Section 1:  Prevention of incisional hernia:

·       We recommend that all midline laparotomies should be closed with non-absorbable or long-term absorbable sutures, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾). 

·       We advise closing all midline laparotomies with a small bite continuous technique achieving a wound to suture length ratio of at least 4:1. Prophylactic mesh may be advised in high-risk patients, (Conditional recommendation, high certainty evidence, ⁽¹⁸⁾).

Section 2: Indications for surgery:

·       We recommend that the decision for surgery in patients with asymptomatic hernias should individualized based on patient risk, co-morbidities, life expectancy and type of hernia, (Strong recommendation, high certainty evidence, (18)).

·       We recommend repair for all symptomatic hernias, unless there are contra-indications to surgery or anesthesia, (Strong recommendation, high certainty evidence, (18)). 

·       We recommend performing emergency surgery for strangulated hernia without delay, aiming for the simplest procedure with the lowest complication rate, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾). 

·       Where technically feasible laparoscopic ventral hernia surgery is the preferred and       advised approach for patients with BMI >35kg/m², (Conditional recommendation, high certainty evidence, ⁽¹⁸⁾).   

·       We advise performing laparoscopic repair in the setting of incarcerated or strangulated hernias. The risk reduction in SSI rates is noted though the surgeon's experience will dictate the approach, (Conditional recommendation, moderate certainty evidence, ⁽¹⁸⁾).   

·       We recommend performing concurrent umbilical hernia repair during laparoscopic cholecystectomy, (Strong recommendation, moderate certainty evidence, ⁽¹⁸⁾).   

·       We advise performing umbilical hernia repair with mesh as a concurrent procedure when performing laparoscopic groin hernia repair, (Conditional recommendation, low certainty evidence, ⁽¹⁸⁾).   

·       We advise performing concomitant repair of an incisional or ventral hernia as a single stage procedure during bariatric surgery, (Conditional recommendation, moderate certainty evidence, ⁽¹⁸⁾).   

·       In patients with liver disease, we advise performing an early elective mesh repair of umbilical hernia. Preoperative control of ascites is especially critical to a successful outcome, (Conditional recommendation, moderate certainty evidence, ⁽¹⁸⁾). 

·       We advise performing mesh repair for hernia at the time of Caesarean Section, (Conditional recommendation, moderate certainty evidence, ⁽¹⁸⁾). 

·       We recommend repairing rectus diastasis accompanied by a midline hernia during the hernia repair, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾).    

Section 3: Perioperative management:

·       We recommend administration of a single dose preoperative prophylactic antibiotic before hernia repair, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾).   

·       We recommend the general surgical principles of DVT prophylaxis before the hernia repair, (Strong recommendation, moderate certainty evidence, ⁽¹⁸⁾). 

·       Care should be taken to optimize the patient both medically and surgically preoperatively in order to ensure the best surgical and anesthetic outcome, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾).    

Section 4: Use of mesh:

·       A minimum overlap of 5 cm before defect closure should be planned in all mesh repairs, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾).   

·       We recommend performing extra-peritoneal repairs in ventral hernia with plain large pore polypropylene or polyester mesh, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾).   

·       We recommend performing intraperitoneal mesh repairs with a composite barrier mesh or strand coated anti-adhesion mesh, (Strong recommendation, moderate certainty evidence, ⁽¹⁸⁾). 

·       We do not advise the use of polypropylene mesh in grade 3A wounds, as it carries a high risk for septic complications, (Conditional recommendation, moderate certainty evidence, ⁽¹⁸⁾), (table 7). 

·       There is no evidence to support the routine use of biologic meshes. We may advise the use of biologics or delayed fully re-absorbable meshes in grade 3A and 3B wounds, (Conditional recommendation, Low certainty evidence, ⁽¹⁸⁾). 

·       We recommend performing every incisional hernia with a mesh repair because there is a significantly lower recurrence rate, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾). 

·       We recommend performing mesh repair for primary ventral hernias with a defect greater than 2 cm, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾).   

·       For primary hernias less than 2 cm in patients with risk factors for recurrence (obesity, concurrent hernia, recurrent hernia, concurrent diastasis or aneurysmal disease), we recommend a mesh repair, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾).   

·       Mesh placement for small hernias less than 2 cm is advised as the treatment of choice based on less recurrence rate, (Conditional recommendation, high certainty evidence, ⁽¹⁸⁾).    

·       Patients presenting with a para-stomal hernia are recommended to have an elective repair, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾).   

Section 5: Complications:

·       We recommend careful inspection of the bowel pre, intra and post dissection to avoid missed enterotomy, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾).    

·       We recommend management of superficial wound sepsis with standard conservative means, (Strong recommendation, high certainty evidence, ⁽¹⁸⁾).    

·        For deep surgical site infection with the possibility of mesh sepsis, we advise removal of the mesh, (Conditional recommendation, moderate certainty evidence, ⁽¹⁸⁾).

·       We recommend conservative management of post-operative seroma, (Strong recommendation, moderate certainty evidence, ⁽¹⁸⁾).     

Section 6: Laparoscopic versus Open:

·       We advise performing laparoscopic ventral hernia repair as it had has a lower rate of wound infections and complications compared to open repair, (Conditional recommendation, moderate certainty evidence, ⁽¹⁹⁾).   

·        We recommend against laparoscopic ventral hernia repair in special situations such as loss of domain, active entero-cutaneous fistula, the need to remove previously placed prosthetic mesh, (Strong recommendation, moderate certainty evidence, ⁽¹⁹⁾).