BackgroundInternational guidelines recommend an anterior mesh-based Lichtenstein repair for recurrent groin hernias following previous laparo-endoscopic repair. Whether the mesh-free Shouldice technique provides comparable outcomes in this setting remains unknown. This study compared perioperative and one-year outcomes after Shouldice and Lichtenstein repair using data from the Herniamed Registry.MethodsAdult patients undergoing elective repair of a first unilateral recurrent groin hernia after previous laparo-endoscopic repair were identified from the Herniamed Registry. Patients treated with either Shouldice or Lichtenstein repair and with complete one-year follow-up were eligible. A 1:1 propensity score matching was performed using demographic, clinical, hernia-related, and operative variables to minimize baseline differences. All outcome variables such as intraoperative, postoperative and general complications, complication-related reoperations, surgical site complications, hernia recurrence at 1 year and patient-reported pain outcomes at 1 year were analysed in this study.ResultsOf 12,498 eligible patients, 253 underwent Shouldice repair and 12,245 underwent Lichtenstein repair. Propensity score matching yielded 248 well-balanced patient pairs. No significant differences were observed between the two procedures regarding one-year recurrence, intraoperative or postoperative complications, complication-related reoperations, postoperative haemorrhage, seroma, surgical-site infection, or patient-reported pain outcomes after adjustment for multiple testing. Pain on exertion at 1 year was reported less frequently after Shouldice repair than after Lichtenstein repair (18.5% vs. 27.0%; P=0.031), although this difference did not remain statistically significant after Bonferroni correction.ConclusionIn this propensity score–matched registry analysis, no statistically significant differences in perioperative and one-year outcomes were detected between Shouldice repair and guideline-recommended Lichtenstein repair for first recurrent groin hernias following previous laparo-endoscopic repair. Given the small number of Shouldice procedures and the wide confidence intervals, clinically relevant differences cannot be excluded. In carefully selected patients and when performed by experienced surgeons, the Shouldice technique may nevertheless represent a mesh-free option. Larger comparative studies with long-term follow-up are required to confirm these findings and further define its role in the management of recurrent groin hernia.
BackgroundIncisional hernias with loss of domain (LOD) following open abdomen management, visceral surgery, and cutaneous grafting present an extreme reconstructive challenge. Intraoperative fascial traction (IFT) using the Fasciotens® Abdomen device has been established as an effective adjunct to reduce fascial gaps in large ventral hernias (EHS W3). Conventional application targets the anterior rectus sheath. We describe a sequential double-layer IFT approach, first applied to the posterior and then to the anterior layer, in an extreme LOD case, and report whether posterior-layer traction allowed closure of the posterior layer without a bridging mesh.Case PresentationA 35-year-old male (BMI 24, DM II, nicotine abuse, polytoxicomania) presented with a massive LOD incisional hernia following polytrauma (2011) with right nephrectomy, transverse colon resection, colostomy/ileostomy, open abdomen, split-skin grafting, and a prior failed IPOM bridging repair (2021). After multimodal prehabilitation (weight reduction, drug detoxification, partial tissue expansion, and botulinum toxin A [BTA] 8 weeks preoperatively), definitive reconstruction was performed in March 2025 using a combined Rives–Stoppa/Madrid/bilateral TAR approach. IFT applied to the posterior layer for 30 min (up to 18 kg) allowed closure of this layer from the caudal margin to the umbilicus, but not in the cranial segment, where peritoneum was absent after open abdomen management and skin grafting; a bridging mesh, OviTex® S2 (30 × 25 cm, ≥5 cm overlap), was therefore placed cranially as a visceral separation layer. A second IFT phase targeting the anterior sheath (30 min) then allowed primary closure of the remaining 10-cm anterior defect. A retromuscular mesh DynaMesh®-CICAT (30 × 35 cm) was placed, and the linea alba was reconstructed using the small-bites technique (Monomax 2.0). A seroma at 6 months was aspirated once (400 mL, sterile); CT at 12 months confirmed no recurrence.DiscussionTo our knowledge, this is the first reported case of sequential posterior–anterior IFT using the Fasciotens® device. Posterior-layer traction allowed closure of the caudal posterior layer but did not avoid a bridging mesh in the cranial segment. After anterior IFT, the anterior fascia was closed primarily. Whether posterior IFT reduces the bridged area cannot be determined from a single case.
