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Table of Contents
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 75-77

Guidelines in hernia surgery – friend or foe

1 Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
2 3rd Department of Surgery, Motol University Hospital; 1st Faculty of Medicine, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
3 Hernia Istanbul, Sisli, Istanbul, Turkey

Date of Submission14-Jul-2019
Date of Acceptance15-Jul-2019
Date of Web Publication30-Aug-2019

Correspondence Address:
Dr. A C de Beaux
Department of General Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, Scotland
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_28_19

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How to cite this article:
Pawlak M, East B, Gok H, de Beaux A C. Guidelines in hernia surgery – friend or foe. Int J Abdom Wall Hernia Surg 2019;2:75-7

How to cite this URL:
Pawlak M, East B, Gok H, de Beaux A C. Guidelines in hernia surgery – friend or foe. Int J Abdom Wall Hernia Surg [serial online] 2019 [cited 2023 Jun 9];2:75-7. Available from: http://www.herniasurgeryjournal.org/text.asp?2019/2/3/75/265865

The definition of a medical guideline is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of medicine.

Over the last 15 years, the hernia world has woken up to the idea of guidelines, and a number of such documents relating to hernia practice have been published.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] While medical guidelines have been in use for thousands of years, they have, until recently, been based on tradition and authority. Modern medical guidelines are based on an examination of current evidence, so-called evidence-based medicine, and created using guideline methodology, which is in itself an evolving science. Indeed, two important pieces of evidence are necessary for worthwhile guideline development in any area: (1) evidence of good practice and (2) evidence that variation in practice exists in the region that the guideline is written for. A number of recent guidelines[3],[4],[5] have highlighted lack of evidence of good practice, but they can still have value, as a consensus statement, highlighting important areas for further research.

Evidence itself is going through its own development. Many papers published in years past would not be accepted for publication today, because of their methodology failings, bias, lack of patient follow-up and the definitions of any complications reported not given. Indeed, one of the most cited papers relating to hernia surgery[13] would have unlikely been published in its current form today. Yet, the Lichtenstein inguinal hernia repair is now in use worldwide and sometimes referred to as the “gold standard.” Many guidelines based the strength of their recommendations on the so-called hierarchy of clinical evidence, from systematic review of randomized controlled trials at the top to expert opinion at the bottom. However, this approach has been questioned and in many cases superseded by other ways of assessing medical knowledge which will be discussed further below. Indeed, Sir Michael Rawlins, then Head of the National Institute for Health and Care Excellence (NICE), commented in 2008[14] that “randomised controlled trials, long regarded as the 'gold standard' of evidence, have been put on an undeserved pedestal. Their appearance at the top of 'hierarchies' of evidence is inappropriate; and hierarchies, themselves, are illusory tools for assessing evidence. They should be replaced by a diversity of approaches that involve analysing the totality of the evidence-base.” Indeed, his 2008 Harveian Oration on the subject makes very interesting reading.[15] In hernia surgery, registries are becoming an important part of patient care, and they are an important source of information to inform on guideline development. However, there are inherent risks and bias to registry data also. A recent paper on the subject articulates these pitfalls well.[16]

Guideline methodology is evolving as already mentioned. The current standards of guideline development involve Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology and the Appraisal for Guidelines, Research, and Evaluation (AGREE II) instrument. GRADE is a process that places at its core the members of the guideline development group. This group should be made up of interested parties relating to the subject of the guideline, including doctors, healthcare professionals, patients, and laypersons. Guidelines are not textbooks but start with identifying the key questions in the management of a condition, which are worthy of a guideline. The available evidence is examined, graded, and brought together by the group to result in statements and recommendations. Analysis of the evidence is an active process. The quality of evidence can be graded down based on the quality relating to a number of factors, including bias, inconsistency, indirectness, imprecision, and publication bias. In contrast, some evidence may be graded up, due to their outcome having a large effect or large dose–response. From this evidence base will come the recommendations. However, again, the guideline group is important in writing such recommendations. A recommendation will be a consideration of the balance of consequences. Quality of evidence remains a key to this, but also the balance of benefit versus harm, value and preferences, feasibility, equity and acceptability, and resource use and resource availability, for example, all influence the final guideline. Based on this process, the guideline will “recommend” or “suggest” that treatment should or should not be undertaken. Further knowledge of GRADE methodology is available on their website.[17] Finally, the AGREE II instrument is a tool that assesses the methodological rigor and transparency in which a guideline is developed.(Further information on this can be obtained from their website.[18]) Guidelines must be transparent, clear, and actionable. Many guidelines now will include future research topics to inform on key questions where evidence is lacking. However, an important step once a guideline is live is to have a dissemination and implementation strategy to encourage clinicians to use the guideline in practice[19] and also inform the relevant patient groups discussed in the guideline.[20]

It has been interesting to note the behavior of herniologists, both in medical journals and on social media platforms, as recent guidelines have been published. This was predicted by Prof. Feder in 1993 when he commented in a lecture, “One day soon medical sociologists will discover that the clinical guidelines industry is a microcosm of medicine worthy of close study. When guidelines are being developed, bloody struggles are waged over medical knowledge, all protagonists claim that 'evidence' supports their views, and final recommendations always require fine judgements and compromise.”

