WSES guidelines for emergency repair of complicated abdominal wall hernias

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WSES guidelines for emergency repair of complicated abdominal wall hernias
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World Journal of Emergency Surgery
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Massimo Sartelli, Federico Coccolini, Gabrielle H van Ramshorst, Giampiero Campanelli, Vincenzo Mandalà, Luca Ansaloni, Ernest E Moore, Andrew Peitzman, George Velmahos, Fredrick Alan Moore, Ari Leppaniemi, Clay Cothren Burlew, Walter Biffl, Kaoru Koike, Yoram Kluger, Gustavo P Fraga, Carlos A Ordonez, Salomone Di Saverio, Ferdinando Agresta, Boris Sakakushev, Igor Gerych, Imtiaz Wani, Michael D Kelly, Carlos Augusto Gomes, Mario Paulo Faro Jr, Korhan Taviloglu, Zaza Demetrashvili, Jae Gil Lee, Nereo Vettoretto, Gianluca Guercioni, Cristian Tranà, Yunfeng Cui, Kenneth YY Kok, Wagih M Ghnnam, Ashraf El-Sayed Abbas, Norio Sato, Sanjay Marwah, Muthukumaran Rangarajan, Offir Ben-Ishay, Abdul Rashid K Adesunkanmi, Helmut Alfredo Segovia Lohse, Jakub Kenig, Stefano Mandalà, Andrea Patrizi, Rodolfo Scibé and Fausto Catena
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World Journal of Emergency Surgery
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Emergency repair of complicated abdominal hernias is associated with poor prognosis and a high rate of post-operative complications. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013, during the 2nd Congress of the World Society of Emergency Surgery with the goal of defining recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel.

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University of Florida
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REVIEWOpenAccessWSESguidelinesforemergencyrepairof complicatedabdominalwallherniasMassimoSartelli1*,FedericoCoccolini2,GabrielleHvanRamshorst3,GiampieroCampanelli4,VincenzoMandal5, LucaAnsaloni2,ErnestEMoore6,AndrewPeitzman7,GeorgeVelmahos8,FredrickAlanMoore9,AriLeppaniemi10, ClayCothrenBurlew6,WalterBiffl6,KaoruKoike11,YoramKluger12,GustavoPFraga13,CarlosAOrdonez14, SalomoneDiSaverio15,FerdinandoAgresta16,BorisSakakushev17,IgorGerych18,ImtiazWani19,MichaelDKelly20, CarlosAugustoGomes21,MarioPauloFaroJr22,KorhanTaviloglu23,ZazaDemetrashvili24,JaeGilLee25, NereoVettoretto26,GianlucaGuercioni27,CristianTran1,YunfengCui28,KennethYYKok29,WagihMGhnnam30, AshrafEl-SayedAbbas30,NorioSato11,SanjayMarwah31,MuthukumaranRangarajan32,OffirBen-Ishay12, AbdulRashidKAdesunkanmi33,HelmutAlfredoSegoviaLohse34,JakubKenig35,StefanoMandal36, AndreaPatrizi1,RodolfoScib1andFaustoCatena37AbstractEmergencyrepairofcomplicatedabdominalherniasisassociatedwithpoorprognosisandahighrateof post-operativecomplications. AWorldSocietyofEmergencySurgery(WSES)ConsensusConferencewasheldinBergamoinJuly2013,duringthe 2ndCongressoftheWorldSocietyofEmergencySurgerywiththegoalofdefiningrecommendationsfor emergencyrepairofabdominalwallherniasinadults.Thisdocumentrepresentstheexecutivesummaryofthe consensusconferenceapprovedbyaWSESexpertpanel.IntroductionAlargenumberofabdominalherniasrequireemergency surgery.However,theseproceduresareassociatedwith poorprognosesandahigherrateofpost-operativecomplications[1]. AWorldSocietyofEmergencySurgery(WSES)ConsensusConferencewasheldinBergamoonJuly2013,during the2ndCongressoftheWorldSocietyofEmergencySurgerywiththegoalofdefiningrecommendationsforemergencyrepairofabdominalwallherniasinadults.This documentrepresentstheexecutivesummaryoftheconsensusconferenceapprovedbyaWSESexpertpanel. Abdominalherniasmaybeclassifiedasgroinhernias (femoralandinguinal)andventralhernias(umbilical, epigastric,spigelianandincisional). Anincarceratedherniamaybedefinedasaherniain whichthecontentshavebecomeirreducibleduetoanarrowopeningintheabdominalwalloradhesionswithinthe cavity.Intestinalobstruction cancomplicateanincarcerated hernia.Incontrast,astrangulatedherniaisoneinwhich thebloodsupplytothecontentsofthehernia(egomentum,bowel)sbecomescompromised[2]. Strangulatedherniasremainasignificantchallenge,as theyaresometimesdifficulttodiagnosepurelybyphysical examinationyetrequireurgents urgicalintervention.Early surgicalinterventionofastrangulatedherniawithobstructioniscrucialasdelayeddiagnosiscanleadtobowelresectionwithlongerrecoveryanditsattendantcomplications. Strangulatedherniascanhaveseriousdeleteriouseffects suchas,bowelobstruction,bact erialtranslocation,andintestinalwallnecrosis(potentiallyresultinginbowelperforation).Itposesasignificantrisktoemergencyherniarepair, asthereisanincreasedincidenceofsurgicalfieldcontamination,leadingtohighratesofpost-operativeinfectionand probablyrecurrence. Bacteriainherentlycolonizeallsurgicalwounds,butonly afractionofthesecontaminatesultimatelyleadtoinfection. Inmostpatientsinfectiondoesnotoccurbecauseinnate hostdefencesareabletoeliminatemicrobesatthesurgical *Correspondence: m.sartelli@virgilio.it1DepartmentofSurgery,MacerataHospital,Macerata,Italy Fulllistofauthorinformationisavailableattheendofthearticle WORLD JOURNAL OF EMERGENCY SURGERY 2013Sartellietal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycited.TheCreativeCommonsPublicDomainDedication waiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle,unlessotherwise stated.Sartelli etal.WorldJournalofEmergencySurgery 2013, 8 :50 http://www.wjes.org/content/8/1/50

