Review

EHS and AHS guidelines for treatment of primary ventral

hernias in rare locations or special circumstances
N. A. Henriksen1 , R. Kaufmann2,3 , M. P. Simons4 , F. Berrevoet5 , B. East6,7 , J. Fischer8 ,
W. Hope9 , D. Klassen10 , R. Lorenz11 , Y. Renard12 , M. A. Garcia Urena13 and A. Montgomery14 ,
on behalf of the European Hernia Society and the Americas Hernia Society
1
Department of Surgery, Zealand University Hospital, Koege, Denmark, 2 Erasmus University Medical Centre, Rotterdam, 3 Tergooi, Hilversum, and
4
Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands, 5 Department of General and Hepato-Pancreato-Biliary Surgery, Gent
University Hospital, Gent, Belgium, 6 Third Department of Surgery, Motol University Hospital, and 7 First and Second Faculty of Medicine, Charles

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University, Prague, Czech Republic, 8 University of Pennsylvania Health System, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, and
9
New Hanover Regional Medical Center, Wilmington, North Carolina, USA, 10 Department of Surgery, Dalhousie University, Halifax, Canada, 11 Praxis
3+CHIRURGEN, Berlin, Germany, 12 Department of Digestive Surgery, Robert Debré University Hospital, Reims, France, 13 Henares University
Hospital, Faculty of Health Sciences, Francisco de Vitoria University, Madrid, Spain, and 14 Department of Surgery, Lund University, Skåne University
Hospital, Malmö, Sweden
Correspondence to: Dr N. A. Henriksen, Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, DK-4600 Koege, Denmark
(e-mail: [email protected])

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

Paper accepted 26 November 2019

Published online 9 January 2020 in Wiley Online Library (www.bjsopen.com). DOI: 10.1002/bjs5.50252

Introduction strategy may be challenging. This could be in patients with

cirrhosis, those on dialysis, women of childbearing age, or
Procedures for umbilical and epigastric hernias are per- patients who have a rectus diastasis concomitant to a ven-
formed frequently in younger healthy individuals1 . How- tral hernia. A further clinical challenge is the diagnosis and
ever, in clinical practice these hernias are sometimes seen in treatment of rare primary ventral hernias, such as Spigelian
patients with special associated conditions where treatment and lumbar hernias.

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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

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for each KQ. When up-to-date high-quality meta-analyses
The project was approved by the EHS and AHS boards or systematic reviews on the subject were available, the
in February 2017 as a part project of the guideline for conclusions were derived from these. At the next level
treatment of primary ventral hernias. Two of the present in quality were RCTs, and thereafter observational stud-
authors were appointed to coordinate the project. The ies. Case series were included if they added substantial
guideline was intended primarily for surgeons, but also for evidence information to the KQ, or if no higher level
other physicians, general practitioners and patients. The of evidence was available. Case reports and expert opin-
guideline group members covered northern, southern and ions were not included. The Appraisal of Guidelines
eastern Europe, together with Canada and the USA. The for Research and Evaluation (AGREE) instrument was
group consisted of 11 general surgeons and one plastic used to validate the guidelines (Appendix SI, supporting
surgeon, all specialized in abdominal wall repair. Care was information).
taken to include both open and laparoscopic surgeons, as
well as surgeons with expertise in the creation of guidelines
(both young PhD physicians and experienced researchers). Literature search
Any conflict of interest (COI) for each member was ana-
A systematic literature search was performed by two of the
lysed transparently and, when an issue existed, handled
present authors independently on 1 May 2018 and updated
appropriately.
on 1 February 2019. The Cochrane Library, PubMed,
Embase, CINAHL and Google Scholar were searched
Timeline and meetings using Medical Subject Headings (MeSH) terms.
A protocol including key questions (KQs) and timeline was PubMed search terms were: (‘Liver Cirrhosis’[Mesh]
approved at the AHS/EHS congress in Miami, Florida, OR ‘Ascites’[Mesh]) AND ‘Hernia, Ventral’[Majr]; ‘Peri-
USA, in March 2018, by eight group participants. The first toneal Dialysis’[Mesh] AND ‘Hernia, Ventral’[Majr];
guidelines meeting was held in Amsterdam, the Nether- ‘Hernia, Ventral’[Mesh] AND ‘Diastasis Recti And
lands, in September 2018 with 11 participants; each team Weakness Of The Linea Alba’[Supplementary Con-
presented their systematic review of the literature for each cept]; rect* divarc* OR diast* AND umbilical hernia;
subject, and recommendations were proposed. Subjects (‘Pregnancy’[Mesh] OR ‘Reproductive Behavior’[Mesh]
needing further work were identified. At the second meet- AND ‘Hernia, Ventral’[Majr]) AND Review[ptyp];
ing in February 2019 in Malmö, Sweden, all suggested rec- (Spigelian[All Fields] AND (‘hernia’[MeSH Terms] OR
ommendations were discussed, in some cases reformulated, ‘hernia’[All Fields])); (grynfelt[All Fields] AND (‘her-
and approved. A total of nine members participated and the nia’[MeSH Terms] OR ‘hernia’[All Fields])) OR (petit’s[All
remaining two contributed by approving the recommenda- Fields] AND (‘hernia’[MeSH Terms] OR ‘hernia’[All
tions by e-mail. All members of the group participated in Fields])).
person in at least two of the three meetings. The meetings The records were screened by title and abstract by two
were funded by the EHS and AHS. There was no involve- assessors independently for each subject. Full texts were
ment of industry. evaluated by two assessors independently for eligibility
with the use of SIGN critical appraisal checklists. Only
papers rated as ‘acceptable’ or ‘high quality’ by SIGN
Methodology were included, to limit the risk of bias. Any disagreement
The Grading of Recommendations Assessment, Devel- between assessors was settled by discussion either in the
opment and Evaluation (GRADE) approach was used entire group or by a third assessor.

