Substantial variation among hernia experts in the decision for treatment of patients with incisional hernia: a descriptive study on agreement

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.