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Table 3 Resume of recommendation guidelines

From: 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias

GoR Recommendation
Timing of intervention
 1C Patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected
 1C Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, CPK, and D-dimer levels are predictive of bowel strangulation
Laparoscopic approach
 2B Diagnostic laparoscopy may be a useful tool with the target of assessing bowel viability after spontaneous reduction of strangulated groin hernias
 2C Repair of incarcerated hernias—both ventral and groin—may be performed with a laparoscopic approach in the absence of strangulation and suspicion of the need of bowel resection, where an open preperitoneal approach is preferable
Emergency hernia repair in “clean surgical field” (CDC wound class I)
 1A The use of mesh in clean surgical fields (CDC wound class I) is associated with a lower recurrence rate, if compared to tissue repair, without an increase in the wound infection rate. Prosthetic repair with a synthetic mesh is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection (clean surgical field)
Emergency hernia repair in “clean-contaminated surgical field” (CDC wound class II)
 1A For patients having complicated hernia with intestinal strangulation and/or concomitant need of bowel resection without gross enteric spillage (clean-contaminated surgical field, CDC wound class II), emergent prosthetic repair with synthetic mesh can be performed (without any increase in 30-day wound-related morbidity) and is associated with a significant lower risk of recurrence, regardless of the size of hernia defect
Emergency hernia repair in “contaminated-dirty surgical field” (CDC wound classes III and IV)
 2C For stable patients with strangulated hernia with bowel necrosis and/or gross enteric spillage during intestinal resection (contaminated, CDC wound class III) or peritonitis from bowel perforation (dirty surgical field, CDC wound class IV), primary repair is recommended when the size of the defect is small (< 3 cm); when direct suture is not feasible, a biological mesh may be used for repair
 2C The choice between a cross-linked and a non-cross-linked biological mesh should be evaluated depending on the defect size and degree of contamination
 2C If biological mesh is not available, either polyglactin mesh repair or open wound management with delayed repair may be a viable alternative
 2C For unstable patients (experiencing severe sepsis or septic shock), open management is recommended to prevent abdominal compartment syndrome; intra-abdominal pressure may be measured intraoperatively
 2C Following stabilization of the patient, surgeons should attempt early, definitive closure of the abdomen. Primary fascial closure may be possible only when the risk of excessive tension or recurrent intra-abdominal hypertension (IAH) is minimal
 2C When early definitive fascial closure is not possible, progressive closure can be gradually attempted at every surgical wound revision. Cross-linked biological meshes may be considered as a delayed option for abdominal wall reconstruction
 1C When definitive fascial closure cannot be achieved, a skin-only closure is a viable option and subsequent eventration can be managed at a later stage with delayed abdominal closure and synthetic mesh repair
 1B The component separation technique may be a useful and low-cost option for the repair of large midline abdominal wall hernias
Antimicrobial prophylaxis
 2C In patients with intestinal incarceration with no evidence of ischaemia and no bowel resection (CDC wound class I), short-term prophylaxis is recommended
 2C In patients with intestinal strangulation and/or concurrent bowel resection (CDC wound classes II and III), 48-h antimicrobial prophylaxis is recommended
 2C Antimicrobial therapy is recommended for patients with peritonitis (CDC wound class IV)
Anaesthesia
 1C LA can be used, providing effective anaesthesia with less postoperative complications for emergency inguinal hernia repair in the absence of bowel gangrene