Systematic review and meta-analysis of the incidence of incisional hernia in urological surgery.

PURPOSE: To evaluate the incidence of incisional hernia in patients undergoing direct access to the abdominal cavity in urological surgery. METHODS: We conducted a systematic review in Pubmed, Embase, and Cochrane Central from 1980 to the present according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Eighty-four studies were selected for inclusion in this analysis, and meta-analysis and meta-regression were performed. RESULTS: The total incidence in the 84 studies was 4.8% (95% CI 3.7% - 6.2%) I2 93.84%. Depending on the type of incision, it was higher in the open medial approach: 7.1% (95% CI 4.3%-11.8%) I2 92.45% and lower in laparoscopic surgery: 1.9% (95% CI 1%-3.4%) I2 71, 85% According to access, it was lower in retroperitoneal: 0.9% (95% CI 0.2%-4.8%) I2 76.96% and off-midline: 4.7% (95% CI 3.5%-6.4%) I2 91.59%. Regarding the location of the hernia, parastomal hernias were more frequent: 15.1% (95% CI 9.6% - 23%) I2 77.39%. Meta-regression shows a significant effect in reducing the proportion of hernias in open lateral, laparoscopic and hand-assisted compared to medial open access. CONCLUSION: The present review finds the access through the midline and stomas as the ones with the highest incidence of incisional hernia. The use of the lateral approach or minimally invasive techniques is preferable. More prospective studies are warranted to obtain the real incidence of incisional hernias and evaluate the role of better techniques to close the abdomen.

Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies.

BACKGROUND: Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia. METHODS: A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative. RESULTS: Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised. CONCLUSION: These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.

An incisional hernia results from a weakness of the abdominal wall muscles that allows fat from the inside or organs to bulge out. These hernias are quite common after abdominal surgery at the site of a previous incision. There is research that discusses different ways to close an incision and this may relate to the chance of hernia formation. The aim of this study was to review the latest research and to provide a guide for surgeons on how best to close incisions to decrease hernia rates. When possible, surgery through small incisions may decrease the risk of hernia formation. If small incisions are used, it may be better if they are placed away from areas that are already weak (such as the belly button). If the incision is larger than 1 cm, it should be closed with a deep muscle-fascia suture in addition to skin sutures. If there is a large incision in the middle of the abdomen, the muscle should be sutured using small stitches that are close together and a slowly absorbable suture should be used. For patients who are at higher risk of developing hernias, when closing the incision, the muscle layer can be strengthened by using a piece of (synthetic) mesh. There is no good research available on recovery after surgery and no clear guides on activity level or whether a binder will help prevent hernia formation.

A prospective study comparing rectal water contrast-transvaginal ultrasonography with sonovaginography for the diagnosis of deep posterior endometriosis.

INTRODUCTION: Preoperative assessment of deep endometriotic (DE) nodules is necessary to inform patients about the possible treatments and provide informed consent in case of surgery. This study aims to investigate the diagnostic performance of rectal water-contrast transvaginal ultrasonography (RWC-TVS) and sonovaginography (SVG) in women with suspicion of posterior DE. MATERIAL AND METHODS: This prospective comparative study (NCT04296760) enrolled women with clinical suspicion of DE at our institution (Piazza della Vittoria 14 SRL, Genoa, Italy). Exclusion criteria were previous diagnosis of DE by imaging techniques or laparoscopy. All patients underwent RWC-TVS and SVG, independently performed by two gynecological sonologists blinded to the other technique's results. Patients underwent laparoscopic surgery within the following three months; imaging findings were compared with surgical and histological results. RESULTS: In 208 of 281 (74.0%) patients included, posterior DE was surgically confirmed in rectosigmoid (n = 88), vagina (n = 21), rectovaginal septum (n = 34) and uterosacral ligaments (n = 156). RWC-TVS and SVG demonstrated similar sensitivity (SE; 93.8% vs 89.4%; p = 0.210) and specificity (SP; 86.3% vs 79.4%; p = 0.481) in diagnosing posterior DE. Specifically, both examinations had similar accuracy in detecting nodules of uterosacral ligaments (p = 0.779), vagina (p = 0.688) and rectovaginal septum (p = 0.824). RWC-TVS had higher SE (95.2% vs 82.0%; p = 0.003) and similar SP (99.5% vs 98.5%; p = 0.500) in diagnosing rectosigmoid endometriosis and estimated better infiltration of intestinal submucosa (p = 0.039), and distance between these nodules and anal verge (p < 0.001); only RWC-TVS allowed the estimation of bowel lumen stenosis. A similar proportion of discomfort was experienced during both examinations (p = 0.191), although a statistically higher mean visual analog score was reported during RWC-TVS (p < 0.001). CONCLUSIONS: Although RWC-TVS and SVG have similar accuracy in the diagnosis of DE, RWC-TVS performed better in assessment of the characteristics of rectosigmoid endometriosis.