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site.However,thereissomeevidencethattheimplantation offoreignmaterials,suchasprostheticmesh,mayleadtoa decreasedthresholdforinfection[3]. Whilemanyfactorscaninfluencesurgicalwoundhealing andpost-operativeinfection ,bacterialburdenisthemost significantriskfactor.Wound sareclassifiedaccordingto thelikelihoodanddegreeofwoundcontaminationatthe timeofoperation.Classificationsinclude:cleanwounds, clean-contaminatedwounds,contaminatedwounds,and dirtyorinfectedwounds[4]. Thepathogensinvolvedinaninfectiondependonthe typeofsurgery.Inanasepticsurgicalprocedure, Staphylococcusaureus isacommonsourceofinfection,eitherfrom thepatient ’ sownskinfloraorsurroundingenvironment. Surgeonscanminimizetheriskofinfectionandassociated complicationsbyroutinelyemplo yingsite-specificspectrum antibioticprophylaxis. Inclean-contaminated,contaminated,anddirtysurgicalprocedures,thepolymicrobialaerobicandanaerobic floracloselyresemblethenormalendogenousmicroflora ofthegastrointestinal(GI)tractandarethemostfrequentlyobservedpathogens.ThecontaminatingpathogensinGIsurgeryincludegram-negativebacilli(e.g., Escherichiacoli )andgram-positivemicrobes,suchas enterococciandanaerobicorganisms.Aclassification schemehasbeendemonstratedinmultiplestudiesto predicttherelativeprobabilitythatagivenwoundwill becomeinfected[5,6]. Severalstudiesshowclearadvantagesofmeshusein electivecases,whereinfectionshouldbeuncommon.Mesh significantlyreducestherateofherniarecurrenceyetis easytouseandhaslowcomplicationrates.Ontheother hand,fewstudieshaveinvestigatedtheoutcomeofmesh useinanemergencysetting,wherethereisoftensurgical fieldcontaminationduetobowelinvolvement[7,8]. Theuseofbiologicalmeshhasmanyadvantages,includingadecreasedimmuneresponsemountedagainst theforeignbody,aswellasdecreasedincidenceoffistulaeformation,fibrosis,anderosions. Thereis,however,apaucityofhighqualityevidence onthesuperiorityofbiologicalmeshandthereremains asignificantpricepremiumwiththeiruse[9]. Recommendationguidelinesareevaluatedaccording totheGradingofRecommendationsAssessment,Development,andEvaluation(GRADE),ahierarchical, evidence-basedrubric[10,11]summarizedinTable1, whichisaguidelineusedtoassessthestrengthof recommendations.RecommendationsTimingofinterventionPatientsshouldundergoemergencyherniarepairimmediatelywhenintestinalstrangulationissuspected(grade 1Crecommendation). Systemicinflammatoryresponsesyndrome(SIRS) signs,contrast-enhancedCTfindingsaswellaslactate, CPKandD-dimerlevelsarepredictiveofbowelstrangulation(grade1Crecommendation). Unfortunately,morbidityandmortalityratesremain highforpatientswhoundergoemergencyrepairofabdominalhernias.Earlydiagnosisofstrangulatedobstructionmaybedifficult,anddelayeddiagnosiscanleadto septiccomplications.However,inthecaseofsuspected bowelstrangulationthebenefitsoutweightherisksof surgeryandpatientsshouldundergoimmediatesurgical intervention. ArecentstudyperformedbyMartnez-Serranoetal. prospectivelyanalyzedmorbidityandmortalityratesfollowingemergencyherniarepair[12].Thestudypopulationincluded244patientswithcomplicatedabdominal wallherniasrequiringsurgicalrepair.Inthisstudy,the patientsweretreatedaccordingtostandardizedprotocolswithdetailedactionstobetakenduringthepre-, intra-,andpost-operativeperiods.Clinicaloutcomes werecomparedretroactivelytothatof402patientswho hadundergonesimilarproceduresbeforethedevelopmentandimplementationoftheprotocolsoutlinedin thestudy.Resultsshowedhigherratesofmortalityin patientswithacutecomplicationastheirfirstherniarelatedsymptomandwhosetreatmentwasdelayedfor morethan24hours.Thus,theauthorsconcludedthat earlydetectionofcomplicatedabdominalherniasmay bethebestmeansofreducingtherateofmortality[12]. In2007,Dericietal.publishedaretrospectivestudyusing univariateandmultivariateanalysistoinvestigatefactorsaffectingmorbidityandmortalityratesincasesofincarceratedabdominalwallhernias[13] .Usingunivariateanalysis, resultsshowedthatsymptom aticperiodslastinglonger than8hours,thepresenceofcomorbiddisease,high AmericanSocietyofAnesthesiology(ASA)scores,theuse ofgeneralanesthesia,thepresenceofstrangulation,andthe presenceofnecrosissignifican tlyaffectmorbidityrates.In contrast,advancedage,thepresenceofcomorbiddiseases, highASAscores,thepresenceofstrangulation,thepresenceofnecrosis,andherniarepairwithgraftwerefoundto significantlyaffectmortalityr atesbyunivariateanalysis;the presenceofnecrosis,however,wastheonlyfactorthatappearedtosignificantlyaffectmortalityratesbasedonmultivariateanalysis[10]. Aretrospectivestudywasrecentlypublishedevaluatingtheriskfactorsassociatedwithbowelresectionand treatmentoutcomeinpatientswithincarceratedgroin hernias[14]. Thestudyanalyzed182adultpatientswithincarceratedgroinherniaswhounderwentemergencyherniarepairinthe10-yearperiodfromJanuary1999toJune 2009.Ofthesepatients,bowelresectionwasrequiredin 15.4%ofcases(28/182).AlogisticregressionmodelSartelli etal.WorldJournalofEmergencySurgery 2013, 8 :50Page2of11 http://www.wjes.org/content/8/1/50

