Parker, Samuel George; (2021) Abdominal Wall Reconstruction: Improving Research Quality and Identifying the Predictors of Ventral Hernia Recurrence. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Abdominal wall reconstruction (AWR) is an emerging subspecialty within general surgery. To date, research has focused mostly on surgical reconstruction techniques without sufficient regard to research quality. As a result, much published work has produced spurious data with unstandardised variable definitions. Published data is therefore challenging to interpret, giving little robust evidence to guide AWR surgeons. Consequently, the first part of this thesis focuses on improving research quality. Initially, I performed two systematic reviews analysing variable reporting amongst interventional trials, demonstrating the current heterogeneous reporting of perioperative variables, post-operative outcomes, and patient reported outcomes as well as poor trial methodology. Next, I targeted “loss of domain” (LOD) and published a systematic review and a clinician survey which revealed current inconsistent definitions, both in the literature and amongst practicing surgeons. Whilst performing these systematic reviews, I also identified that terms used to defined and name abdominal wall planes were used inconsistently. To rectify this, I performed a series of consensus studies. First, I performed a Nominal Group Technique study and established minimum datasets for primary and incisional ventral hernia interventional trials. These datasets reached consensus on standardised peri-operative variable definitions and detection methods, outcomes reporting, follow-up duration, and criteria to improve trial methodology. Next, I performed two Delphi studies with 20 international hernia experts. The first established new written and volumetric definitions for LOD. The second study created ‘ICAP’, an International Classification of Abdominal wall Planes, which defines and names the tissue planes into which mesh can be placed for ventral hernia repair. The second part of this thesis uses systematic review and meta-analysis across 20 years of AWR literature to identify peri-operative factors that significantly predispose to hernia recurrence after apparently curative repair. This systematic review forms the evidence-base from which to develop a prognostic model of ventral hernia recurrence.

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