Defining complex groin hernia and contextualizing approach selection: a three-round Delphi consensus framework

The term "complex groin hernia" is widely used in clinical practice but lacks a standardized operational definition and a structured framework to guide escalation, referral pathways, and approach selection.

A three-round Delphi process was conducted with a fixed panel of 54 Italian expert abdominal wall surgeons evaluating 85 statements across elective and emergency scenarios spanning (1) definition of complexity, (2) hernia characteristics, (3) patient characteristics, and (4) previous surgical history. Items were scored on a 5-point Likert scale in Rounds 1-2 and on a 3-point scale in Round 3. Consensus was graded as no consensus (< 65%), leaning agreement/disagreement (65-80%), or agreement/disagreement (> 80%).

Overall, 44 of 85 statements (51.8%) achieved at least leaning consensus (≥ 65%): 34 in agreement and 10 in disagreement; strong consensus (> 80%) was reached for 18 statements (21.2%). In elective surgery, complexity was mainly defined by escalation needs, including requirement for a highly experienced surgeon and/or referral to a dedicated center. Emergency presentation should be regarded as a time-sensitive complexity setting; within this domain, consensus clustered around bowel compromise/obstruction and contaminated or dirty fields as severity and planning markers, not as transfer criteria. For approach selection, the panel converged toward a change-of-plane principle for recurrence. Obesity-related items showed heterogeneous views and did not translate into a single preferred approach. Operative time emerged as a pathway-planning modifier rather than a fixed determinant of operative plane.

This Delphi study proposes a conservative, non-prescriptive framework to define and report complex groin hernia. Its most robust outputs concern expertise escalation, emergency risk markers, and the change-of-plane principle for recurrence, while areas of weaker agreement should be interpreted as expertise-sensitive decision nodes requiring external validation.