Certified Fellowship in Abdominal Wall Surgery-A Collaboration Between the UEMS and the European Hernia Society.

Background: Abdominal wall surgery (AWS) is characterised by the increasing caseload and the complexity of the surgical procedures. The introduction of a tailored approach to AWS utilising laparoendoscopic, robotic and/or open techniques requires the surgeon to master several surgical techniques. All of which have an associated learning curve, and the necessary knowledge/experience to know which operation is the right one for the individual patient. However, the reality in general surgery training shows that training in just a limited number of procedures is not enough. By the end of general surgery training, many chief residents do not feel they are yet ready to carry out surgery independently. Therefore, hernia surgery experts and societies have called for the introduction of a Fellowship in Abdominal Wall Surgery. Methods: The UEMS (Union Européenne des Médecins Spécialistes, European Union of Medical Specialists) in collaboration with the European Hernia Society (EHS) introduced a fellowship by examination in 2019. As a prerequisite, candidates must complete further training of at least 2 years with a special focus on abdominal wall surgery after having completed their training in general surgery. To be eligible for the examination, candidates must provide evidence of having performed 300 hernia procedures. In addition, candidates must have accrued sufficient "knowledge points" by attending abdominal wall surgery congresses, courses and clinical visitations, and engaged in scientific activities. On meeting the requirements, a candidate may be admitted to the written and oral examination. Results: To date, three examinations have been held on the occasion of the Annual Congress of the European Hernia Society in Copenhagen (2021), Manchester (2022) and Barcelona (2023). Having met the requirements, 48 surgeons passed the written and oral examination and were awarded the Fellow European Board of Surgery-Abdominal Wall Surgery certificate. During this time period, a further 25 surgeons applied to sit the examination but did not fulfil all the criteria to be eligible for the examination. Fifty experienced abdominal wall surgeons applied to become an Honorary Fellow European Board of Surgery-Abdominal Wall Surgery. Fourty eight were successful in their application. Conclusion: The Fellowship of the European Board of Surgery - Abdominal Wall Surgery by examination has been successfully introduced at European level by the joint work of the UEMS and the EHS. The examination is also open to surgeons who work outside the European area, if they can fulfil the eligibility criteria.

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.

Nonpharmaceutical interventions reduce the incidence and mortality of COVID-19: A study based on the survey from the International COVID-19 Research Network (ICRN).

The recently emerged novel coronavirus, "severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)," caused a highly contagious disease called coronavirus disease 2019 (COVID-19). It has severely damaged the world's most developed countries and has turned into a major threat for low- and middle-income countries. Since its emergence in late 2019, medical interventions have been substantial, and most countries relied on public health measures collectively known as nonpharmaceutical interventions (NPIs). We aimed to centralize the accumulative knowledge of NPIs against COVID-19 for each country under one worldwide consortium. International COVID-19 Research Network collaborators developed a cross-sectional online survey to assess the implications of NPIs and sanitary supply on the incidence and mortality of COVID-19. The survey was conducted between January 1 and February 1, 2021, and participants from 92 countries/territories completed it. The association between NPIs, sanitation supplies, and incidence and mortality were examined by multivariate regression, with the log-transformed value of population as an offset value. The majority of countries/territories applied several preventive strategies, including social distancing (100.0%), quarantine (100.0%), isolation (98.9%), and school closure (97.8%). Individual-level preventive measures such as personal hygiene (100.0%) and wearing facial masks (94.6% at hospitals; 93.5% at mass transportation; 91.3% in mass gathering facilities) were also frequently applied. Quarantine at a designated place was negatively associated with incidence and mortality compared to home quarantine. Isolation at a designated place was also associated with reduced mortality compared to home isolation. Recommendations to use sanitizer for personal hygiene reduced incidence compared to the recommendation to use soap. Deprivation of masks was associated with increased incidence. Higher incidence and mortality were found in countries/territories with higher economic levels. Mask deprivation was pervasive regardless of economic level. NPIs against COVID-19 such as using sanitizer, quarantine, and isolation can decrease the incidence and mortality of COVID-19.

The Impact of the COVID-19 Pandemic on Hernia Surgery: The South-East Scotland Experience.

