Colorectal and emergency surgical patients in the literature supporting EHS and AHS guidelines on abdominal wound closure: a granular analysis

TL;DR

This study evaluates the quality of evidence supporting hernia surgery guidelines for colorectal and emergency surgery patients, finding significant gaps in data quality and applicability.

Contribution

The paper provides a detailed analysis of the evidence base for hernia guidelines in colorectal and emergency surgery populations, highlighting critical limitations and the need for better research.

Findings

Most studies supporting hernia guidelines have low or critically low quality, with significant risk of bias.

Recommendations for colorectal patients are more supported than for emergency patients, who are largely excluded from key evidence.

The study emphasizes the lack of patient-centered outcomes and calls for targeted research in these populations.

Abstract

To critically appraise the evidence supporting the European and American Hernia Society (EHS/AHS) guidelines on abdominal wall closure in colorectal and emergency surgery patients, we conducted a granular analysis focused on the representation and quality of available data.

References that addressed key questions (KQ) and recommendations in the original guidelines were screened and included if colorectal/emergency surgery was reported. Data extraction was performed with a standardised form and authors were contacted for missing data. Quality and risk of bias were assessed independently by two reviewers.

Out of 33 studies included: 15 systematic reviews and one literature review were rated low or critically low (AMSTAR 2); 12 randomised controlled trials had moderate to high risk of bias (Cochrane RoB-2 tool); five observational studies were of low to very low quality (GRADE) with serious risk of bias (ROBINS-I). 32 studies included colorectal (n = 15,856) and 14 emergency patients (n = 4,582). To answer KQ1 on ‘minimally invasive or open surgery’ and ‘type of incision’ 9/10 studies included colorectal and no studies included emergency patients. 1/4 and 8/9 studies included colorectal/emergency patients for recommendations regarding trocar sites closure (KQ2) and closure after laparotomy (KQ3). Regarding the use of mesh (KQ5), 11/11 studies included colorectal/emergency patients. 3/3 and 1 studies included colorectal patients for KQ6 (abdominal binders) and one for KQ7 (restriction of activity), but none included emergency patients.

Recommendations for KQs 1, 3, 5, 6, and 7 appear applicable to colorectal patients, whereas evidence for KQ2 remains insufficient. For emergency patients, recommendations related to KQs 1, 2, 6, and 7 should not be extrapolated. This study further highlights critical limitations in the evidence base, including the lack of patient-centred outcomes, and underscores the need for targeted, high-quality research in these populations.

The online version contains supplementary material available at 10.1007/s10029-025-03493-7.

Figures