• Society for Surgery of the Alimentary Tract (SSAT). Surgical repair of incisional hernias. Manchester (MA): Society for Surgery of the Alimentary Tract (SSAT); 2003 Feb. 3 p.

This is the current release of the guideline.

Incisional hernias

Diagnosis
Treatment

Family Practice
Gastroenterology
Internal Medicine
Surgery

Physicians

To guide primary care physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs

Patients with incisional hernias

Diagnosis

1. Assessment of symptoms (e.g., sharp pain, peritoneal signs)
2. Physical examination (presence of visible bulge or palpable fascial edges)

Treatment (Surgical Repair)

1. Primary tissue approximation
2. Use of prosthetic materials
3. Laparoscopic techniques
4. Limitation of patient activity

• Repair of incisional hernias
• Risk of recurrence after surgical repair

Searches of Electronic Databases

Not stated

Not stated

Not stated

Not applicable

Review

Not applicable

Expert Consensus

The Society for Surgery of the Alimentary Tract (SSAT) guidelines are based on statements and recommendations that were overwhelmingly supported by clinical evidence. Each represents a consensus of opinion and is considered a reasonable plan for a specific clinical condition.

(See companion document Gadacz TR, Traverso LW, Fried GM, Stabile B, Levine BA. Practice guidelines for patients with gastrointestinal surgical diseases. J Gastrointest Surg 1998;2:483-484.)

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

The guidelines were reviewed by several committee members and then by the entire committee on several occasions. Each guideline was then sent back to the original author for final comment and reviewed again by the committee. Each guideline was approved by the Board of Trustees of the Society for Surgery of the Alimentary Tract and final comments were reviewed by the committee.

(See companion document Gadacz TR, Traverso LW, Fried GM, Stabile B, Levine BA. Practice guidelines for patients with gastrointestinal surgical diseases. J Gastrointest Surg 1998;2:483-484.)

Symptoms and Diagnosis

Incisional hernias can present in a variety of different ways, but the most frequent complaint is pain. The pain is usually located over the abdominal wall defect and is greatest at the fascial margins. It is usually dull in nature and typically does not radiate. Straining maneuvers may exacerbate symptoms or demonstrate a previously unnoticed defect. Patients may describe changes in bowel habits that can result from incarceration of abdominal viscera. The presence of an irreducible hernia should prompt surgical referral. Sharp pain or peritoneal signs suggest the possible diagnosis of strangulation with tissue necrosis; urgent surgical referral is necessary.

The diagnosis is made by physical examination. Findings may include a visible bulge or palpable fascial edges. The size and number of fascial defects are often difficult to determine preoperatively. Usually, the clinical exam represents the "tip of the iceberg"; additional fascial defects not appreciated preoperatively are often identified at surgery. A palpable mass in a suspected incisional hernia should not be aspirated since this mass may contain bowel.

Treatment

There are many ways to surgically repair incisional hernias. Smaller incisional hernias (< 3 cm.) can be repaired with primary tissue approximation. Repair of larger defects generally requires the use of prosthetic materials, which allows for a tension free repair. Laparoscopic techniques may be used for repair of incisional hernias in selected patients. Potential benefits of laparoscopy include good visualization of all fascial defects, and smaller incisions with less pain and quicker recovery.

Qualifications for Performing Incisional Hernia Repairs

Surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform both elective and emergent incisional hernia repair. These surgeons have completed at least five years of surgical training after medical school graduation and are qualified to perform open incisional hernia repair with and without tension-free techniques. The level of training in advanced laparoscopic techniques necessary to conduct minimally invasive incisional herniorrhaphy has not been formally determined but surgeons with advanced laparoscopic experience are qualified to perform this procedure.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

• Prompt repair of incisional hernias will reduce symptoms (e.g., pain), prevent enlargement of the incisional hernia, and avoid incarceration and strangulation of bowel.
• Potential benefits of laparoscopy include good visualization of all fascial defects, and smaller incisions with less pain and quicker recovery.

• The risks of incisional hernia repair include: seroma, wound infection, injury to intra-abdominal structures, and recurrent hernia.
• The risk of recurrence increases dramatically in patients who have had previous failed repairs, in patients with very large hernias, and in cases where one or more margins of the hernia defect is bone or cartilage.
• Major complications such as a mesh infection or enterocutaneous fistula may result in prolonged morbidity and require reoperation.

These guidelines have been written by the Patient Care Committee of the Society for Surgery of the Alimentary Tract (SSAT). Their goal is to guide primary care physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addresses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately, but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

An implementation strategy was not provided.

Getting Better

Effectiveness

• Society for Surgery of the Alimentary Tract (SSAT). Surgical repair of incisional hernias. Manchester (MA): Society for Surgery of the Alimentary Tract (SSAT); 2003 Feb. 3 p.

Not applicable: The guideline was not adapted from another source.

2003 Feb 1

Society for Surgery of the Alimentary Tract, Inc - Medical Specialty Society

Society of Surgery of the Alimentary Tract, Inc.

Patient Care Committee

Not stated

Not stated

This is the current release of the guideline.

The following is available:

• Gadacz TR, Traverso LW, Fried GM, Stabile B, Levine BA. Practice guidelines for patients with gastrointestinal surgical diseases. J Gastrointest Surg 1998;2:483-484.

Electronic copies: Not available at this time.

Print copies: Available from the Society for Surgery of the Alimentary Tract, Inc., 900 Cummings Center, Suite 221-0, Beverly, MA 01915; Telephone: (978) 927-8330; Fax: (978) 524-8890.

None available

This NGC summary was completed by ECRI on September 17, 2004.