). | |
Level 5 | Mesh–skin contact can contaminate the mesh with bacteria. |
The largest lightweight mesh can be inserted safely through a 10- to 12-mm port. |
Recommendations
Grade B | Large meshes should be rolled up tightly for safe and effective insertion. |
Grade C | For very large meshes (35 × 30 cm), a 15-mm port may be used. |
Mesh–skin contact should be avoided. |