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identifiedthreeindependentriskfactorsforbowelresection:lackofhealthinsurance(oddsratio[OR],5, P=0.005),obviousperitonitis(OR,11.52,P=0.019),and femoralhernia(OR,8.31,P<0.001)[14]. Manyauthorsreportedthatearlydetectionofprogressionfromanincarceratedherniatoastrangulatedherniaisdifficulttoachievebyeitherclinicalorlaboratory means,whichpresentsalargechallengeinearlydiagnosis[15-17].SignsofSIRSincludingfever,tachycardia, andleukocytosis,aswellasabdominalwallrigidity,are consideredcommonindicatorsofstrangulatedobstruction.However,aninvestigationbySarretal.demonstratedthatthecombinationoffourclassicsignsof strangulation – continuousabdominalpain,fever,tachycardia,andleukocytosis – couldnotdistinguishstrangulatedfromsimpleobstructions[16].Furthermore, Shatillaetal.reportedalowincidenceoftheseclassical findingsandstatedthattheirpresenceindicatedanadvancedstageofstrangulation,whichwouldbeoflimited valueforearlydiagnosis[16].In2006,Tsumuraetal. publishedaretrospectivestudyinvestigatingSIRSasa predictorofstrangulatedsmallbowelobstruction. MultivariateanalysisrevealedthatthepresenceofSIRS alongsideabdominalmuscleguardingwasindependently predictiveofstrangulatedsmallbowelobstruction[18]. Amongpossiblediagnostictests,serumcreatinine phosphokinase(CPK)appearstobearelativelyreliable indicatorofearlyintestinalstrangulation[19,20].Icoz etal.publishedaprospectivestudyinvestigatingthe relevanceofserumD-dimermeasurementasapotential diagnosticindicatorofstrangulatedintestinalhernia. TheauthorsconcludedthatD-dimerassaysshouldbe performedonpatientspresentingwithintestinalemergenciestobetterevaluateandpredictischemicevents. Despitehavinglowspecificity,elevatedD-dimerlevels measureduponadmissionwerefoundtocorrelate stronglywithintestinalischemia[21]. In2012aninterestingretrospectivestudyexamining whethervariouslaboratoryparameterscouldpredictviabilityofstrangulationinpatientswithbowelobstruction waspublished.Fortypatientsdiagnosedwithbowel strangulationoperatedwithin72hoursofthestartof symptomswereincludedinthestudy.Lactatelevelwas theonlylaboratoryparametersignificantlyassociated Table1GradingofRecommendationsAssessment,Development,andEvaluation(GRADE)fromGuyattand colleagues[10,11]Gradeof recommendation Clarityofrisk/benefitQualityofsupportingevidenceImplications 1A Strong recommendation, high-qualityevidence Benefitsclearlyoutweighriskand burdens,orviceversa RCTswithoutimportantlimitationsor overwhelmingevidencefromobservational studies Strongrecommendation,appliesto mostpatientsinmost circumstanceswithoutreservation 1B Strong recommendation, moderate-quality evidence Benefitsclearlyoutweighriskand burdens,orviceversa RCTswithimportantlimitations(inconsistent results,methodologicalflaws,indirectanalysesor impreciseconclusions)orexceptionallystrong evidencefromobservationalstudies Strongrecommendation,appliesto mostpatientsinmost circumstanceswithoutreservation 1C Strong recommendation, low-qualityorvery low-qualityevidence Benefitsclearlyoutweighriskand burdens,orviceversa ObservationalstudiesorcaseseriesStrongrecommendationbut subjecttochangewhenhigher qualityevidencebecomesavailable 2A Weak recommendation, high-qualityevidence Benefitscloselybalancedwithrisks andburden RCTswithoutimportantlimitationsor overwhelmingevidencefromobservational studies Weakrecommendation,bestaction maydifferdependingonthe patient,treatmentcircumstances, orsocialvalues 2B Weak recommendation, moderate-quality evidence Benefitscloselybalancedwithrisks andburden RCTswithimportantlimitations(inconsistent results,methodologicalflaws,indirector imprecise)orexceptionallystrongevidencefrom observationalstudies Weakrecommendation,bestaction maydifferdependingonthe patient,treatmentcircumstances, orsocialvalues 2C Weak recommendation, Low-qualityorvery low-qualityevidence Uncertaintyintheestimatesof benefits,risks,andburden;benefits, risk,andburdenmaybeclosely balanced ObservationalstudiesorcaseseriesVeryweakrecommendation; alternativetreatmentsmaybe equallyreasonableandmerit consideration Sartelli etal.WorldJournalofEmergencySurgery 2013, 8 :50Page3of11 http://www.wjes.org/content/8/1/50

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withviability(P<0.01,Mann-Whitneytest).Otherlaboratorydatadidnotshowstatisticallysignificantassociations.TheAuthorsconcludedthatarterialblood lactatelevel(2.0mmol/Lorgreater)wasausefulpredictorofnonviablebowelstrangulation[22]. Earlydiagnosticmethodstodetectbowelstrangulation haveadvancedsubstantiallyfollowingthedevelopment andrefinementofradiologicaltechniques,suchasComputedTomography(CT)scanning[23].Jancelewicz etal.recentlypublishedaretrospectiveanalysisdemonstratingthatCTfindingsofreducedwallenhancement werethemostsignificantindependentpredictorof bowelstrangulation,with56%sensitivityand94%specificity.Bycontrast,elevatedwhitebloodcell(WBC) countandguardingonphysicalexaminationwereonly moderatelypredictive.Itshouldbenoted,however,that anelevatedWBCwastheonlyvariablefoundtobeindependentlypredictiveofbowelstrangulationinpatients withsmallbowelobstruction[24].LaparoscopicapproachRepairofincarceratedhernias – bothventraland groin – maybeperformedwithalaparoscopicapproach(grade1Crecommendation). Recentprospectivestudiesandrecentguidelines [25-31]havefocusedonthelaparoscopicapproachto herniarepairinanelectivesetting. Bycontrast,fewstudieshavefocusedonthelaparoscopicapproachtoherniarepairinanemergencysetting.In2004,Landauetal.publishedaretrospective studyinvestigatingtheuseoflaparoscopyintherepair ofincarceratedincisionalandventralhernias.Theauthorsarguedthatlaparoscopicrepairwasfeasibleand