title: Substantial variation among hernia experts in the decision for treatment of patients with incisional hernia: a descriptive study on agreement.
abstract: Benign elective procedures give rise to heterogeneity in indication for surgery and surgical technique among specialized surgeons in a variety of surgical fields. The objective was to analyze the extent of agreement in surgical management among expert hernia surgeons when evaluating the same patient in a standardized setting.
  
  
  
  Five Danish hernia experts answered questions concerning indication for surgery and surgical technique for 25 video recorded real-life clinical cases. The experts evaluated the patients by answering a standardized questionnaire.
  
  
  
  All surgeons were experienced in incisional hernia repair with a median of 253 repairs (range 164-450 repairs). Perfect overall agreement among all the experts in indication, operation type, component separation, mesh fixation and mesh position was found in only five cases (20%). Agreement in indication for surgery was present in 14 cases (56%). The most common reason for not performing surgery was due to comorbidities. Agreement in operation type (open vs. laparoscopic) was present in 10 cases (40%). Agreement in mesh fixation (absorbable tacks/non-absorbable tacks/suture/other) method was also present in 10 cases (40%). Agreement in mesh position (onlay, sublay or intraperitoneal) was found in 40% of cases. The highest overall agreement among the surgeons was observed with regard to whether patients needed component separation (yes/no), 21 cases, (84%).
  
  
  
  In a standardized setting, agreement in choice of treatment strategy for patients with incisional hernias was very low among experienced surgeons. A standardization of surgical decision making is desirable to develop new interventions and improve clinical outcomes.
authors.affiliation: Center for Surgical Science, Department of Surgery, Zealand University Hospital and Copenhagen University, Lykkebækvej 1, 4600, Køge, Denmark. dunja.kokotovic@hotmail.com.
authors.forename: D
authors.identifier: 0000-0003-1544-8927
authors.initials: D
authors.lastname: Kokotovic
authors.affiliation: Center for Surgical Science, Department of Surgery, Zealand University Hospital and Copenhagen University, Lykkebækvej 1, 4600, Køge, Denmark.
authors.forename: I
authors.initials: I
authors.lastname: Gögenur
authors.affiliation: Center for Surgical Science, Department of Surgery, Zealand University Hospital and Copenhagen University, Lykkebækvej 1, 4600, Køge, Denmark.
authors.forename: F
authors.initials: F
authors.lastname: Helgstrand
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D000075202:Contraindications; D003657:Decision Making; D017558:Elective Surgical Procedures; D005260:Female; D006555:Hernia, Ventral / Q000601:surgery* / Q000628:therapy; D059685:Herniorrhaphy / Q000379:methods; D006801:Humans; D000069290:Incisional Hernia / Q000601:surgery* / Q000628:therapy; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D013526:Surgical Mesh; D011795:Surveys and Questionnaires
keywords: Disagreement; Guidelines; Incisional hernia; Surgical technique; Treatment indication