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Purpose <p>Subxiphoid incisional hernias (SIH) are rare and challenging to repair, often occurring post- cardiac surgery after sternotomy and pericardial drainage. The literature on SIH is limited, with small patient cohorts and no established consensus on optimal repair strategies published yet. This present study aimed at proposing the definition and the surgical management and decision-making processes for SIH repair through an international Delphi consensus among expert surgeons.</p> Methods <p>Using a modified Delphi technique, 69 international abdominal wall surgeons were invited. Three rounds were conducted to reach consensus on the definition, characteristics, classification, preoperative imaging and surgical approaches for SIH. Consensus was defined as more than 70% of agreement on 32 statements across 12 topics.</p> Results <p>Sixty-nine experts were enrolled from 5 continents. Concerning definition of SIH, consensus was reached: a defect where the M1 part represents the most challenging and representative part. According to the expert panel, a mesh should be used in an extraperitoneal position. Both open and minimal invasive surgical (MIS) approach (E-TEP and/or ventral TAPP) are viable for W1 (&lt; 4&#xa0;cm) SIH repair. Achieving sufficient mesh overlap (&gt; 5&#xa0;cm) and defect closure are the 2 primary goals during SIH repair, whatever the approach and the technique. Expert panel agreed that a solid understanding of the anatomy is crucial and difficult in this area, due to the proximity of bony structures. For cranial overlap, exposing the central tendon of the diaphragm after cutting the posterior rectus sheath horizontally reached consensus. Concerning lateral overlap, the panel agreed on a retro rectus repair with TAR for ≥W2 hernia, while total preperitoneal repair is not. Mesh fixation is deemed unnecessary if adequate overlap is achieved. In case of difficulties of closure, only TAR might be helpful, with bridging as a last resort. They agreed that SIH ≥W2 should be referred to an expert hernia center.</p> Conclusion <p>This Delphi consensus defined SIH and was an opportunity to emphasize the anatomy of the subxiphoid region. It opens the way for future strong studies on the subject, leading for recommendations.</p>

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Subxiphoid hernia, definition and repair: an international delphi consensus

  • 期刊论文

  • 发表日期：

    2025年2月28日

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  • Alix Donadieu,
  • Sarfaraz Jalil Baig,
  • Beny Charbit,
  • David Lourié,
  • Miguel Angel Garcia Urena,
  • Yohann Renard,
  • Vedra Augenstein,
  • Ramana Balasubramaniam,
  • Conrad Ballecer,
  • Thierry Bège,
  • Frederik Berrevoet,
  • Marja Boermeester,
  • Knut Borch,
  • Jose Bueno-Lledo,
  • Giampiero Campanelli,
  • David Chen,
  • Praminthra Chitsabesan,
  • Joachim Conze,
  • Diego Cuccurullo,
  • Jorge Daes,
  • Andrew de Beaux,
  • Eva Deerenberg,
  • Ulrich A. Dietz,
  • Vincent Dubuisson,
  • Antonio Espinosa de los Monteros,
  • António Ferreira,
  • John Fischer,
  • René Fortelny,
  • Jean-François Gillion,
  • Pierre Gueroult,
  • Hakan Gök,
  • Todd Heniford,
  • Nadia Henriksen,
  • Pilar Hernández-Granados,
  • Henry Hoffmann,
  • William Hope,
  • Lars Nannestad Jorgensen,
  • Haitham Khalil,
  • Manuel López Cano,
  • Flavio Malcher,
  • Marc Miserez,
  • Salvador Morales-Conde,
  • David Moszkowicz,
  • Filip Muysoms,
  • Yuri Novitsky,
  • Pablo Ortega Deballon,
  • Chinnusamy Palanivelu,
  • David Parker,
  • Sam Parker,
  • Guillaume Passot,
  • Eric Pauli,
  • Maciej Pawlak,
  • José A. Pereira,
  • Victor Radu,
  • Archana Ramaswamy,
  • Wolfgang Reinpold,
  • Sónia Ribas,
  • Benoit Romain,
  • Michael Rosen,
  • Mário Rui Goncalves,
  • David Sanders,
  • Anil Sharma,
  • Aali J. Sheen,
  • Marteen Simons,
  • Kellee Slater,
  • Neil Smart,
  • Cesare Stabilini,
  • Bernd Stechemesser,
  • Alexis Theodorou,
  • Maaike Vierstraete,
  • David Wardill,
  • Mette Willaume,
  • Guido Woest

摘要

Purpose

Subxiphoid incisional hernias (SIH) are rare and challenging to repair, often occurring post- cardiac surgery after sternotomy and pericardial drainage. The literature on SIH is limited, with small patient cohorts and no established consensus on optimal repair strategies published yet. This present study aimed at proposing the definition and the surgical management and decision-making processes for SIH repair through an international Delphi consensus among expert surgeons.

Methods

Using a modified Delphi technique, 69 international abdominal wall surgeons were invited. Three rounds were conducted to reach consensus on the definition, characteristics, classification, preoperative imaging and surgical approaches for SIH. Consensus was defined as more than 70% of agreement on 32 statements across 12 topics.

Results

Sixty-nine experts were enrolled from 5 continents. Concerning definition of SIH, consensus was reached: a defect where the M1 part represents the most challenging and representative part. According to the expert panel, a mesh should be used in an extraperitoneal position. Both open and minimal invasive surgical (MIS) approach (E-TEP and/or ventral TAPP) are viable for W1 (< 4 cm) SIH repair. Achieving sufficient mesh overlap (> 5 cm) and defect closure are the 2 primary goals during SIH repair, whatever the approach and the technique. Expert panel agreed that a solid understanding of the anatomy is crucial and difficult in this area, due to the proximity of bony structures. For cranial overlap, exposing the central tendon of the diaphragm after cutting the posterior rectus sheath horizontally reached consensus. Concerning lateral overlap, the panel agreed on a retro rectus repair with TAR for ≥W2 hernia, while total preperitoneal repair is not. Mesh fixation is deemed unnecessary if adequate overlap is achieved. In case of difficulties of closure, only TAR might be helpful, with bridging as a last resort. They agreed that SIH ≥W2 should be referred to an expert hernia center.

Conclusion

This Delphi consensus defined SIH and was an opportunity to emphasize the anatomy of the subxiphoid region. It opens the way for future strong studies on the subject, leading for recommendations.