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Resumen Introduccion La hernia incisional (HI) es una complicacion frecuente. El objetivo principal de este estudio es comparar caracteristicas, complicaciones y recurrencias de las HI producidas por la colocacion de un trocar laparoscopico umbilical (M3T) con las de misma localizacion tras cirugia abierta (M3O); y de forma secundaria, la identificacion de factores de riesgo. Metodo Estudio observacional transversal analizando al registro EVEREG durante el periodo entre julio del 2012 y junio del 2018. Las variables principales fueron recurrencias y complicaciones postoperatorias. Se compararon ambos grupos (M3T y M3O). Se realizo regresion logistica multiple para identificar los factores de riesgo de la cohorte completa. Resultados Se incluyeron un total de 882 casos. El grupo M3O presento un ASA superior, HI con criterios de mayor complejidad para la reparacion, mayor numero de recurrencias a los 12 y 24 meses (8,6 vs. 2,5%; p Conclusiones Las HI M3 de trocar umbilical son menos complejas que las originadas por cirugia abierta. La complejidad no se relaciona con el origen de la hernia, sino con sus caracteristicas y las del paciente.

Purpose The small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by the guidelines to prevent incisional hernias (IHs) and fascial dehiscence (FD). Our aim was to implement a protocol combining both the techniques and to analyze its outcomes. Methods Prospective data of all EMLs were collected for 2 years. Results were analyzed at 1 month and during follow-up. The incidence of HI and FD was compared by groups (M = Mesh vs. S = suture) and by subgroups depending on using SB. Results A lower number of FD appeared in the M group (OR 0.0692; 95% CI 0.008–0.56; P = 0.01) in 197 operations. After a mean follow-up of 29.23 months (N = 163; min. 6 months), with a lower frequency of IH in M group (OR 0.769; 95% CI 0.65–0.91; P P P P Conclusion Following the protocol using PM and SB showed a lower rate of FD and HI. A PM is safe and effective for the prevention of both HI and FD after MLE, regardless of the closure technique used.

Objective: To inform the development of an AGREE II extension specifically tailored for surgical guidelines. Summary background data: AGREE II was designed to inform the development, reporting, and appraisal of clinical practice guidelines. Previous research has suggested substantial room for improvement of the quality of surgical guidelines. Methods: A previously published search in MEDLINE for clinical practice guidelines published by surgical scientific organizations with an international scope between 2008 and 2017, resulted in a total of 67 guidelines. The quality of these guidelines was assessed using AGREE II. We performed a series of statistical analyses (reliability, correlation and Factor Analysis, Item Response Theory) with the objective to calibrate AGREE II for use specifically in surgical guidelines. Results: Reliability/correlation/factor analysis and Item Response Theory produced similar results and suggested that a structure of 5 domains, instead of 6 domains of the original instrument, might be more appropriate. Furthermore, exclusion and re-arrangement of items to other domains was found to increase the reliability of AGREE II when applied in surgical guidelines. Conclusions: The findings of this study suggest that statistical calibration of AGREE II might improve the development, reporting, and appraisal of surgical guidelines.

Resumen Introduccion Los resultados de la reparacion de la hernia paraestomal (HP) basados en datos provenientes de registros son escasos. El objetivo del presente trabajo es analizar los datos recogidos sobre la HP en el Registro Nacional de Hernia Incisional (EVEREG) y asi evaluar las practicas actuales y resultados en la reparacion de una HP. Metodos Se analizan los datos de la cohorte de HP registradas en el periodo desde julio de 2012 hasta junio de 2018. Se analizan las complicaciones, recidivas y factores asociados a ellas de la cohorte completa de HP, independientemente del tipo de estoma al que se asocian. Posteriormente, se realiza el mismo analisis del grupo de HP con relacion a una colostomia (grupo mas numeroso). Resultados Se estudiaron 353 HP. De estas, 259 (73%) fueron HP en el contexto de una colostomia terminal, 74 (21%) en el de una ileostomia terminal y 20 (6%) en el de una ureteroileostomia (Bricker). La edad media global fue de 68,7 ± 11,1 anos y 135 (38%) pacientes fueron del sexo femenino. El abordaje abierto y la cirugia electiva fueron predominantes (78% y 92%, respectivamente). El 99% se reparo con una malla sintetica no absorbible. Las complicaciones postoperatorias globales fueron altas (30,6%), asi como la recurrencia global (27,5%) tras un seguimiento medio de 9,4 meses. Conclusiones La reparacion de la HP es poco frecuente comparada con el conjunto de reparaciones de la hernia incisional. La cirugia de la HP parece relacionarse con un porcentaje elevado de complicaciones postoperatorias y recidiva.