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BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd
344 N. A. Henriksen, R. Kaufmann, M. P. Simons, F. Berrevoet, B. East, J. Fischer et al.

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

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n = 1376 Recommendation: It is suggested to use an open repair
with onlay or preperitoneal mesh for umbilical or epigas-
Records excluded tric hernias in patients with compromised liver function.
n = 1181
Quality of evidence:
Strength of recommendation: Weak
Eligibility

Full-text articles assessed

for eligibility
n = 195 Umbilical hernia is seen frequently in patients with cir-
rhosis and associated ascites, with a reported incidence
Full-text articles
excluded of 20 per cent3 . Perioperative morbidity and mortality
n = 131 may increase in patients with cirrhosis, making timing
of surgery important. The 30-day mortality rate after
Included

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.

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BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd
Guidelines for treatment of primary ventral hernias in special circumstances 345

One high-quality review11 from 2012 on non-hepatic

Statement: It is unknown whether an asymptomatic
surgery in patients with cirrhosis included a separate
umbilical or epigastric hernia repair may become symp-
section on abdominal wall surgery based on one RCT12 ,
tomatic during peritoneal dialysis. The presence of a her-
two large database studies13,14 and two retrospective case
nia may complicate peritoneal dialysis, as the hernia can
series15,16 . A further four large database studies5,9,10,17
enlarge over time from the instilled fluid. Repair of an
from the American College of Surgeons’ National Surgical
umbilical or epigastric hernia before or during peritoneal
Quality Improvement Program were identified.
dialysis is associated with low morbidity.
Elective umbilical hernia repair with mesh in patients
Recommendation: It is suggested to repair an umbilical
with cirrhosis is associated with low morbidity and mortal-
or epigastric hernia before initiation of peritoneal dial-
ity rates, comparable to rates in non-cirrhotic patients5,14 .
ysis. It seems safe to perform the hernia repair during