Patient-reported outcome measures (PROMs) in benign procedures such as hernia repair are logical and important [1]. However, interpreting the clinical relevance of PROM scores remains a major methodological challenge, and there is no universally accepted approach to determining when differences in PROM scores are clinically meaningful [2]. Registry infrastructure now enables us to report PROM scores for cohorts of thousands of patients using digital infrastructure for data collection [3]. While this provides considerable statistical power, the choice of reporting strategy can markedly influence the interpretation of the results. In large samples, even a small between-group difference in mean PROM scores may reach statistical significance despite limited clinical relevance. This problem is particularly evident when most patients report perfect outcomes with the highest possible PROM scores, while a smaller group experiences persistent symptoms of varying severity. In this situation, the mean score is dominated by the large group with excellent outcomes, so clinically meaningful differences among patients with ongoing symptoms translate into only marginal changes in the overall average. The result is a pronounced ceiling effect, where mean differences are difficult to interpret despite statistical significance. In this common situation, we argue that the Patient Acceptable Symptom State (PASS) is a more interpretable and useful outcome than the difference in means, and we illustrate the point with adjusted data from a large linked survey and registry study of incisional hernia repair.Rather than focusing on small differences in mean PROM scores, PASS focuses on the number of patients who have reached an outcome they consider acceptable. Originally introduced in rheumatology [4,5] and now widely used in orthopedic surgery [6], the concept defines the PROM threshold above which patients consider their state satisfactory: the level at which a patient would say, "I feel well enough." It reframes the analysis from "how many points apart are the groups?" to "what proportion of patients are in an acceptable state?" The summary statistic becomes the proportion achieving PASS, and the between-group contrast becomes a difference in proportions: figures that any clinician, patient, or policymaker can grasp at once. Importantly, the threshold is anchored to patients' own judgment rather than to an arbitrary statistical cut.The difference between the two approaches can be illustrated using adjusted data from patients undergoing incisional hernia repair (unpublished data from the AFTERHERNIA Project [7]). We compared patients with small hernia defects (0-2 cm) with those with larger defects (6-10 cm). We used the Abdominal Hernia-Q (AHQ) [8] as a PROM. Two AHQbased outcomes were examined: the AHQ sum score (16-64 points) and the AHQ physical impact score (6-24 points). The AHQ physical impact score reflects the physical impact subscale within the overall AHQ sum score. Higher scores indicate better outcomes for both measures. For this illustrative example, patients scoring below the 75th percentile of the respective AHQ score distributions were classified as not achieving PASS, corresponding to an AHQ sum score <54 and an AHQ physical impact score <23. These distribution-based thresholds were used solely for illustrative purposes, as established anchor-based PASS thresholds for the AHQ have not yet been established. Although anchor-based thresholds are preferable, the present example illustrates how reporting the proportion of patients above or below a specified threshold may complement comparisons of mean PROM scores. Using the AHQ sum score (Figure 1), the adjusted proportion of patients not achieving PASS was 25.9% among those with 0-2 cm defects and 33.4% among those with 6-10 cm defects. The adjusted difference was 7.5 percentage points (95% CI 2.8 to 12.3; P = 0.002), corresponding to approximately 7 to 8 additional patients per 100 with larger defects who did not reach an acceptable symptom state. By comparison, the adjusted mean AHQ sum score was 56.8 points in the 0-2 cm group and 55.2 points in the 6-10 cm group, an adjusted mean difference of -1.5 points (95% CI -2.4 to -0.7; P <0.001).A similar pattern was observed for the AHQ physical impact score (Figure 1). The adjusted proportion of patients not achieving PASS was 22.9% in the 0-2 cm group and 30.4% in the 6-10 cm group, corresponding to an adjusted difference of 7.6 percentage points (95% CI 2.9 to 12.2; P = 0.001). However, the adjusted mean physical impact score differed by only -0.4 points (95% CI -0.6 to -0.1; P = 0.010), from 22.9 points in the 0-2 cm group to 22.5 points in the 6-10 cm group.Thus, the PASS-based estimates told a consistent and clinically intuitive story in both scoring approaches: patients with larger defects were about 7-8 percentage points less likely to reach an acceptable symptom state. In contrast, the mean-score interpretation depended strongly on the scale used: the same clinical comparison appeared as a 1.5-point difference on the 16-64 AHQ sum score scale, but only a 0.4-point difference on the 6-24 physical impact scale.A ceiling effect makes standard summary statistics difficult to interpret. In the data shown here, AHQ scores clustered near the upper end of their respective scales. On the AHQ sum score, adjusted mean scores were 56.8 and 55.2 on a scale from 16 to 64. On the physical impact score, adjusted mean scores were 22.9 and 22.5 on a scale from 6 to 24. These values indicate generally good outcomes in both defect-width groups, but they do not