Magnetic Resonance Rectal Enema Versus Computed Tomographic Colonography in the Diagnosis of Rectosigmoid Endometriosis.

OBJECTIVES: Rectosigmoid involvement by endometriosis causes intestinal symptoms such as constipation, diarrhea, and dyschezia. A precise diagnosis about the presence, location, and extent of bowel implants is required to plan the most appropriate treatment. The aim of the study was to compare the accuracy of magnetic resonance with distension of the rectosigmoid (MR-e) with computed colonography (CTC) for diagnosing rectosigmoid endometriosis. METHODS: This study was based on the retrospective analysis of a prospectively collected database of patients with suspicion of rectosigmoid endometriosis who underwent both MR-e and CTC, and subsequently were treated by laparoscopy. The findings of imaging techniques were compared with surgical and histological results. RESULTS: Of 90 women included in the study, 44 (48.9%) had rectosigmoid nodules and underwent bowel surgery. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for the diagnosis of rectosigmoid endometriosis were 88.6%, 93.5%, 92.9%, 89.6%, and 91.1% for CTC, and 93.2%, 97.9%, 97.6%, 93.8%, and 95.6% for MR-e. There was no significant difference in the accuracy of both radiologic examinations for diagnosing rectosigmoid endometriosis (P = 0.344). However, MR-e was more accurate than CTC in estimating the largest diameter of the main rectosigmoid nodule (P < 0.001). The pain perceived by the patients was significantly lower during MR-e than during CTC (P < 0.001). CONCLUSIONS: MR-e and CTC have similar diagnostic performance for the diagnosis of rectosigmoid involvement of endometriosis. However, MR-e is more accurate in the estimation of the largest diameter of main rectosigmoid nodule and more tolerated than CTC.

Does Bowel Preparation Improve the Performance of Rectal Water Contrast Transvaginal Ultrasonography in Diagnosing Rectosigmoid Endometriosis?

OBJECTIVES: The primary objective of the study was to compare the performance of the rectal water transvaginal ultrasonography (RWC-TVS) with and without bowel preparation (BP) in diagnosing rectosigmoid endometriosis. The secondary objectives were to compare the performance of the 2 exams in estimating infiltration of the mucosa, length of the largest rectosigmoid nodules, distance of the nodules from the anal verge, and presence of multifocal disease. METHODS: This prospective study included patients with pain symptoms and intestinal complaints suggestive of endometriosis. Patients underwent RWC-TVS with and without BP within an interval of 1 week to 2 months. Two independent and blinded gynecologists performed the exams. The results of the 2 exams were compared with surgical and histologic findings. RESULTS: A total of 155 patients were included in the study; 92 patients had rectosigmoid endometriosis. There was no significant difference in the performance of RWC-TVS with or without BP in diagnosing rectosigmoid endometriosis (P = .727). There was no significant difference in the performance of RWC-TVS with or without BP in diagnosing infiltration of the mucosa (P = .424) and multifocal disease (P = .688), in estimating the main diameter of the largest nodule (P = .644) and the distance between the more distal rectosigmoid nodule and the anal verge (P = .090). The patients similarly tolerated the 2 exams (P = .799). CONCLUSIONS: Bowel preparation does not improve the performance of RWC-TVS in diagnosing rectosigmoid endometriosis and in assessing the characteristics of these nodules.

SECCA procedure for anal incontinence and antibiotic treatment: a case report of anal abscess.

BACKGROUND: Fecal Incontinence (FI) can seriously affect quality of life. The treatment of fecal incontinence starts conservatively but in case of failure, different surgical approaches may be proposed to the patient. Recently several not invasive approaches have been developed. One of these is the radiofrequency (RF) energy application to the internal anal sphincter. CASE PRESENTATION: We report a rare case of an anal abscess related to a SECCA procedure in a 66-year-old woman affected by gas and FI for twenty years. CONCLUSIONS: The complications post-SECCA procedure reported in literature are generally not serious and often self-limited, such as bleeding or anal pain. This is a case of an anal abscess. We suggest that this finding could consolidate the importance of administering antibiotic therapy to patients and to run a full course of at least 6 days rather than a short-term (24 h) therapy, with the aim to minimize the incidence of this complication.