couldbesafelyusedtotreatpatientspresentingwithincarceratedincisionalandventralhernias[32]. Anotherretrospectivestudypublishedin2008investigatedtheroleoflaparoscopyinthemanagementofincarcerated(non-reducible)ventralhernias.Theauthors concludedthatlaparoscopicrepairofventralabdominal wallherniascouldbesafelyperformedwithlowsubsequentcomplicationrates,evenintheeventofan incarceratedhernia.Carefulbowelreductionwithadhesiolysisandmeshrepairinanuncontaminatedabdomen (withoutinadvertententerotomy)usinga5-cmmesh overlapwasanimportantfactorpredictiveofsuccessful clinicaloutcome[33]. In2009,anotherretrospectivestudywaspublishedinvestigatinglaparoscopictechniquesusedtotreatincisionalherniasinanemergencysetting.Theresultsof thisseriesalsodemonstratedthefeasibilityoflaparoscopicsurgerytotreatincarceratedincisionalherniasin anemergencysetting[34]. Additionally,asystematicliteraturereviewperformed in2009identifiedarticlesreportingonlaparoscopic treatment,reduction,andrepairofincarceratedorstrangulatedinguinalherniasfrom1989to2008.Itincluded sevenarticlesonthistopic,reportingon328cases treatedwithtotalextraperitoneal(TEP)ortransabdominalpreperitoneal(TAPP)repair.Laparoscopycanalso beusedtoresectbowel,ifnecessary,ortorepairanoccultcontralateralhernia,presentin11.2 – 50%ofcases. TheAuthorsconcludedthatthelaparoscopicrepairisa feasibleprocedurewithacceptableresults;however,its efficacyneedstobestudiedfurther,ideallywithlarger, multicenterrandomizedcontrolledtrials[35] In2007aseriesofpatientswithlargeirreduciblegroin hernias(omentoceles),treatedbylaparoscopywithout conversions,waspublished.TheAuthorsdescribeda techniquetofacilitatecompleteremovalofthetheherniacontents.Alaparoscopictransperitonealrepairfor largeirreduciblescrotalherniasremovingasmuch omentumaspossiblewasperformed.Thenasmallgroin incisionwasmadetoexcisetheadherentomentumfrom thedistalsac[36]. Hernioscopyisamixedlaparoscopic – opensurgical techniqueforincarceratedinguinalhernias.Specifically, itiseffectiveinevaluatingtheviabilityoftheherniated loop,thusavoidingunnecessarylaparotomy[37].Aprospectiverandomizedstudyin2009aimedtoevaluatethe impactofherniasaclaparoscopyonthemorbidityand mortalityofcaseswithaspontaneousreductionofthe strangulatedherniacontentbeforetheassessmentofits viability.Ninety-fivepatientswererandomlyassignedto 2groups:groupA(21patientsmanagedusinghernia saclaparoscopy)andgroupB(20patientsmanaged withoutlaparoscopy).Themedianhospitalstaywas28 hoursforgroupAand34hoursforgroupB.FourpatientsofgroupBhadmajorcomplications,whereas therewasnoneobservedinthegroupA.Twounnecessarylaparotomiesand2deathsoccurredingroupB.The authorsconcludedthatherniasaclaparoscopyseemsto beanaccurateandsafemethodofpreventingunnecessarylaparotomyandinhigh-riskpatientsitcontributes todecreasedmorbidity[38].Emergencyherniarepairin “ cleansurgicalfield ”Thechoiceoftechniquerepairisbasedonthecontaminationofthesurgicalfield,thesizeofthehernia andtheexperienceofthesurgeon. Prostheticrepairwithsyntheticmeshisrecommendedforpatientswithintestinalincarcerationand nosignsofintestinalstrangulationorconcurrent bowelresection(cleansurgicalfield)(grade1A recommendation). Theincreasedlikelihoodofsurgicalsiteinfection maysuggestadditiveriskforpermanentsynthetic meshrepair(grade1Crecommendation).Sartelli etal.WorldJournalofEmergencySurgery 2013, 8 :50Page4of11 http://www.wjes.org/content/8/1/50

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Primarysuturerepairasanelectivehernia-relatedprocedurecanincreasetheriskofrecurrence,therebyleadingtosubsequentfollow-upsurgery.Thisisthecasein bothventralandinguinalabdominalwallhernias.Numerousstudieshavedemonstratedtheadvantagesof meshuseinclean,sterilecases;suchadvantagesinclude easeofplacement,lowlong-termcomplicationrates, andreductionofrecurrenceforincisionalhernias [39-42].Forpatientswithintestinalincarcerationandno signsofintestinalstrangulationorconcurrentbowelresection,thesurgicalfieldispresumedcleanandtheinfectiousriskforsyntheticmeshislow.Theabsenceof intestinalwallischemiarenderspatientslesspredisposed tobacterialtranslocation,andthereisalowriskofneed forconcurrentbowelresection,whichleadstocontaminationofthesurgicalfield.However,thishasnotbeen provenforcasesofacuteirreduciblehernias. Researchershavepublishedavarietyofsmall-scale studiescomparingmeshusetosuturerepairinthetreatmentofacuteirreduciblehernias[43-46].In2011,Nieuwenhuizenetal.publishedaretrospectivestudy investigatingtheuseofmeshinacutehernia-related procedures.Atotalof203patientswereidentifiedfor thestudy:76inguinal,52umbilical,39incisional,14epigastric,14femoral,5trocar,and3spigelianhernias.For purposesofstatisticalanalysis,epigastric,femoral,trocar, andspigelianherniapatientswerepooledtogetherdue totheirsmallindividualgroupsizes.Onepatientwasexcludedfromtheanalysisbecausetheherniawasnotultimatelycorrectedduringsurgery.Inall,99herniaswere repairedusingmeshcomparedto103primarysuture repairs.Additionally,univariateanalysisdemonstrated thatfemalepatients( P =0.007),overweightpatients ( P =0.016),patientswithanumbilicalhernia( P =0.01), andpatientswhohadundergonebowelresection ( P =0.015)featuredsignificantlyhigherratesofwound infection.Bycontrast,thetypeofrepair(i.e.primarysuturevs.mesh),theuseofantibioticprophylaxis,ASA class,andpatientagedidnotappeartoshareanystatisticallysignificantrelationshipswithpost-operativerates ofsurgicalsiteinfection.Basedonlogisticregression analysis,onlybowelresection( P =0.020)appearedto