Background The closure technique of the abdominal wall is a key factor in the development of incisional hernia. Our aim was to implement a protocol for closure of median laparotomy, to evaluate the grade of implementation, as well as to assess the results and safety of the technique. Methods A series of formative activities to implement the small bites technique for closure of median laparotomy in elective operations were designed. After 1 year, a survey was conducted on knowledge and use of the technique. Prospective compilation of data of all median laparotomy in elective operations and their follow-up was done for 1 year. The incidence of incisional hernia depending on the fulfilment of the protocol was compared. Results A total of 74 surgeons participated in the activities. All the participants accomplished the technique perceiving low difficulty (1.9/10). After 1 year, 44 surgeons answered the survey; 95% stated that they knew the small bites technique and used it always or almost always, but only 52% performed the calculation of the suture length and the incision length ratio. A total of 114 median laparotomy in elective operations were analyzed; among them, 30.7% were closed with small bites presenting a lower frequency of incisional hernia and burst abdomen (small bites 3.6% vs large bites 12.1%; odds ratio 1.30; confidence interval, 0.992--1.711; P = .20). Conclusion The measures were effective for learning, but education alone was not enough to implement the technique in the real scenario. Small bites technique is reproducible, has no risks, and provides low incidence of incisional hernia. More incentives and actions are needed to improve laparotomy closure.

The objective was to assess the effectiveness and safety of a bioabsorbable mesh at the time of closure of a midline laparotomy for IH prevention. A multicenter, randomized clinical trial including patients undergoing abdominal surgical procedures through a midline laparotomy incision was designed. In the group of mesh (n = 167) the incision was closed using a continuous polydioxanone suture (PDS) plus a bioabsorbable mesh. In the control group (n = 165) a continuous PDS single layer suture was only used. Patients were randomly assigned (1:1) to the two groups. The primary outcome was the incidence of IH at 6, 12 and 24 months. Assessment of IH was done using a CT scan. At 6 months, the rates of IH were 15.2% and 24.8% in the experimental and control groups, respectively (relative risk [RR] 0.66, 95% confidence interval [CI] 0.38-0.98, P = 0.042). At 12 months, the rate of IH continued to be significantly lower in the experimental group (21.4% vs. 33.1%, P = 0.033), but at 24 months, there were no significant differences between the study groups with a follow-up rate of only 37.5%. The number needed to treat (NNT) was 11 and 9 at 6 and 12 months, respectively. The bioabsorbable mesh significantly prevented IH during the first year. Not reliable conclusions can be drawn across the second year. This may suggest that the any of the closing technique assessed in this study would have a “palliative” transient effect for preventing IH in the long-term.

Resumen La reparacion de la hernia ventral/incisional mediante cirugia minimamente invasiva asistida por robot ha aumentado exponencialmente en los ultimos anos. Este aumento probablemente este relacionado con las ventajas que aporta, destacando una mejor visualizacion, la implementacion de instrumentos articulados y la mejor ergonomia para el cirujano. La tecnica TARUP (Robotic Transabdominal Retromuscular Umbilical Prosthetic Hernia Repair) combina los beneficios de la cirugia minimamente invasiva asistida por robot con una menor morbilidad relacionada con la herida y la colocacion de una malla en posicion retromuscular.

Background The definition, classification and management of rectus diastasis (RD) are controversial in the literature and a variety of different surgical treatments have been described. This article reports on the European Hernia Society (EHS) Clinical Practice Guideline for RD. Method The Guideline group consisted of eight surgeons. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done in November 2018 and updated in November 2019 and October 2020. Nine Key Questions (KQs) were formulated. Results Literature reporting on the definition, classification, symptoms, outcomes and treatments was limited in quality, leading to weak recommendations for the majority of the KQs. The main recommendation is to define RD as a separation between rectus muscles wider than 2 cm. A new classification system is suggested based on the width of muscle separation, postpregnancy status and whether or not there is a concomitant hernia. Impaired body image and core instability appear to be the most relevant symptoms. Physiotherapy may be considered before surgical management. It is suggested to use linea alba plication in patients without concomitant hernia and a mesh-based repair of RD with concomitant midline hernias. Conclusion RD should be defined as a separation of rectus muscles wider than 2 cm and a new classification system is suggested.