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Sutured repair with non-absorbable sutures resulted
peritoneal dialysis.
in a high recurrence rate of 15 per cent at 6 months’
Quality of evidence:
follow-up5,14 . Cirrhotic patients who have an emergency
Strength of recommendation: Weak
umbilical hernia repair have a higher complication rate
than those having planned surgery. Some 26–37 per cent
of patients not planned for any surgical intervention did KQ 4: What is the preferred method of repair for
receive an emergency repair later5,14 . Emergency repair an umbilical or epigastric hernia in patients on peri-
results in a sevenfold increased mortality rate11,13 . toneal dialysis?
Thirty-day mortality was compared in patients with Statement: Acceptable evidence finds that open umbil-
a MELD score above 9 who underwent either open ical or epigastric hernia repair without access to the
or laparoscopic elective ventral hernia repair, including peritoneal cavity is associated with low morbidity and
both primary and incisional hernias17 . Overall, laparo- recurrence rates. There are no data on laparoscopic
scopic ventral hernia repair was associated with fewer umbilical or epigastric hernia repair before or during
wound-related complications and a shorter length of peritoneal dialysis.
stay. However, in a subgroup analysis of patients with Recommendation: An open umbilical or epigastric her-
ascites, laparoscopic repair was associated with systemic nia repair using onlay or preperitoneal mesh placement
complications and mortality17 . is suggested for patients on peritoneal dialysis.
Whether or not patients with cirrhosis and completely Quality of evidence:
asymptomatic hernias should be offered elective hernia Strength of recommendation: Weak
repair solely due to the risk of having an emergency repair
is difficult to say, based on current evidence. Although The frequency of umbilical hernia in patients having
retrospective database studies did suggest a high risk of peritoneal dialysis is reported to be 3–15 per cent in
emergency repair, studies of non-operative management retrospective case series18,19 . It is likely that many of these
with long-term follow-up are lacking. However, it is hernias were already present before peritoneal dialysis was
suggested that symptomatic patients with cirrhosis and a initiated, as concluded in a prospective case series20 .
MELD score below 15 are offered elective hernia repair. One large database study21 , one observational prospec-
None of the studies evaluated the effect of preoperative tive study20 and some retrospective case series18,19,22,23 were
optimization in patients with cirrhosis. It seems though identified that addressed umbilical hernias in patients on
reasonable to consult a hepatologist for optimization peritoneal dialysis. No reviews, RCTs or studies evalu-
before elective surgery. ating watchful waiting or outcomes after different types
Sutured repair with non-absorbable sutures leads to of hernia repair in patients on peritoneal dialysis were
a very high recurrence rate. Laparoscopic technique available.
increases the risk of complications in patients with ascites. The presence of an abdominal wall hernia may compli-
It is suggested that an open mesh repair technique is used cate peritoneal dialysis, as the hernia is filled with fluid
in patients with ascites. and may enlarge over time. It is not known whether
an asymptomatic ventral hernia diagnosed before dial-
Umbilical and epigastric hernia repair in patients
ysis initiation will become symptomatic during dialysis.
on peritoneal dialysis
One study21 found that the hernia formation during peri-
KQ 3: Should an umbilical or epigastric hernia be toneal dialysis was associated with withdrawal of dialy-
repaired before or during peritoneal dialysis? sis. Another study22 concluded that neither the incidence
nor management of the hernia affected renal function. An

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BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd
346 N. A. Henriksen, R. Kaufmann, M. P. Simons, F. Berrevoet, B. East, J. Fischer et al.

