Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies
EHS/AHS · 2022 · Europe
Source and licence
- Authors
- Eva B Deerenberg, Nadia A Henriksen, George A Antoniou et al.
- Title
- Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies
- Journal
- The British Journal of Surgery, 2022
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC10364727
Licence statement of the original publication
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
KQ1a Which approach, minimally invasive or open, should be used in patients undergoing abdominal surgery?
- StatementThere is a decreased risk of both incisional hernia and surgical-site occurrences in patients undergoing laparoscopic operations compared with open operations.
- RecommendationLaparoscopic surgery is suggested to be used when safe and feasible to reduce the risk of incisional hernia and surgical-site occurrence.
KQ2 Should trocar sites be closed in patients undergoing laparoscopic surgery?
- StatementThe evidence on trocar-site closure is very limited. The risk of developing a trocar-site hernia is increased for trocar sites of 10 mm or larger, for single-incision laparoscopic surgery (SILS) trocars, and for trocars placed at the umbilical site. There are no robust data supporting fascial closure at the trocar site for prevention of trocar-site hernia, and there are no data on surgical-site complications and pain. There are no data on optimal closure technique or material.
- RecommendationIt is suggested to suture the fascial defect for trocar sites of 10 mm or larger, especially after SILS and for trocars located at the umbilical site.
KQ3 What is the preferred strategy for closing a laparotomy?
- StatementIn the available studies of acceptable quality, no superiority of one specific suture material or continuous versus interrupted technique could be shown. The combination of a continuous small-bites suturing technique with a slowly absorbable suture reduces the risk of incisional hernia.
- RecommendationA continuous small-bites suturing technique with a slowly absorbable suture is suggested for closure of elective midline incisions.
KQ5a Is mesh augmentation beneficial for closure of elective laparotomies?
- StatementMesh augmentation after suture closure of a midline abdominal incision reduces the rate of incisional hernia compared with primary suture closure. Studies do not show an increased risk of surgical-site infection. Data on burst abdomen and postoperative pain are limited. Currently, there are no data on mesh augmentation versus primary suture closure of non-midline abdominal incisions.
- RecommendationProphylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia.
KQ5b Which type of mesh should be used for prophylactic mesh augmentation?
- StatementProphylactic mesh augmentation with synthetic permanent mesh reduces the incidence of incisional hernia compared with primary closure. Reduction in incisional hernia rate is not proven for absorbable synthetic or biological meshes. There are no studies comparing different types of mesh.
- RecommendationIt is suggested to use a permanent synthetic mesh for prophylactic mesh augmentation.
KQ5c Which abdominal plane should be used for prophylactic mesh augmentation?
- StatementData concerning prophylactic mesh implantation in different anatomical planes are limited. Onlay and retromuscular mesh implantation seem safe and effective in incisional hernia prevention.
- RecommendationWhen using a prophylactic mesh, onlay or retromuscular implantation is suggested.
KQ5d Is mesh augmentation beneficial during closure of emergency laparotomies?
- StatementData on mesh augmentation in emergency midline laparotomy are heterogeneous and limited.
- RecommendationNo recommendation can be made regarding prophylactic mesh augmentation in emergency laparotomy.
KQ6 Are postoperative abdominal binders advantageous after open abdominal surgery?
- StatementThere are no data on burst abdomen, incisional hernia or surgical-site occurrences related to the use of postoperative binders after open abdominal surgery. There are limited data to suggest that abdominal binders reduce postoperative pain, without compromising pulmonary function.
- RecommendationNo recommendation can be made for or against the use of postoperative binders owing to the lack of data on their effect on incisional hernia or burst abdomen.
KQ7 Is restriction of activity advantageous after open abdominal surgery?
- StatementThere are very limited data on restriction of activity after open abdominal surgery.
- RecommendationNo recommendation on restriction of activity after open abdominal surgery can be made owing to lack of evidence.
Abstract
Background: Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia.
Methods: A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative.
Results: Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised.
Conclusion: These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.
Contents of the original publication
The section headings of the original.
- Introduction
- Methods
- Guideline group
- Methodology and literature search
- Results
- Open and minimally invasive abdominal surgery
- Closure of minimally invasive surgery ports
- Closure of laparotomy incisions
- Identifying patients with an increased risk of incisional hernia development
- Prophylactic mesh augmentation
- Postoperative care
- External appraisal
- Discussion
- Limitations
- Implementation
- Knowledge gaps
- Contributor Information
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