Incisional hernia repair in the UK: a multicentre evaluation of guideline adherence and opportunities for service improvement

INTRODUCTION: International guidelines for incisional hernia repair exist to standardise care. However, the extent of implementation in real-world practice and the impact on service delivery remain unclear. This study aimed to evaluate adherence to key guidelines and identify opportunities to improve patient outcomes. METHODS: We conducted a multicentre, retrospective cohort study of 146 patients who underwent incisional hernia repair between January 2019 and June 2024. This audit included only elective incisional hernia repair cases performed across four UK hospitals. Emergency presentations, such as incarcerated or strangulated hernias, were excluded. Data on patient demographics, hernia characteristics, perioperative variables and postoperative outcomes were collected and analysed. RESULTS: Some 53.4% of patients were female and 46.6% male. Obesity was observed in 39.0% of patients and 54.8% were overweight. Most hernias were midline (76.0%), and the open surgical approach was predominant (97.3%). Mesh was utilised in 80.8% of cases. Prophylactic antibiotics were administered in 41.1% of patients and preoperative computed tomography was used in fewer than half. The onlay mesh position predominated over the recommended sublay technique. These variations in practice were associated with adverse outcomes, with increased hernia recurrence observed in patients with larger defects (>10cm) (10.5%) and those undergoing suture-only repairs (14.3%). The follow-up period was 12 months, during which hernia recurrence was assessed based on clinical or radiological confirmation. CONCLUSIONS: Hernia size, patient comorbidities and surgical technique are key predictors of outcomes in incisional hernia repair. Adherence to international guidelines is inconsistent in real-world practice. Significant opportunities exist to improve the quality of care for patients undergoing incisional hernia repair by addressing the wide gap between evidence-based guidelines and current clinical practice. Standardised local pathways and multidisciplinary teams meetings are required to reduce outcome variability and improve service delivery.