the Management of Ventral Hernia

This guideline describes the management of ventral hernia.

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

·       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). 

·       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). 

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

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

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

·       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).   

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

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

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

·       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). 

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

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

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

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

·       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).

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

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

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

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

·       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). 

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

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

·       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).   

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

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

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

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

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

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

·       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).

·        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).