Radiofrequency Procedure (SECCA®) for Fecal Incontinence: One-Year Experience.

INTRODUCTION: Radiofrequency is a treatment option for patients suffering from fecal incontinence. OBJECTIVE: To assess the one-year follow-up results following the radiofrequency procedure for fecal incontinence. DESIGN: Prospective, single-center, observational study. MATERIALS AND METHODS: Twenty-one patients underwent the SECCA® radiofrequency procedure, 19 of who completed the one-year of follow-up (Cleveland Clinic Florida Fecal Incontinence score, Fecal Incontinence Quality of Life Scale (FIQoL), anorectal manometry, and endoanal ultrasound). MAIN OUTCOME MEASURES: Any change in the Fecal Incontinence Score or Fecal Incontinence Quality of Life scales post SECCA® radiofrequency procedure. RESULTS: The mean Fecal Incontinence Score significantly improved at three months' follow-up from 14.5 prior to treatment to 11.9 post-treatment, and was maintained at six months (12). A slight decrease was observed at one year (12.9), which had no impact on the global satisfaction. During the same period, only 1/4 subsets of the Fecal Incontinence Quality of Life score improved. Manometry and endoanal ultrasound did not show significant changes post procedure. LIMITATIONS: Limited number of patients. CONCLUSIONS: Radiofrequency is a valid treatment option for patients with mild-to-moderate fecal incontinence. This treatment has demonstrated clinically significant improvements in symptoms, as demonstrated by statistically significant reductions in the Fecal Incontinence Score as well as significant improvements in Fecal Incontinence Quality of Life scores at six months, with a slight, though not clinically significant, decrease at one year follow-up.

Stapled Mesh Reinforcement Technique (SMART) to Prevent Parastomal Hernias: Our Initial Experience and Review of the Literature.

Parastomal hernia is one of the most common stoma related complication, with the correlated risk of incarceration, obstruction, and strangulation. The incidence is high (30-50%) and depends on the length of follow up. Different surgical options for repairing are defective with a 25-70% failure and recurrence rate. Prevention of parastomal hernia with mesh reinforcement seems to be effective. Three available trials are recruiting patients: Prism (with matrix porcine prothesis), Prevent (with preperitoneal polypropylene mesh), and the stapled polypropylene mesh stoma reinforcement technique (SMART). We performed the SMART procedure in six patients undergoing definitive colostomy. Our cases show that the procedure is rapid (duration range 15-20 minutes), cost effective (500 euro), and safe (in our experience, there are no post-surgical complications that are procedure-related). A long term follow-up and a higher number of patients will give us confirmation of the initial hopeful results.

Single-access laparoscopic rectal resection versus the multiport technique: a retrospective study with cost analysis.

BACKGROUND: Single-access laparoscopic surgery is not used routinely for the treatment of colorectal disease. The aim of this retrospective cohort study is to compare the results of single-access laparoscopic rectal resection (SALR) versus multiaccess laparoscopic rectal resection with a mean follow-up of 24 months. METHODS: This retrospective cohort study enrolled 42 patients. Between January 2010 and June 2012, 21 SALRs were performed. These patients were compared with a group of 21 other patients who had undergone multiport laparoscopic rectal resection. This control group had the same exclusion criteria and patient demographics. Short-term outcomes were reassessed with a mean follow-up of 2 years. Statistical analysis included the Student t test and Fisher's exact test. Finally, we performed a differential cost analysis between the 2 procedures. RESULTS: Exclusion criteria, patient demographics, and indication for surgery were similar in both groups. The conversion rate was 0% in both groups. There were no intraoperative complications or deaths. Bowel recovery was similar in both groups. No interventions, readmissions, or deaths were recorded at 30 days' follow-up. At a mean follow-up of 24 months, all the patients with a preoperative diagnosis of cancer are still alive and disease free. Considering the selected 3 items, the mean cost per patient for single-access laparoscopic surgery and multiple-access laparoscopic surgery were estimated as 7213 and 7495 Euros, respectively. CONCLUSION: We think that SALR could be performed in selected patients by surgeons with high multiport laparoscopic skills. It is compulsory by law to evaluate outcomes and cost-effectiveness by using randomized controlled trials.

Single-access laparoscopic subtotal spleno-pancreatectomy for pancreatic adenocarcinoma.

