EHS Guidelines on the Management of Primary Ventral and Incisional Hernias Under Emergency Conditions

Emergent primary ventral or incisional hernias (PVIHs) are a common cause of surgical admission, leading to significantly higher rates of morbidity and mortality compared to elective hernia repairs. Despite this, management varies widely due to a lack of evidence-based consensus. This article presents the new European Hernia Society (EHS) guidelines for the emergency treatment of adult patients with PVIH.

This project was developed by the EHS Science Committee following AGREE-S, GRADE, and GIN standards. A guideline panel, composed of general and emergency surgeons along with patient partners, formulated seven key health questions addressing the surgical approach, mesh type and placement, and the management of defects of varying sizes and contamination levels to support general surgeons in their decision-making process. A systematic review was conducted, and recommendations were developed using a formal evidence-to-decision framework, ensuring consensus was reached on all recommendations.

The guidelines expert panel provides recommendations for several clinical scenarios. For defects amenable to direct closure, mesh-based repair is suggested over primary suture repair, regardless of the contamination grade. Furthermore, a laparoscopic approach with intraperitoneal mesh, an open approach with onlay mesh placement, and the use of large-pore synthetic meshes are recommended. For large defects, not amenable to closure, a staged approach that avoids immediate mesh-based repair is suggested.

Adherence to these guidelines can help standardise the management of emergent PVIHs, potentially improving patient outcomes. The recommendations advocate for a "damage control" mindset, prioritising physiological stability over immediate definitive reconstruction. Further research is needed to address gaps in the current literature, particularly with regard to long-term recurrence rates and the specific protocols for managing these complex cases.