SP 1.07 International Guideline Adherence in Elective Primary Umbilical Hernia Repair: CIRCULAR- a prospective cohort study (Collaborative International Research of Umbilical Hernia Repair)

Abstract Globally, >20 million hernia repairs are performed annually, with umbilical hernias accounting for up to 25%. Surgical repair of a primary umbilical hernia is guided by European Hernia Society and Americas Hernia Society recommendations. We aimed to report adherence to these guidelines. A prospective cohort study was performed (April-July 2025) across 21 countries (n=79 hospitals) (CIRCULAR). Adults aged ≥18 years undergoing elective repair of a primary umbilical hernia with defect size ≤4 cm were included. Guideline adherence components recorded were: for hernia defects <1cm, suture (non-absorbable/ slowly absorbable) or mesh were appropriate; hernia defects ≥1cm, mesh is recommended. When mesh was inserted adherence to mesh position (preperitoneal or retromuscular) and mesh overlap (≥5 cm for laparoscopic repairs; ≥3 cm for open) were reported. Differences between countries were assessed (chi-square testing). 1047 patients were included (48% of patients in age range 45-64; 67.9% male). For defects <1cm (15.3% of cases), suture repair was performed in 87.5% (appropriate suture used in 88.6%). For the 12.5% repaired with mesh, appropriate mesh position and overlap was achieved in 88.6%). For defects ≥1cm (84.7%), mesh repair was performed in 63% of cases with appropriate position in 60.1% and overlap in 38.5%. Overall adherence to guidelines was 27.8% and varied significantly between countries, ranging from 12.4% (UK) to 67.7 % (Germany) (χ² = 119.43, d.f. = 19 p < 0.001). Adherence to professional guidelines for primary umbilical hernia repair is low. CIRCULAR’s next analysis will determine whether this variation translates into meaningful differences in patient outcomes.