![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Surgical repair of incisional hernias.

#### BIBLIOGRAPHIC SOURCE(S)

Society for Surgery of the Alimentary Tract (SSAT). Surgical repair of
incisional hernias. Manchester (MA): Society for Surgery of the
Alimentary Tract (SSAT); 2003 Feb. 3 p.

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Incisional hernias

#### GUIDELINE CATEGORY

Diagnosis\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Gastroenterology\
Internal Medicine\
Surgery

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To guide primary care physicians to the appropriate utilization of
surgical procedures on the alimentary tract or related organs

#### TARGET POPULATION

Patients with incisional hernias

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Assessment of symptoms (e.g., sharp pain, peritoneal signs)

2.  Physical examination (presence of visible bulge or palpable fascial
    edges)

**Treatment (Surgical Repair)**

1.  Primary tissue approximation

2.  Use of prosthetic materials

3.  Laparoscopic techniques

4.  Limitation of patient activity

#### MAJOR OUTCOMES CONSIDERED

-   Repair of incisional hernias

-   Risk of recurrence after surgical repair

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not applicable

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The Society for Surgery of the Alimentary Tract (SSAT) guidelines are
based on statements and recommendations that were overwhelmingly
supported by clinical evidence. Each represents a consensus of opinion
and is considered a reasonable plan for a specific clinical condition.

(See companion document Gadacz TR, Traverso LW, Fried GM, Stabile B,
Levine BA. Practice guidelines for patients with gastrointestinal
surgical diseases. J Gastrointest Surg 1998;2:483-484.)

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines were reviewed by several committee members and then by
the entire committee on several occasions. Each guideline was then sent
back to the original author for final comment and reviewed again by the
committee. Each guideline was approved by the Board of Trustees of the
Society for Surgery of the Alimentary Tract and final comments were
reviewed by the committee.

(See companion document Gadacz TR, Traverso LW, Fried GM, Stabile B,
Levine BA. Practice guidelines for patients with gastrointestinal
surgical diseases. J Gastrointest Surg 1998;2:483-484.)

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Symptoms and Diagnosis**

Incisional hernias can present in a variety of different ways, but the
most frequent complaint is pain. The pain is usually located over the
abdominal wall defect and is greatest at the fascial margins. It is
usually dull in nature and typically does not radiate. Straining
maneuvers may exacerbate symptoms or demonstrate a previously unnoticed
defect. Patients may describe changes in bowel habits that can result
from incarceration of abdominal viscera. The presence of an irreducible
hernia should prompt surgical referral. Sharp pain or peritoneal signs
suggest the possible diagnosis of strangulation with tissue necrosis;
urgent surgical referral is necessary.

The diagnosis is made by physical examination. Findings may include a
visible bulge or palpable fascial edges. The size and number of fascial
defects are often difficult to determine preoperatively. Usually, the
clinical exam represents the \"tip of the iceberg\"; additional fascial
defects not appreciated preoperatively are often identified at surgery.
A palpable mass in a suspected incisional hernia **should not be**
aspirated since this mass may contain bowel.

**Treatment**

There are many ways to surgically repair incisional hernias. Smaller
incisional hernias (\< 3 cm.) can be repaired with primary tissue
approximation. Repair of larger defects generally requires the use of
prosthetic materials, which allows for a tension free repair.
Laparoscopic techniques may be used for repair of incisional hernias in
selected patients. Potential benefits of laparoscopy include good
visualization of all fascial defects, and smaller incisions with less
pain and quicker recovery.

**Qualifications for Performing Incisional Hernia Repairs**

Surgeons who are certified or eligible for certification by the American
Board of Surgery, the Royal College of Physicians and Surgeons of
Canada, or their equivalent should perform both elective and emergent
incisional hernia repair. These surgeons have completed at least five
years of surgical training after medical school graduation and are
qualified to perform open incisional hernia repair with and without
tension-free techniques. The level of training in advanced laparoscopic
techniques necessary to conduct minimally invasive incisional
herniorrhaphy has not been formally determined but surgeons with
advanced laparoscopic experience are qualified to perform this
procedure.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Prompt repair of incisional hernias will reduce symptoms (e.g.,
    pain), prevent enlargement of the incisional hernia, and avoid
    incarceration and strangulation of bowel.

-   Potential benefits of laparoscopy include good visualization of all
    fascial defects, and smaller incisions with less pain and quicker
    recovery.

#### POTENTIAL HARMS

-   The risks of incisional hernia repair include: seroma, wound
    infection, injury to intra-abdominal structures, and recurrent
    hernia.

-   The risk of recurrence increases dramatically in patients who have
    had previous failed repairs, in patients with very large hernias,
    and in cases where one or more margins of the hernia defect is bone
    or cartilage.

-   Major complications such as a mesh infection or enterocutaneous
    fistula may result in prolonged morbidity and require reoperation.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These guidelines have been written by the Patient Care Committee of the
Society for Surgery of the Alimentary Tract (SSAT). Their goal is to
guide primary care physicians to the appropriate utilization of surgical
procedures on the alimentary tract or related organs and they are based
on critical review of the literature and expert opinion. Both of the
latter sources of information result in a consensus that is recorded in
the form of these Guidelines. The consensus addresses the **range** of
acceptable clinical practice and should not be construed as a standard
of care. These Guidelines require periodic revision to ensure that
clinicians utilize procedures appropriately, but the reader must realize
that clinical judgment may justify a course of action outside of the
recommendations contained herein.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Society for Surgery of the Alimentary Tract (SSAT). Surgical repair of
incisional hernias. Manchester (MA): Society for Surgery of the
Alimentary Tract (SSAT); 2003 Feb. 3 p.

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Feb 1

#### GUIDELINE DEVELOPER(S)

Society for Surgery of the Alimentary Tract, Inc - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

Society of Surgery of the Alimentary Tract, Inc.

#### GUIDELINE COMMITTEE

Patient Care Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Not stated

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Society for Surgery of the
Alimentary Tract, Inc. Web
site](http://www.ssat.com/cgi-bin/guidelines.cgi).

Print copies: Available from the Society for Surgery of the Alimentary
Tract, Inc., 900 Cummings Center, Suite 221-U, Beverly, MA 01915;
Telephone: (978) 927-8330; Fax: (978) 524-0461.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Gadacz TR, Traverso LW, Fried GM, Stabile B, Levine BA. Practice
    guidelines for patients with gastrointestinal surgical diseases. J
    Gastrointest Surg 1998;2:483-484.

Electronic copies: Not available at this time.

Print copies: Available from the Society for Surgery of the Alimentary
Tract, Inc., 900 Cummings Center, Suite 221-0, Beverly, MA 01915;
Telephone: (978) 927-8330; Fax: (978) 524-8890.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on September 17, 2004.

#### COPYRIGHT STATEMENT

For terms governing downloading, use, and reproduction of these
guidelines, please contact: <ssat@prri.com>.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008