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      Total endoscopic sublay mesh repair for umbilical hernias

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          Abstract

          Umbilical hernias constitute some of the most common surgical diseases addressed by surgeons. Endoscopic techniques have become standard of care together with the conventional open techniques for the treatment of umbilical hernias. Several different approaches were described to achieve laparoscopic sublay repair.

          We prospectively collected and reviewed the medical records of 10 patients with umbilical hernias underwent total endoscopic sublay repair (TES) at our institution from November 2017 to November 2019. All operations were performed by a same surgical team. The demographics, intraoperative details, and postoperative complications were evaluated.

          All TES procedures were successfully performed without conversion to an open operation. No intraoperative morbidity was encountered. The average operative time was 109.5 minutes (range, 80–140 minutes). All the patients resumed an oral diet within 6 hours after the intervention. The mean time to ambulation was 7.5 hours (range, 4–14 hours), and mean postoperative hospital stay was 2.2 day (range, 1–4 days). One patient developed postoperative seroma. No wound complications, chronic pain, or recurrence were registered during the follow-up.

          Initial experiences with this technique show that the TES is a safe, and effective procedure for the treatment of umbilical hernias.

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          Most cited references 42

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          Classification of primary and incisional abdominal wall hernias

          Purpose A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable. Methods Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias. Results To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome. Conclusions A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.
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            Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society)