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.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.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.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.

The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument was developed to evaluate the quality of clinical practice guidelines. Evidence suggests that development, reporting, and appraisal of guidelines on surgical interventions may be better informed by modification of the instrument.We aimed to develop an AGREE II extension specifically designed for appraisal of guidelines of surgical interventions.In a three-part project funded by the United European Gastroenterology and the European Association for Endoscopic Surgery, (i) we identified factors that were associated with higher quality of surgical guidelines, (ii) we statistically calibrated the AGREE II instrument in the context of surgical guidelines using correlation, reliability, and factor analysis, and (iii) we undertook a Delphi consensus process of stakeholders to inform the development of an AGREE II extension instrument for surgical interventions.Several features were prioritized by stakeholders as of particular importance for guidelines of surgical interventions, including development of a guideline protocol, consideration of practice variability and surgical expertise in different settings, and specification of infrastructures required to implement the recommendations. The AGREE-S-AGREE II extension instrument for surgical interventions has 25 items, compared to the 23 items of the original AGREE II instrument, organized into the following 6 domains: Scope and purpose, Stakeholders, Evidence synthesis, Development of recommendations, Editorial independence, and Implementation and update. As the original instrument, it concludes with an overall appraisal of the quality of the guideline and a judgement on whether the guideline is recommended for use. Several items were amended and rearranged among domains, and an item was deleted. The Rigor of Development domain of the original AGREE II was divided into Evidence Synthesis and Development of Recommendations. Items of the AGREE II domain Clarity of Presentation were incorporated in the new domain Development of Recommendations. Three new items were introduced, addressing the development of a guideline protocol, support by a guideline methodologist, and consideration of surgical experience/expertise.The AGREE-S appraisal instrument has been developed to be used for assessment of the methodological and reporting quality of guidelines on surgical interventions.

Our main goal is to describe how to start and develop a multicenter, prospective, randomized, controlled trial. The first step is to have an idea that will become the hypothesis and a main objective. A bibliographic search should be done to check for clinical interest and originality. Moreover, the study must be feasible and should be finished within 4 years. In order to start the multicenter study, a protocol should be written (in accordance with the SPIRIT guidelines Standard Protocol items: Recommendations for Interventional Trials), including the design type, sample size and participating hospitals. Randomization is key to the design and, therefore, the CONSORT (Consolidated Standards of Reporting Trials) guidelines must be followed. However, if the study cannot be randomized, the TREND (Transparent Reporting of Evaluations with Non-Randomized Designs) guidelines are recommended. When the protocol is approved by the Ethics Committee for Clinical Investigation of the hospital, we ought to create visibility. It is suggested to register the trial on ClincalTrials.gov and submit its publication to indexed magazines. Financial resources are necessary to execute the study and maintain an online database. This allows the registry to be updated and accessible to all the participants in the study. What is more, randomization can be done immediately. And last, but not least, is motivation. Multicentricity equals to participation of all the chosen medical centers. Updating and motivating them by sending a newsletter every 1-3 months keeps participants engaged in the study.

Resumen El objetivo de este articulo es ilustrar como poner en marcha y desarrollar un estudio multicentrico prospectivo, controlado y aleatorizado. Por ello, lo primero que se necesita es crear una idea que genere una hipotesis y un objetivo principal. La busqueda bibliografica nos permite ver su relevancia clinica y las evidencias publicadas. Ademas, hay que plantearse si el estudio es viable economicamente y si puede ser completado en un periodo menor a 4 anos. Una vez ideado el estudio multicentrico, para ejecutarlo se debe redactar un protocolo (segun la guia Standard Protocol items: Recommendations for Interventional Trials [SPIRIT 2013]). En el se recogeran el tipo de diseno, el tamano muestral y los centros que participaran. La aleatorizacion es clave en el diseno. Si puede ser aleatorizado, se recomienda utilizar la guia Consolidated Standards of Reporting Trials (CONSORT), si no, la Transparent Reporting of Evaluations with Non-Randomized Designs (TREND). Cuando el protocolo es aprobado por el Comite Etico de Investigacion Clinica del hospital, hay que darle visibilidad. Es por eso que se recomienda su registro en ClincalTrials.gov y su publicacion en revistas indexadas. Para el inicio del estudio, se requiere buscar fuentes de financiacion. Estas permiten tener una base de datos on line, que permiten aleatorizar al momento y mantener el registro al dia desde cualquier centro. Por ultimo, hay que destacar que es imprescindible la motivacion. La multicentricidad solo se entiende si todos los centros participan. Asi que informar de resultados y dar animos cada 1-3 meses (en forma de newsletter) es una manera de conseguir un buen funcionamiento del estudio.

