Delphi consensus statement for understanding and managing the subcostal hernia: subcostal hernias collaborative report (scholar study)

S J Baig; G V Kulkarni; P Priya; M Y Afaque; J Bueno-Lledo; S Chintapatla; A de Beaux; J A Gandhi; M A Garcia Urena; T M Hammond; D Lomanto; R Liu; A Mehta; M Miserez; A Montgomery; S Morales-Conde; C Palanivelu; E M Pauli; S A Rege; Y Renard; M Rosen; D L Sanders; V K Singhal; D A J Slade; O J Warren; S Wijerathne

doi:10.1007/s10029-024-02963-8

Delphi consensus statement for understanding and managing the subcostal hernia: subcostal hernias collaborative report (scholar study)

Hernia. 2024 Feb 16. doi: 10.1007/s10029-024-02963-8. Online ahead of print.

Authors

S J Baig¹, G V Kulkarni², P Priya³, M Y Afaque⁴, J Bueno-Lledo⁵, S Chintapatla⁶, A de Beaux⁷, J A Gandhi⁸, M A Garcia Urena⁹, T M Hammond², D Lomanto¹⁰, R Liu¹¹, A Mehta¹², M Miserez¹³, A Montgomery¹⁴, S Morales-Conde¹⁵, C Palanivelu¹⁶, E M Pauli¹⁷, S A Rege⁸, Y Renard¹⁸, M Rosen¹⁹, D L Sanders²⁰, V K Singhal²¹, D A J Slade²², O J Warren²³, S Wijerathne²⁴

Affiliations

¹ Department of Minimal Access Surgery, Belle Vue Clinic, Digestive Surgery Clinic, Bellevue Hospital Kolkata, Kolkata, 700017, India. docsarfarazbaig@gmail.com.
² Department of Colorectal Surgery, Broomfield Hospital (Mid and South Essex NHS Trust), Essex, UK.
³ Department of Minimal Access Surgery, Belle Vue Clinic, Digestive Surgery Clinic, Bellevue Hospital Kolkata, Kolkata, 700017, India.
⁴ Department of Surgery, J N Medical College, AMU, Aligarh, Uttar Pradesh, 202002, India.
⁵ Hospital Universitari I Politecnic La Fe, Universidad de Valencia, Valencia, Spain.
⁶ Department of General Surgery, York Abdominal Wall Unit (YAWU), York & Scarborough Teaching Hospitals NHS Foundation Trust, Wigginton Road, York, UK.
⁷ Spire Murrayfield Hospital, Edinburgh, UK.
⁸ Department of Surgery, King Edward Memorial Hospital, Parel, Mumbai, 400012, India.
⁹ Department of Surgery, Hospital Universitario del Henares, 28822, Madrid, Spain.
¹⁰ Minimally Invasive Surgical Centre, National University Hospital, Singapore, 119074, Singapore.
¹¹ Med Director Robotic Surgery, Alta Bates Summit Medical Center, Oakland, CA, 94609, USA.
¹² Department of Colorectal Surgery, St. Mark's Hospital, London, UK.
¹³ Department of Abdominal Surgery, University Hospital Gasthuisberg, KU Leuven, Louvain, Belgium.
¹⁴ Department of Surgery, Skåne University Hospital, Malmö, Sweden.
¹⁵ Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital Virgen del Rocio, University of Sevilla, Seville, Spain.
¹⁶ GEM Hospital and Research Centre, Coimbatore, India.
¹⁷ Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
¹⁸ Reims Champagne-Ardennes, Department of General, Digestive and Endocrine Surgery, Robert Debré University Hospital, Reims, France.
¹⁹ Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA.
²⁰ Department of Abdominal Wall Surgery, Royal Devon University Foundation Trust, North Devon District Hospital, Barnstaple, UK.
²¹ Department of GI Surgery, Medanta Medicity Hospital, Gurugram, Haryana, India.
²² Department of Colorectal Surgery, Salford Royal NHS Foundation Trust, Salford, UK.
²³ Department of Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
²⁴ Department of General Surgery, Alexandra Hospital, National University Health System), Singapore, Singapore.

PMID: 38366238
DOI: 10.1007/s10029-024-02963-8

Abstract

Introduction: Subcostal hernias are categorized as L1 based on the European Hernia Society (EHS) classification and frequently involve M1, M2, and L2 sites. These are common after hepatopancreatic and biliary surgeries. The literature on subcostal hernias mostly comprises of retrospective reviews of small heterogenous cohorts, unsurprisingly leading to no consensus or guidelines. Given the limited literature and lack of consensus or guidelines for dealing with these hernias, we planned for a Delphi consensus to aid in decision making to repair subcostal hernias.

Methods: We adopted a modified Delphi technique to establish consensus regarding the definition, characteristics, and surgical aspects of managing subcostal hernias (SCH). It was a four-phase Delphi study reflecting the widely accepted model, consisting of: 1. Creating a query. 2. Building an expert panel. 3. Executing the Delphi rounds. 4. Analysing, presenting, and reporting the Delphi results. More than 70% of agreement was defined as a consensus statement.

Results: The 22 experts who agreed to participate in this Delphi process for Subcostal Hernias (SCH) comprised 7 UK surgeons, 6 mainland European surgeons, 4 Indians, 3 from the USA, and 2 from Southeast Asia. This Delphi study on subcostal hernias achieved consensus on the following areas-use of mesh in elective cases; the retromuscular position with strong discouragement for onlay mesh; use of macroporous medium-weight polypropylene mesh; use of the subcostal incision over midline incision if there is no previous midline incision; TAR over ACST; defect closure where MAS is used; transverse suturing over vertical suturing for closure of circular defects; and use of peritoneal flap when necessary.

Conclusion: This Delphi consensus defines subcostal hernias and gives insight into the consensus for incision, dissection plane, mesh placement, mesh type, and mesh fixation for these hernias.

Keywords: Complex hernia; Delphi consensus; L1 hernia; Subcostal hernia; Ventral hernia.