            Introduction Guidelines are the bridge between science and clinical practice [1]. Science is a dynamic process and it is continuously evolving. Consequently, there is a continual development of new insights necessitation updates of existing guidelines. For this update, the authors concentrated on studies with level of 1 and 2 evidence. All references are marked with the level of evidence, according to the Oxford classification. In general “Recommendation Grade D” does not constitute a recommendation, but in some instances it is shown in the text to indicate lack of quality data. We recommended all readers to download the original statements and recommendations [2], for fully appreciation of the Update Guidelines on Laparoscopic Hernia Surgery. Updates should include issues that were not yet sufficiently covered in the original guidelines or those which have gained increased clinical importance. For this reason, the Update includes four new chapters: single port surgery, convalescence, costs and training. The update process was started in March 2013. All the authors were requested to commence revision of their chapters between January 2009 and September 30th 2013. An Update Consensus Conference was held on October 23–26, 2013 in Windhoek/Namibia, following which, the first versions of the updates were presented to the delegates and extensively discussed. Based on these discussions the definite update was formulated and circulated for approval by all the involved experts. References (in parentheses graduation of evidence) Eccles M, Mason J (2001) How to develop cost-conscious guidelines. Health Technol Assess 5(16):1–69. Reviews Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ, Fortelny RH, Klinge U, Kockerling F, Kuhry E, Kukleta J, Lomanto D, Misra MC, Montgomery A, Morales-Conde S, Reinpold W, Rosenberg J, Sauerland S, Schug-Pass C, Singh K, Timoney M, Weyhe D, Chowbey P (2011) Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 25(9):2773–284 Chapter 1: Perioperative management: evidence for antibiotic and thromboembolic prophylaxis in endoscopic/laparoscopic inguinal hernia surgery? Agneta montgomery Antibiotic prophylaxis Search terms: “Antibiotic prophylaxis*” AND “laparoscopy” AND “inguinal hernia”; “Antibiotic prophylaxis*” AND “TEP”; “Antibiotic prophylaxis*” AND “TAPP”; “Antibiotic prophylaxis*” AND “randomized controlled trial” AND “inguinal hernia”; “Antibiotic prophylaxis*” AND “meta-analysis” AND “inguinal hernia”. Thromboembolic prophylaxis “Thromboembolic prophylaxis*” AND “laparoscopy” AND “inguinal hernia; “Thromboembolic prophylaxis*” AND “TEP”; “Thromboembolic prophylaxis*” AND “TAPP”; “Thromboembolic prophylaxis*” AND “randomized controlled trial” AND “inguinal hernia”; “Thromboembolic prophylaxis*” AND “meta-analysis” AND “inguinal hernia”. Search machines PubMed and the Cochrane Colorectal Cancer Group specialized register and reference lists of the included studies were search for studies for potential inclusion. New publications A total of 45 studies were identified as Level 1 or Level 2. No RCTs including TEP or TAPP with antibiotic or thromboembolic prophylaxis as primary outcome were identified. Three RCT studies on TEP or TAPP, having antibiotic treatment in the protocol and including more than 200 patients, were identified [1, 2, 3]. The first compared TEP to Lichtenstein [1] and the other two compared different mesh types in TAPP repair [2, 3]. Two reported on thromboembolic complications [2, 3]. Four meta-analyses on antibiotic prophylaxis for prevention of surgical site infections as a primary outcome were identified [4–7]. All included only open hernia repairs. No meta-analyses on thromboembolic complications were identified. Antibiotic prophylaxis No new statements or recommendations. Thromboembolic prophylaxis No new statements or recommendations. Comments An update of the Cochrane report analyzing open hernia repairs, non-mesh and mesh repairs, was published in 2012 (search until October 2011) including 7,843 hernia operations in 17 studies [4]. The overall infection rates were 3.1 % in the prophylaxis group and 4.5 % in the control group (OR 0.64, 95 % CI 0.50–0.82). The subgroup with mesh had infection rates of 2.4 and 4.2 % in the prophylaxis and control groups, respectively (OR 0.56, 95 % CI 0.38–0.81). The recommendation in this report was: “Antibiotic prophylaxis for elective inguinal hernia repair cannot be universally recommended for open hernia repair. Neither can the administration be recommended against when high rates of wound infection are observed.” The three other meta-analyses are all performed on