Table 2.
Summary of the 2022 Italian guidelines on the laparoscopic treatment of primary and incisional ventral hernias
| PICO Question | Recommendation | Strength of recommendation | |
|---|---|---|---|
| 1A | In patients with a primary or incisional ventral hernia (P), is it preferable to choose laparoscopic (I) or open (C) surgery in terms of (O) mortality, morbidity, recurrence, quality of life, length of hospitalization, postoperative pain, and costs? | For treating patients with a primary or incisional ventral hernia in the general population, the panel suggested that laparoscopic surgery be used as an alternative to open surgery for hernia defects smaller than 10 cm | Conditional, based on LOW confidence in effect estimates for mortality, and MODERATE confidence in effect estimates on the other outcomes |
| 1B | In elderly patients with primary or incisional ventral hernia (P), is it preferable to choose laparoscopic (I) or open (C) surgery in terms of (O) mortality, morbidity, recurrence, quality of life, length of hospitalization, postoperative pain, and costs? | For the treatment of elderly patients (> 70 years) who require surgery for primary or incisional ventral hernia, the panel suggested that laparoscopic treatment be used as an alternative to open surgery | Conditional, based on VERY LOW confidence in effect estimates |
| 1C | In people with obesity (body mass index ≥ 30 kg/m2) and primary or incisional ventral hernia (P) is it preferable to choose laparoscopic (I) or open (C) surgery in terms of (O) mortality, morbidity, recurrence, quality of life, length of hospitalization, postoperative pain, and costs? | The panel suggested that laparoscopic treatment be used as an alternative to open surgery for primary or incisional ventral hernias in patients with obesity | Conditional, based on LOW confidence in effect estimates |
| 1D | In the emergency treatment of patients with a primary or incisional ventral hernia (P) is it preferable to choose laparoscopic (I) or open (C) surgery in terms of (O) mortality, morbidity, and recurrence? | The panel suggested that laparoscopic surgery be used as an alternative to open surgery for the treatment of patients with a primary or incisional ventral hernia in emergency settings |
Conditional, based on VERY LOW confidence in effect estimates for mortality, morbidity and recurrence |
| 1E | In treating patients with a border primary or incisional hernias (P) is it preferable to choose laparoscopic (I) or open (C) surgery in terms of (O) mortality, morbidity, recurrence, quality of life, length of hospitalization, postoperative pain, and costs? | The panel cannot provide a recommendation about the treatment of patients with a border primary or incisional hernia, due to insufficient confidence in the effect estimates | No recommendation. The confidence in effect estimates was VERY LOW |
| 1F | In patients with a parastomal hernia (P) is it preferable to choose laparoscopic (I) or open (C) surgery in terms of (O) mortality, morbidity, recurrence, quality of life, length of hospitalization, postoperative pain, and costs? | The panel suggested that laparoscopic surgery be used as an alternative to open treatment for patients with a parastomal hernia | Conditional, based on VERY LOW confidence in effect estimates |
| 2A | In the laparoscopic treatment of patients with primary or incisional ventral hernia (P) is it preferable to close the defect (IPOM plus) (I) or not (IPOM) (C) in terms of (O) mortality, morbidity, recurrence, quality of life, length of stay, postoperative pain, and costs? | The panel suggested that the hernia defect be sutured in the laparoscopic treatment of patients with primary or incisional ventral hernia | Conditional, based on VERY LOW confidence in effect estimates |
| 2B | In patients undergoing minimally invasive surgery for ventral or incisional hernia (P), is a robotic (I) or laparoscopic (C) approach preferable in terms of (O) mortality, morbidity, recurrence, quality of life, length of stay, postoperative pain, costs? | For patients with primary or incisional ventral hernia, the panel suggested that either laparoscopic or robotic techniques be used | Conditional, based on LOW confidence in effect estimates |
| 2C | In patients undergoing laparoscopic parastomal hernia repair (P), is the Keyhole (I) or Sugarbaker (C) technique preferable in terms of (O) mortality, morbidity, recurrence, quality of life, length of stay, postoperative pain, and costs? | For the laparoscopic treatment of parastomal hernias, the panel suggested that the Sugarbaker technique be used rather than the keyhole technique | Conditional, based on VERY LOW confidence in effect estimates |
| 2D | For the laparoscopic repair of patients with ventral or incisional hernia (P), is it preferable to fix the mesh with sutures (I) or mechanical tacks (C) in terms of (O) mortality, morbidity, recurrence, quality of life, length of stay, postoperative pain, and costs? | For the laparoscopic treatment of patients with primary or incisional ventral hernia, the panel suggested that the mesh be fixed by mechanical tacks rather than transfixed sutures | Conditional, based on VERY LOW confidence in effect estimates |
| 2E | For the laparoscopic treatment of patients with ventral or incisional hernia (P), is it preferable to fix the mesh with absorbable (I) or non-absorbable (C) fixation devices in terms of (O) mortality, morbidity, recurrence, quality of life, length of stay, postoperative pain, and costs? | For the laparoscopic treatment of patients with primary or incisional ventral hernia, the panel suggested that the mesh be fixed either with absorbable or permanent devices | Conditional, based on VERY LOW confidence in effect estimates |
| 2F-A | For the laparoscopic treatment of patients with ventral or incisional hernia (P) with the IPOM technique, what is the optimal overlap of the mesh on the abdominal wall surface (I) (C) in terms of (O) mortality, morbidity, recurrence, quality of life, length of stay, postoperative pain, and costs? | In the treatment of patients with primary or incisional ventral hernia, with a defect diameter of 4 cm or larger, the panel suggested a minimum overlap of the mesh beyond the margins of the defect of 5 cm on each side | Conditional, based on VERY LOW confidence in effect estimates |
| 2F-B | For the laparoscopic treatment of patients with ventral or incisional hernia (P) with the IPOM technique, what is the optimal overlap of the mesh on the abdominal wall surface (I) (C) in terms of (O) mortality, morbidity, recurrence, quality of life, length of stay, postoperative pain, and costs? | In the treatment of patients with primary or incisional ventral hernia, with a defect less than 4 cm, the panel suggested a minimum overlap of the mesh beyond the margins of the defect of 3–5 cm on each side | Conditional based on VERY LOW confidence in effect estimates |
| 3A | In patients operated with a minimally invasive approach for primary or incisional ventral hernia, or parastomal hernia (P), is deep neuromuscular block (I) preferable to a moderate one (C) (TOF > 0), in terms of (O) success of the procedure, evaluation of the intra-abdominal workspace, postoperative pain, operator satisfaction, and difficulty of the procedure? | The panel could not issue any recommendation in favor or against deep neuromuscular block | No recommendation. The confidence in effect estimates in this research field was VERY LOW |
| 4A | In patients operated on for primary or incisional ventral or parastomal hernia with a minimally invasive approach (P), is it preferable to combine (I) or not to combine (C) an analgesic loco-regional anesthesia with general anesthesia in terms of (O) success of the procedure, evaluation of the intra-abdominal workspace, postoperative pain, operator satisfaction, and difficulty of the procedure? | In the laparoscopic treatment of patients with a primary or incisional ventral hernia, the panel suggested that regional anesthesia be associated with general anesthesia | Conditional to MODERATE confidence in effect estimates |