The steering group consisted of four general and abdominal wall surgeons with a specific interest in hernia surgery (CS, MP, ED, and AT), members of the EHS Board and/or experts in guideline development and evidence synthesis. They reported no financial or intellectual conflicts of interest, as per GIN standards [20].

One of the members of the steering committee (CS) is a certified guideline methodologist in training through the INGUIDE programme [17] and led the guideline under the supervision of a certified guideline methodologist (SAA - INGUIDE certificate number 2022-L3-V1- 00014).

The panel composition (Supplementary Material 2) aimed to ensure representation of all genders, international diversity, and both academic and non-academic affiliations. All members of the panel received training and certification through the INGUIDE programme (level 1 certification).

Two teams executed the systematic search: the clinical review team (ED, AT, ACQ, SCG, KG, UB, BR, and YR) handled article retrieval and outcome reporting, while the EtD team (FP, SCG, and ES) identified framework context items such as equity, feasibility, and patient values.

The project, initiated in November 2023 on behalf of the European Hernia Society (EHS), was conceived within the framework of the ENGINE project for guideline production and updates [21].

The inaugural kick-off meeting was held in May 2024 in Prague, during the European Hernia Society’s annual conference.

In January 2025, a face-to-face meeting was held in Genoa, where the summarised evidence and provisional recommendations were discussed and then finalised during a subsequent online meeting in March 2025.

The results, recommendations, and treatment algorithm were presented during a plenary session at the EHS annual conference in Paris in June 2025.

These guidelines (GLs) address the following health questions, referring to the Centers for Disease Control and Prevention (CDC) classification for wound contamination.

KQ 1 – Should mesh-based repair vs. tissue repair be used for the emergency treatment of a PVIH hernia in CDC I, stable patients with a defect amenable to direct closure?

The panel acknowledges that pooling primary and incisional hernias represents a methodological limitation with regard to the different features of these defect types [22], but this grouping was dictated by the inherent heterogeneity of the defects in the relevant literature and the lack of sufficient subgroup data in the existing studies.

This guideline specifically refers to adult patients with acutely complicated abdominal wall hernias (primary ventral or incisional) who are deemed fit for surgery and are in a stable condition. The hernia contents can include preperitoneal fat, omentum, or viscera, which can become acutely irreducible and may be associated with obstruction, strangulation or perforation.

Open abdomen (OA), burst abdomen (BA), and acutely complicated parastomal hernias are outside the scope of the present document. For optimal management in such scenarios, readers should refer to the ‘EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen’ and the European Hernia Society guidelines on the prevention and treatment of parastomal hernias [23, 24].

This project aims to provide a decision tool for general, abdominal, trauma and emergency surgeons facing this clinical scenario in cases where a specific abdominal wall subspecialist is unavailable.

A specific patient-friendly version of the present GLs will be made available and developed in accordance with the EHS Secretary for Publications.

The following section refers to the standards and nomenclature adopted for the present guidelines.

Onlay: The mesh is positioned superficial to the anterior rectus sheath and external oblique aponeurosis, lying deep to the subcutaneous tissue.

This concept can be applied as a clarification to any of the aforementioned planes to indicate that the mesh spans the defect without direct approximation of the native fascia [32].

A protocol was developed by the steering group and published in JAWS [35]. The guidelines’ questions and outcomes were refined in collaboration with the guidelines panel members.

To better align with the specific scenarios being analysed, the comparison terms for KQ3 and KQ4 have been modified from “mesh” and “sutures” to “repair” versus “no repair”. This change prevents misunderstandings about repair techniques that were judged to be not relevant to the current analysis by the panel, because they are impossible to accomplish (direct suturing) or possibly detrimental for the patients (component separation without mesh).

The importance of outcomes was rated by panel members using the GRADE scale [36].

Outcomes were classified by the steering group into each of the three categories (not important, important, critical) under consideration of panel members’ ratings. The panel considered the importance of outcomes and thresholds as results of the survey on outcomes and differences available in Supplementary Material 3. According to the previously published scoping review [7], the outcome “Quality of Life” could not be prioritized since it has never been reported in papers.