correlatesignificantlywithpost-operativesurgicalsite infection[47]. Anincreasedlikelihoodforsurgicalsiteinfectionmay suggestadditiveriskforpermanentsyntheticmeshrepair[48-50].Inarecentmulticentercohortstudy,patientswhounderwentincisionalherniarepairduring otherconcomitantintra-abdominalproceduresexperiencedgreaterthan6-foldincreasesintheriskofsubsequentmeshremoval.Ofthe1,071meshrepairs retrospectivelyanalyzedduringthe4-yearperiodfrom 1998to2002,5.1%(55/1,071)underwentmeshremoval atamediantimeof7.3months(interquartilerange1.422.2)followingincisionalherniarepairwithpermanent meshprosthesis.Infectionwasthemostcommonreason formeshremoval,accountingfor69%ofcases.Nostatisticallysignificantdifferenceswereobservedbasedon themethodofsurgicalrepair.Afteradjustingforcovariates,bothsame-siteconcomitantsurgery(hazardratio [HR]=6.3)andpost-operativesurgicalsiteinfection (HR=6.5)wereassociatedwithmeshremoval[51].Emergencyherniarepairin “ potentiallycontaminated surgicalfield ”Forpatientswithintestinalstrangulationand/orconcurrentbowelresection(potentiallycontaminated surgicalfield),directsutureisrecommendedwhen theherniadefectinquestionissmall.Syntheticmesh repairmaybeperformed,butwithcaution.Biological meshesmaybeavalidoptionbutmeritdetailed cost-benefitanalysis(grade2Crecommendation). Manystudiesdiscussandadvocatetheuseofprostheticmeshincleansurgicalfields.However,theuseof prostheticgraftsinpotentially-contaminatedandcontaminatedsettingsisseldomdescribed.Despitediscrepanciesindataandconflictingreports,prosthetic materialsarenotgenerallyrecommendedforabdominal herniarepairincontaminatedsettings.Moststudieson thesubjectdonotfocusonemergencyrepair,andas such,theirresultsareoflimitedvalue.Accordingto manyresearchers,theuseofmeshisstronglydiscouragedinpotentiallycontaminatedsurgicalfields. Onestudyanalyzedandcomparedpost-operativeoutcomefollowingventralherniarepairusingprosthetic meshinclean-contaminatedandcontaminatedwounds [52].AllpatientsofU.S.hospitalsparticipatingin theNationalSurgicalQualityImprovementProgram (NSQIP)whowereadmittedformesh-mediatedventral herniarepairinthe5-yearperiodfromJanuary1,2005, toApril4,2010,wereincludedinthestudy.Compared tocleancases,clean-contaminatedcasesfeaturedasignificantlygreaterlikelihoodofwounddisruption,pneumonia,andsepsisaswellassuperficial,deep,and ventralsurgicalsiteinfections(SSIs).Bothcleancontaminatedandcontaminatedmesh-mediatedcases featuredanincreasedriskofsepticshock(5.82%and 26.74%,respectively)andventilatoruselastinglonger than48hours(5.59%and26.76%,respectively).Cleancontaminatedcasesofmesh-mediatedventralherniarepairalsofeaturedasignificantlyincreasedoddsratiofor complications(2.52)[52]. Inarecentstudy,Xourafasetal.examinedtheimpactof meshuseonventralherniarepairswithsimultaneous bowelresectionsattributable toeithercancerorbowelocclusion.Researchersfoundasig nificantlyhigherincidence ofpost-operativeinfectioninpatientswithprostheticmesh comparedtothosewithoutmesh .AccordingtomultivariateSartelli etal.WorldJournalofEmergencySurgery 2013, 8 :50Page5of11 http://www.wjes.org/content/8/1/50

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regressionanalysis,prosthe ticmeshusewastheonlysignificantriskfactorirrespecti veofothervariablessuchas drainuse,defectsize,ortypeofbowelresection[53].By contrast,otherresearchersh aveassertedthatprosthetic repairofabdominalherniascanbesafelyperformedalongsidesimultaneouscolonicoperations.Suchjointprocedures,theyargue,exhibitacc eptableratesofinfectious complicationsandrecurrence,andconsequently,they maintainthatthereisinsufficientevidencetoadvocatethe avoidanceofprostheticmeshinpotentiallycontaminated fields,assumingthattheap propriatetechniqueisused [54,55]. In2000Mandaletal.publishedaseriesofpatients withincisionalherniastreatedwithnonabsorbableprosthesesandassociatedvisceralsurgery.Thelowincidence ofsuppurativecomplications,withneitherremovalof thepatchnorrecurrencesintheshortterm,showedthat nonabsorbablemeshrepairinpotentiallycontaminated fieldswassafe[56]. StudiesbyVixetal.,Birolinietal.,andGeisleretal. reportwound-relatedmorbidityratesof10.6%,20%,and 7%,respectively,followingmeshuseinbothcleancontaminatedandcontaminatedprocedures[57-59].A differentstudybyCampanellietal.analyzedtenprostheticherniarepairsinpotentiallycontaminatedfields andreportednomajororminorcomplicationsaftera 21-monthfollow-upperiod[60]. RecentlyastudybyCarbonelletal.[61]investigated Openventralherniarepairsperformedwithpolypropylenemeshintheretro-rectuspositionincleancontaminatedandcontaminatedfields.The30-daysurgicalsiteinfectionratewas7.1%forclean-contaminated cases;forcontaminatedcasesthe30-daysurgicalsiteinfectionratewas19.0%. Itshouldbenoted,however,thatmostofthesestudies didnotfocusonemergencyrepairofincarcerated hernias. AstudybyKellyetal.reporteda21%infectionrate inaseriesofemergencyandelectiveincisionalhernia repairs[62].AstudybyDaviesetal.focusedexclusivelyonasubsetofherniacasesinwhichpatients presentedwithanobstructedbowelandrequired emergencysurgery.Thisstudyfoundhighratesofinfectioninpatientsrequiringemergencyrepairforall typesofabdominalhernias[63].Aretrospective multivariateanalysisbyNieuwenhuizenetal.revealed bowelresectiontobeamajorfactorassociatedwith woundinfection,butthatotherclinicalramifications oftheprocedurewererelativelyrare[47].Arecently publishedretrospectiveanalysisofemergencyrepair