Guidelines for Treatment of Umbilical and Epigastric Hernias From the European and Americas Hernia Societies-A Web-Based Survey on Surgeons' Opinion.

Background and aims: The European and Americas Hernia Society's (EHS and AHS) Guidelines on the treatment of primary midline ventral hernias were launched to guide surgeons. As a part of a dissemination plan of the guideline, this study aimed to evaluate the level of consensus between recommendations and the current surgical practices of EHS and AHS members before implementation. Material and methods: A questionnaire was constructed including questions on the current practice of the members and nine selected key recommendations from the guidelines. An on-stage consensus voting was performed at the EHS Congress in Hamburg 2019 followed by a SurveyMonkey sent to all EHS and AHS members. Consensus with a recommendation was defined as an agreement of ≥70%. Results: A total of 178 votes were collected in Hamburg. A further 499/1,754 (28.4%) of EHS and 150/1,100 (13.6%) of AHS members participated in the SurveyMonkey. A consensus was reached for 7/9 (78%) of the recommendations. The two recommendations that did not reach consensus were on indication and the technique used for laparoscopic repair. In current practice, more AHS participants used a preformed patch; 50.7% (76/150) compared with EHS participants 32.1% (160/499), p < 0.001. Conclusion: A consensus was achieved for most recommendations given by the new guideline for the treatment of umbilical and epigastric hernias. Recommendations that did not reach consensus were on indication and technique for laparoscopic repair, which may reflect the lack of evidence on these topics.

Evaluation of the immunogenicity and protective efficacy of a recombinant CS6-based ETEC vaccine in an Aotus nancymaae CS6 + ETEC challenge model.

Colonization factors or Coli surface antigens (CFs or CS) are important virulence factors of Enterotoxigenic E. coli (ETEC) that mediate intestinal colonization and accordingly are targets of vaccine development efforts. CS6 is a highly prevalent CF associated with symptomatic ETEC infection both in endemic populations and amongst travelers. In this study, we used an Aotus nancymaae non-human primate ETEC challenge model with a CS6 + ETEC strain, B7A, to test the immunogenicity and protective efficacy (PE) of a recombinant CS6-based subunit vaccine. Specifically, we determined the ability of dscCssBA, the donor strand complemented recombinant stabilized fusion of the two subunits of the CS6 fimbriae, CssA and CssB, to elicit protection against CS6 + ETEC mediated diarrhea when given intradermally (ID) with the genetically attenuated double mutant heat-labile enterotoxin LT(R192G/L211A) (dmLT). ID vaccination with dscCssBA + dmLT induced strong serum antibody responses against CS6 and LT. Importantly, vaccination with dscCssBA + dmLT resulted in no observed diarrheal disease (PE = 100%, p = 0.03) following B7A challenge as compared to PBS immunized animals, with an attack rate of 62.5%. These data demonstrate the potential role that CS6 may play in ETEC infection and that recombinant dscCssBA antigen can provide protection against challenge with the homologous CS6 + ETEC strain, B7A, in the Aotus nancymaae diarrheal challenge model. Combined, these data indicate that CS6, and more specifically, a recombinant engineered derivative should be considered for further clinical development.

Accuracy and usefulness in assessing proficiency of the observational clinical human reliability assessment checklist of the open inguinal hernia repair procedure: A cross-sectional study.