A practical decision was made to conduct a single comprehensive search covering all KQs due to the little available literature on the topic.

The search included studies published on PubMed and SCOPUS between 1 January 2000 and 1 November 2024 to capture contemporary evidence, with no language restrictions adopted. Moreover, series with fewer than 20 patients, systematic reviews and meta-analyses, case reports, editorials and letters were excluded from the search. The research was updated in November 2025 to include all recently published articles, using the same search strings. The search syntaxes are provided in Supplementary Material 4.

The evidence review team (ED, AT, AC, SC, KG, UB, BR, and YR) performed record screening using the ASreview platform [37]. Reviewers were blinded to each other’s judgements, and the senior author (CS) resolved any disagreements after unblinding. The same reviewers, in collaboration with the methodologist, selected articles based on full-text screening.

The overarching inclusion criterion was adult patients with abdominal wall defects presenting under emergency conditions, but specific inclusion and exclusion criteria were adopted and are provided in Supplementary Material 4.

After the definition of relevant outcomes, an Excel spreadsheet was prepared to allow uniform data collection (Supplementary Material 5).

All statistical analyses were conducted independently by a designated statistician, with no involvement from the steering group or panel members. The analysis plan was specified a priori in the guideline protocol.

For each KQ, where data were available from two or more studies, a meta-analysis was performed. Given the anticipated clinical and methodological heterogeneity across studies (e.g., variations in patient populations, specific surgical techniques, and study designs), a random-effects model using the DerSimonian and Laird method was employed for all meta-analyses. This approach provides a more conservative estimate of the treatment effect by incorporating both within-study and between-study variance.

For dichotomous outcomes such as mortality, surgical site infection, reoperation, and recurrence, Odds Ratios (ORs) with 95% Confidence Intervals (CIs) were calculated. The selection of ORs as a common measure of effect was derived from the inclusion of case-control studies in the meta-analysis, as in this study type, the incidence of outcomes is not directly estimable, and risk ratios (RRs) cannot be calculated. When zero events occurred in one arm, a continuity correction of 0.5 was applied to all cells in the 2 × 2 table. Statistical heterogeneity was assessed using both the Cochran’s Q test (with a p-value <0.10 indicating significant heterogeneity) and the I² statistic. The I² statistic was interpreted as follows: <40% indicates low heterogeneity, 40%–75% indicates moderate heterogeneity, and >75% indicates substantial heterogeneity. Subgroup analyses were planned to investigate potential sources of heterogeneity, such as differences between primary and incisional hernias, and varying degrees of contamination. However, due to limitations in the data reported in the primary studies, these analyses were not feasible. Similarly, an assessment of publication bias using funnel plots and Egger’s test was planned. However, this was not conducted for any of the KQs, as each meta-analysis included fewer than 10 studies, a threshold below which these tests are considered to have low power and can produce misleading results. All statistical analyses were performed using Cochrane RevMan Web. A two-sided p-value <0.05 was considered statistically significant for all analyses except for the assessment of heterogeneity, for which a p-value <0.10 was used.

RoB-2 and ROBINS-I [38, 39] were used to assess the risk of bias in randomised controlled trials and cohort studies with a comparative arm, respectively. All statistical analyses were performed independently by the statisticians’ group, with no involvement from the steering group or panel members.

The certainty of evidence was determined by the risk of bias across studies, incoherence, indirectness, imprecision, publication bias, and other parameters [40].

Minimal important differences, which were determined in advance through a survey of panel members, were used to inform the judgements about precision and coherence.

A formal anonymous online vote was carried out to finalise the judgements during the in-person and remote meetings. A total of three meetings were held: one in October 2024 (online), one in January 2025 in Genoa (in person), and one in March 2025 (online). Based on the evidence-to-decision framework, the panel anonymously voted on the strength and the direction of the recommendation through Google Forms.

