title: European Hernia Society guidelines on the closure of abdominal wall incisions.
abstract: BACKGROUND
  The material and the surgical technique used to close an abdominal wall incision are important determinants of the risk of developing an incisional hernia. Optimising closure of abdominal wall incisions holds a potential to prevent patients suffering from incisional hernias and for important costs savings in health care.
  
  
  METHODS
  The European Hernia Society formed a Guidelines Development Group to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the materials and methods used to close the abdominal wall. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and methodological guidance was taken from Scottish Intercollegiate Guidelines Network (SIGN). The literature search included publications up to April 2014. The guidelines were written using the AGREE II instrument. An update of these guidelines is planned for 2017.
  
  
  RESULTS
  For many of the Key Questions that were studied no high quality data was detected. Therefore, some strong recommendations could be made but, for many Key Questions only weak recommendations or no recommendation could be made due to lack of sufficient evidence.
  
  
  CONCLUSIONS
  To decrease the incidence of incisional hernias it is strongly recommended to utilise a non-midline approach to a laparotomy whenever possible. For elective midline incisions, it is strongly recommended to perform a continuous suturing technique and to avoid the use of rapidly absorbable sutures. It is suggested using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique without separate closure of the peritoneum. A small bites technique with a suture to wound length (SL/WL) ratio at least 4/1 is the current recommended method of fascial closure. Currently, no recommendations can be given on the optimal technique to close emergency laparotomy incisions. Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients. For laparoscopic surgery, it is suggested using the smallest trocar size adequate for the procedure and closure of the fascial defect if trocars larger or equal to 10 mm are used. For single incision laparoscopic surgery, we suggest meticulous closure of the fascial incision to avoid an increased risk of incisional hernias.
authors.affiliation: Department of Surgery, AZ Maria Middelares, Kortrijksesteenweg 1026, 9000, Ghent, Belgium, filip.muysoms@azmmsj.be.
authors.forename: F E
authors.initials: FE
authors.lastname: Muysoms
authors.forename: S A
authors.initials: SA
authors.lastname: Antoniou
authors.forename: K
authors.initials: K
authors.lastname: Bury
authors.forename: G
authors.initials: G
authors.lastname: Campanelli
authors.forename: J
authors.initials: J
authors.lastname: Conze
authors.forename: D
authors.initials: D
authors.lastname: Cuccurullo
authors.forename: A C
authors.initials: AC
authors.lastname: de Beaux
authors.forename: E B
authors.initials: EB
authors.lastname: Deerenberg
authors.forename: B
authors.initials: B
authors.lastname: East
authors.forename: R H
authors.initials: RH
authors.lastname: Fortelny
authors.forename: J-F
authors.initials: JF
authors.lastname: Gillion
authors.forename: N A
authors.initials: NA
authors.lastname: Henriksen
authors.forename: L
authors.initials: L
authors.lastname: Israelsson
authors.forename: A
authors.initials: A
authors.lastname: Jairam
authors.forename: A
authors.initials: A
authors.lastname: Jänes
authors.forename: J
authors.initials: J
authors.lastname: Jeekel
authors.forename: M
authors.initials: M
authors.lastname: López-Cano
authors.forename: M
authors.initials: M
authors.lastname: Miserez
authors.forename: S
authors.initials: S
authors.lastname: Morales-Conde
authors.forename: D L
authors.initials: DL
authors.lastname: Sanders
authors.forename: M P
authors.initials: MP
authors.lastname: Simons
authors.forename: M
authors.initials: M
authors.lastname: Śmietański
authors.forename: L
authors.initials: L
authors.lastname: Venclauskas
authors.forename: F
authors.initials: F
authors.lastname: Berrevoet
mesh_terms: D034861:Abdominal Wall / Q000601:surgery*; D058107:Abdominal Wound Closure Techniques; D000328:Adult; D005260:Female; D006555:Hernia, Ventral / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects; D007813:Laparotomy / Q000009:adverse effects; D008297:Male; D013526:Surgical Mesh; D013536:Suture Techniques; D013537:Sutures