BACKGROUND: The Observational Clinical Human Reliability Assessment (OCHRA) can be used to score errors during surgical procedures. To construct an OCHRA-checklist, steps, substeps, and hazards of a surgical procedure need to be defined. A step-by-step framework was developed to segment surgical procedures into steps, substeps, and hazards. The first aim of this study was to investigate if the step-by-step framework could be used to construct an accurate Lichtenstein open inguinal hernia repair (LOIHR) stepwise description. The second aim was to investigate if the OCHRA-checklist based on this stepwise description was accurate and useful for surgical training and assessment. MATERIALS AND METHODS: Ten expert surgeons rated statements regarding the accuracy of the LOIHR stepwise description, the accuracy, and the usefulness of the LOIHR OCHRA-checklist (eight, seven, and six statements, respectively) using a 5-point Likert scale. One-sample Wilcoxon signed-rank test was used to compare the outcomes to the neutral value of 3. RESULTS: The accuracy of the stepwise description and the accuracy and usefulness of the OCHRA-checklist were rated statistically significantly higher than the neutral value of 3 (median 4.75 [5.00-4.00] with p = .009, median 5.00 [5.00-4.00] with p = .012, median 4.00 [5.00-4.00] with p = .047, respectively). The experts rated the OCHRA-checklist to be useful for the training (5.00 [5.00-4.00], p = .009), and assessment (4.50 [5.00-4.00], p = .010) of surgical residents. CONCLUSION: This preliminary study showed that the stepwise LOIHR description constructed using the step-by-step framework was found to be accurate. The LOIHR OCHRA-checklist developed using the stepwise description was also accurate, and particularly useful for the training and assessment of proficiency of surgical residents.

Learning inguinal hernia repair? A survey of current practice and of preferred methods of surgical residents.

PURPOSE: During surgical residency, many learning methods are available to learn an inguinal hernia repair (IHR). This study aimed to investigate which learning methods are most commonly used and which are perceived as most important by surgical residents for open and endoscopic IHR. METHODS: European general surgery residents were invited to participate in a 9-item web-based survey that inquired which of the learning methods were used (checking one or more of 13 options) and what their perceived importance was on a 5-point Likert scale (1 = completely not important to 5 = very important). RESULTS: In total, 323 residents participated. The five most commonly used learning methods for open and endoscopic IHR were apprenticeship style learning in the operation room (OR) (98% and 96%, respectively), textbooks (67% and 49%, respectively), lectures (50% and 44%, respectively), video-demonstrations (53% and 66%, respectively) and journal articles (54% and 54%, respectively). The three most important learning methods for the open and endoscopic IHR were participation in the OR [5.00 (5.00-5.00) and 5.00 (5.00-5.00), respectively], video-demonstrations [4.00 (4.00-5.00) and 4.00 (4.00-5.00), respectively], and hands-on hernia courses [4.00 (4.00-5.00) and 4.00 (4.00-5.00), respectively]. CONCLUSION: This study demonstrated a discrepancy between learning methods that are currently used by surgical residents to learn the open and endoscopic IHR and preferred learning methods. There is a need for more emphasis on practising before entering the OR. This would support surgical residents' training by first observing, then practising and finally performing the surgery in the OR.

EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances.

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.

ANTECEDENTES: Las hernias de localización rara, así como las hernias ventrales primarias en determinadas circunstancias (cirrosis, diálisis, diástasis de recto, tras un embarazo) pueden ser complejas desde el punto de vista técnico. El objetivo fue identificar situaciones en las que la estrategia de tratamiento pudiera ser diferente del tratamiento habitual. MÉTODOS: Esta guía fue elaborada por cirujanos de las sociedades europeas y americana de hernia (European Hernia Society, EHS y American Hernia Society, AHS). La búsqueda sistemática de la literatura se efectuó el 1 de mayo de 2018 y se actualizó el 1 de febrero de 2019. Para evaluar la calidad de los artículos completos seleccionados se utilizó la normativa SIGN (Scottish Intercollegiate Guidelines Network). Las recomendaciones formuladas siguieron la metodología GRADE (Grading of Recommendations Assessment, Development and Evaluation) y la redacción de la guía siguió las normas AGREE (Appraisal of Guidelines for Research & Evaluation). RESULTADOS: La literatura es limitada en cantidad y calidad. La mayoría de las recomendaciones se calificaron como débiles en función de la baja calidad de la evidencia. En pacientes con cirrosis o en diálisis, se sugiere una reparación con malla preperitoneal. Un embarazo tras la reparación de una hernia es un factor de riesgo de recidiva. La reparación debería posponerse hasta después del último embarazo. Debido a la falta de evidencia no se pudo hacer ninguna recomendación para la reparación de hernias en pacientes con diástasis de recto concomitante o con hernias de Spigel o lumbares. CONCLUSIÓN: Esta es la primera guía europea y americana del tratamiento de hernias umbilicales y epigástricas en pacientes con patologías especiales, incluyendo las hernias de Spigel y lumbares. Todas las recomendaciones fueron débiles debido a la falta de evidencia. Se necesitan más estudios en pacientes con diástasis de recto, hernias de Spigel y lumbares.

Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society.

BACKGROUND: Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias. METHODS: The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019. RESULTS: Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity. CONCLUSION: This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.

ANTECEDENTES: La reparación de las hernias umbilicales y epigástricas es un procedimiento quirúrgico frecuente con una tasa esperada de complicaciones baja. Sin embargo, sigue en discusión cuál es el mejor método de reparación óptimo para obtener los mejores resultados a corto y a largo plazo. El objetivo del estudio fue desarrollar una guía para el tratamiento de las hernias umbilicales y epigástricas. MÉTODOS: El grupo para la elaboración de la guía estuvo formado por cirujanos europeos y norteamericanos junto con miembros de la European Hernia Society (EHS) y de la America's Hernia Society (AHS). Para elaborar la guía, se siguieron las recomendaciones GRADE (Grading of Recommendations Assessment, Development and Evaluation), SIGN (Scottish Intercollegiate Guidelines Network) y AGREE (Appraisal of Guidelines for Research & Evaluation). Se realizó una búsqueda sistemática de la literatura el 1 de mayo de 2018, que luego se actualizó el 1 de febrero de 2019. RESULTADOS: Los trabajos dedicados de forma específica a las hernias umbilicales y epigástricas eran muy limitados en cantidad y calidad, por lo que la mayoría de las recomendaciones que se extrajeron fueron calificadas como débiles y basadas en una baja calidad de la evidencia. La recomendación principal era utilizar una malla en la reparación de las hernias umbilicales y epigástricas para reducir la tasa de recidiva. La mayoría de las hernias umbilicales y epigástricas pueden repararse mediante un abordaje abierto con una malla plana preperitoneal. Se puede considerar el abordaje laparoscópico si el defecto de la hernia es grande o si el paciente tiene un riesgo aumentado de morbilidad de la herida. CONCLUSIÓN: Esta es la primera guía europea y americana del tratamiento de las hernias umbilicales y epigástricas. Se sugiere reparar las hernias sintomáticas umbilicales y epigástricas mediante un abordaje abierto con una malla plana preperitoneal.

Abdominal wall hernia surgery in The Netherlands: a national survey.

PURPOSE: In The Netherlands, the quality of abdominal wall hernia surgery is largely unknown due to the lack of a hernia registry. This study was designed to assess the current state of abdominal wall hernia surgery in The Netherlands, to create a starting point for future evaluation of new quality measures. METHODS: Dutch hernia management indicators and recently proposed European Hernia Society (EHS) requirements for accredited/certified hernia centers were used. The number of Dutch hospitals that meet the four main EHS requirements (on volume, experience, use of a registry and quality control) was assessed by analyzing governmental information and the results of a survey amongst all 1.554 Dutch general surgeons. RESULTS: The survey was representative with 426 respondents (27%) from all 75 hospitals. Fifty-one percent of the hospitals had a median inguinal repair volume of more than 290 (14-1.238) per year. An open or laparo-endoscopic inguinal repair technique was not related to hospital volume. Experienced hernia surgeons, use of a registry and a structured quality control were reported to be present in, respectively, 97%, 39%, and 15% of the hospitals. Consensus in answers between the respondents per hospital was low (< 20%). Two hospitals (3%) met all four requirements for accreditation. CONCLUSION: This descriptive analysis demonstrates that hernia surgery in the Netherlands is performed in every hospital, by all types of surgeons, using many different techniques. If the suggested EHS requirements are used as a measuring rod, only 3% of the Dutch hospitals could be accredited as a hernia center.

