EHS and AHS Guidelines For Treatment of Primary Ventral
EHS and AHS Guidelines For Treatment of Primary Ventral
EHS and AHS Guidelines For Treatment of Primary Ventral
Background: Rare locations of hernias, as well as primary ventral hernias under certain circumstances
(cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim
was to identify situations where the treatment strategy might deviate from routine management.
Methods: The guideline group consisted of surgeons from the European and Americas Hernia Societies.
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was
used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN)
critical appraisal checklists were used to evaluate the quality of full-text papers. A systematic literature
search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for
Research and Evaluation (AGREE) instrument was followed.
Results: Literature was limited in quantity and quality. A majority of the recommendations were graded
as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal
mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be
postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a
Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of
evidence.
Conclusion: This is the first European and American guideline on the treatment of umbilical and
epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All
recommendations were weak owing to a lack of evidence. Further studies are needed on patients with
rectus diastasis, Spigelian and lumbar hernias.
Funding information
Guideline meetings funded by the European Hernia Society and Americas Hernia Society
© 2020 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd BJS Open 2020; 4: 342–353
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Guidelines for treatment of primary ventral hernias in special circumstances 343
As a part of the European (EHS) and Americas (AHS) in formulating the recommendations. Scottish Intercolle-
Hernia Societies’ guideline on the treatment of umbil- giate Guidelines Network (SIGN) critical appraisal check-
ical and epigastric hernias2 , this separate guideline was lists were used to evaluate the quality of full-text papers.
developed with the aim of identifying situations where KQs proposed by the two coordinators were revised and
surgeons need to take special considerations into account, approved by the entire group.
and where recommendations on treatment strategy might The group was divided into teams (2–3 members
deviate from routine management. per team) working on specific KQs. Each team decided
on important outcomes of the specific questions using
Methods the PICO (patient, intervention, comparator, outcome)
approach. A systematic literature review was performed
The guideline group
Fig. 1 PRISMA flow diagram showing selection of articles for KQ 2: What is the preferred method of repair of
review an umbilical or epigastric hernia in patients with
compromised liver function?
Statement: Acceptable evidence finds that open
Identification
Records identified through Additional records identified umbilical hernia repair with mesh is safe in patients
database searching through other sources
n = 1785 n = 67 with cirrhosis and/or ascites. Laparoscopic hernia repair
seems safe in patients without ascites. In patients with
ascites, the risk of complications increases. Sutured
repair has a very high recurrence rate. There is no
Records screened after duplicates
evidence on epigastric hernia repair.
Screening
removed
Studies included umbilical hernia repair in patients with cirrhosis has been
in guidelines
n = 64 reported to be around 5 per cent, compared with less than
1 per cent in the general population4,5 .
The severity of cirrhosis may be assessed using the
Child–Pugh classification, including total bilirubin,
serum albumin, prothrombin time or international nor-
Results
malized ratio (INR) level, presence of ascites and/or
Umbilical and epigastric hernia repair in patients encephalopathy6 . Elective surgery is generally accepted
with compromised liver function in patients with Child–Pugh grade A, and may be tol-
erated also in patients with grade B after preoperative
Twelve KQs were formulated, and a total of 64 studies were optimization. Surgery in patients with Child–Pugh grade
finally included (Fig. 1). C is associated with a high risk of morbidity and mortality.
Downstaging of Child–Pugh grades should be considered
KQ 1: Should patients with compromised liver func- if possible6,7 .
tion be offered elective umbilical or epigastric hernia The Model for End-stage Liver Disease (MELD) score is
repair? a widely used scale predicting surgical morbidity and mor-
Statement: Acceptable evidence finds that elective tality (based on total bilirubin, INR and creatinine levels)8 .
umbilical hernia repair is safe in most patients with Two large database studies9,10 evaluated risk stratification
cirrhosis and/or ascites. Emergency repair is associated for hernia repair in patients with ascites. The presence of
with a high rate of morbidity and mortality. Risk factors non-malignant ascites was a risk factor for increased mor-
for poor outcome are a Model for End-stage Liver bidity at 30 days. Morbidity increased by approximately
Disease (MELD) score above 15, presence of ascites 3 per cent for each MELD score above 1510 . This is
and albumin level below 3 g/dl. There is no evidence on consistent with findings by others5 , demonstrating age
epigastric hernia repair. above 65 years, MELD score above 15 and albumin level
Recommendation: It is suggested to offer elective below 3 g/dl to be associated with increased morbidity after
umbilical or epigastric hernia repair after optimization umbilical hernia repair. A nomogram has been proposed9
of liver function in patients with liver cirrhosis (MELD based on a multivariable logistic regression analysis, includ-
score below 15). ing MELD score, white blood cell count, platelets and
Quality of evidence: albumin to predict mortality in patients with ascites under-
Strength of recommendation: Weak going umbilical hernia repair.
umbilical hernia is suggested to be repaired before peri- challenge with respect to operative management. The
toneal dialysis initiation24 . If an umbilical hernia devel- recurrence rate after small umbilical or epigastric her-
ops during peritoneal dialysis, repair is associated with low nia repair with a concomitant rectus diastasis has been
morbidity18,25 . reported to be higher than that in patients without a
Umbilical hernia repair was reported during ongoing rectus diastasis33 . The literature is limited. Six studies
peritoneal dialysis in a total of 54 patients18,23,25 . Open were identified: three prospective cohort27,34,35 and three
repair with placement of a preperitoneal or onlay mesh retrospective36 – 38 studies.
without access to the peritoneal cavity was reported to be Endoscopic repair with plication of the diastasis using
associated with low morbidity and no recurrences. How- a non-absorbable loop suture followed by an onlay or
ever, if no mesh was implanted, the recurrence rate was preperitoneal polypropylene mesh was performed of the
12 per cent23 . Owing to raised intra-abdominal pressure
Primary ventral hernia repair in women A primary ventral hernia diagnosed during pregnancy
of childbearing age was uncommon: 0⋅08 per cent in a large register-based
study of more than 20 000 women44 . None underwent
KQ 6: Should women of childbearing age with symp- elective or emergency repair during pregnancy. All had an
tomatic umbilical or epigastric hernia be offered uncomplicated childbirth. During postpartum follow-up
elective hernia repair? (median 4⋅4 years), a total of five women (0⋅02 per cent)
Statement: Elective umbilical and epigastric hernia had an elective primary ventral hernia repair.
repair is safe in women in childbearing age. Subse- The most recent systematic review39 included nine stud-
quent pregnancy after hernia repair is associated with ies of both primary ventral and incisional hernias in women
an increased risk of recurrence, which is why surgery of childbearing age. Results for type of repair were not
small bowel. The risk of incarceration is increased in KQ 12: What is the preferred repair method for
patients with a high BMI, age above 50 years and in primary lumbar hernias?
women57 . Occult hernia orifices are sometimes found at Statement: Open and laparoscopic repair have been
laparoscopy for any indication and reported in 2 per cent of described for lumbar hernias. No data on the preferred
adults58 . method exists.
One study59 evaluated the diagnostic accuracy of clinical Recommendation: As lumbar hernias are rare, it is sug-
examination, CT and ultrasonography compared with the gested to consider referring the patient to a specialized
operative findings in 54 patients. CT showed a sensitivity of hernia centre.
100 per cent and a positive predictive value (PPV) of 100 Quality of evidence:
per cent, and ultrasonography a sensitivity of 90 per cent Strength of recommendation: Weak
and a PPV of 100 per cent compared with operative find-
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