We used the evidence-to-decision framework to develop recommendations by considering the following factors [41]:

Anticipated benefits and harms of the intervention

External advisors contributed to discussions but did not participate in judgements on the evidence-to-decision domains. Following the consensus meeting, panel members completed an anonymous online vote on the direction and strength of each recommendation and were invited to propose modifications in accordance with the GRADE methodology [42].

We considered consensus to be agreement among >70% of panel members if, after exhaustive deliberations, a unanimous consensus was not achieved.

Strong Recommendation: the panel is highly confident that the desirable effects clearly outweigh the undesirable effects for most, if not all, patients. This means that the majority of informed individuals would choose the recommended action.

The present recommendations are intended as a tool for general, abdominal, trauma and emergency surgeons, who are not specialists in abdominal wall surgery.

Tables 1–8 present the final recommendations, the evidence supporting them and an explanatory text detailing the additional evidence and panel considerations. Figure 1 (EHS - Emergency Ventral Hernia Treatment Algorithm) illustrates the recommended algorithm for emergency PVIH management.

A policy of performing emergent mesh repair of acutely complicated PVIH only in cases where the defect can be closed without myofascial release was suggested by this interdisciplinary panel.

Implementation of these guidelines significantly impacts resource allocation. Hospitals should ensure the immediate availability of appropriate mesh types for emergency use.

Utilisation of staged repairs will frequently necessitate prolonged intensive care unit admissions, requiring adequate critical care capacity.

Inter-hospital transfer protocols should be developed with clear policies and funding for the safe and efficient transfer of complex emergency hernia patients from general hospitals to specialised centres. This includes ambulance services, receiving protocols, and communication channels.

Referral to specialised centres for the management of large defects raises the need to identify existing qualified units or develop new ones within the territory. This involves defining criteria for accreditation (e.g., volume, expertise, and outcomes), ensuring equitable access, and potentially developing tiered referral systems along with a clear network for the management of complex abdominal conditions [63].

Furthermore, healthcare systems must meticulously evaluate the cost-effectiveness implications of mesh deployment and extended hospitalisations.

These guidelines, if adopted, could determine a robust shift towards mesh-based repair for defects amenable to closure in emergent settings, challenging the historical reliance on primary suture repair, particularly in clean wounds. For large, non-closable defects, the standard will transition to a staged approach, prioritising temporary abdominal closure (TAC), necessitating surgeon proficiency in these techniques. This constitutes a critical shift in mindset, prioritising physiological stability via a “damage control” approach over immediate definitive reconstruction.

This paradigm shift requires enhanced surgical expertise and a strengthened referral network. Surgeons will require specialised training in emergent mesh-based repairs and TAC. Crucially, the guidelines underscore the importance of recognising when a case exceeds a surgeon’s immediate competency, thereby fostering a culture of referral to specialised centres for the definitive reconstruction of complex defects following initial life-saving intervention. Managing these patients also mandates a multidisciplinary approach, involving collaboration between surgeons, intensivists, and ancillary specialists [64, 85].

Finally, these recommendations carry substantial implications for surgical education and training. Surgical residency and fellowship curricula must integrate these emergency hernia management strategies. Continuing Medical Education (CME) will be paramount for practising surgeons to remain up to date with evolving best practices. Rigorous documentation and systematic audit will be indispensable throughout for monitoring guideline adherence and assessing patient outcomes.

When considering these recommendations in an emergency scenario where patient communication is difficult, their implications shift significantly. Patients, who often lack the capacity for full informed consent due to their critical condition, will heavily rely on surrogate decision-makers, placing a significant burden on families. In these circumstances, the necessity of the recommended intervention, driven by guidelines aimed at optimising survival and minimising severe complications, will take precedence over individual preferences. Patients will have limited ability to process complex information, highlighting the importance of post-operative education to explain procedures. They will be highly dependent on the surgical team’s judgement and trust in pre-defined, evidence-informed protocols. Crucially, they must be prepared for a potentially longer and more complex recovery journey involving multiple stages and possibly transfers to specialised facilities. This underscores the ethical imperative for meticulous documentation of urgent decisions and transparent communication with available family members.