Validity of a low-cost Lichtenstein open inguinal hernia repair simulation model for surgical training.

PURPOSE: Simulation training allows trainees to gain experience in a safe environment. Computer simulation and animal models to practice a Lichtenstein open inguinal hernia repair (LOIHR) are available; however, a low-cost model is not. We constructed an inexpensive model using fabric, felt, and yarn that simulates the anatomy and hazards of the LOIHR. This study examined the fidelity, and perceived usefulness of our developed simulation model by surgical residents and expert surgeons. METHODS: A total of 66 Dutch surgical residents and ten international expert surgeons were included. All participants viewed a video-demonstration of LOIHR on the simulation model and subsequently performed the surgery themselves on the model. Afterward, they assessed the model by rating 13 statements concerning its fidelity (six model, three equipment, and four psychological) and six usefulness statements on a five-point Likert scale. One-sample Wilcoxon signed-rank test was used to compare to the neutral value of 3. RESULTS: The fidelity was assessed as being high by residents [model 4.00 (3.00-4.00), equipment 4.00 (3.00-4.00), psychological 4.00 (3.00-4.00); all p's < 0.001] and by expert surgeons [model 4.00 (3.00-4.00), p = 0.025; equipment 4.00 (3.00-5.00), p < 0.001; psychological 4.00 (3.00-4.00), p = 0.053]. The usefulness was rated high by residents and experts, especially the usefulness for training of residents [residents 4.00 (4.00-5.00), p < 0.001; experts 4.50 (3.75-5.00), p = 0.015]. CONCLUSION: Our developed Lichtenstein open inguinal hernia repair simulation model was assessed by surgical residents and expert surgeons as a model with high fidelity and high potential usefulness, especially for the training of surgical residents.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery.

INTRODUCTION: The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature. METHODS: A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated. RESULTS: All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures. CONCLUSION: A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

Accreditation and certification requirements for hernia centers and surgeons: the ACCESS project.

INTRODUCTION: There is a need for hernia centers and specialist hernia surgeons because of the increasing complexity of hernia surgery procedures due to new techniques, more difficult cases and a tailored approach with an increasing public awareness demanding optimal treatment results. Therefore, the requirements for accredited/certified hernia centers and specialist hernia surgeons should be formulated by the international and national hernia societies, while taking account of the respective health care systems. METHODS: The European Hernia Society (EHS) has appointed a working group composed of 18 hernia experts from all regions of Europe (ACCESS Group-Hernia Accreditation and Certification of Centers and Surgeons-Working Group) to formulate scientifically based requirements for hernia centers and specialist hernia surgeons while taking into consideration different health care systems. A consensus was reached on the key questions by means of a meeting, a telephone conference and the exchange of contributions. The requirements formulated below were deemed implementable by all participating hernia experts in their respective countries. RESULTS: The ACCESS Group suggests for an adequately equipped hernia center the following requirements: (a) to be accredited/certified by a national or international hernia society, (b) to perform a higher case volume in all types of hernia surgery compared to an average general surgery department in their country, (c) to be staffed by experienced hernia surgeons who are beyond the learning curve for all types of hernia surgery recommended in the guidelines and are responsible for education and training of hernia surgery in their department, (d) to treat hernia patients according to the current guidelines and scientific recommendations, (e) to document each case prospectively in a registry or quality assurance database (f) to perform follow-up for comparison of their own results with benchmark data for continuous improvement of their treatment results and ensuring contribution to research in hernia treatment. To become a specialist hernia surgeon, the ACCESS Group suggests a general surgeon to master the learning curve of all open and laparo-endoscopic hernia procedures recommended in the guidelines, perform a high caseload and additionally to implement and fulfill the other requirements for a hernia center. CONCLUSION: Based on the above requirements formulated by the European Hernia Society for accredited/certified hernia centers and hernia specialist surgeons, the national and international hernia societies can now develop their own programs, while taking account of their specific health care systems.

