Guidelines are increasingly determining the decision process in day-to-day clinical work. Guidelines describe the current best possible standard in diagnostics and therapy. They should be developed by an international panel of experts, whereby alongside individual experience, above all, the results of comparative studies are decisive.

In 2014, the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias." Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. Methods For the development of the original guidelines, all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based Medicine. For the present update, all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne), the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. Results Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques-minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite insufficient evidence with respect to these new techniques, it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. Conclusion Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initial guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

In 2014 the International Endohernia Society (IEHS) published the first international “Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias”. Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature.MethodsFor the development of the original guidelines all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based-Medicine. For the present update all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne) the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included.ResultsDue to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques—minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite still insufficient evidence with respect to these new techniques it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields.ConclusionGuidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initially guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

With the Internet-based English- and German-language hernia register, a new instrument is now available for outcome research in hernia surgery.

• What are the incidences of bowel injury, and what are the safest techniques for avoiding them? • What is the safest management for bowel injury, and do alternatives exist?Electronic supplementary material The online version of this article (doi:10.1007/s00464-013-3171-5) contains supplementary material, which is available to authorized users. Bowel injuries are classified in one of three categories. Immediately recognized injuries result either from bowel trauma during initial port insertion or from bowel manipulation, especially adhesiolysis. Bowel injuries sustained during adhesiolysis may be missed, to be recognized postoperatively by the development of sepsis during the first 24 h. Delayed injuries occur from progression of a thermal injury caused by energized dissection such as monopolar electrosurgery or ultrasonic dissection. These present within the first 5 days postoperatively [7][8][9]. R. Bittner (&)HerniaAvoiding bowel injury is of utmost importance during LVHR. It is advisable to gain access to the abdominal cavity via an open technique far removed from the hernia or scar. Sharp dissection should always be used in areas of dense adhesions, particularly when the presence of bowel is suspected. Again, the use of energized dissection close to bowel may cause delayed injuries, with significantly increased morbidity and mortality [7]. An alternative is to repair the bowel and delay the hernia repair until after a period of inpatient observation and administration of parenteral antibiotics [7, 10]. If the surgeon lacks experience with laparoscopic bowel repair, an immediate conversion to a laparotomy is advisable. In such a case, the bowel injury is repaired and the hernia defect managed according to the extent of contamination. In the presence of gross spillage and contamination, the hernia should be repaired primarily without the use of mesh [6, 11].In 2010, Itani et al.[3] reported a series of 73 patients who underwent conversion to an open technique for bowel injury with minimal contamination during LVHR. In three patients, the enterotomy was repaired, and the herniorrhaphy was performed with polypropylene (PP) mesh laparoscopically. None of the patients who underwent conversion to laparotomy, including those in whom mesh was placed, experienced a surgical-site infection.Alternative methods for dealing with bowel injury during LVHR In the event of a bowel injury, there are several alternatives to conversion to laparotomy. Carbajo et al. [11] and Heniford et al.[6] both have described a case in which a minilaparotomy was performed to repair the bowel injury. The incision was made away from the hernia and under direct visualization with the laparoscope. The injured bowel was exteriorized through the incision and repaired extracorporeally. The incision then was closed, and the LVHR was resumed.In the presence of gross contamination, another valid option entails laparoscopic repair of the injury, with postponement of the herniorrhaphy to a later date. Lederman and Ramshaw [5] reported a series of nine ...

IntroductionAlthough many surgeons have adopted the use of biologic and biosynthetic meshes in complex abdominal wall hernia repair, others have questioned the use of these products. Criticism is addressed in several review articles on the poor standard of studies reporting on the use of biologic meshes for different abdominal wall repairs. The aim of this consensus review is to conduct an evidence-based analysis of the efficacy of biologic and biosynthetic meshes in predefined clinical situations.MethodsA European working group, “BioMesh Study Group”, composed of invited surgeons with a special interest in surgical meshes, formulated key questions, and forwarded them for processing in subgroups. In January 2016, a workshop was held in Berlin where the findings were presented, discussed, and voted on for consensus. Findings were set out in writing by the subgroups followed by consensus being reached. For the review, 114 studies and background analyses were used.ResultsThe cumulative data regarding biologic mesh under contaminated conditions do not support the claim that it is better than synthetic mesh. Biologic mesh use should be avoided when bridging is needed. In inguinal hernia repair biologic and biosynthetic meshes do not have a clear advantage over the synthetic meshes. For prevention of incisional or parastomal hernias, there is no evidence to support the use of biologic/biosynthetic meshes. In complex abdominal wall hernia repairs (incarcerated hernia, parastomal hernia, infected mesh, open abdomen, enterocutaneous fistula, and component separation technique), biologic and biosynthetic meshes do not provide a superior alternative to synthetic meshes.ConclusionThe routine use of biologic and biosynthetic meshes cannot be recommended.

Section 7: Mesh technology Do we have an ideal mesh in terms of prevention of adhesions? Are coated meshes really necessary? Are there data to support the manufacturers' claims of superiority? Is a permanent or absorbable barrier preferred?

Introduction: Recently, the promising results of new procedures for the treatment of rectus diastasis with concomitant hernias using extraperitoneal mesh placement and anatomical restoration of the linea alba were published. To date, there is no recognized classification of rectus diastasis (RD) with concomitant hernias. This is urgently needed for comparative assessment of new surgical techniques. A working group of the German Hernia Society (DHG) and the International Endohernia Society (IEHS) set itself the task of devising such a classification.Materials and Methods: A systematic search of the available literature was performed up to October 2018 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library. A meeting of the working group was held in May 2018 in Hamburg. For the present analysis 30 publications were identified as relevant.Results: In addition to the usual patient- and technique-related influencing factors on the outcome of hernia surgery, a typical means of rectus diastasis classification and diagnosis should be devised. Here the length of the rectus diastasis should be classified in terms of the respective subxiphoidal, epigastric, umbilical, infraumbilical, and suprapubic sectors affected as well as by the width in centimeters, whereby W1 < 3 cm, W2 = 3− ≤ 5 cm, and W3 > 5 cm. Furthermore, gender, the concomitant hernias, previous abdominal surgery, number of pregnancies and multiple births, spontaneous birth or caesarian section, skin condition, diagnostic procedures and preoperative pain rate and localization of pain should be recorded.Conclusion: Such a unique classification is needed for assessment of the treatment results in patients with RD.