clearly convey the proportion of patients who still had an unacceptable symptom state.The problem is not only that mean differences are small. It is also that their apparent size depends on the scoring range. A difference of -1.5 points on the AHQ sum score and -0.4 points on the physical impact score may appear quite different, even though the PASSbased analyses showed nearly identical differences in the proportion of patients below an acceptable symptom state. Although expressing mean differences relative to their respective scale ranges improves comparability, it does not directly convey the proportion of patients reaching an acceptable symptom state, which is the principal advantage of PASS-based outcomes. This illustrates a practical limitation of mean PROM scores: they require the reader to understand the scale, the direction, the range, and the likely clinical meaning of a given point difference. By contrast, the PASS-based result is immediately interpretable. A 7-8 percentage-point difference means that, for every 100 patients with larger defects rather than smaller defects, approximately 7 to 8 more patients did not reach a patient-acceptable symptom state.When most patients report high scores, clinically important variation often lies in the lower tail of the distribution, among patients who do not achieve a good outcome. Mean scores summarize the entire distribution and are therefore dominated by the majority of patients who do well. PASS instead focuses directly on the clinically relevant question: how many patients have not reached an acceptable state? For this reason, PASS should not necessarily replace mean PROM scores, but it can provide a more clinically interpretable summary when ceiling effects are present.An experienced reader will object that dichotomizing a continuous outcome is poor practice; it discards information and usually reduces statistical power [9]. The objection is sound, but it targets a different practice: the arbitrary splitting of continuous variables (median splits, "high versus low") chosen for convenience and often driven by the data at hand. PASS differs in three ways. First, the threshold is externally derived and patientanchored, fixed before the analysis rather than chosen to fit the data. Second, under a strong ceiling, the upper range of the continuous score carries little usable information anyway, so the information sacrificed by dichotomizing is small. Third, the resulting outcome, the proportion of patients in an acceptable state, is exactly the interpretable quantity the mean fails to deliver. The honest recommendation is therefore not "PASS instead of the mean" but "PASS alongside the mean." When the two agree on significance yet diverge in meaning, the PASS-based estimate should anchor the interpretation.PASS is not a universal threshold and should be applied thoughtfully. The PASS threshold is specific to the instrument, the subscale, and the population; a value derived for one PROM or setting cannot be borrowed for another. Authors should state how their PASS was obtained, typically as an anchor-based estimate or as the 75th percentile of scores. Importantly, the thresholds used in our illustrative example were distribution-based rather than anchor-based and should therefore not be interpreted as validated PASS thresholds. They serve solely to illustrate the potential value of reporting proportions alongside mean PROM scores. Ideally, the threshold is taken from, or validated in, an independent sample rather than estimated from the same data that drive the primary analysis, to avoid optimistic cut-points. Although survey and registry cohorts of this size can absorb the power cost of dichotomization, the PASS analysis should still be pre-specified. Finally, PASS should not be confused with the minimal important difference (MID) [10]: the MID concerns the smallest difference worth noticing, whereas PASS concerns an acceptable absolute state. The two answer different questions and are complementary [6].Much of modern hernia and benign-surgery outcomes research studies populations that, by design, mostly do well. In these settings, differences in mean PROM scores are easy to make statistically significant in large samples but hard to make clinically meaningful. Reporting the proportion of patients who reach a patient-anchored acceptable state, and the absolute difference in that proportion between groups, restores clinical sense to the analysis and aligns the statistic with the question patients actually ask: "Am I going to be all right?" When ceiling effects are present, a PASS-based outcome alongside the difference in means will increase the clinical impact of the research.Figure 1: Adjusted mean scores and proportions not achieving PASS by hernia defect width. The graphs show Abdominal Hernia-Q (AHQ) sum scores, ranging from 16 to 64, and physical impact scores, ranging from 6 to 24. Bar charts present adjusted estimates for patients with incisional hernia and defect width 0-2 cm or 6-10 cm. Analyses included only responders. For each score, the left panel shows the adjusted proportion of patients not achieving a patient acceptable symptom state (PASS), and the right panel shows the adjusted mean score. Estimates were obtained using g-computation and adjusted for age, sex, Charlson Comorbidity Index, surgical approach, follow-up time, and mesh/closure technique. Error bars indicate 95% confidence intervals. Differences compare patients with defect width 6-10 cm with those with defect width 0-2 cm. PASS not achieved was defined as an AHQ sum score <54 and an AHQ physical impact score <23.