Inguinal endometriosis, a rare entity of which surgeons should be aware: clinical aspects and long-term follow-up of nine cases.

INTRODUCTION: Inguinal endometriosis is a rare disease and often misdiagnosed for other, more common groin pathology. We present nine cases of women with inguinal endometriosis with long-term follow-up. METHODS: In this retrospective case series, the Dutch PALGA system was searched for all patients diagnosed with extrapelvic endometriosis located in the groin in the OLVG hospital, Amsterdam, between 2000 and 2016. Relevant information regarding pre- and postoperative characteristics and symptoms was collected. Follow-up consisted of a telephone call from the attending surgeon. RESULTS: None of the patients had a history of pelvic endometriosis. Typically, they presented with a right-sided swelling in the groin. Preoperative ultrasound and MRI were in most cases inconclusive. In one of two patients fna indicated endometriosis. In only three patients the surgeon considered the diagnosis endometriosis preoperatively. Surgical removal was effective with no reported complications. A coexisting hernia sac was resected in four cases, and there was a suspicion of a persistent processus vaginalis (canal of Nuck) in three, suggesting that a persistent processus vaginalis is possibly an important key to the pathogenesis. In none of the cases there was an indication for mesh implantation. One patient was later diagnosed with pelvic endometriosis. CONCLUSION: Follow-up by a gynecologist is advised to check for intra-abdominal disease and inform patients on fertility perspective. Surgeons should be aware of the possibility of inguinal endometriosis in fertile women with a lump in the groin.

Can experienced surgeons predict the additional value of a CT scan in patients with displaced intra-articular distal radius fractures?

There are no clear guidelines when an additional CT scan should be obtained for the treatment of displaced intra-articular distal radius fractures (DRF). This study aimed to investigate whether surgeons can predict the usefulness of CT scans to facilitate choice of treatment plan and/or pre-operative planning for DRF. Four surgeons evaluated 51 patients with displaced DRF. The choice of treatment (operative or nonoperative) was based on conventional radiographs. Subsequently, the surgeons were asked whether they would have requested an additional CT scan to determine this treatment choice, and also whether they required a CT scan for pre-operative planning. After 4 weeks, the additional CT scan was provided and the cases were assessed again. Based on these data, we calculated the number needed to scan (NNS) and number needed to harm (NNH) for two decision models. Model 1: Only provide a CT scan if the surgeon requested one based on their judgment of the X-rays. Model 2: CT scans for all displaced intra-articular DRF. For choice of treatment, the NNS was lower for model 1 than for model 2 (2.6 vs. 4.3) and the NNH is higher for model 1 (3.1 vs. 1.3). For pre-operative planning, the NNS (1.3 vs. 1.4) and NNH (3.7 vs. 3.4) were comparable for both models. Surgeons are able to predict the usefulness of an additional CT scan for intra-articular displaced DRF for OR indication. However, for pre-operative planning the usefulness of a CT scan is much harder to predict.

Spectrum bias, a common unrecognised issue in orthopaedic agreement studies: do CT scans really influence the agreement on treatment plans in fractures of the distal radius?