Resumen Las revisiones sistematicas con metaanalisis son pruebas esenciales para resumir de manera fiable la eficacia de las intervenciones sanitarias. Un metaanalisis basado exclusivamente en un pequeno numero de ensayos a menudo no sera concluyente o puede aportar resultados positivos falsos. La estimacion del tamano optimo de la informacion (OIS) puede reducir el riesgo de obtener resultados falsos positivos y determinar si se requieren ensayos clinicos adicionales. El calculo del OIS tiene similitudes con el realizado para calcular el tamano de la muestra de un ensayo clinico. El numero requerido de participantes para el metaanalisis debe ser al menos tan grande como un solo ensayo con la potencia adecuada. El concepto del OIS proporciona un marco estadistico en el que la informacion acumulada es convincente para indicar si se necesitan mas ensayos clinicos para abordar los efectos de la intervencion.

Systematic reviews with meta-analysis are essential tools to reliably summarize the effectiveness of health interventions. A meta-analysis based exclusively on a small number of trials will often not be conclusive or may yield false positive results. The estimation of the OIS — optimal information size — can reduce the risk of obtaining false positive results and determine if additional clinical trials are required. The estimation of the OIS is very similar to that used to estimate the sample size of a clinical trial. The required number of participants for the meta-analysis should be at least as large as a single trial with adequate power. The OIS concept provides a statistical framework in which the accumulated information is convincing to indicate whether more clinical trials are needed to address the effects of the intervention.

Aim Small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by guidelines to prevent incisional hernias (IHs) and burst abdomen (BA). Our aim was to implement a protocol combining both and to analyze its outcomes. Material and Methods Prospective data collection of all EMLs for one year. Results were analyzed at one month and during follow-up. The incidence of IH and BA was compared by groups depending on the use of a PM (M Group) or not (S Group), and in subgroups related to the closure technique: SB (Subgroups MSB and SSB) or not (Subgroups MLB and MSB). Results A lower number of BA was diagnosed in the M group (OR 0.0692; CI95% 0.008-0.56; P = 0.01) in 197 operations. 163 patients completed a mean follow-up of 29.23 months, with a lower frequency of IH in M group patients (OR = 0.769; CI 95% 0.65 - 0.91; P Conclusions A PM is the most powerful tool for prevention both IH and BA after EMLs, regardless of the closure technique in patients at high-risk for IHs.

Aim Aim of our study was to analyze outcomes and safety of bilateral inguinal hernia repair in unilateral groin complicated hernia with contralateral groin hernia. Material and Methods Retrospective cohorts study following STROBE statements on a prospective Emergency Surgery Department database. Inclusion criteria were: patients with emergency hernia repair from 2008 to 2018, 18 years old. Unilateral or bilateral inguinal hernia repair without other abdominal wall hernia repairs. Comparative analysis between two group unilateral hernia repair (UH) vs bilateral hernia repair (BH) those patients with unilateral complicated inguinal hernia with contralateral inguinal hernia. Propensity score matching (PSM) between groups was performed to eliminate statistically groups differences. Outcomes between groups were analyzed with special attention to postoperative morbimortality and hernia recurrence. Results 341 patients were included, 38(11.1%) were performed bilateral hernia repair. Groups differences were: higher rate of inguinoscrotal inguinal hernia (36.8 vs 22.8), prophylactic antibiotics use (94.7 vs 81.8) and general Anesthesia use (52.6% vs 50.2%). General high rates of morbidity and mortality were observed (5.9% and 41.9) and 22 (6.5%) hernia repair recurrence were detected. After PSM no differences between surgery outcomes groups were observed with similar morbidity, recurrence or hospital stay. Conclusions Emergency inguinal hernia repair has high morbidity and mortality rates in our experience. Emergency Bilateral inguinal hernia repair in context of hernia complication seems safe without recurrence or hospital stay increase.

