Colorectal and emergency surgical patients in the literature supporting EHS and AHS guidelines on abdominal wound closure: a granular analysis

BACKGROUND: To critically appraise the evidence supporting the European and American Hernia Society (EHS/AHS) guidelines on abdominal wall closure in colorectal and emergency surgery patients, we conducted a granular analysis focused on the representation and quality of available data. METHODS: References that addressed key questions (KQ) and recommendations in the original guidelines were screened and included if colorectal/emergency surgery was reported. Data extraction was performed with a standardised form and authors were contacted for missing data. Quality and risk of bias were assessed independently by two reviewers. RESULTS: Out of 33 studies included: 15 systematic reviews and one literature review were rated low or critically low (AMSTAR 2); 12 randomised controlled trials had moderate to high risk of bias (Cochrane RoB-2 tool); five observational studies were of low to very low quality (GRADE) with serious risk of bias (ROBINS-I). 32 studies included colorectal (n = 15,856) and 14 emergency patients (n = 4,582). To answer KQ1 on 'minimally invasive or open surgery' and 'type of incision' 9/10 studies included colorectal and no studies included emergency patients. 1/4 and 8/9 studies included colorectal/emergency patients for recommendations regarding trocar sites closure (KQ2) and closure after laparotomy (KQ3). Regarding the use of mesh (KQ5), 11/11 studies included colorectal/emergency patients. 3/3 and 1 studies included colorectal patients for KQ6 (abdominal binders) and one for KQ7 (restriction of activity), but none included emergency patients. CONCLUSION: Recommendations for KQs 1, 3, 5, 6, and 7 appear applicable to colorectal patients, whereas evidence for KQ2 remains insufficient. For emergency patients, recommendations related to KQs 1, 2, 6, and 7 should not be extrapolated. This study further highlights critical limitations in the evidence base, including the lack of patient-centred outcomes, and underscores the need for targeted, high-quality research in these populations.