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

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midline hernia and the coexisting rectus diastasis in three
in peritoneal dialysis, mesh insertion seems advantageous. studies27,34,35 . The studies of Köckerling and colleagues34
No studies evaluated the role of laparoscopic hernia repair, and Claus et al.35 included both incisional and primary ven-
but it seems logical to consider the risks of port-site her- tral hernias, and Bellido Luque and co-workers27 included
nia, fluid leakage from port sites, and intraperitoneal mesh solely primary ventral hernias. Follow-up was 20 months,
placement. 8 months and 1 year respectively. The main complication
It is suggested that an umbilical or epigastric hernia is was seroma, which occurred in up to 27% of the patients35 .
repaired before the initiation of peritoneal dialysis. If an It was concluded that endoscopic repair is feasible, with a
umbilical or epigastric hernia develops during peritoneal low number of wound impairments. One study35 reported
dialysis, it is suggested that it is repaired using an open one recurrence of the diastasis, whereas no recurrences
mesh repair technique without accessing the peritoneal of either the umbilical hernia or the rectus diastasis were
cavity. reported by the others27,34 .
Two retrospective cohort studies36,37 analysed open
suture plication of the diastasis and concomitant ventral
Ventral hernia repair in the setting of rectus
hernia by polydioxanone or polypropylene followed by
diastasis
polypropylene mesh placement. Short-term outcomes
showed eight cases of minor wound dehiscence and five
KQ 5: What is the optimal surgical approach to an of haematoma/seroma in 50 patients36 , and two seromas
umbilical or epigastric hernia with a concomitant and no wound infections in 32 patients37 . Follow-up was
rectus diastasis? 2–8 years36 and mean 15 months37 , with no recurrences or
Statement: There is insufficient evidence to recommend bulging. A retrospective cohort study38 described an open
a specific type of repair for umbilical or epigastric hernias technique with self-fixating mesh in the preperitoneal
with a concomitant rectus diastasis. The presence of a space extending superiorly including27 the umbilical
rectus diastasis is a known risk factor for recurrence after hernia, with no wound complications but one hernia
sutured repair. recurrence in 58 patients.
Recommendation: It is suggested to use a mesh repair Data are lacking concerning the indication for surgery
for umbilical and epigastric hernias in patients with in the included studies. Whether it was pain from the
rectus diastasis. Simultaneous rectus diastasis repair is hernia, bulging, core instability or cosmesis is unknown,
optional. which is key for examining the effect of surgery. Fur-
Quality of evidence: thermore, patient-related outcomes measures are generally
Strength of recommendation: Weak lacking, and recurrence may not be the most important
outcome.
Based on limited data, both open and endoscopic repair
Rectus diastasis is characterized by a thinning and widen- techniques for umbilical hernia in combination with rectus
ing of the linea alba26 . A large rectus diastasis can cause diastasis repair are feasible. The presence of a rectus diasta-
similar complaints to a large ventral hernia, but does not sis seems to be a risk factor for hernia recurrence, and mesh
have the risk of incarceration or strangulation27 – 29 . Rec- augmentation of the hernia is therefore suggested. Simul-
tus diastasis can be classified by quantitative and qualitative taneous repair of the diastasis is optional and needs to be
classification systems30 – 32 . discussed with the patient. It might be helpful to consider
The presence of a rectus diastasis and a concomi- collaboration with a plastic surgeon, especially if there is
tant umbilical or epigastric hernia presents a significant skin surplus.

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Guidelines for treatment of primary ventral hernias in special circumstances 347

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

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should be postponed until after last planned pregnancy, analysed separately, but the incidence of incisional her-
whenever possible. A watchful waiting approach is safe nia was probably low in comparison with primary ven-
when having a reducible hernia during pregnancy. tral hernias in this age group. All included studies were
Recommendation: Elective umbilical and epigastric retrospective except one that included more than 35 000
hernia repair should, if possible, be postponed until after women. Three outcomes were reported: risk of recurrence
pregnancy and preferably until after last pregnancy in after prepregnancy ventral hernia repair; safety of umbil-
women of childbearing age. ical hernia repair during pregnancy; and repair in com-
Quality of evidence: bination with caesarean section. Prepregnancy repair was
Strength of recommendation: Strong (upgraded) associated with an increased risk of having a ventral her-
nia recurrence after delivery. Repair during pregnancy was
KQ 7: Which is the preferred repair method for recommended to be reserved for emergency cases. Rou-
women of childbearing age with a symptomatic tine repair at caesarean section has been reported to be
umbilical or epigastric hernia? safe45 . Data suggest that an umbilical hernia can be left
Statement: For women of childbearing age becom- untreated at caesarean section, as postpartum repair is sel-
ing pregnant subsequent to an umbilical and epigastric dom needed.
hernia repair, the use of mesh seems to decrease the In a national register-based study41 , 224 women were
recurrence rate, but increases the risk of chronic pain sig- identified who had either an umbilical or an epigastric
nificantly compared with a sutured repair. hernia repair and subsequently became pregnant. The
Recommendation: If hernia repair cannot be postponed cumulative reoperation rate for recurrence was 16 per
until after the last pregnancy, a sutured repair is sug- cent after mesh repair and 11 per cent after suture repair
gested for umbilical and epigastric hernias in women of (adjusted for BMI and hernia defect size). In contrast, in a
childbearing age. A mesh repair could be performed after recent questionnaire study46 , 195 women of childbearing
the last pregnancy. age with a history of umbilical or epigastric hernia repair
Quality of evidence: who subsequently became pregnant were compared with a
Strength of recommendation: Weak propensity-matched controlled group of 246 women; the
use of mesh was found to be independently associated with
Primary ventral hernia repair is commonly performed in reduced recurrence rates. However, the use of mesh was
women of childbearing age39 . Physiological changes of the associated with an increased risk of chronic pain (17⋅5 per
abdominal wall during pregnancy may increase the risk cent) compared to that for suture repair (9⋅5 per cent) when
of recurrence, which is why optimal timing of the repair having a subsequent pregnancy.
is important for women of childbearing age. The current Primary ventral hernia is rare during pregnancy, and the
recommendations are based on four large cohort studies incidence of emergency repair is extremely low. An oper-
and two systematic reviews39 – 43 . ation, if needed, can be safely postponed until after preg-
In a large national cohort study39 , the frequency of pri- nancies. A mesh repair may decrease the risk of recurrence,
mary ventral hernia repair was assessed in 470 000 women but increase the risk of chronic pain. As there are pros and
of childbearing age. The cumulative incidence was 14 per cons of using mesh versus suture, the risks should be dis-
cent over a 10-year period. Having a subsequent pregnancy cussed with the patient, leading to a shared decision on
after a hernia repair resulted in a 1⋅6-fold increased risk of repair and/or type of technique. If hernia repair cannot be
recurrence. There was a sevenfold increased risk in parous postponed until after the last pregnancy, it is suggested to
women having a hernia repair compared with the risk in use a sutured repair for umbilical and epigastric hernias in
nulliparous women. women of childbearing age.

