Abdominal Wall

BackgroundGroin hernia repair is one of the most common operations performed globally, with more than 20 million procedures per year. The last guidelines on groin hernia management were published in 2018 by the HerniaSurge Group. The aim of this project was to assess new evidence and update the guidelines. The guideline is intended for general and abdominal wall surgeons treating adult patients with groin hernias.MethodA working group of 30 international groin hernia experts and all involved stakeholders was formed and examined all new literature on groin hernia management, available until April 2022. Articles were screened for eligibility and assessed according to GRADE methodologies. New evidence was included, and chapters were rewritten. Statements and recommendations were updated or newly formulated as necessary.ResultsTen chapters of the original HerniaSurge inguinal hernia guidelines were updated. In total, 39 new statements and 32 recommendations were formulated (16 strong recommendations). A modified Delphi method was used to reach consensus on all statements and recommendations among the groin hernia experts and at the European Hernia Society meeting in Manchester on October 21, 2022.ConclusionThe HerniaSurge Collaboration has updated the international guidelines for groin hernia management. The updated guidelines provide an overview of the best available evidence on groin hernia management and include evidence-based statements and recommendations for daily practice. Future guideline development will change according to emerging guideline methodology.

PurposeTo systematically review technical aspects and treatment regimens of botulinum toxin A (BTA) injections in the lateral abdominal wall musculature. We also investigated the effect of BTA on abdominal muscle- and hernia dimensions, and clinical outcome.MethodsPubMed, EMBASE, CENTRAL, and CINAHL were searched for studies that investigate the injection of BTA in the lateral abdominal wall muscles. Study characteristics, BTA treatment regimens, surgical procedures, and clinical outcomes are presented descriptively. The effect of BTA on muscle- and hernia dimensions is analyzed using random-effects meta-analyses, and exclusively for studies that investigate ventral incisional hernia patients.ResultsWe identified 23 studies, comprising 995 patients. Generally, either 500 units of Dysport® or 200-300 units of Botox® are injected at 3-5 locations bilaterally in all three muscles of the lateral abdominal wall, about 4 weeks prior to surgery. No major procedural complications are reported. Meta-analyses show that BTA provides significant elongation of the lateral abdominal wall of 3.2 cm per side (95% CI 2.0-4.3, I2 = 0%, p 2 = 94%, p = 0.04). Furthermore, meta-analysis shows that BTA pretreatment in ventral hernia patients significantly increases the fascial closure rate [RR 1.08 (95% CI 1.02-1.16, I2 = 0%, p = 0.02)].ConclusionThe injection technique and treatment regimens of botulinum toxin A as well as patient selection require standardization. Bilateral pretreatment in hernia patients significantly elongates the lateral abdominal wall muscles, making fascial closure during surgical hernia repair more likely.Study registrationA review protocol for this meta-analysis was registered at PROSPERO (CRD42020198246).

BackgroundDiastasis of the rectus abdominis muscle is a common condition. There are no generally accepted criteria for diagnosis or treatment of diastasis of the rectus abdominis muscle, which causes uncertainty for the patient and healthcare providers alike.MethodsThe consensus document was created by a group of Swedish surgeons and based on a structured literature review and practical experience.ResultsThe proposed criteria for diagnosis and treatment of diastasis of the rectus abdominis muscle are as follows: (1) Diastasis diagnosed at clinical examination using a caliper or ruler for measurement. Diagnostic imaging by ultrasound or other imaging modality, should be performed when concurrent umbilical or epigastric hernia or other cause of the patient's symptoms cannot be excluded. (2) Physiotherapy is the firsthand treatment for diastasis of the rectus abdominis muscle. Surgery should only be considered in diastasis of the rectus abdominis muscle patients with functional impairment, and not until the patient has undergone a standardized 6-month abdominal core training program. (3) The largest width of the diastasis should be at least 5 cm before surgical treatment is considered. In case of pronounced abdominal bulging or concomitant ventral hernia, surgery may be considered in patients with a smaller diastasis. (4) When surgery is undertaken, at least 2 years should have elapsed since last childbirth and future pregnancy should not be planned. (5) Plication of the linea alba is the firsthand surgical technique. Other techniques may be used but have not been found superior.DiscussionThe level of evidence behind these statements varies, but they are intended to lay down a standard strategy for treatment of diastasis of the rectus abdominis muscle and to enable uniformity of management.

IntroductionIncisional hernias following liver transplantation are common, particularly with bi-subcostal (Mercedes) incisions. Durable repair options and perioperative outcomes in this immunosuppressed population remain poorly defined. We analyzed outcomes following minimally invasive abdominal wall reconstruction (AWR) utilizing robotic-assisted transversus abdominis release (rTAR).MethodsSingle-center, retrospective review of a prospectively maintained series of post-liver transplant patients referred for incisional hernia repair. Adult patients undergoing elective AWR via robotic TAR between January 2018 and July 2025 were included.Results51 patients underwent elective hernia repair. Mean age was 61, mean BMI at repair was 29.7 kg/m2, and 65% were male. Mean time from transplant to repair was 20.8 months (range 7-64.9 mo). At time of repair, 27.5% were on single-agent, 58.8% on dual-agent, and 13.7% on triple-agent immunosuppression. Median hernia defect size was 144 cm2 (24-507 cm2) and median mesh size was 832 cm2 (390-1512 cm2). Mean operative time was 363 min and average length of stay was 3.8 days (2-9 days). Surgical site occurrences occurred in 4 patients (7.8%), including 2 surgical site infections. No reoperations were required. No hernia recurrences were identified at a median follow-up of 13.4 months.ConclusionsRobotic-assisted AWR with rTAR provides a durable and safe approach for complex post-transplant incisional hernias. Minimally invasive component separation limits wound morbidity in the setting of immunosuppression while enabling broad sublay mesh coverage. Further long-term follow-up is ongoing.