Abstract
Since the introduction of anaesthesia by Morton in 1846, and as survivable abdominal surgery became more common, so did the incidence of incisional hernias. Since then, more than 4000 peer-reviewed articles have been published on the topic, many of which have tried to reduce the incidence or introduce techniques to improve outcomes from surgical repair. Despite this, the incidence of incisional hernias and the recurrence rates after repair remain high. A wide range of incisional hernia rates are reported. A meta-analysis including over 14 000 patients reported a weighted incidence of 12.8 per cent 2 years after a midline incision, and that one-third of patients with an incisional hernia undergo surgical repair. Recurrence rates after repair of incisional hernia range between 23 and 50 per cent, with increasing rates of complications and re-recurrence after each subsequent failed repair. Arguably, no other benign disease has seen so little improvement in terms of surgical outcome.
The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) published guidelines on laparoscopic ventral hernia repair (which included incisional hernia) in 2016. An expert-guided consensus for the management of all types of ventral hernias exists, and the World Society of Emergency Surgery (WSES) addressed emergency repairs of both primary ventral and incisional hernias. Similarly, the International EndoHernia Society (IEHS) published guidelines on the laparoscopic repair of both primary ventral and incisional hernias in 2014 and updated these in 2019. However, to date, no guidelines have been published exclusively focusing on the treatment of incisional hernias.
The focus of debate about incisional hernias is often about the more complex end of the spectrum, including large incisional hernias requiring a component separation or hernias occurring in incisions that are close to bony prominences (for example subcostal or flank hernias). Whilst these are important topics and certainly of interest, the authors wanted to focus these guidelines on the assessment and treatment of the most common incisional hernias faced by general surgeons and in primary care, and where the greatest body of evidence was likely to lie to be able to produce robust guideline recommendations. Therefore, these guidelines focus on midline incisional hernias in adult patients where it is anticipated that the fascial defect could be closed without performing an advanced technique such as a component separation, or any other adjunctive technique facilitating myofascial closure.