Management of Primary Ventral and Incisional Hernias Under Emergency Conditions

Primary Ventral and incisional hernias (PVIHs) represent conditions that negatively impact patients’ quality of life and require surgical repair. The emergency presentation of abdominal wall and groin hernias is one of the most severe complications, representing a common reason for emergency surgical admission and accounting for around 25% of all hernia repairs. Trends in emergent incisional hernia repair have remained relatively stable among older women, at 24.9 and 23.5 per 100,000 person-years in 2001 and 2010, respectively. However, rates of emergent incisional hernia repair among older men are reported to have risen significantly, from 7.8 to 32.0 per 100,000 person-years from 2001 to 2010, respectively. The outcomes of emergent incisional hernia repair are worse than those of elective repair; a tenfold increase in mortality has been reported, along with increased morbidity rates. A recent scoping review performed by our group showed that pooled proportions of surgical site infections (SSIs), mortality, any complications, and the risk of reoperation were 12%, 4%,31%, and 8%, respectively.

The emergent presentation of a ventral or incisional hernia can give rise to different clinical scenarios, ranging from pain alone to irreducibility, bowel obstruction, strangulation and, ultimately, peritonitis secondary to perforation; these scenarios represent a spectrum that is time-dependent and severely impacts subsequent treatment. General surgeons facing this situation are compelled to make difficult decisions concerning the surgical approach (e.g., open vs. laparoscopic), the choice of mesh (synthetic, biological, or biosynthetic), the type of repair, and the management of contaminated fields or bowel dilation.

Several factors further complicate decision-making in these scenarios. The lack of adequate patient prehabilitation, coupled with the difficulty of achieving true shared decision-making due to time constraints, significantly impacts treatment choices. Furthermore, specialists in abdominal wall surgery are not always readily available for complex defects, meaning that the majority of management is the responsibility of general surgeons, who often have limited expertise in this specific field.

The World Society of Emergency Surgeons has previously issued guidelines for managing emergent patients with these conditions, with their latest iteration in 2020 focusing primarily on wound contamination status, encompassing every type of abdominal wall defect (inguinal, primary ventral, and incisional).

Complementing this, the European Hernia Society has decided to compile guidelines focusing on abdominal wall hernias that are different from inguinal hernias, based on the belief that the clinical presentation of emergent primary ventral and incisional hernias may necessitate a prioritisation of surgical objectives, whereby the hernia itself may not be the primary focus of treatment, but merely the primum movens. This guideline project, specifically targeted at general surgeons without a special interest in abdominal wall surgery, is devoted to developing an intraoperative decision-making aid (algorithm) based on defect characteristics, contamination and patient stability.

This document details these recommendations, outlines the framework used to develop these guidelines, and provides the supporting scientific data with their critical appraisals.

The guidelines were produced by the European Hernia Society and published in September 2023.

Reference: Stabilini C, Theodorou A, Pawlak M, Antoniou S, Berrevoet F, Bougard H, Bracale U, Capoccia Giovannini S, Fortelny R, Gaarder C, Garcia-Urena MA, Gilmore K, Gomez-Ochoa SA, Köckerling F, Mäkäräinen E, Morales-Conde S, Pecchini F, Pereira Rodríguez JA, Quiroga-Centeno AC, Renard Y, Romain B, Schembari E and Deerenberg E (2026) EHS Guidelines on the Management of Primary Ventral and Incisional Hernias Under Emergency Conditions. J. Abdom. Wall Surg. 5:16228. doi: 10.3389/jaws.2026.16228.