Aim The coronavirus disease 2019 (COVID-19) pandemic resulted in a lockdown in South East Scotland on 23 March 2020. This had an impact on the volume of benign elective surgery able to be undertaken. The degree to which this reduced hernia surgery was unknown. The aim of this study was to review the hernia surgery workload in the Lothian region of Scotland and assess the impact of COVID-19 on hernia surgery. Methods The Lothian Surgical Audit database was used to identify all elective and emergency hernia operations over a six-month period from 23 March 2020 and for the same time period in 2019. Data were collected on age, gender, anatomical location of the hernia, hernia repair technique, and whether elective or emergency operation. Statistical analysis was performed using the chi-squared test in R-Studio, with a p-value of <0.05 accepted as statistically significant. Results The total number of hernia repairs reduced considerably between 2019 and 2020 (570 vs 149). The majority of this can be explained by a decrease in elective operating (488 vs 87), with the percentage of elective repairs reducing significantly from 85.6% to 58.4% (p<0.001). The inguinal hernia subgroup had a 24% rise in emergency operations from 21 to 26 operations, despite a reduction from 270 to 84 total inguinal repairs. There were just two elective hernia repairs carried out in the first three months of the 2020 study period (5.6% of all operations for April-June) compared to 265 (87.7%) for the same period in 2019 (p<0.001). No statistically significant differences were observed in the rates of laparoscopic versus open operating techniques across the two study periods on any analysis. The age and gender of the patients were similar over the two time periods. Conclusion The COVID-19 pandemic led to a marked reduction in the number of elective hernia repairs (especially incisional hernia surgery), with the effect most pronounced over the first three months of lockdown. Despite an overall reduction in total emergency operative figures, possibly due to more widespread use of non-operative strategies, there was still an increase in emergency inguinal hernia repairs during the lockdown. Further studies are needed to evaluate if the delays to elective operating will result in a long-term increase in the rates of emergency presentation.

Leveraging Twitter and its Unique #HashTag Capability: A Novel Social Media Resource From the European Hernia Society.

Background: Digital and Social Media (#SoMe) platforms have revolutionized the way information is shared, classified and accessed among medical professionals worldwide. The aim of this study was to review the hashtags used on Twitter by @EuroHerniaS to provide a practical roadmap for easier social media utilization for hernia surgery stakeholders. Methods: The hashtags used in tweets and retweets of the @EuroHerniaS Twitter feed were collated since its foundation in November 2016. Results: The first hashtag used was #HerniaSurgery. Since foundation to July 2021, the @EuroHerniaS Twitter feed has used 90 separate hashtags. The number of new hashtags per year was increasing leading to the development of an online library. The increasing diversity of hernia related hashtags allows for the more detailed posting and searching of hernia related information on the #SoMe platform Twitter. Conclusion: The more detailed use of hashtags on Twitter is to be encouraged. Hernia surgeons can make use of them both when posting and reviewing posts to aid the categorization of posts.

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.

Patient Views Around Their Hernia Surgery: A Worldwide Online Survey Promoted Through Social Media.

Introduction: Hernias are one of the most common surgical diagnoses, and general surgical operations are performed. The involvement of patients in the decision making can be limited. The aim of this study was to explore the perspectives of patients around their hernia and its management, to aid future planning of hernia services to maximise patient experience, and good outcomes for the patient. Methods: A SurveyMonkey questionnaire was developed by patient advocates with some advice from surgeons. It was promoted on Twitter and Facebook, such as all found "hernia help" groups on these platforms over a 6-week period during the summer of 2020. Demographics, the reasons for seeking a hernia repair, decision making around the choice of surgeon, hospital, mesh type, pre-habilitation, complications, and participation in a hernia registry were collected. Results: In total, 397 questionnaires were completed in the study period. The majority of cases were from English speaking countries. There was a strong request for hernia specialists to perform the surgery, to have detailed knowledge about all aspects of hernia disease and its management, such as no operation and non-mesh options. Chronic pain was the most feared complication. The desire for knowledge about the effect of the hernia and surgery on the sexual function in all age groups was a notable finding. Pre-habilitation and a hernia registry participation were well-supported. Conclusions: Hernia repair is a quality of life surgery. Whether awaiting surgery or having had surgery with a good or bad outcome, patients want information about their condition and treatment, such as the effect on aspects of life, such as sex, and they wish greater involvement in their management decisions. Patients want their surgery by surgeons who can also manage complications of such surgery or recommend further treatment. A large group of "hernia surgery injured" patients feel abandoned by their general surgeon when complications ensue.

A polypropylene mesh modified with poly-ε-caprolactone nanofibers in hernia repair: large animal experiment.