Guidelines – friend or foe? Guidelines that conform to current development standards should be our friend. There seems to be a fear among many herniologists that guidelines set a standard of care. And deviation from them will thus become ammunition for patients and their lawyers to trip us up. This is a view that is very wrong, both for what guidelines are for and what they mean. We end this editorial with the words of John Kinsella, recently retired Chair of the Scottish Intercollegiate Guidelines Network (SIGN). “In the era of realistic medicine, SIGN guidelines should be the starting point for decision-making at the clinician-patient interface, and should inform the joint decision, not dictate a particular course of action.”[21]

  References Top

Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009;13:343-403.  Back to cited text no. 1
Miserez M, Peeters E, Aufenacker T, Bouillot JL, Campanelli G, Conze J, et al. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2014;18:151-63.  Back to cited text no. 2
Antoniou SA, Agresta F, Garcia Alamino JM, Berger D, Berrevoet F, Brandsma HT, et al. European Hernia Society guidelines on prevention and treatment of parastomal hernias. Hernia 2018;22:183-98.  Back to cited text no. 3
Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia 2015;19:1-24.  Back to cited text no. 4
López-Cano M, García-Alamino JM, Antoniou SA, Bennet D, Dietz UA, Ferreira F, et al. EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen. Hernia 2018;22:921-39.  Back to cited text no. 5
Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 2011;25:2773-843.  Back to cited text no. 6
Birindelli A, Sartelli M, Di Saverio S, Coccolini F, Ansaloni L, van Ramshorst GH, et al. 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg 2017;12:37.  Back to cited text no. 7
Menzo EL, Hinojosa M, Carbonell A, Krpata D, Carter J, Rogers AM. American Society for Metabolic and Bariatric Surgery and American Hernia Society consensus guideline on bariatric surgery and hernia surgery. Surg Obes Relat Dis 2018;14:1221-32.  Back to cited text no. 8
HerniaSurge Group. International guidelines for groin hernia management. Hernia 2018;22:1-65.  Back to cited text no. 9
Liang MK, Holihan JL, Itani K, Alawadi ZM, Gonzalez JR, Askenasy EP, et al. Ventral hernia management: Expert consensus guided by systematic review. Ann Surg 2017;265:80-9.  Back to cited text no. 10
Bittner R, Bain K, Bansal VK, Berrevoet F, Bingener-Casey J, Chen D, et al. Correction to: Update of guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-part A. Surg Endosc 2019. [Epub ahead of print].  Back to cited text no. 11
Bittner R, Bain K, Bansal VK, Berrevoet F, Bingener-Casey J, Chen D, et al. Update of guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)): Part B. Surg Endosc 2019. [Epub ahead of print].  Back to cited text no. 12
Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension-free hernioplasty. Am J Surg 1989;157:188-93.  Back to cited text no. 13
Royal College of Physicians: Sir Michael Rawlins attacks Traditional Ways of Assessing Evidence. Press Release; 2008. Available from: https://www.politics.co.uk/opinion-formers/royal-college-of-physicians/article/royal-college-of-physicians-sir-michael-rawlins-attacks-trad. [Last accessed on 2019 Jul 09].  Back to cited text no. 14
Rawlins M. Harveian Oration; 2008. Available from: https://www.kcl.ac.uk/lsm/study/pgofferholders/docs/Mike-Rawlins-Harvian-lecture.pdf. [Last accessed on 2019 Jul 09].  Back to cited text no. 15
Schwab R, Dietz UA, Menzel S, Wiegering A. Pitfalls in interpretation of large registry data on hernia repair. Hernia 2018;22:947-50.  Back to cited text no. 16
Available from: http://www.gradeworkinggroup.org/. [Last accessed on 2019 Jul 09].  Back to cited text no. 17
Available from: https://www.agreetrust.org/agree-ii/. [Last accessed on 2019 Jul 09].  Back to cited text no. 18
Feder G, Eccles M, Grol R, Griffiths C, Grimshaw J. Clinical guidelines: Using clinical guidelines. BMJ 1999;318:728-30.  Back to cited text no. 19
Schipper K, Bakker M, De Wit M, Ket JC, Abma TA. Strategies for disseminating recommendations or guidelines to patients: A systematic review. Implement Sci 2016;11:82.  Back to cited text no. 20
Kinsella J, James R. Guidelines in the era of realistic medicine. J R Coll Physicians Edinb 2016;46:74-6.  Back to cited text no. 21


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