BackgroundProphylactic mesh reinforcement reduces the incidence of incisional hernia (IH) after midline laparotomy and is recommended for high-risk patients. However, concerns regarding contamination, mesh infection, and prosthetic-related morbidity have limited its implementation in emergency surgery. Whether emergency indication is associated with worse outcomes among mesh-treated patients remains uncertain.MethodsA retrospective registry-based cohort study used data from the Spanish National Incisional Hernia Registry (EVEREG) from 2020 to 2025 (17 hospitals). Adults undergoing midline laparotomy with permanent prophylactic mesh reinforcement were stratified by elective or emergency indication. In-hospital outcomes included overall and general complications (cardiac, respiratory or renal failure), surgical-site occurrence (SSO), mesh infection, mesh removal, abdominal complications during the index stay and mortality at 30 days. Analyses used 204 patients with completed in-hospital data and clinically specified multivariable logistic regression models.ResultsThe registered cohort included 234 patients: 104 elective and 130 emergency procedures. Among 204 patients with completed in-hospital modules (85 elective, 119 emergency), overall complications occurred in 38.8% versus 62.2% and general complications in 21.2% versus 48.7%, respectively; both remained significant after multiplicity correction. No statistically detectable differences were observed in SSO, mesh infection, mesh removal, abdominal complications or mortality (10.6% versus 11.8%). Recorded Clavien–Dindo categories were higher after emergency surgery (P = 0.006). After adjustment, emergency indication was associated with general complications (OR 2.13, 95% CI 1.01–4.47), but not mortality (OR 1.00, 95% CI 0.39–2.57). Renal disease and contamination were associated with overall complications, and contamination with abdominal complications. Older age and higher body mass index (BMI) were associated with mortality (BMI: OR 1.64 per 5 kg/m2, 95% CI 1.06–2.53).ConclusionIn this selected registry cohort, emergency indication was associated with greater early general morbidity, whereas no statistically detectable increase in short-term wound- or mesh-related events was observed, with considerable uncertainty. As a cautious implication requiring confirmation, emergency indication per se might not be an absolute contraindication to prophylactic mesh in selected patients. The small number of mesh-related events, the absence of a non-mesh control group and the loss to follow-up preclude conclusions on equivalent safety or effectiveness in preventing incisional hernia.
Incisional hernia is a common late complication of abdominal organ transplantation, with reported frequency ranging from a pooled 4% after kidney transplantation to a prevalence of 43% on clinical examination after liver transplantation. Immunosuppression places recipients at least in Ventral Hernia Working Group grade 2, and concern about wound failure, mesh infection and recurrence often delays repair. This mini review synthesises evidence on elective repair in adult liver, kidney and pancreas recipients around three questions: whether transplant status independently predicts adverse outcome, how immunosuppression relates to outcome, and how operative access, reconstruction, mesh plane, material and fascial closure should be chosen. In most registry and matched comparisons, 30-day wound morbidity and length of stay were similar to those of non-transplant patients, although one matched laparoscopic series found more surgical site occurrences. Study-specific recurrence ranges from 0% in selected specialist series to 37%, with differing follow-up and ascertainment, and observational comparisons do not establish whether transplantation independently increases recurrence. A randomised trial showed more wound complications with de novo sirolimus after kidney transplantation; the association between maintenance sirolimus and recurrence after later repair rests on small, conflicting series, and perioperative conversion is untested. Recent series of transversus abdominis release report recurrence of 0%–25%, depending on incision, defect size, follow-up and comparator. Diaphragmatic tack fixation should be avoided. Two randomised trials of prophylactic mesh at transplant closure are registered, without published results. Research priorities include transplant-specific registry fields, standardised recurrence ascertainment, longer post-repair follow-up and graft-related outcomes.