Laparoscopic distal or subtotal pancreatectomy can be performed safely and effectively unless there is a clear reason why not to do so. With the aim of reducing postoperative trauma and improving the cosmesis, single-access laparoscopic surgery has been introduced into daily practice. We report the first case of distal single-access laparoscopic pancreasectomy for an adenocarcinoma. The procedure was carried out in 170 minutes without postoperative complications. Despite some technical difficulties, we think that a single-access laparoscopic approach could be adequate for a pancreatic resection. However, an adequate analysis of cost-effectiveness as well as regarding the reproducibility should be carried out.

Systematic review and meta-analysis of postoperative outcomes after combined stoma reversal and incisional hernia repair versus stoma reversal alone.

BACKGROUND: The optimal management and timing of the abdominal wall reconstruction concomitantly performed with stoma closure are controversial. This study aims to compare short-term postoperative outcomes after concurrent stoma reversal (SR) with incisional hernia repair (IHR) and SR alone. METHODS: PubMed/MEDLINE, Scopus and Web of Science databases were consulted to identify comparative studies. Random and common-effect models were used for the pooled analysis of the proportions and means. RESULTS: Three studies met the inclusion criteria and a total of 504 patients who underwent simultaneous SR and IHR (N.=200) or SR alone (N.=304) were included in the meta-analysis. Postoperative morbidity increased after combined stoma and hernia surgery with a pooled OR for Surgical Site Occurrence (SSO) and severe postoperative complications (Clavien-Dindo ≥III) of 1.72 (95% CI 1.02-2.90) and 3.83 (95% CI 1.46-10.02), respectively. No significant difference was found between the two groups in terms of mortality (OR: 1.66; 95% CI 0.64-4.27), length of hospital stay (OR: 1.37; 95% CI 0.73-3.47). and readmission rate (OR: 1.17; 95% CI 0.67-2.06). CONCLUSIONS: There is limited evidence suggesting that synchronous repair of SR and IH appears to be associated with a higher risk of SSO and severe postoperative complications. Therefore, a stepwise approach may be considered the best strategy in this setting.

Protocol for an 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).

INTRODUCTION: Incisional hernia (IH) is a prevalent and potentially dangerous complication of abdominal surgery, especially in high-risk groups. Mesh reinforcement of the abdominal wall has been studied as a potential intervention to prevent IHs. Randomised controlled trials (RCTs) have demonstrated that prophylactic mesh reinforcement after abdominal surgery, in general, is effective and safe. In patients with abdominal aortic aneurysm (AAA), prophylactic mesh reinforcement after open repair has not yet been recommended in official guidelines, because of relatively small sample sizes in individual trials. Furthermore, the identification of subgroups that benefit most from prophylactic mesh placement requires larger patient numbers. Our primary aim is to evaluate the efficacy and effectiveness of the use of a prophylactic mesh after open AAA surgery to prevent IH by performing an individual patient data meta-analysis (IPDMA). Secondary aims include the evaluation of postoperative complications, pain and quality of life, and the identification of potential subgroups that benefit most from prophylactic mesh reinforcement. METHODS AND ANALYSIS: We will conduct a systematic review to identify RCTs that study prophylactic mesh placement after open AAA surgery. Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase, Web of Science Core Collection and Google Scholar will be searched from the date of inception onwards. RCTs must directly compare primary sutured closure with mesh closure in adult patients who undergo open AAA surgery. Lead authors of eligible studies will be asked to share individual participant data (IPD). The risk of bias (ROB) for each included study will be assessed using the Cochrane ROB tool. An IPDMA will be performed to evaluate the efficacy, with the IH rate as the primary outcome. Any signs of heterogeneity will be evaluated by Forest plots. Time-to-event analyses are performed using Cox regression analysis to evaluate risk factors. ETHICS AND DISSEMINATION: No new data will be collected in this study. We will adhere to institutional, national and international regulations regarding the secure and confidential sharing of IPD, addressing ethics as indicated. We will disseminate findings via international conferences, open-source publications in peer-reviewed journals and summaries posted online. PROSPERO REGISTRATION NUMBER: CRD42022347881.

Minimally invasive approach to incisional hernia in elective and emergency surgery: a SICE (Italian Society of Endoscopic Surgery and new technologies) and ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) online survey.