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BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd
348 N. A. Henriksen, R. Kaufmann, M. P. Simons, F. Berrevoet, B. East, J. Fischer et al.

Spigelian hernia Fig. 2 Anatomical location of Spigelian hernias

KQ 8: What is the definition of a Spigelian hernia

and how are they classified?
Statement: A Spigelian hernia is a protrusion through
a defect in the aponeurosis of the transverse abdominal
muscle limited by the semilunar line and the lateral edge
of the rectus muscle (Fig. 2).
Recommendation: No specific classification system for
Spigelian hernias exists, but it is recommended to use the
existing EHS classification system for ventral hernias.

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Quality of evidence:
Strength of recommendation: Strong (upgraded)
1
2
KQ 9: Which diagnostic modalities are the most
suitable for diagnosing Spigelian hernias?
Statement: Dynamic ultrasonography, CT and MRI A C
are modalities that could be useful in combination with
clinical examination for diagnosing Spigelian hernias. In B 3
unclear cases, diagnostic laparoscopy could be of value in
4
symptomatic patients, offering a simultaneous repair in
the case of a positive finding.
Recommendation: Clinical examination, ultrasonogra-
phy or CT is suggested for diagnosing a Spigelian hernia.
Quality of evidence:
Strength of recommendation: Weak
A, Spigelian hernia belt: transverse 6-cm wide zone above the interspinal
plane; B, interspinal plane; C, Spigelian fascia; 1, muscular–aponeurosis
KQ 10: Which is the preferred method of repair for transition of external oblique muscle; 2, muscular–aponeurosis tran-
Spigelian hernias? sition of internal oblique muscle; 3, muscular–aponeurosis transi-
tion of transverse abdominal muscle; 4, lateral edge of rectus muscle
Statement: Open and laparoscopic repair have been (artist: Y. Renard).
described. Data are limited on the preferred method. If
there is no palpable lump, laparoscopic repair may be
advantageous.
Recommendation: It is suggested to repair a Spigelian defect in the Spigelian aponeurosis (the aponeurosis of the
hernia with the use of mesh. An open or laparoscopic transverse abdominal muscle limited by the linea semilu-
approach may be used, based on the surgeon’s expertise. naris laterally and by the lateral edge of the rectus mus-
Quality of evidence: cle medially). These hernias are commonly located in the
Strength of recommendation: Weak ‘Spigelian hernia belt’, a 6-cm wide zone above the inter-
spinal plane (Fig. 2). The hernias can be either interstitial
between the lateral muscles in the abdominal wall or sub-
The Spigelian hernia got its name from the Flemish cutaneous. Sometimes only preperitoneal fat is protruding,
anatomist/surgeon, Adriaan van den Spieghel. He was the without a peritoneal sac54 . No specific classification system
first to describe the semilunar line in 164547 . The first exists, but the EHS classification system for ventral hernia
description of a Spigelian hernia was in 1764 by the Czech includes Spigelian hernias55 .
anatomist, Josef Thaddäus Klinkosch (1735–1778)48 . The Spigelian hernias are difficult to diagnose unless caus-
Latin terms hernia spigeli and hernia lineae semilunari are ing symptoms56 . The incidence of Spigelian hernia is
also used. Literature is sparse, including only a limited unknown, but seems to be higher in the fourth to seventh
number of patients. Three reviews, one RCT and one decade of life, including more women than men, and more
prospective case series were identified49 – 53 . left-sided than right-sided52,56 . It has been reported52,56
A Spigelian hernia is the protrusion of preperitoneal fat, that 17–25 per cent of Spigelian hernias are operated
peritoneal sac or organ(s) through a congenital or acquired on as emergency cases, sometimes with incarceration of