ofincarceratedincisionalherniaswithsimultaneous bowelobstructioninpotentiallycontaminatedfields demonstratedthattheuseofpermanentprosthetic meshinthesesurgerieswasassociatedwithhighrates ofwoundinfection.Noinfectionsoccurredinpatients whosesurgicalwoundswereleftopentogranulate [64]. In2013aprospectivestudytopresenta7-yearexperiencewiththeuseofprostheticmeshrepairinthemanagementoftheacutelyincarceratedand/orstrangulated ventralherniaswaspublished.Theherniawasparaumbilicalin71patients(89%),epigastricin6patients (8%)andincisionalin3patients(4%).Eighteenpatients (23%)hadrecurrenthernias.Resection-anastomosisof non-viablesmallintestinewasperformedin18patients (23%)andwasnotregardedasacontraindicationfor prostheticrepair[65]. Biologicalmeshprostheticsaremostcommonlyusedin infectedfieldsinvolvinglarge,complexabdominalwallherniarepairs.Theuseofbiologicalmesh,whichbecomesvascularizedandremodelledin toautologoustissueafter implantation,mayofferalow-morbidityalternativetoprostheticmeshproductsinthes ecomplexsettings,withgood resultsalsoinimmunocompromisedpatients[66].Theuse ofbiologicalmaterialsinclinicalpracticehasledtoinnovativemethodsoftreatingabdominalwalldefectsincontaminatedsurgicalfields. Manyretrospectivestudieshaveexploredthepromising roleofbiologicalmeshincontaminatedfields,butmostof theseinvestigationsdidnotfocusonemergencyrepairof incarceratedhernias[67-87]. Althoughbiologicmeshinthesesituationsissafe,longtermdurabilityhasstillnotbeendemonstrated[88].A studybyCatenaetal.publishedin2007focusedoncomplicatedincisionalherniarepairusingmeshprostheticsmade ofporcinedermalcollagen(PDC).Incisionalhernioplasty usingPDCgraftswasfoundtobeasafeandefficientapproachtodifficultcasescomplicatedbypotentialcontamination[82]. ArecentliteraturereviewbyCoccolinietal.coveredthe useofbiologicalmeshesforabdominalreconstructionin emergencyandelectivesettingintransplantedpatients,and reportedacomplicationrateof9.4%[85]. Byincorporatingbiologicalmesh,surgeonshopeto provideacollagen-basedextracellularmatrixscaffold bywhichhostfibroblastscaninduceangiogenesisand depositnewcollagen.Thenon-syntheticmaterialof biologicalmeshmakesitlesssusceptibletoinfection, andseveralbiologicalgraftsareavailableinthe currentmarket.Theirclassificationisbasedonthe speciesoforigin(allogenicorxenogenic),thetypeof collagenmatrixutilized(dermis,pericardium,orintestinalsubmucosa),thedecellularizationprocess,the presenceorabsenceofcross-linkage,temperaturerelatedstoragerequirements,andtheuseofrehydration[86]. Onthebasisofeitherthepresenceornotofthe cross-linking,biologicalprosthesisaredividedintotwoSartelli etal.WorldJournalofEmergencySurgery 2013, 8 :50Page6of11 http://www.wjes.org/content/8/1/50

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subgroups:thepartiallyremodeling(cross-linked)and thecompletelyremodelingones(notcross-linked). Thankstothepresenceofadditionallinkagesthepartiallyremodelingonesresistbetterandforalonger periodtomechanicalstress[66]. Coccolinietal.recentlypublishedtheresultsofthe first193patientsoftheItalianRegisterofBiological Prosthesis(IRBP)[87].Thisprospectivemulti-centre study,suggeststheusefulness,versatilityandeaseof usingbiologicalprosthesisinmanydifferentsituations, includingcleanorcontaminatedsurgicalfields.Despite thelackofacohesivebodyofevidence,publishedstudiesonbiologicalmeshsuggestthatcross-linkedmesh prostheticshavethelowestfailurerateinpotentially contaminatedandoutrightinfectedfields.Thistrend shouldbeinvestigatedfurtherbymeansoflarge,prospective,randomizedstudies[89]. Recentlyacriticalreviewofbiologicmeshuseinventralherniarepairsundercontaminatedfieldwaspublished.Allliteraturereviewsfoundinmedlinedatabase supportedbiologicmeshuse,especiallyinthesettingof contaminatedfields,buttheprimaryliteratureincluded inthesereviewsconsistedentirelyofcaseseriesandcase reportswithlowlevelsofevidence[90].Tobetterguide surgeons,prospective,randomizedtrialsshouldbe undertakentoevaluatetheshort-andlong-termoutcomesassociatedwithbiologicalmeshesunderthevarioussurgicalwoundclassifications[91].Emergencyherniarepairin “ contaminated-dirtysurgical field ”Forstablepatientswithstrangulatedobstructionand peritonitisbybowelperforation(contaminated-dirty surgicalfield)directtissuesutureisrecommended whentheherniadefectissmall;intheeventsthat directtissuesutureisnotpossible,biologicalmesh repairmaybesuggested(grade2Crecommendation). Thechoicebetweenacross-linkedoranoncrosslinkedbiologicalmeshshouldbeevaluateddependingonthedefectsizeanddegreeofcontamination (grade2Crecommendation). Ifbiologicalmeshisnotavailable,bothpolyglactin meshrepairandopenmanagementwithdelayedrepair maybeaviablealternative(grade2Crecommendation). Forunstablepatients(thoseexperiencingsevere sepsisorsepticshock),openmanagementisrecommendedtopreventabdominalcompartmentsyndrome;intra-abdominalpressuremaybemeasured intra-operatively(grade2Crecommendation). Followingstabilizationofthepatient,surgeons shouldattemptearly,definitiveclosureoftheabdomen.Primaryfascialclosuremaybepossiblewhen thereisminimalriskofexcessivetensionor recurrenceofintra-abdominalhypertension(IAH) (grade2Crecommendation). Intheeventthatearly,definitivefascialclosureis notpossible,surgeonsmustresorttoprogressive closureperformedincrementallyeachtimethepatientreturnsforasubsequentprocedure.Crosslinkedbiologicalmeshesmaybeconsideredanoptioninabdominalwallreconstruction(grade2C