Guideline sources The following summarized guidelines for the evaluation and management of incisional hernia are prepared by our editorial team based on guidelines from the European Hernia Society (EHS/AHS 2022), the International Endohernia Society (IEHS 2019), and the World Society of Emergency Surgery (WSES 2017). 1 2 3 Guidelines 1. Classification and risk stratification Risk factors: Recognize that incisional hernia formation results from a combination of factors, such as: patient comorbidities genetics anatomy health-related behaviors immunosuppressive medications surgical technique soft tissue healing https://web.pathway.md/diseases/recJDQmrSnHfinNWY 1/4 6/24/23, 2:28 PM Incisional hernia Pathway soft tissue healing surgical site infection. E Insufficient evidence to recommend a universal or standard definition of what constitutes a high- risk patient, as risk varies significantly across procedures and specialties. Take into consideration risk relative to a specific procedure and specialty. I Classification: use the EHS classification for ventral and incisional hernias. B 2. Diagnostic investigations Evaluation for bowel strangulation: assess for systemic inflammatory response syndrome, obtain contrast-enhanced CT, serum lactate, creatinine phosphokinase, and D-dimer to assess for bowel strangulation. B 3. Perioperative care Antibiotic prophylaxis: administer short-term antimicrobial prophylaxis in patients with intestinal incarceration with no evidence of ischemia and no bowel resection (CDC wound class I). B Show 2 more 4. Surgical interventions Indications for emergency repair: As per IEHS 2019 guidelines: Consider repairing enterotomy followed by a mesh repair of the hernia in patients with recognized bowel injury, without significant enteric fluid leakage. C Consider repairing the hernia laparoscopically after 5-7 days in the absence of signs of infection if there is a conversion to open surgery to repair the enterotomy. C As per WSES 2017 guidelines, perform emergency hernia repair immediately when intestinal strangulation is suspected. B Show 2 more Technical considerations for surgery: decide on the choice between a cross-linked and a non- cross-linked biological mesh depending on the defect size and degree of contamination. Consider using either polyglactin mesh or open wound management with delayed repair as a viable alternative if a biological mesh is not available. B Show 3 more 5. Specific circumstances Patients with obesity: https://web.pathway.md/diseases/recJDQmrSnHfinNWY 2/4 6/24/23, 2:28 PM Incisional hernia Pathway Prefer the laparoscopic approach due to its lower wound infection and wound complication rates in patients with obesity presenting with a ventral or incisional hernia. A Consider undertaking additional technical steps (greater mesh fixation, more overlap, suture closure of the defect) when using the laparoscopic approach in patients with obesity, as they are at increased risk of recurrence. C 6. Preventative measures Incision techniques (surgical approach): Recognize that there is a decreased risk of both incisional hernia and surgical site occurrences in patients undergoing laparoscopic operations compared with open operations. E Consider performing laparoscopic surgery when safe and feasible to reduce the risk of incisional hernia and surgical site occurrence. C Incision techniques (incision type): Recognize that midline incisions have the highest rate of incisional hernia, including smaller incisions such as specimen extraction sites. Insufficient evidence regarding surgical site occurrence, pain, abdominal wall function, or cosmesis. E Avoid performing midline incisions for laparotomies and specimen extraction sites to reduce the risk of incisional hernia. D Abdominal closure techniques (trocar site closure): Insufficient evidence regarding trocar site closure. Recognize that the risk of developing a trocar site hernia is increased for trocar sites of 10 mm, single-incision laparoscopic surgery trocars, and trocars placed at the umbilical site. Insufficient evidence to recommend fascial closure at the trocar site for the prevention of trocar site hernia. Insufficient evidence regarding surgical site complications and pain. Insufficient evidence to recommend optimal closure technique or material. I Consider suturing the fascial defect for trocar sites of 10 mm, especially after single-incision laparoscopic surgery and for trocars located at the umbilical site. C Abdominal closure techniques (laparotomy closure): Insufficient evidence to recommend a specific suture material or continuous versus interrupted technique. Consider using the combination of a continuous small bites suturing technique with a slowly absorbable suture to reduce the risk of incisional hernia. I Consider using a continuous small bites suturing technique with a slowly absorbable suture to close elective midline incisions. C Prophylactic mesh augmentation: perform mesh augmentation after suture closure of a midline abdominal incision to reduce the rate of incisional hernia compared with primary suture closure. Recognize that there is no increased risk of surgical site infection. Insufficient evidence regarding burst abdomen and postoperative pain. Insufficient evidence regarding mesh augmentation versus primary suture closure of non-midline abdominal incisions. E Show 3 more https://web.pathway.md/diseases/recJDQmrSnHfinNWY 3/4 6/24/23, 2:28 PM Incisional hernia Pathway Postoperative abdominal binders: Insufficient evidence regarding the burst abdomen, incisional hernia, or surgical site occurrences related to using postoperative binders after open abdominal surgery. Insufficient evidence to suggest that abdominal binders reduce postoperative pain without compromising pulmonary function. I Insufficient evidence to recommend for or against the use of postoperative binders. I Postoperative activity restrictions: insufficient evidence to recommend restriction of activity after open abdominal surgery. I References 1. Bittner R, Bain K, Bansal VK et al. Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias. Surg Endosc. 2019 Oct;33 10 3069 3139. Open 2. Eva B Deerenberg, Nadia A Henriksen, George A Antoniou et al. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. Br J Surg. 2022 Nov 22;109 12 1239 1250. Open 3. Arianna Birindelli, Massimo Sartelli, Salomone Di Saverio et al. 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg. 2017 Aug 7;12 37. Open 4. Gianfranco Silecchia, Fabio Cesare Campanile, Luis Sanchez et al. Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines [corrected]. Surg Endosc. 2015 Sep;29 9 2463 84. Open https://web.pathway.md/diseases/recJDQmrSnHfinNWY 4/4