Optimizing surgical management of abdominal wall hernias

In this thesis, two crucial advances in abdominal wall management are addressed: the importance of including patient-reported outcomes (PROs) while evaluating the management of incisional hernia; and the development of the first international groin hernia guideline. Chapter 2 describes several controversies in ventral hernia repair. Debate persists regarding the selection of patients, the variety of outcomes and length of follow-up. In light of the absence of a well-designed RCT and the ongoing debate about the expected advantages of laparoscopic incisional hernia repair, the INCisional Hernia-Trial (INCH-Trial) was designed. The INCH-trial compares outcomes of laparoscopic versus open incisional hernia repair. In total, 88 incisional hernia patients were randomized. Chapter 3 presents the short- and long-term outcomes. Primary outcome of the INCH-trial was length of hospital stay, which was 3 (range 1-36) days in the open group and 3 (range 1-12) days in the laparoscopic group (p = 0.481). In search of a simple and reliable method of follow-up after incisional hernia repair, the Post-INCisional-Hernia-repair-Phone (PINCH-Phone) was developed. The PINCH-Phone is a telephonic questionnaire of four questions with the aim the detect recurrences. Chapter 4 describes the results of the study. In total 210 patients after incisional hernia repair were called first and seen at the outer patient clinic afterwards. The overall sensitivity and specificity of the PINCH-Phone for the detection of recurrences were 82% and 38%, respectively. Although the PINCH-Phone was developed with the focus on recurrences as primary outcome, a sub-study was performed assessing PROs. Chapter 5 shows that 63% of patients after incisional hernia repair still report symptoms, such as feelings of discomfort, pain, and bulging, at 3 years follow-up. Ten percent of the patients in this sub-study of the PINCH-Phone would not undergo the operation if allowed to go back. International guidelines for the management of groin hernias were lacking. To that end, representatives of seven continental hernia societies started an initiative by the name ‘HerniaSurge.’ The goal of HerniaSurge was to develop a set of guidelines to improve groin hernia management worldwide. Chapter 6 includes the first chapter of the International guidelines for groin hernia management and describes the development process of the guideline. Despite several guideline instruments, the process of writing international guidelines is not standardized. HerniaSurge involved a diverse group of surgeons, representing five hernia societies. Experts from different regions, professional backgrounds, and perspectives collaboratively contributed to the guidelines, synthesizing their knowledge and experiences. The guideline development process is summarized in chapter 7. HerniaSurge organized several consensus meetings to study the level of agreement with the international guidelines among healthcare professionals worldwide. Chapter 8 describes the process and the results. Consensus was reached on 87% (40/46) of statements and recommendations. The high level of consensus provides a solid basis for standard groin hernia management. Disagreement on 13% of statements and recommendations provides valuable input for further studies. The HerniaSurge conferences provide a new method to study the adherence of the general surgical community to new guidelines and to gather research questions for further research.