Page 117 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

Discussion
Limitations
Not many strong recommendations could be made due to lack of su cient evidence on many of the PICO questions. It is somewhat confusing to notice that the rst strong recommendation in these guidelines is to avoid midline laparotomies in favour of alternative incisions and that all other recommendations are only valid for elective midline incisions. Indeed most research is focused on midline laparotomies. A midline laparotomy is still the favoured approach for most surgeons. It allows quick entrance to the abdominal cavity and extension of the incision is easy if this is required for the operation. Nevertheless, the linea alba is probably the most vulnerable and least vascularized part of the abdominal wall. Some refer to incisional hernias as “a midline crisis”. Optimising closure of abdominal wall incisions would appear to hold a large potential in reducing the incidence of incisional hernias and the subsequent need for incisional hernia repair. This has obvious bene ts for the individual patient relating to an improved quality of life, avoidance of secondary operations and at a macro-economical level a signi cant reduction in costs for health care resources. It is not easy to see the impact of each recommendation separately. Therefore, implementation of the optimised abdominal wall closure is probably best done by teaching all involved specialists a standardised technique described as the “Principles” of abdominal wall closure(17). This incorporates all recommendations, although the Guidelines Development Group is aware that the level of evidence for the di erent aspects is sometimes low to very low. David Sackett, a pioneer in evidence-based medicine wrote: “... any external guideline must be integrated with individual clinical expertise in deciding whether and how it matches the patient’s clinical state, predicament, and preferences, and thus whether it should be applied”(140).
Discussions
For most Key Questions on the technique and material to close abdominal wall incisions, the grading of the Quality of Evidence and the choice of recommendation was straightforward. For several recommendations, while the quality of evidence was low, there was good consensus between the members of the Guidelines Development Group on the formulated statements. For prophylactic mesh augmentation there was disagreement
5
EHS guidelines
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