Minimally invasive abdominal wall surgery is growing worldwide, with a constant and fast improvement of surgical techniques and surgeons' confidence in treating both primary and incisional hernias (IH). The Italian Society of Endoscopic Surgery and new technologies (SICE) and the ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) worked together to investigate state of the art in IH treatment in elective and emergency settings in Italy. An online open survey was designed, and Italian surgeons interested in abdominal wall surgery were invited to fill out a 20-point questionnaire on IH surgical procedures performed in their departments. Surgeons were asked to express their points of view on specific questions about technical and clinical variables in IH treatment. Preferred approach in elective IH surgery was minimally invasive (59.7%). Open surgery was the preferred approach in 40.3% of the responses. In emergency settings, open surgery was the preferred approach (65.4%); however, 34.5% of the involved surgeons declare to prefer the laparoscopic/endoscopic approach. Most respondents opted for conversion to open surgery in case of relevant surgical field contamination, with a non-mesh repair of abdominal wall defects. Among those that used the laparoscopic approach in the emergent setting, the majority (74%) used the size of the defect of 5 cm as a decisional cut-off. The spread of minimally invasive approaches to IH repair in emergency surgery in Italy is gaining relevance. Code-sharing through scientific societies can improve clinical practice in different departments and promote a tailored approach to IH surgery.

EHS Rapid Guideline: Evidence-Informed European Recommendations on Parastomal Hernia Prevention-With ESCP and EAES Participation.

Background: Growing evidence on the use of mesh as a prophylactic measure to prevent parastomal hernia and advances in guideline development methods prompted an update of a previous guideline on parastomal hernia prevention. Objective: To develop evidence-based, trustworthy recommendations, informed by an interdisciplinary panel of stakeholders. Methods: We updated a previous systematic review on the use of a prophylactic mesh for end colostomy, and we synthesized evidence using pairwise meta-analysis. A European panel of surgeons, stoma care nurses, and patients developed an evidence-to-decision framework in line with GRADE and Guidelines International Network standards, moderated by a certified guideline methodologist. The framework considered benefits and harms, the certainty of the evidence, patients' preferences and values, cost and resources considerations, acceptability, equity and feasibility. Results: The certainty of the evidence was moderate for parastomal hernia and low for major morbidity, surgery for parastomal hernia, and quality of life. There was unanimous consensus among panel members for a conditional recommendation for the use of a prophylactic mesh in patients with an end colostomy and fair life expectancy, and a strong recommendation for the use of a prophylactic mesh in patients at high risk to develop a parastomal hernia. Conclusion: This rapid guideline provides evidence-informed, interdisciplinary recommendations on the use of prophylactic mesh in patients with an end colostomy. Further, it identifies research gaps, and discusses implications for stakeholders, including overcoming barriers to implementation and specific considerations regarding validity.

Update Systematic Review, Meta-Analysis and GRADE Assessment of the Evidence on Parastomal Hernia Prevention-A EHS, ESCP and EAES Collaborative Project.

Objective: To perform a systematic review and meta-analysis on the effectiveness of prophylactic mesh for the prevention of parastomal hernia in end colostomy, with the ultimate objective to summarize the evidence for an interdisciplinary, European rapid guideline. Methods: We updated a previous systematic review with de novo evidence search of PubMed from inception up to June 2022. Primary outcome was quality of life (QoL). Secondary outcomes were clinical diagnosis of parastomal hernia, surgery for parastomal hernia, and 30 day or in-hospital complications Clavien-Dindo ≥3. We utilised the revised Cochrane Tool for randomised trials (RoB 2 tool) for risk of bias assessment in the included studies. Minimally important differences were set a priori through voting of the panel members. We appraised the evidence using GRADE and we developed GRADE evidence tables. Results: We included 12 randomized trials. Meta-analysis suggested no difference in QoL between prophylactic mesh and no mesh for primary stoma construction (SMD = 0.03, 95% CI [-0.14 to 0.2], I2 = 0%, low certainty of evidence). With regard to parastomal hernia, the use of prophylactic synthetic mesh resulted in a significant risk reduction of the incidence of the event, according to data from all available randomized trials, irrespective of the follow-up period (OR = 0.33, 95% CI [0.18-0.62], I2 = 74%, moderate certainty of evidence). Sensitivity analyses according to follow-up period were in line with the primary analysis. Little to no difference in surgery for parastomal hernia was encountered after pooled analysis of 10 randomised trials (OR = 0.52, 95% CI [0.25-1.09], I2 = 14%). Finally, no significant difference was found in Clavien-Dindo grade 3 and 4 adverse events after surgery with or without the use of a prophylactic mesh (OR = 0.77, 95% CI [0.45-1.30], I2 = 0%, low certainty of evidence). Conclusion: Prophylactic synthetic mesh placement at the time of permanent end colostomy construction is likely associated with a reduced risk for parastomal hernia and may confer similar risk of peri-operative major morbidity compared to no mesh placement. There may be no difference in quality of life and surgical repair of parastomal hernia with the use of either approach.