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BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd
Guidelines for treatment of primary ventral hernias in special circumstances 349

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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ings, whereas clinical examination alone had a sensitivity of Hernias located in the lumbar region may be acquired after
100 per cent and a PPV of 36 per cent59 . trauma or retroperitoneal surgery as incisional hernias60,61 .
One RCT53 compared 11 laparoscopic with 11 open Primary or spontaneous lumbar hernias are rare, and are
repairs performed as a total extraperitoneal (TEP) repair the only ones addressed in this guideline.
or an intraperitoneal onlay mesh (IPOM). Patients repaired The literature search revealed two reviews61,62 of accept-
by the open approach had significantly more wound com- able quality and two papers60,63 describing atypical ventral
plications and a longer hospital stay. However, the number hernias. Further, a number of anatomical and radiologi-
of included patients was too small to draw any valid conclu- cal studies were identified23,64 – 66 . There were no RCTs,
sions. In a prospective case series50 from the same group, cohort studies or case series evaluating surgical technique
including 16 patients undergoing either TEP or IPOM and/or outcomes after primary lumbar hernia repair.
repair, there were no differences in postoperative morbidity A lumbar hernia is defined as a hernia located in the
and no recurrences at 48 months’ follow-up. lumbar region60,63,65 . The lumbar region is bounded by
In summary, for classification of Spigelian hernias it the 12th rib above, the iliac crest below, the free border
is recommended to use the EHS classification, and for of the external oblique muscles anteriorly, and the verte-
diagnosis it is suggested to use clinical examination, ultra- bral column and the erector spinae muscles posteriorly.
sonography or CT. For repair of a Spigelian hernia, a Primary lumbar hernias may be subclassified anatomically
laparoscopic approach may decrease wound complications, as superior (Grynfeltt–Lesshaft) or inferior (Petit) lumbar
and may be advantageous for both diagnostic and curable hernias61 (Fig. 3). The superior lumbar triangle is the area
intervention if there is no palpable lump. Owing to limited for penetration of the 12th intercostal nerve pedicle, and is
data, no recommendation on a specific surgical method can the most common location for primary lumbar hernias65 .
be made. Either an open or laparoscopic approach may be CT or MRI is recommended to confirm the diagno-
used, based on the surgeon’s expertise. sis, assess the anatomical location and plan a suitable
repair60 – 63 . It is unknown whether a watchful waiting strat-
egy is safe, and which patients will benefit from repair.
Lumbar hernias
Repairing a lumbar hernia may be a surgical challenge
because of the proximity to bony structures, which may
KQ 11: What is the definition of a primary lumbar limit proper dissection and mesh overlap61 . A lumbar her-
hernia, and how are these hernias classified? nia may be repaired by an open approach with preperi-
Statement: A primary lumbar hernia is a defect in the toneal mesh placement or by a laparoscopic approach with
lumbar region, which is bounded by the 12th rib above, preperitoneal or intraperitoneal mesh placement60 – 62 . As
the iliac crest below, the free border of the external lumbar hernias are rare, it may be considered to refer
oblique muscles anteriorly, and the vertebral column patients to a specialized hernia centre.
posteriorly. Primary lumbar hernias may be subclassified
anatomically as superior (Grynfeltt–Lesshaft) or inferior
Comment
(Petit) (Fig. 3).
Recommendation: No specific classification system for This guideline addresses a small, but clinically challenging,
lumbar hernias exists, but it is suggested to use the population of patients. Overall, the amount of evidence
existing EHS classification system for ventral hernias. is limited in both quantity and quality, which is why the
Quality of evidence: majority of recommendations were weak. The guideline for
Strength of recommendation: Weak treatment of umbilical and epigastric hernias from the EHS