Aim The objective of this study was to gather information on patient-reported knowledge (PRK) in the field of hernia surgery. Material and Methods A prospective quantitative study was designed to explore different aspects of PRK and opinions regarding hernia surgery. Patients referred for the first time to a surgical service with a presumed diagnosis of hernia and eventual hernia repair were eligible, and those who gave consent completed a simple self-assessment questionnaire before the clinical visit. Results The study population included 449 patients (72.8% men, mean age 61.5). Twenty (4.5%) patients did not have hernia on physical examination. The patient’s perceived health status was “neither bad nor good” or “good” in 56.6% of cases. Also, more patients considered that hernia repair would be an easy procedure (35.1%) rather than a difficult one (9.8%). Although patients were referred by their family physicians, 32 (7.1%) answered negatively to the question of coming to the visit to assess the presence of a hernia. The most important reason of the medical visit was to receive medical advice (77.7%), to be operated on as soon as possible (40.1%) or to be included in the surgical waiting list (35.9%). Also, 46.1% of the patients considered that they should undergo a hernia repair and 56.8% that surgery will be a definitive solution. Conclusions PRK of patients referred for the first time to an abdominal wall surgery unit with a presumed diagnosis of hernia was quite limited and there is still a long way towards improving knowledge of hernia surgery.

An ostomy is a surgical procedure by which an artificial opening in the abdominal wall, known as a stoma, is created. We assessthe effects of stoma location on the abdominal wall mechanics. We perform three–dimensional finite element simulations on ananatomy model which was generated on the basis of medical images. Our simulation methodology is entirely based on opensource software. We consider seventeen different locations for the stoma incision (trephine) and we simulate the mechanicalresponse of the abdominal wall when an intraabdominal pressure as high as 20 kPa is applied. We focus on factors relatedto the risk of parastomal hernia development such as the deformation experienced by the abdominal wall, the stress levelssupported by its tissues and the corresponding level of trephine enlargement.No significant dependence was found between stoma location and the levels of abdominal wall deformations or stress supportedby tissues, except for the case with a stoma located on the linea alba. Trephine perimeter and area respectively increased byas much as 44% and 85%. The level of trephine deformation depends on stoma location with considerably higher trephineenlargements found in stomas laterally located with respect to the rectus abdominis muscle.

Information about surgeons' attitudes toward using prophylactic mesh (PM) for parastomal hernia (PSH) prevention is limited. PURPOSE A survey was conducted to assess attitudes/beliefs and surgical practice related to PM use for preventing PSH. METHODS A cross-sectional email survey was conducted during April 2017 among members (surgeons) of the American Hernia Society, European Hernia Society, and International Hernia Collaboration. Survey items included participant demographic characteristics, knowledge about the incidence of PSH, number of permanent stomas created annually, beliefs/opinions (knowledge/interest) regarding the use of PM, and surgical practices (mesh type and position). Data were collected and tallied using SurveyMonkey. Descriptive statistics were used to analyze the data. RESULTS Of the 5445 emails sent, 497 responses were received, 235 (47.3%) from the United States and 197 (39.6%) from Europe. The majority of participants were general surgeons (371, 74.6%); a small percentage were colorectal surgeons (37, 7.4%). Most respondents (353, 71.0%) reported at least 11 years of surgical experience, with 37.3% reporting >20 years' experience. The majority of respondents (340, 68.4%) created

Background: Surgical site infections (SSIs) remains a concern for surgeons because of the negative impact on outcomes and health care costs. Our purpose was to assess whether topical antibiotics before primary incision closure reduced the rate of SSIs. Methods: Systematic review of MEDLINE/PubMed, Scopus, CINAHL, and Web of Science databases from inception to January 2017. Only randomized controlled trials (RCTs) were retrieved. The primary outcome was the SSI rate. Meta-analysis was complemented with trial sequential analysis (TSA). Results: Thirty-five RCTs (10,870 patients) were included. Only β-lactams and aminoglycosides were used. A substantial reduction of the incidence of SSIs with the application of antibiotic agents before incision closure (risk ratio [RR] 0.49, 95% confidence interval [CI] 0.37-0.64) was found, which remained in the analysis of 12 RCTs after removal of studies of uncertain quality. The use of β-lactams was effective to reduce SSI in elective surgery only (RR 0.33, 95% CI 0.13-0.85). In clean-contaminated fields and as an irrigation solution, β-lactams did not reduce the risk of SSI. Aminoglycosides were not effective (RR 0.74, 95% CI 0.49-1.10). After TSA, the evidence accumulated was far below the optimal information size. The heterogeneity of studies was high and methodological quality of most RCTs included in the meta-analysis was uncertain. Conclusions: Results of this meta-analysis show the data present in the literature are not sufficiently robust and, therefore, the use of topical β-lactams or aminoglycosides before incision closure to reduce SSI cannot be recommended or excluded.