Update of the international HerniaSurge guidelines for groin hernia management.

BACKGROUND: Groin hernia repair is one of the most common operations performed globally, with more than 20 million procedures per year. The last guidelines on groin hernia management were published in 2018 by the HerniaSurge Group. The aim of this project was to assess new evidence and update the guidelines. The guideline is intended for general and abdominal wall surgeons treating adult patients with groin hernias. METHOD: A working group of 30 international groin hernia experts and all involved stakeholders was formed and examined all new literature on groin hernia management, available until April 2022. Articles were screened for eligibility and assessed according to GRADE methodologies. New evidence was included, and chapters were rewritten. Statements and recommendations were updated or newly formulated as necessary. RESULTS: Ten chapters of the original HerniaSurge inguinal hernia guidelines were updated. In total, 39 new statements and 32 recommendations were formulated (16 strong recommendations). A modified Delphi method was used to reach consensus on all statements and recommendations among the groin hernia experts and at the European Hernia Society meeting in Manchester on October 21, 2022. CONCLUSION: The HerniaSurge Collaboration has updated the international guidelines for groin hernia management. The updated guidelines provide an overview of the best available evidence on groin hernia management and include evidence-based statements and recommendations for daily practice. Future guideline development will change according to emerging guideline methodology.

Protocol for EHS Rapid Guideline: Systematic Review, Meta-Analysis, GRADE Assessment, and European Recommendations on Parastomal Hernia Prevention.

Background: Parastomal hernia presents frequently after construction of a permanent end colostomy. Previous guidelines recommend using a prophylactic mesh for hernia prevention. Randomized controlled trials (RCTs) published hereafter demonstrate conflicting outcomes. Methods and Analysis: A rapid guideline will be developed and reported in accordance with GRADE, GIN and AGREE-S standards. The steering group will consist of general and colorectal surgeons, members of the EHS Scientific Advisory Board with expertise and experience in guideline development, advanced medical statistics and evidence synthesis, and a certified guideline methodologist. The guideline panel will consist of three general surgeons, three colorectal surgeons, two stoma care nurses, and two patient representatives. A single question will address the safety and efficacy of the use of a prophylactic mesh in patients with a permanent end colostomy, and sensitivity analyses will focus on the use of non-absorbable versus absorbable meshes, and on different anatomical spaces for mesh placement. A systematic review will be conducted and evidence synthesis will be performed by statisticians independently. The results of evidence synthesis will be summarized in summary of findings tables. Recommendation(s) will be finalized through Delphi process of the guideline panel within an evidence-to-decision framework. Ethics and Dissemination: The funding body will not be involved in the development of this guideline. Conflicts of interest, if any, will be addressed by re-assigning functions or replacing participants with direct conflicts, according to Guidelines International Network recommendations.

Description of the Current Da Vinci® Training Pathway for Robotic Abdominal Wall Surgery by the European Hernia Society.

Background: Robot assisted laparoscopic abdominal wall surgery (RAWS) has seen a rapid adoption in recent years. The safe introduction of the robot platform in the treatment of abdominal wall hernias is important to safeguard the patient from harm during the learning curve. The scope of this paper is to describe the current European training curriculum in RAWS. Methods and Analysis: The pathway to competence in RAWS will depend on the robot platform, experience in other abdominal procedures (novice to expert) and experience in the abdominal wall repair techniques. An overview of the learning curve effect in the initial case series of several early adopters in RAWS was reviewed. In European centres, current training for surgeons wanting to adopt RAWS is managed by the specific technology-based training organized by the company providing the robot. It consists of four phases where phases I and II are preclinical, while phases III and IV focus on the introduction of the robotic platform into surgical practice. Conclusion: On behalf of the Robotic Surgery Task Force of the European Hernia Society (EHS) we believe that the EHS should play an important role in the clinical phases III and IV training. Courses organized in collaboration with the robot provider on relevant surgical anatomy of the abdominal wall and procedural steps in complex abdominal wall reconstruction like transversus abdominis release are essential. Whereas the robot provider should be responsible for the preclinical phases I and II to gain familiarity in the specific robot platform.