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BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd
350 N. A. Henriksen, R. Kaufmann, M. P. Simons, F. Berrevoet, B. East, J. Fischer et al.

Fig. 3 Anatomical location of primary lumbar hernias

should be performed with or without mesh in women
planning a subsequent pregnancy. Spigelian and primary
lumbar hernias are rare, and the available evidence is con-
sequently sparse. Prospective database studies are needed
to clarify the optimal treatment strategies.
To evaluate the best repair method for rare hernias,
large database studies might be the best option to collect
wider experience of both indications for operation and
operative techniques to be used. The information on both
preoperative important patient and hernia conditions, as
well as technical details at surgery, needs to be addressed

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3
4 thoroughly in the registers in order to have a fair chance
A of comparing the techniques used. These details would
6 preferably be addressed internationally and coordinated for
1 use in registers globally. A minimum core outcome data set
2 B
6 should be identified.
5 An update of the guideline is planned for 2023. Sig-
nificant results from new research are not likely to be
presented before this that would change the present
recommendations.

Acknowledgements

The two guideline coordinators were N.A.H. and M.P.S.

A, Grynfeltt–Lesshaft triangle (superior lumbar triangle); B, Petit’s tri- N.A.H. has an indirect COI as a member of the Dan-
angle (inferior lumbar triangle); 1, internal oblique muscle; 2, quadratus ish Hernia Database steering committee and has attended
lumborum and erector spinae muscles; 3, serratus posterior inferior muscle;
an industry-sponsored meeting. A.M. is a member of the
4, latissimus dorsi muscle; 5, iliac crest; 6, external oblique muscle (artist:
Y. Renard). EHS board and has received speaker’s fees from Intu-
itive and Bard (direct COI). R.K. has been at sponsored
meetings (indirect COI). F.B. has received speaker’s fees
and AHS suggests using open repair with a preperitoneal
from Medtronic and Acelity (direct COI). J.F. has received
flat mesh for the vast majority of patients2 . In patients with
speaker’s fees from Bard, Gore and Allergan (direct COI).
compromised liver function or on dialysis, the same repair
W.H. has received speaker’s fees from Bard, Gore and Intu-
method is suggested in the present guideline. For patients
itive, and is a member of advisory boards for Mesh Suture
with a concomitant rectus diastasis, the optimal repair
and Deep Blue Medical (direct COI). D.K. has received
method for umbilical and epigastric hernia is unknown, speaker’s fees from Gore, Bard and Cook (direct COI). R.L.
but a mesh is suggested owing to the increased risk of has a direct COI in terms of speaker’s fees from Medtronic
recurrence. For women of childbearing age, subsequent and training courses from Bard (fee), and an indirect COI
pregnancy increases the recurrence rate, and for this reason from being a member of the EHS board, participation
repair should be postponed until after the last pregnancy. in sponsored meetings, and being part of Hernientage
There are insufficient data to suggest a particular repair and HerniaMed. Y.R. has received research funding from
method for Spigelian and primary lumbar hernias. Medtronic, Bard and Hartmann (direct COI). M.A.G.U.
has received speaker’s fees from Gore, Medtronic and
Perspectives Dynamesh. M.P.S. is a member of the EHS board and par-
ticipated in sponsored meetings (indirect COI).
Umbilical or epigastric hernia repair in patients with a con- Disclosure The authors declare no other conflicts of interest.
comitant rectus diastasis is an unexplored area from a sci-
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Supporting information
Additional supporting information can be found online in the Supporting Information section at the end of the
article.

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