mesh repairs and all except one study is included in the Cochrane report [5–7]. They all conclude that antibiotic prophylaxis is beneficial for protection of surgical site infections in open mesh repair. References (in parentheses graduation of evidence) Langeveld HR, van’t Riet M, Weidema WF, Stassen LP, Steyerberg EW, Lange J, Bonjer HJ, Jeekel J (2010) Total extraperitoneal inguinal hernia repair compared with Lichtenstein (the LEVEL-Trial): a randomized controlled trial. Ann Surg 251(5):819–824. (1B) Bittner R, Schmedt CG, Leibl BJ, Schwarz J (2011) Early postoperative and one year results of a randomized controlled trial comparing the impact of extralight titanized polypropylene mesh and traditional heavyweight polypropylene mesh on pain and seroma production in laparoscopic hernia repair (TAPP). World J Surg 35(8):1791–1797. (1B) Bittner R, Leibl BJ, Kraft B, Schwarz J (2011) One-year results of a prospective, randomised clinical trial comparing four meshes in laparoscopic inguinal hernia repair (TAPP). Hernia 15(5):503–510. (1B) Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL (2012) Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev 2012 Issue 2. Art. CD003769. doi: 10.1002/14651858.CD003769.pub4. (1A) Mazaki T, Mado K, Masuda H, Shiono M (2013) Antibiotic prophylaxis for the prevention of surgical site infection after tension-free hernia repair: a Bayesian and frequentist meta-analysis. J Am Coll Surg 217(5):788–801. (1A) Li JF, Lai DD, Zhang XD, Zhang AM, Sun KX, Luo HG, Yu Z (2012) Meta-analysis of the effectiveness of prophylactic antibiotics in the prevention of postoperative complications after tension-free hernioplasty. Can J Surg 55(1):27–32. (1A) Yin Y, Song T, Liao B, Luo Q, Zhou Z (2012) Antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia: a meta-analysis. Am Surg 78(3):359–365. (1A) Chapter 2: Technical key points in TAPP repair Jan F. Kukleta, Reinhard Bittner Search terms: “Inguinal hernia“, “TAPP repair“, “TAPP”, “TAPP technique”, “hernia repair”, “endoscopic repair”. Filters: Engl., Ger., Ital., French, Port., Span. RCT, Meta-analysis, multicenter study, systematic review, controlled trial. Search machines PubMed, Medline and reference lists of articles selected for inclusion. New publications Of 1,684 papers involved with “endoscopic repair”, to “TAPP Hernia” with 355 and TAPP repair with 305. Of the 176 contributions to “TAPP technique” 37 were published in the last 3 years. (18 RCT’s, 3 meta-analysis and 16 reviews). Comments Due to the present structure of the guidelines some of the fundamental technical key points of TAPP repair like the mesh choice, mesh size, slitting/non-slitting and fixation /non fixation are discussed in depth in other chapters. These key points do influence obviously the patient’s outcome and represent an important part of the TAPP’s best practice. In several instances Recommendation Grade D is mentioned. In general “Recommendation Grade D” is no recommendation at all, due to weak evidence. Nevertheless it is used in this text to demonstrate that some important data are still missing. Which is the safest and most effective method of establishing pneumoperitoneum and obtaining access to the abdominal cavity? New statements—identical to previous except statement below. Level 1B In thin patients (BMI  60 min) [7, 8, 10, 14, 15, 19, 24, 31], high recurrence rates for laparoscopic repair (10 %) [33] and high conversion rate (6–10 %) [21, 27, 29] reported indicate lack of experience. Moreover studies not mentioning the kind of instruments and materials are useless for cost calculations. In contrast to these RCT’s when analyzing routine administrative highly standardized, patient-level cost data (collected in 15 German hospitals participating in the national cost data study) Wittenbecher et al. 2013 [34] found lower costs for TEP/TAPP and concluded that laparoscopic approaches are not necessarily associated with higher hospital resource consumption than open mesh repair. These conflicting data demonstrate clearly that cost calculations in hernia surgery are complex because of the nearly countless number of cost-relevant variables. These factors may be dependent on the patient, the pathology of the hernia, type of anesthesia, case load of hernias per year, type of procedure, skills of the surgeon, operating time, materials, meshes, type of fixation or no fixation, complications, setting in which operation is performed (ambulatory, size of hospital/institution, country, region), number of postoperative visits/home care, time of sick leave, outcome (recurrence rate, quality of life), salaries of the personnel, depreciation