International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair

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  • S G Parker
    Abdominal Wall Unit, University College London Hospital , London,
  • S Halligan
    UCL Centre for Medical Imaging , London,
  • M K Liang
    Department of Surgery, McGovern Medical Center, University of Texas Health Science Center , Houston, Texas,
  • F E Muysoms
    Department of Surgery, Maria Middelares Hospital , Ghent,
  • G L Adrales
    Division of Minimally Invasive Surgery, Johns Hopkins Hospital , Baltimore, Maryland,
  • A Boutall
    Colorectal Unit, Groote Schuur Hospital , Cape Town,
  • A C Beaux
    Department of Surgery, Royal Infirmary of Edinburgh , Edinburgh,
  • U A Dietz
    Department of Visceral, Vascular and Thoracic Surgery, Kantonal Hospital of Olten , Olten,
  • C M Divino
    Department of General Surgery, Department of Surgery, Mount Sinai School of Medicine , New York,
  • M T Hawn
    Department of Surgery, Stanford University Medical Center , Palo Alto, California,
  • T B Heniford
    Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center , Charlotte, North Carolina,
  • J P Hong
    Department of Plastic Surgery, Asan Medical Centre, University of Ulsan , Seoul,
  • N Ibrahim
    Department of General Surgery, Macquarie University Hospital, Macquarie University , Sydney, New South Wales,
  • K M F Itani
    Department of General Surgery, Veterans Affairs Boston Health Care System, Boston and Harvard Universities , West Roxbury, Massachusetts,
  • L N Jorgensen
    Digestive Disease Centre, Bispebjerg University Hospital , Copenhagen,
  • A Montgomery
    Department of Surgery, Skåne University Hospital Malmö , Malmö,
  • S Morales-Conde
    Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital ‘Virgen del Rocio’ , Seville,
  • Y Renard
    Department of General, Digestive and Endocrine Surgery, Robert-Debré University Hospital, University of Reims Champagne-Ardenne , Reims Cedex,
  • D L Sanders
    Department of General and Upper Gastrointestinal Surgery, North Devon District Hospital , Barnstaple,
  • N J Smart
    Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital , Exeter,
  • J J Torkington
    Department of Colorectal Surgery, University Hospital of Wales , Cardiff,
  • A C J Windsor
    Abdominal Wall Unit, University College London Hospital , London,

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<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Background</jats:title> <jats:p>Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including ‘inlay’, ‘sublay’ and ‘underlay’, can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms ‘onlay’, ‘inlay’, ‘preperitoneal’ and ‘intraperitoneal’. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for ‘anterectus’, ‘interoblique’, ‘retro-oblique’ and ‘retromuscular’. Default consensus was achieved for the ‘retrorectus’ and ‘transversalis fascial’ planes.</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusion</jats:title> <jats:p>Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.</jats:p> </jats:sec>

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