Background: Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short-and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias. Methods: The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019. Results: Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity. Conclusion: This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.

Background Rare locations of hernias, as well as primary ventral hernias under certain circumstances (cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim was to identify situations where the treatment strategy might deviate from routine management. Methods The guideline group consisted of surgeons from the European and Americas Hernia Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists were used to evaluate the quality of full‐text papers. A systematic literature search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was followed. Results Literature was limited in quantity and quality. A majority of the recommendations were graded as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of evidence. Conclusion This is the first European and American guideline on the treatment of umbilical and epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All recommendations were weak owing to a lack of evidence. Further studies are needed on patients with rectus diastasis, Spigelian and lumbar hernias.

An objective pass/fail evaluation can be given to individuals tested with the MISTELS system.

Background:In February 2006, a hernia clinic was established at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia. It was based on a group model of care and was established to increase effective use of resources to reduce waiting times. We conducted a survey of patients referred to the hernia clinic to determine compliance. Methods:We developed and mailed a questionnaire to all patients who had surgery after assessment at the hernia clinic. Data were analyzed for the entire study group and for 2 subgroups: patients in group I had the same surgeon for assessment and surgery, whereas patients in group II had a different surgeon for assessment and surgery. Differences between subgroups were assessed using the 2-tailed Fisher exact test. Waiting times were recorded. Results:In all, 94 patients responded to the survey. Of these, 67% had the same surgeon for assessment and surgery, and 31% had a different surgeon; 2% were not sure. Two-thirds were comfortable having their surgery performed by a surgeon whom they met the day of surgery. Most patients had confidence in the competence of any surgeon and considered service to be better and faster in a specialized centre. Most felt that a group of surgeons providing hernia care uses resources more effectively. Conclusion :L'observance des patients à l'endroit du modèle de soins regroupés pour la chirurgie de l'hernie est élevée.

Following laparoscopic donor nephrectomy (LDN), recovery has only been studied using traditional outcomes, subjective and confounded by comorbidity and psychosocial variables. The purpose of this study is to estimate surgical recovery following LDN using stan-

Purpose Groin herniorrhaphy is the most common operation performed by general surgeons. Annually, more than 20 million groin hernias are repaired worldwide. The general approach towards groin hernias is surgical repair regardless of the presence of symptoms. The rationale to recommend surgery for asymptomatic groin hernias is prevention of visceral strangulation. The goal of this review is to evaluate the appropriateness of surgery in patients with asymptomatic groin hernias. Methods The review was based on an extensive literature search of Pubmed, Medline and the Cochrane Library. Results The risk of incarceration is approximately 4 per 1,000 patients with a groin hernia per year. Risk factors for incarceration are age above 60 years, femoral hernia site and duration of signs less than 3 months. Morbidity and mortality rates of emergency groin hernia repair are higher in patients who are older than 49 years, have a delay between onset of symptoms and surgery of more than 12 h, have a femoral hernia, have nonviable bowel and have an ASA-class of 3 or 4. The recurrence rate after tension-free mesh repair in the management of emergency groin hernias is comparable to that of elective repair. There is no diVerence in pain and quality of life after elective repair compared to watchful waiting. There is no advantage in cost-eVectiveness of elective repair compared to watchful waiting. ConclusionWatchful waiting for asymptomatic groin hernias is a safe and cost-eVective modality in patients who are under 50 years old, have an ASA class of 1 or 2, an inguinal hernia, and a duration of signs of more than 3 months.

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The LAS procedure after previous splenectomy is feasible and safe. Perioperative localization methods aid in the intraoperative identification of an accessory spleen. Accessory spleens missed at initial splenectomy are generally found in unusual locations. Treatment of recurrent or unresolved ITP with LAS can be effective for some patients.