of equipment, and an appropriate share of the costs of the most relevant support departments: administration, house keeping, cleaning, sterilization, equipment maintenance. According to that apparently countless number of factors the published data with regard to costs show a huge range from about 126 US-$ to more than 4116 US $ [3, 20]. Moreover even within one institution there is a large variation in costs generated by individual providers [3]. Only a few of these factors may be influenced by the surgeon. Operating time, quality of the surgical intervention as well as the choice of instruments and materials are directly under the responsibility of the surgeon [29, 30, 34, 35]. In most of the papers it is stated that the higher costs found in laparoscopic surgery is mainly a reflection of the greater use of expensive disposable equipment and longer operating time for laparoscopic hernia repair [5, 10, 12, 13, 15, 17, 20, 24, 27, 30]. Multiple sensitivity analyses demonstrated that when use of disposable trocars, graspers, preperitoneal balloon, and stapling devices (“tacker”) were included, direct costs and charges were significantly higher for laparoscopic hernia repair. On the other hand, in a large volume laparoscopic surgery center with minimal use of disposable instruments and avoidance of preperitoneal balloon and tackers for mesh fixation, the actual direct costs of laparoscopic repair are comparable to open repairs [24]. Controversially discussed are the use of low-cost meshes [36] and the use of indigenous dilatation balloons [37] for further cost reduction. But without doubt experience is a significant factor for decreasing operating time as well as the rate of complications, recurrences and long-term complaints like chronic pain [29, 30, 34, 38]. In so far surgical performance is directly correlated to quality of life and QALY’S. Different to the results of the calculations of hospital costs (direct) nearly all RCT’s, systematic reviews, and meta-analysis prove that the societal costs(indirect) are less after laparoscopic repair mainly due to more rapid recovery and a shorter time of sick leave [4, 5, 7, 10–13, 15, 16, 19, 30, 35] when compared to open surgery. In summary, up to now due to the higher hospital costs worldwide acceptance of laparoscopic hernia repair is low despite less pain and more rapid recovery in comparison to open surgery. Therefore cost containment measures are to consider like increase of the case load (more rapid depreciation of equipment costs, large experience) [39], shortening of the learning curve and improvement of surgical performance by standardizing the technique and systematic training [38, 40]. Other recommendations are using non-disposable trocars and instruments [24, 25, 41, 42, 43], avoidance of “tacker” fixation [44] and implantation of low-cost meshes [36, 45]. References (in parentheses graduation of evidence) Stroupe KT, Manheim LM, Luo P, Giobbie-Hurder A, Hynes DM, Jonasson O, Reda DJ, Gibbs JO, Dunlop DD, Fitzgibbons RJ Jr (2006) Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost-effectiveness analysis. J Am Coll Surg 203(4):458–468. (1B) Fitzgibbons RJ Jr, Ramanan B, Arya S, Turner SA, Li X, Gibbs JO, Reda DJ, Investigators of the Original Trial (2013) Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg 258(3):508–515. (1B) Coronini-Cronberg S, Appleby J, Thompson J (2013) Application of patient-reported outcome measures (PROMs) data to estimate cost-effectiveness of hernia surgery in England. J R Soc Med 106: 278–287. (2C) Stylopoulos N, Gazelle GS, Rattner DW (2002) A cost-utility analysis of treatment options for inguinal hernia in 1,513,008 adult patients. Surg Endosc 17(2):180–189. (1A) Gholghesaei M, Langeveld HR, Veldkamp R, Bonjer HJ (2005) Costs and quality of life after endoscopic repair of inguinal hernia vs open tension-free repair: a review. Surg Endosc 19(6):816–821. (1A) Payne JH Jr, Grininger LM, Izawa MT, Podoll EF, Lindahl PJ, Balfour J (1994) Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial. Arch Surg 129(9):973–979; (1B) Brooks DC (1994) A prospective comparison of laparoscopic and tension-free open herniorrhaphy. Arch Surg 129(4):361–366. (2B) Lawrence K, McWhinnie D, Goodwin A, Gray A, Gordon J, Storie J, Britton J, Collin J (1995) Randomised controlled trial of laparoscopic versus open repair of inguinal hernia: early results. BMJ 311(7011):981–985. (1B) Lawrence K, McWhinnie D, Goodwin A, Gray A, Gordon J, Storie J, Britton J, Collin J (1996) An economic evaluation of laparoscopic versus open inguinal hernia repair. J Public Health Med 18(1):41–48. (1B) Liem