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EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen

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Abstract

Purpose

To provide guidelines for all surgical specialists who deal with the open abdomen (OA) or the burst abdomen (BA) in adult patients both on the methods used to close the musculofascial layers of the abdominal wall, and regarding possible materials to be used.

Methods

The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach including publications up to January 2017. When RCTs were available, outcomes of interest were quantitatively synthesized by means of a conventional meta-analysis. When only observational studies were available, a meta-analysis of proportions was done. The guidelines were written using the AGREE II instrument.

Results

For many of the Key Questions that were researched, there were no high quality studies available. While some strong recommendations could be made according to GRADE, the guidelines also contain good practice statements and clinical expertise guidance which are distinct from recommendations that have been formally categorized using GRADE.

Recommendations

When considering the OA, dynamic closure techniques should be prioritized over the use of static closure techniques (strong recommendation). However, for techniques including suture closure, mesh reinforcement, component separation techniques and skin grafting, only clinical expertise guidance was provided. Considering the BA, a clinical expertise guidance statement was advised for dynamic closure techniques. Additionally, a clinical expertise guidance statement concerning suture closure and a good practice statement concerning mesh reinforcement during fascial closure were proposed. The role of advanced techniques such as component separation or relaxing incisions is questioned. In addition, the role of the abdominal girdle seems limited to very selected patients.

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Acknowledgements

We acknowledge the external experts for their review and evaluation using the AGREE II instrument of these guidelines prior to submission of the manuscript: Prof Manuel Armengol Carrasco (Department of General Surgery, Hospital Universitario Vall d’Hebrón, Universidad Autónoma de Barcelona, Barcelona, Spain), Prof Lars Nannestad Jørgensen (Department of Surgery, Bispebjerg University Hospital, Copenhagen, Denmark), Maarten P. Simons, MD, PhD (Department of Surgery, Onze Lieve Vrouw Gasthuis, Amsterdam, The Netherlands). We acknowledge the help, comments and advices of Pablo Alonso-Coello MD, PhD (Centro Cochrane Iberoamericano-Epidemiología Clínica y Salud Pública, IIB Sant Pau, Barcelona, Spain) and Prof Luis Grande Posa (Department of General Surgery, Parc de Salut Mar, Universidad Autónoma de Barcelona, Barcelona, Spain). We acknowledge the help with the online generated database to Felix Herrmann (Institute for Artificial Intelligence and Applied Informatics (VI), University of Wuerzburg, Germany).

Funding

These guidelines were investigator-initiated collaboration, supported by the European Hernia Society and an educational grant from ACELITY®. The funders had no role in the design or conduct of the study, collection, analysis and interpretation of the data, or preparation, review or approval of the guidelines. Final decisions regarding the key questions or other issues that arose during the guidelines development process were solely the responsibility of the guidelines development group.

Author information

Authors and Affiliations

  1. Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Passeig Vall d’Hebron 119-129, 08035, Barcelona, Spain

    M. López-Cano

  2. DPhil Programme in Evidence-Based Healthcare, University of Oxford, Oxford, UK

    J. M. García-Alamino

  3. Department of Colorectal Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK

    S. A. Antoniou

  4. Royal Bournemouth and Christchurch Hospital, Castle Lane East, Bournemouth, BH7 7DW, UK

    D. Bennet

  5. Department of General and Visceral Surgery, Cantonal Hospital of Olten,, Olten, Switzerland

    U. A. Dietz

  6. Department of Surgery: Upper Gastrointestinal and Abdominal Wall Surgery, Pedro Hispano Hospital, Matosinhos, Porto, Portugal

    F. Ferreira

  7. Department of General Surgery, CUF, Porto Hospital, Porto, Portugal

    F. Ferreira

  8. Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Vienna, Austria

    R. H. Fortelny

  9. Medical Faculty of Sigmund Freud University Vienna, Vienna, Austria

    R. H. Fortelny

  10. Unidad de Cirugía General, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain

    P. Hernandez-Granados

  11. Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium

    M. Miserez

  12. Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden

    A. Montgomery

  13. Unit of Innovation in Minimally Invasive Surgery, General and Digestive Surgery Unit, University Hospital Virgen del Rocío, Seville, Spain

    S. Morales-Conde

  14. Department of Surgery, Maria Middelares Hospital, Ghent, Belgium

    F. Muysoms

  15. Servei de Cirurgia General, Hospital del Mar, Parc de Salut Mar, Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain

    J. A. Pereira

  16. General and Thoracic Surgery, Federal Armed Forces Central Hospital, Koblenz, Germany

    R. Schwab

  17. Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands

    N. Slater

  18. Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospita, Ghent, Belgium

    A. Vanlander & F. Berrevoet

  19. The Netherlands Cancer Institute, Amsterdam, The Netherlands

    G. H. Van Ramshorst

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  1. M. López-Cano
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  2. J. M. García-Alamino
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  3. S. A. Antoniou
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Correspondence to M. López-Cano.

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The authors declare no competing interests related with these guidelines.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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López-Cano, M., García-Alamino, J.M., Antoniou, S.A. et al. EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen. Hernia 22, 921–939 (2018). https://doi.org/10.1007/s10029-018-1818-9

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