PURPOSE: Incisional hernia repair is an unsuccessful field of surgery, with long-term recurrence rates reaching up to 50% regardless of technique or mesh material used. Various implants and their positioning within the abdominal wall pose numerous long-term complications that are difficult to treat due to their permanent nature and the chronic foreign body reaction they trigger. Materials mimicking the 3D structure of the extracellular matrix promote cell adhesion, proliferation, migration, and differentiation. Some electrospun nanofibrous scaffolds provide a topography of a natural extracellular matrix and are cost effective to manufacture. MATERIALS AND METHODS: A composite scaffold that was assembled out of a standard polypropylene hernia mesh and poly-ε-caprolactone (PCL) nanofibers was tested in a large animal model (minipig), and the final scar tissue was subjected to histological and biomechanical testing to verify our in vitro results published previously. RESULTS: We have demonstrated that a layer of PCL nanofibers leads to tissue overgrowth and the formation of a thick fibrous plate around the implant. Collagen maturation is accelerated, and the final scar is more flexible and elastic than under a standard polypropylene mesh with less pronounced shrinkage observed. However, the samples with the composite scaffold were less resistant to distracting forces than when a standard mesh was used. We believe that the adverse effects could be caused due to the material assembly, as they do not comply with our previous results. CONCLUSION: We believe that PCL nanofibers on their own can cause enough fibroplasia to be used as a separate material without the polypropylene base, thus avoiding potential adverse effects caused by any added substances.

Contemporary concepts in hernia prevention: Selected proceedings from the 2017 International Symposium on Prevention of Incisional Hernias.

Incisional hernia is a frequent complication of midline laparotomy and enterostomal creation and is associated with high morbidity, decreased quality of life, and high costs. The International Symposium on Incisional Hernia Prevention was held October 19-20, 2017, at the InterContinental Hotel in San Francisco, CA, hosted by the Department of Surgery, University of California, San Francisco. One hundred and three attendees included general and plastic surgeons from 9 countries, including principal participants for several of the seminal studies in the field. Over the course of the 2-day meeting, there were 38 oral presentations, 3 keynote lectures, and 2 panel discussions. The Symposium was a combination of new information but also a comprehensive review of the existing data so as to assess the current state of the field and to set the stage for future research. Further, the Symposium sought to increase awareness and thus emphasize the importance of preventing the formation of incisional and enterostomal hernias.

Significant improvement of biocompatibility of polypropylene mesh for incisional hernia repair by using poly-ε-caprolactone nanofibers functionalized with thrombocyte-rich solution.

Incisional hernia is the most common postoperative complication, affecting up to 20% of patients after abdominal surgery. Insertion of a synthetic surgical mesh has become the standard of care in ventral hernia repair. However, the implementation of a mesh does not reduce the risk of recurrence and the onset of hernia recurrence is only delayed by 2-3 years. Nowadays, more than 100 surgical meshes are available on the market, with polypropylene the most widely used for ventral hernia repair. Nonetheless, the ideal mesh does not exist yet; it still needs to be developed. Polycaprolactone nanofibers appear to be a suitable material for different kinds of cells, including fibroblasts, chondrocytes, and mesenchymal stem cells. The aim of the study reported here was to develop a functionalized scaffold for ventral hernia regeneration. We prepared a novel composite scaffold based on a polypropylene surgical mesh functionalized with poly-ε-caprolactone (PCL) nanofibers and adhered thrombocytes as a natural source of growth factors. In extensive in vitro tests, we proved the biocompatibility of PCL nanofibers with adhered thrombocytes deposited on a polypropylene mesh. Compared with polypropylene mesh alone, this composite scaffold provided better adhesion, growth, metabolic activity, proliferation, and viability of mouse fibroblasts in all tests and was even better than a polypropylene mesh functionalized with PCL nanofibers. The gradual release of growth factors from biocompatible nanofiber-modified scaffolds seems to be a promising approach in tissue engineering and regenerative medicine.

Abdominal closure reinforcement by using polypropylene mesh functionalized with poly-ε-caprolactone nanofibers and growth factors for prevention of incisional hernia formation.

Incisional hernia affects up to 20% of patients after abdominal surgery. Unlike other types of hernia, its prognosis is poor, and patients suffer from recurrence within 10 years of the operation. Currently used hernia-repair meshes do not guarantee success, but only extend the recurrence-free period by about 5 years. Most of them are nonresorbable, and these implants can lead to many complications that are in some cases life-threatening. Electrospun nanofibers of various polymers have been used as tissue scaffolds and have been explored extensively in the last decade, due to their low cost and good biocompatibility. Their architecture mimics the natural extracellular matrix. We tested a biodegradable polyester poly-ε-caprolactone in the form of nanofibers as a scaffold for fascia healing in an abdominal closure-reinforcement model for prevention of incisional hernia formation. Both in vitro tests and an experiment on a rabbit model showed promising results.