MS, Halsema JA, van der Graaf Y, Schrijvers AJ, van Vroonhoven TJ (1997) Cost-effectiveness of extraperitoneal laparoscopic inguinal hernia repair: a randomized comparison with conventional herniorrhaphy. Coala trial group. Ann Surg 226(6):668–675(1B) Kald A, Anderberg B, Carlsson P, Park PO, Smedh K (1997) Surgical outcome and cost-minimization-analyses of laparoscopic and open hernia repair: a randomised prospective trial with one year follow up. Eur J Surg 163(7):505–510. (1B) Heikkinen TJ, Haukipuro K, Hulkko A (1998) A cost and outcome comparison between laparoscopic and Lichtenstein hernia operations in a day-case unit. A randomized prospective study. Surg Endosc 12 (10):1199–1203. (1B) Wellwood J, Sculpher MJ, Stoker D, Nicholls GJ, Geddes C, Whitehead A, Singh R, Spiegelhalter D (1998) Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost. BMJ 317(7151):103–110. (1B) Paganini AM, Lezoche E, Carle F, Carlei F, Favretti F, Feliciotti F, Gesuita R, Guerrieri M, Lomanto D, Nardovino M, Panti M, Ribichini P, Sarli L, Sottili M, Tamburini A, Taschieri A (1998) A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair. Surg Endosc 12(7):979–986. (1B) Johansson B, Hallerbäck B, Glise H, Anesten B, Smedberg S, Román J (1999) Laparoscopic mesh versus open preperitoneal mesh versus conventional technique for inguinal hernia repair: a randomized multicenter trial (SCUR Hernia Repair Study. Ann Surg 230(2):225–231. (1B) Jönsson B, Zethraeus N (2000) Costs and benefits of laparoscopic surgery—a review of the literature. Eur J Surg Suppl(585):48–56. (1A) Medical Research Council Laparoscopic Groin Hernia Trial Group (2001) Cost-utility analysis of open versus laparoscopic groinhernia repair: results from a multicentre randomized clinical trial. Br J Surg 88(5):653–61. (1B) Papachristou EA, Mitselou MF, Finokaliotis ND (2002) Surgical outcome and hospital cost analyses of laparoscopic and open tension-free hernia repair. Hernia. 6(2):68–72. (3) Schneider BE, Castillo JM, Villegas L, Scott DJ, Jones DB (2003) Laparoscopic totally extraperitoneal versus Lichtenstein herniorrhaphy: cost comparison at teaching hospitals. Surg Laparosc Endosc Percutan Tech 13(4):261–267. (3) Vale L, Ludbrook A, Grant A (2003) Assessing the costs and consequences of laparoscopic vs. open methods of groin hernia repair: a systematic review. Surg Endosc 17(6):844–849. (1A) Hildebrandt J, Levantin O (2003) Tension-free methods of surgery of primary inguinal hernias. Comparison of endoscopic, total extraperitoneal hernioplasty with the Lichtenstein operation. Chirurg 74(10):915–921. (1B) Hahn S, Whitehead A (2003) An illustration of the modelling of cost and efficacy data from a clinical trial. Stat Med 22(6):1009–1024. (1B) Anadol ZA, Ersoy E, Taneri F, Tekin E (2004) Outcome and cost comparison of laparoscopic transabdominal preperitoneal hernia repair versus Open Lichtenstein technique. J Laparoendosc Adv Surg Tech A 14(3):159–163. (3) Khajanchee YS, Kenyon TA, Hansen PD, Swanström LL(2004) Economic evaluation of laparoscopic and open inguinal herniorrhaphies: the effect of cost-containment measures and internal hospital policy decisions on costs and charges. Hernia 8(3):196–202. (2b) McCormack K, Wake B, Perez J, Fraser C, Cook J, McIntosh E, Vale L, Grant A (2005) Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation. Health Technol Assess 9(14):1–203. (1A) Hynes DM, Stroupe KT, Luo P, Giobbie-Hurder A, Reda D, Kraft M, Itani K, Fitzgibbons R, Jonasson O, Neumayer L (2006) Cost effectiveness of laparoscopic versus open mesh hernia operation: results of a Department of Veterans Affairs randomized clinical trial. J Am Coll Surg 203(4):447–457. (1B) Butler RE, Burke R, Schneider JJ, Brar H, Lucha PA Jr (2007) The economic impact of laparoscopic inguinal hernia repair: results of a double-blinded, prospective, randomized trial. Surg Endosc 21(3):387–390. (1B) Kuhry E, van Veen RN, Langeveld HR, Steyerberg EW, Jeekel J, Bonjer HJ (2007) Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review. Surg Endosc 21(2):161–166. (1A) Langeveld HR, van’t Riet M, Weidema WF, Stassen LP, Steyerberg EW, Lange J, Bonjer HJ, Jeekel J (2010) Total extraperitoneal inguinal hernia repair compared with Lichtenstein (the LEVEL-Trial): a randomized controlled trial. Ann Surg 251(5):819–824. (1B) Eklund A, Carlsson P, Rosenblad A, Montgomery A, Bergkvist L, Rudberg C (2010) Swedish Multicentre Trial of Inguinal Hernia Repair by Laparoscopy (SMIL) study group. Br J Surg. 97(5):765–771. (1B) Smart P, Castles L (2012) Quantifying the costs of laparoscopic inguinal hernia repair. ANZ J Surg 82(11):809–812. (3) Wang WJ, Chen