Subxiphoid hernia, definition and repair: an international delphi consensus

Purpose: Subxiphoid incisional hernias (SIH) are rare and challenging to repair, often occurring post- cardiac surgery after sternotomy and pericardial drainage. The literature on SIH is limited, with small patient cohorts and no established consensus on optimal repair strategies published yet. This present study aimed at proposing the definition and the surgical management and decision-making processes for SIH repair through an international Delphi consensus among expert surgeons. Methods: Using a modified Delphi technique, 69 international abdominal wall surgeons were invited. Three rounds were conducted to reach consensus on the definition, characteristics, classification, preoperative imaging and surgical approaches for SIH. Consensus was defined as more than 70% of agreement on 32 statements across 12 topics. Results: Sixty-nine experts were enrolled from 5 continents. Concerning definition of SIH, consensus was reached: a defect where the M1 part represents the most challenging and representative part. According to the expert panel, a mesh should be used in an extraperitoneal position. Both open and minimal invasive surgical (MIS) approach (E-TEP and/or ventral TAPP) are viable for W1 (< 4 cm) SIH repair. Achieving sufficient mesh overlap (> 5 cm) and defect closure are the 2 primary goals during SIH repair, whatever the approach and the technique. Expert panel agreed that a solid understanding of the anatomy is crucial and difficult in this area, due to the proximity of bony structures. For cranial overlap, exposing the central tendon of the diaphragm after cutting the posterior rectus sheath horizontally reached consensus. Concerning lateral overlap, the panel agreed on a retro rectus repair with TAR for ≥W2 hernia, while total preperitoneal repair is not. Mesh fixation is deemed unnecessary if adequate overlap is achieved. In case of difficulties of closure, only TAR might be helpful, with bridging as a last resort. They agreed that SIH ≥W2 should be referred to an expert hernia center. Conclusion: This Delphi consensus defined SIH and was an opportunity to emphasize the anatomy of the subxiphoid region. It opens the way for future strong studies on the subject, leading for recommendations.