OBJECTIVES: Current studies on the additional benefit of using computed tomography (CT) in order to evaluate the surgeons' agreement on treatment plans for fracture are inconsistent. This inconsistency can be explained by a methodological phenomenon called 'spectrum bias', defined as the bias inherent when investigators choose a population lacking therapeutic uncertainty for evaluation. The aim of the study is to determine the influence of spectrum bias on the intra-observer agreement of treatment plans for fractures of the distal radius. METHODS: Four surgeons evaluated 51 patients with displaced fractures of the distal radius at four time points: T1 and T2: conventional radiographs; T3 and T4: radiographs and additional CT scan (radiograph and CT). Choice of treatment plan (operative or non-operative) and therapeutic certainty (five-point scale: very uncertain to very certain) were rated. To determine the influence of spectrum bias, the intra-observer agreement was analysed, using Kappa statistics, for each degree of therapeutic certainty. RESULTS: In cases with high therapeutic certainty, intra-observer agreement based on radiograph was almost perfect (0.86 to 0.90), but decreased to moderate based on a radiograph and CT (0.47 to 0.60). In cases with high therapeutic uncertainty, intra-observer agreement was slight at best (-0.12 to 0.19), but increased to moderate based on the radiograph and CT (0.56 to 0.57). CONCLUSION: Spectrum bias influenced the outcome of this agreement study on treatment plans. An additional CT scan improves the intra-observer agreement on treatment plans for a fracture of the distal radius only when there is therapeutic uncertainty. Reporting and analysing intra-observer agreement based on the surgeon's level of certainty is an appropriate method to minimise spectrum bias. Cite this article: Bone Joint Res 2015;4:190-194.

European Hernia Society guidelines on the closure of abdominal wall incisions

BACKGROUND: The material and the surgical technique used to close an abdominal wall incision are important determinants of the risk of developing an incisional hernia. Optimising closure of abdominal wall incisions holds a potential to prevent patients suffering from incisional hernias and for important costs savings in health care. METHODS: The European Hernia Society formed a Guidelines Development Group to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the materials and methods used to close the abdominal wall. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and methodological guidance was taken from Scottish Intercollegiate Guidelines Network (SIGN). The literature search included publications up to April 2014. The guidelines were written using the AGREE II instrument. An update of these guidelines is planned for 2017. RESULTS: For many of the Key Questions that were studied no high quality data was detected. Therefore, some strong recommendations could be made but, for many Key Questions only weak recommendations or no recommendation could be made due to lack of sufficient evidence. RECOMMENDATIONS: To decrease the incidence of incisional hernias it is strongly recommended to utilise a non-midline approach to a laparotomy whenever possible. For elective midline incisions, it is strongly recommended to perform a continuous suturing technique and to avoid the use of rapidly absorbable sutures. It is suggested using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique without separate closure of the peritoneum. A small bites technique with a suture to wound length (SL/WL) ratio at least 4/1 is the current recommended method of fascial closure. Currently, no recommendations can be given on the optimal technique to close emergency laparotomy incisions. Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients. For laparoscopic surgery, it is suggested using the smallest trocar size adequate for the procedure and closure of the fascial defect if trocars larger or equal to 10 mm are used. For single incision laparoscopic surgery, we suggest meticulous closure of the fascial incision to avoid an increased risk of incisional hernias.(AU)

European Hernia Society guidelines on the closure of abdominal wall incisions.

BACKGROUND: The material and the surgical technique used to close an abdominal wall incision are important determinants of the risk of developing an incisional hernia. Optimising closure of abdominal wall incisions holds a potential to prevent patients suffering from incisional hernias and for important costs savings in health care. METHODS: The European Hernia Society formed a Guidelines Development Group to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the materials and methods used to close the abdominal wall. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and methodological guidance was taken from Scottish Intercollegiate Guidelines Network (SIGN). The literature search included publications up to April 2014. The guidelines were written using the AGREE II instrument. An update of these guidelines is planned for 2017. RESULTS: For many of the Key Questions that were studied no high quality data was detected. Therefore, some strong recommendations could be made but, for many Key Questions only weak recommendations or no recommendation could be made due to lack of sufficient evidence. RECOMMENDATIONS: To decrease the incidence of incisional hernias it is strongly recommended to utilise a non-midline approach to a laparotomy whenever possible. For elective midline incisions, it is strongly recommended to perform a continuous suturing technique and to avoid the use of rapidly absorbable sutures. It is suggested using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique without separate closure of the peritoneum. A small bites technique with a suture to wound length (SL/WL) ratio at least 4/1 is the current recommended method of fascial closure. Currently, no recommendations can be given on the optimal technique to close emergency laparotomy incisions. Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients. For laparoscopic surgery, it is suggested using the smallest trocar size adequate for the procedure and closure of the fascial defect if trocars larger or equal to 10 mm are used. For single incision laparoscopic surgery, we suggest meticulous closure of the fascial incision to avoid an increased risk of incisional hernias.

Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients.

PURPOSE: In 2009, the European Hernia Society published the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. The guidelines expired January 1, 2012. To keep them updated, a revision of the guidelines was planned including new level 1 evidence. METHODS: The original Oxford Centre for Evidence-Based Medicine ranking was used. All relevant level 1A and level 1B literature from May 2008 to June 2010 was searched (Medline and Cochrane) by the Working Group members. All chapters were attributed to the two responsible authors in the initial guidelines document. One new chapter on fixation techniques was added. The quality was assessed by the Working Group members during a 2-day meeting and the data were analysed, especially with respect to any change in the level and/or text of any of the conclusions or recommendations of the initial guidelines. In the end, all relevant references published until January 1, 2013 were included. The final text was approved by all Working Group members. RESULTS: For the following topics, the conclusions and/or recommendations have been changed: indications for treatment, treatment of inguinal hernia, day surgery, antibiotic prophylaxis, training, postoperative pain control and chronic pain. The addendum contains all current level 1 conclusions, Grade A recommendations and new Grade B recommendations based on new level 1 evidence (with the changes in bold). CONCLUSIONS: Despite the fact that the Working Group responsible for it tried to represent most kinds of surgeons treating inguinal hernias, such general guidelines inevitably must be fitted to the daily practice of every individual surgeon treating his/her patients. There is no doubt that the future of guideline implementation will strongly depend on the development of easy to use decision support algorithms tailored to the individual patient and on evaluating the effect of guideline implementation on surgical outcome. At the 35th International Congress of the EHS in Gdansk, Poland (May 12-15, 2013), it was decided that the EHS, IEHS and EAES will collaborate from now on with the final goal to publish new joint guidelines, most likely in 2015.

Systematic review and meta-analysis on heavy and lightweight polypropylene mesh in Lichtenstein inguinal hernioplasty.

BACKGROUND: Recurrence and pain are the two most important outcomes after inguinal hernia surgery. The concept of lightweight or partially absorbable macroporous meshes was developed under the assumption that the observed pain rate could be decreased without increasing the number of recurrences. Few randomized trials were published to analyze their clinical value, and some concern was raised because of an increased risk of recurrence. A systematic review and a meta-analysis of RCTs were carried out to determine whether the use of lightweight meshes influenced the pain and recurrence rate after Lichtenstein hernioplasty. METHODS: To assess the value of the lightweight mesh, an extensive literature search was performed. The random-effect meta-analysis model was used to correct for clinical diversity and methodological variations between studies. Recurrence rate, aspects of chronic pain and foreign body feeling at 6-60 months postoperatively were assessed. RESULTS: Eight prospective RCTs of good quality were identified. Analysis demonstrated no significant difference regarding recurrence (OR, 1.11; 95 % CI, 0.57-2.14; p = 0.77). No significant difference was observed concerning severe pain (OR, 0.99; 95 % CI, 0.48-2.02; p = 0.97). Description of any pain resulted in a significant improvement in the lightweight group (OR, 0.65; 95 % CI, 0.50-0.84; p = 0.001). The presence of foreign body feeling was favoring the lightweight group (OR, 0.62; 95 % CI, 0.41-0.94; p = 0.02). CONCLUSIONS: The use of lightweight mesh did not neither increase the recurrence rate nor reduce the incidence of severe pain. A significant reduction in foreign body feeling and overall pain rate in the postoperative period was recorded. Lightweight meshes could be considered as a material of choice in primary inguinal hernioplasty.