JZ, Fang Q, Li JF, Jin PF, Li ZT (2013) Comparison of the effects of laparoscopic hernia repair and Lichtenstein tension-free hernia repair. J Laparoendosc Adv Surg Tech A 23(4):301–305. (1B) Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, Reda D, Henderson W; Veterans Affairs Cooperative Studies Program 456 Investigators (2004) Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 350(18):1819–1827. (1B) Wittenbecher F, Scheller-Kreinsen D, Röttger J, Busse R (2013) Comparison of hospital costs and length of stay associated with open-mesh, totally extraperitoneal inguinal hernia repair, and transabdominal preperitoneal inguinal hernia repair: an analysis of observational data using propensity score matching. Surg Endosc 27(4):1326–1333. (2C) Aly O, Green A, Joy M, Wong CH, Al-Kandari A, Cheng S, Malik M (2011) Is laparoscopic inguinal hernia repair more effective than open repair? J Coll Physicians Surg Pak 21(5):291–296. (1A) Yang J, Papandria D, Rhee D, Perry H, Abdullah F (2011) Low-cost mesh for inguinal hernia repair in resource-limited settings. Hernia 15(5):485–489. (1A) Misra MC, Kumar S, Bansal VK (2008) Total extraperitoneal (TEP) mesh repair of inguinal hernia in the developing world: comparison of low-cost indigenous balloon dissection versus direct telescopic dissection: a prospective randomized controlled study. Surg Endosc 22(9):1947–1958. (1B) Koperna T (2004) How long do we need teaching in the operating room? The true costs of achieving surgical routine. Langenbecks Arch Surg 389(3):204–208. (3) Chatterjee S, Laxminarayan R (2013) Costs of surgical procedures in Indian hospitals. BMJ Open 20:3(6). pii: e002844.(2C) Kurashima Y, Feldman LS, Kaneva PA, Fried GM, Bergman S, Demyttenaere SV, Li C, Vassiliou MC (2014) Simulation-based training improves the operative performance of totally extraperitoneal (TEP) laparoscopic inguinal hernia repair: a prospective randomized controlled trial. Surg Endosc 28(3):783–788. (1B) Lau H, Lee F, Patil NG, Yuen WK (2002) Two hundred endoscopic extraperitoneal inguinal hernioplasties: cost containment by reusable instruments. Chin Med J (Engl) 115(6):888–891. (3) Farinas LP, Griffen FD (2000) Cost containment and totally extraperitoneal laparoscopic herniorrhaphy. Surg Endosc 14(1):37–40. (3) Basu S, Chandran S, Somers SS, Toh SK (2005) Cost-effective laparoscopic TEP inguinal hernia repair: the Portsmouth technique. Hernia 9(4):363–367. (3) Taylor C, Layani L, Liew V, Ghusn M, Crampton N, White S (2008) Laparoscopic inguinal hernia repair without mesh fixation, early results of a large randomised clinical trial. Surg Endosc 22(3):757–762. (1B) Cavallo JA, Ousley J, Barrett CD, Baalman S, Ward K, Borchardt M, Thomas JR, Perotti G, Frisella MM, Matthews BD (2014) A material cost-minimization analysis for hernia repairs and minor procedures during a surgical mission in the Dominican Republic. Surg Endosc 28(3):747–766. (3)
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              Ventral Hernia Management: Expert Consensus Guided by Systematic Review.

              To achieve consensus on the best practices in the management of ventral hernias (VH).
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                Author and article information

                Journal
                Medicine (Baltimore)
                Medicine (Baltimore)
                MEDI
                Medicine
                Lippincott Williams & Wilkins (Hagerstown, MD )
                0025-7974
                1536-5964
                25 June 2021
                25 June 2021
                : 100
                : 25
                Affiliations
                Department of General and Minimally Invasive Surgery, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
                Author notes
                []Correspondence: Qi-long Chen, Department of General and Minimally Invasive Surgery, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (e-mail: faithchen@ 123456zju.edu.cn ).
                Article
                MD-D-20-06565 26334
                10.1097/MD.0000000000026334
                8238308
                34160398
                Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

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                Funding
                Funded by: Scientific and Technological Project of Zhejiang Province
                Award ID: LGF19H150007
                Award Recipient : Qi-long Chen
                Categories
                7100
                Research Article
                Quality Improvement Study
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