Background: Groin hernia repair is one of the most common operations performed globally, with more than 20 million procedures per year. The last guidelines on groin hernia management were published in 2018 by the HerniaSurge Group. The aim of this project was to assess new evidence and update the guidelines. The guideline is intended for general and abdominal wall surgeons treating adult patients with groin hernias. Method: A working group of 30 international groin hernia experts and all involved stakeholders was formed and examined all new literature on groin hernia management, available until April 2022. Articles were screened for eligibility and assessed according to GRADE methodologies. New evidence was included, and chapters were rewritten. Statements and recommendations were updated or newly formulated as necessary. Results: Ten chapters of the original HerniaSurge inguinal hernia guidelines were updated. In total, 39 new statements and 32 recommendations were formulated (16 strong recommendations). A modified Delphi method was used to reach consensus on all statements and recommendations among the groin hernia experts and at the European Hernia Society meeting in Manchester on October 21, 2022. Conclusion: The HerniaSurge Collaboration has updated the international guidelines for groin hernia management. The updated guidelines provide an overview of the best available evidence on groin hernia management and include evidence-based statements and recommendations for daily practice. Future guideline development will change according to emerging guideline methodology.

Since the introduction of anaesthesia by Morton in 1846, and as survivable abdominal surgery became more common, so did the incidence of incisional hernias. Since then, more than 4000 peer-reviewed articles have been published on the topic, many of which have tried to reduce the incidence or introduce techniques to improve outcomes from surgical repair. Despite this, the incidence of incisional hernias and the recurrence rates after repair remain high. A wide range of incisional hernia rates are reported^1–5. A meta-analysis including over 14 000 patients reported a weighted incidence of 12.8 per cent 2 years after a midline incision, and that one-third of patients with an incisional hernia undergo surgical repair⁶. Recurrence rates after repair of incisional hernia range between 23 and 50 per cent, with increasing rates of complications and re-recurrence after each subsequent failed repair⁷. Arguably, no other benign disease has seen so little improvement in terms of surgical outcome.

A ‘complex’ hernia is often referred to in the published literature, yet has not been clearly defined to date. ‘Large’ and ‘giant’ may also be used to describe a complex incisional hernia indirectly^1–3. Meanwhile, a ‘complex hernia’ in reference to the technical surgical challenge of abdominal wall repair is different from a ‘complex patient’, the latter relating more to a patient’s mental or physical health. Several risk scores have been developed and described in the literature^2,4–6. Although hernia dimensions and defect characteristics alongside patient co-morbidities have demonstrated some correlation with poor surgical outcomes^1,3, postoperative complications alone should not define complexity^6,7. Slater et al.⁸ subsequently published criteria to define a complex abdominal wall hernia, comprising four categories: size and location, contamination/soft tissue condition, patient history/risk factors, and clinical scenario; three severity classes were defined, namely minor, moderate, and major. Although often referenced in publications, this definition has not been found to be an efficient working definition of a complex incisional hernia^4,9. Furthermore, with increasing preoperative adjuncts and operative strategies available to manage incisional hernia^6,10, and increased surgical specialization in the field^2,10, a revised consensus definition is required.