Despite the extensive work of research performed by the guidelines development group, several issues related to PVIH treatment under emergency conditions were encountered, particularly with regard to methodological bias concerning the selection of patients, which precludes definitive conclusions. In particular, biases that were already highlighted in elective settings were found to be more prevalent in studies on the management of emergency hernias. Several articles included mixed cohorts in terms of defect type (inguinal vs. ventral; primary vs. incisional), patient risk profile, type of mesh used and contamination grade. Evidence regarding the robotic approach to emergency abdominal wall hernias is limited to some non-comparative studies, and this could represent a possible future area of research [86].

Future research should target:

Mesh repair vs. suture repair

We recommend conducting matched, multicentre studies to ensure adequate statistical power and to obtain precise effect estimates.

Surgeon expertise and training gaps, along with clinical routine, probably represent the primary obstacles [87]. In particular, the lack of interest in innovations in advanced abdominal wall reconstruction techniques and temporary abdominal closure among general surgeons, especially in smaller or non-specialised hospitals, is considered the main issue. The shift towards mesh-based repair in emergencies and staged approaches requires experience, encompassing both abdominal wall surgery and damage control strategies, which many surgeons may not possess.

Moreover, implementing these guidelines demands specific resources that may not be universally available. These include access to diverse mesh types in emergency stock, sufficient ICU bed capacity for prolonged post-operative care in staged approaches, and specialised equipment.

Financial and reimbursement challenges may also be an issue, since the recommended approaches can be more expensive in the short term due to the cost of mesh, longer hospital stays (especially in the ICU), and the need for multiple procedures in staged repairs. Current reimbursement models may not adequately cover these complex, multi-stage treatments, potentially creating disincentives for hospitals and surgeons.

Referral system limitations can represent a relevant barrier: the emphasis on referring complex cases to specialised centres relies on a robust and efficient inter-hospital transfer system. Barriers could include a lack of established referral pathways, limited availability of specialised centres, or logistical difficulties in transferring critically ill patients over long distances.

Finally, communication and shared decision-making with patients or their surrogates in emergency settings is already challenging. Explaining complex, multi-stage plans with nuanced benefits and risks can be a significant hurdle.

The EHS has courses and fellowships across Europe designed to fill the knowledge gap on this topic. These are held by experts in abdominal wall and trauma surgery. These will help by increasing the availability of surgeons with sufficient skills to manage acutely complicated abdominal wall defects. The financial accessibility of this type of training, facilitated by policymaker support, is essential for building the necessary expertise. While extensive patient-centred decision aids are difficult to implement in an acute setting, the underlying principles of clear, concise communication become crucial when engaging with surrogate decision-makers, helping them to quickly understand the urgent situation and the rationale behind critical treatment choices. The EHS Publication Wing has developed materials aimed at clarifying the aspects of the intervention discussed in this document, for both surgeons and patients.

Use of the guidelines will be monitored by the Executive Board of the EHS through an online questionnaire sent to members within 3 years of publication from the Social Media Wing of the Society. Additionally, use of the guidelines will be monitored through direct citations of each article and dedicated metrics from the Journal of Abdominal Wall Surgery. Any feedback received from target users in the form of email communication, publications, and social media engagement will be documented to inform future versions of the present document. We advise monitoring the implementation of these interventions at all respective institutions and establishing clinical outcomes among surgeons at all institutions for the purpose of quality improvement.

A scoping search of ClinicalTrials.gov (conducted on 30 June 2025) for trials on emergency PVIH management returned no currently active studies. The most recent publication in this area is Crepaz et al.'s work in Updates in Surgery this year [54]. While a scoping review by Quiroga in Hernia [7] indicates a rising trend in publications on this topic, with an average of five articles per year, not all of these are comparative studies. Given the absence of ongoing trials and the nature of recent publications, it is unlikely that new trials with a substantial impact on the current evidence base will be completed within the next 5 years. Therefore, the recommendations of the present guidelines for emergency ventral hernia management are valid until June 2030.

We plan to update these guidelines in 2031, unless substantial new evidence becomes available.