recommendation). Incasesofbacterialperitonitis,patientsmustundergo contaminatedsurgicalintervention,whichmeansthat thesurgicalfieldisinfectedandtheriskofsurgicalsite infectionisveryhigh.Asmentionedearlier,theuseof biologicalmaterialsinclinicalpracticehasledtoinnovativemethodsoftreatingabdominalwalldefectsincontaminatedsurgicalfields,althoughthereisstill insufficientlevelofhigh-qualityevidenceontheirvalue, andthereisstillaveryhugepricedifferencebetween thesyntheticandbiologicalmeshes(9). Someauthorsinvestigatedtheuseofabsorbableprostheticmaterials[86].However,theuseofabsorbable prosthesisexposesthepatienttoaninevitableherniarecurrence.Thesemeshes,onceimplanted,initiateaninflammatoryreactionthat,throughahydrolyticreaction, removesanddigeststheimplantedprostheticmaterial completely.Inthiscase,thehighriskofherniarecurrenceisexplainedbythecompletedissolutionofthe prostheticsupport[92]. Patientswithstrangulatedobstructionandperitonitis causedbybowelperforationareoftenconsideredcriticallyillduetosepticcomplications;further,theymayexperiencehighintra-operativeintra-abdominalpressure, whichcanleadtoabdominalcompartmentsyndrome. Althoughintra-abdominalhypertensionhasbeenknown tocausephysiologicalperturbationsincetheearly19th century,itsclinicalimplicationshaveonlyrecentlybeen recognizedinpatientssustainingintra-abdominal trauma.Suchhypertensionmaybetheunderlyingcause ofincreasedpulmonarypressures,reducedcardiacoutput,splanchnichypoperfusion,andoliguria.Insummary, thisclinicalconditionisknownasabdominalcompartmentsyndrome.Abdominalcompartmentsyndromeresultsfromshockandresuscitationyieldingischemic reperfusion-relatedinjury.Cellulardamageresultsfrom ischemia,subsequentcellularmembranedysfunction, andintra-andextra-cellularedema.Thiscapillaryleak resultsinmassiveedemaoflocaltissues,mostnotably thoseoftheintestines.Prophylactictreatmenttoavoid abdominalcompartmentsyndromeinvolvesrefraining fromabdominalclosurewhenfascialapproximationbecomesproblematicduetoexcessivetension[93]. Intestinalstrangulationcanleadtoincreasedintraabdominalpressure,andultimately,toabdominal compartmentsyndrome.AstudypublishedbyBeltranSartelli etal.WorldJournalofEmergencySurgery 2013, 8 :50Page7of11 http://www.wjes.org/content/8/1/50

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etal.examined81consecutiveunselectedpatients presentingwithcomplicatedherniasandintestinalobstruction.Theresearchersmeasuredintra-abdominal pressureusingtheintra-vesicularpressuremethod, andtheseserialmeasurementsofintra-abdominal pressurewereusedtoassesstheclinicalseverityof strangulatedhernias.Intra-abdominalpressuremeasurementmaybeusedasapredictorofintestinal strangulationforpatientspresentingwithacuteabdominalcompartmentsyndromesecondarytocomplicatedherniation[94]. Followingstabilizationofthepatient,theprimary objectiveisearlyanddefinitiveclosureoftheabdomentominimizecomplications.Formanypatients, primaryfascialclosuremaybepossiblewithinafew daysoftheinitialoperation.Inotherpatients,early definitivefascialclosuremaynotbepossible.Inthese cases,surgeonsmustresorttoprogressiveclosure,in whichtheabdomenisincrementallyclosedeachtime thepatientundergoesasubsequentsurgery. Manymethodsoffascialclosurehavebeendescribed inthemedicalliterature[95-100]. In2012aretrospectiveanalysisevaluatingtheuseof vacuum-assistedclosureandmesh-mediatedfascialtraction (VACM)astemporaryabdominalclosurewaspublished. Thestudycompared50patientstreatedwith(VACM)and 54usingnon-tractiontechniques(controlgroup). VACMresultedinahigherfascialclosurerateand lowerplannedherniaratethanmethodsthatdidnot providefascialtraction[100]. Occasionallyabdominalclosureisonlypartially achieved,resultinginlarge,debilitatingherniasofthe abdominalwallthatwilleventuallyrequirecomplex surgicalrepair.Inthesecases,delayedrepairoruse ofbiologicalmeshesmaybesuggested.Bridging mesheswilloftenresultinbulgingorrecurrences [101].TheItalianBiologicalProsthesisWorking Group(IBPWG)proposedadecisionalalgorithmin usingbiologicalmeshestorestoreabdominalwalldefects[60]. Anotheroptionifdefinitivefascialclosureisnot possiblecouldbeskinonlyclosureandsubsequent managementoftheeventrationwithdeferredabdominalclosurewithsyntheticmeshesafterhospitaldischarge(grade1Crecommendation). Damagecontrolsurgeryhasbeenwidelyusedin traumapatientsanditsuseisrapidlyexpandingin thesettingofAcuteCareSurgery.Damagecontrol surgerycanbeusedinpatientswithstrangulatedobstructionandperitonitiscausedbybowelperforation. Skinonlyclosurecouldbeanalternativeforpatients withfailureofdefinitivefasciaclosure,reducingthe riskofcomplicationsofopenabdomenandabdominalcompartmentalsyndrome[102].Patientscouldbe deferredfordefinitiveabdominalclosurewithmesh afterhospitaldischarge. Thecomponentseparationtechniquemaybeuseful fortherepairoflargemidlineabdominalwallhernias(grade1Brecommendation). Thistechniqueforreconstructingabdominalwalldefectswithouttheuseofprostheticmaterialwasdescibed in1990,byRamirezetal.[103]. Thetechniqueisbasedonenlargementoftheabdominalwallsurfacebytranslationofthemuscularlayers withoutseveringtheinnervationandbloodsupplyof themuscles[104]. Reherniationratesintheliteraturevarybetween0% and8.6%.Intheseseries,severalmodificationsareused, includingapplicationofprostheticmaterial[105-109]. InaprospectiverandomizedtrialcomparingCSTwith bridgingthedefectwithprostheticmaterial,CSTwas foundtobesuperiortotheinsertionofprostheticmaterial,althoughasimilarreherniationratewasfound afterafollow-upof24months[110]. Whenothermeansofreconstructionhavealready beenusedorareinsufficientalsoamicrovasculartensor fasciaelatae(TFL)flapisafeasibleoptionforreconstructionofexceptionallylargeabdominalwalldefects. Itcanalsobecombinedwithothermethodsof reconstruction. Vascularizedflapsprovidehealthyautologoustissue coveragewithoutimplantationofforeignmaterialatthe closuresite.Aclosecollaborationbetweenplasticand abdominalsurgeonsisimportantforthisreconstruction [111].AntimicrobialprophylaxisForpatientswithintestinalincarcerationwithnoevidenceofischaemiaandnobowelresection,shortterm prophylaxisisrecommended. Forpatientswithintestinalstrangulationand/or concurrentbowelresection,48-hourantimicrobial prophylaxisisrecommended.Antimicrobialtherapy isrecommendedforpatientswithperitonitis(grade 2Crecommendation). Inasepticherniarepair, Staphylococcusaureus from theexogenousenvironmentorthepatient ’ sskinflorais typicallythesourceofinfection.Inpatientswithintestinalstrangulation,thesurgicalfieldmaybecontaminatedbybacterialtranslocation[7,8]fromintestinalvilli ofincarceratedischemicbowelloopsaswellasbyconcomitantbowelresections.Inpatientswithperitonitis bothantimicrobialtherapyandsurgeryisalways recommended.Competinginterests Theauthorsdeclarethattheyhavenocompetinginterests.Sartelli etal.WorldJournalofEmergencySurgery 2013, 8 :50Page8of11 http://www.wjes.org/content/8/1/50

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Authors ’ contributions MSwrotethemanuscript.Allauthorsreviewedandapprovedthefinal manuscript. Authordetails1DepartmentofSurgery,MacerataHospital,Macerata,Italy.2GeneralSurgery Department,PapaGiovanniXXIIIhospital,Bergamo,Italy.3Departmentof Surgery,RedCrossHospitalBeverwijk,ErasmusUniversityMedicalCenter, Rotterdam,Netherlands.4DepartmentofSurgicalScience,Istitutoclinic Sant ’ Ambrogio,Milan,Italy.5DepartmentofSurgery,BuccheriLaFerla Hospital,Palermo,Italy.6DepartmentofSurgery,DenverHealthMedical Center,Denver,CO,USA.7DepartmentofSurgery,UniversityofPittsburgh SchoolofMedicine,Pittsburgh,USA.8HarvardMedicalSchool,Divisionof Trauma,EmergencySurgeryandSurgicalCriticalCareMassachusettsGeneral Hospital,Boston,MA,USA.9DepartmentofSurgery,UniversityofFlorida, Gainesville,Florida,USA.10DepartmentofAbdominalSurgery,University HospitalMeilahti,Helsinki,Finland.11DepartmentofPrimaryCare& EmergencyMedicine,KyotoUniversityGraduateSchoolofMedicine,Kyoto, Japan.12DepartmentofGeneralSurgery,RambamHealthCareCampus, Haifa,Israel.13DivisionofTraumaSurgery,HospitaldeClinicas-,Schoolof MedicalSciences,UniversityofCampinas,Campinas,Brazil.14Departmentof Surgery,FundacionValledelLili,UniversidaddelValle,Cali,Colombia.15DepartmentofSurgery,MaggioreHospital,Bologna,Italy.16Departmentof Surgery,AdriaCivilHospital,Adria,RO,Italy.17FirstClinicofGeneralSurgery, UniversityHospital/UMBAL/StGeorgePlovdiv,Plovdiv,Bulgaria.18DepartmentofSurgery1,LvivRegionalHospital,DanyloHalytskyLviv NationalMedicalUniversity,Lviv,Ukraine.19DepartmentofSurgery, Sheri-KashmirInstituteofMedicalSciences,Srinagar,India.20GriffithBase Hospital,Griffith,NSW,Australia.21FaculdadedeCinciasMdicasedaSade deJuizdeFora(SUPREMA),FederalUniversityofJuizdeFora(UFJF),Juizde Fora,MG,Brazil.22DepartmentofGeneralSurgery,TraumaandEmergency SurgeryDivision,ABCMedicalSchool,SantoAndr,SP,Brazil.23Department ofGeneralSurgery,IstanbulDoctor ’ sCenter,Istanbul,Turkey.24Department ofSurgery,TbilisiStateMedicalUniversity,Tbilisi,Georgia.25Departmentof Surgery,YonseiUniversityCollegeofMedicine,Seoul,Korea.26Laparoscopic SurgicalUnit,M.MelliniHospital,Chiari,BS,Italy.27DepartmentofSurgery, MazzoniHospital,AscoliPiceno,Italy.28DepartmentofSurgery,TianjinNankai Hospital,NankaiClinicalSchoolofMedicine,TianjinMedicalUniversity, Tianjin,China.29DepartmentofSurgery,RipasHospital,BandarSeriBegawan, Brunei.30DepartmentofSurgeryMansoura,FacultyofMedicine,Mansoura University,Mansoura,Egypt.31DepartmentofSurgery,PtBDSPost-graduate InstituteofMedicalSciences,Rohtak,India.32DepartmentofLaparoscopic Surgery,GEMHospital&ResearchCenter,Coimbatore,India.33Department ofSurgery,CollegeofHealthSciences,ObafemiAwolowoUniversity Hospital,Ile-Ife,Nigeria.34IICtedradeClnicaQuirrgica,Hospitalde Clnicas,FacultaddeCienciasMdicas,UniversidadNacionaldeAsuncion, SanLorenzo,Paraguay.353rdDepartmentofGeneralSurgery,Jagiellonian UniversityCollegiumMedium,Krakow,Poland.36DepartmentofSurgery,G. GiglioHospitalCefal,Palermo,Italy.37EmergencySurgery,MaggioreParma Hospital,Parma,Italy. Received:21November2013Accepted:25November2013 Published:1December2013 References1.HelgstrandF,RosenbergJ,KehletH,BisgaardT: Outcomesafter emergencyversuselectiveventralherniarepair:aprospective nationwidestudy. WorldJSurg 2013, 37 (10):2273 – 2279. 2.MiserezM,AlexandreJH,CampanelliG,CorcioneF,CuccurulloD,Pascual MH,HoeferlinA,KingsnorthAN,MandalaV,PalotJP,SchumpelickV, SimmermacherRK,StoppaR,FlamentJB: TheEuropeanherniasociety groinherniaclassification:simpleandeasytoremember. Hernia 2007, 11 (2):113 – 116. 3.HoranTC,GaynesRP,MartoneWJ,JarvisWR,EmoriTG: CDCdefinitionsof nosocomialsurgicalsiteinfections,1992:amodificationofCDC definitionsofsurgicalwoundinfections. AmJInfectControl 1992, 20: 271 – 274. 4.FalagasME,KasiakouSK: Mesh-relatedinfectionsafterherniarepair surgery. 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