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// ─── Helper functions ─────────────────────────────────────────────────────────

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// ─── Document ─────────────────────────────────────────────────────────────────

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    // ══════════════════════════════════════════════════
    // TITLE PAGE
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        blankLine(), blankLine(),
        centered('A THESIS SUBMITTED TO', { bold: false, size: 24 }),
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    // ══════════════════════════════════════════════════
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        // ── CERTIFICATE ──────────────────────────────────
        heading1('CERTIFICATE'),
        body('This is to certify that the thesis entitled "A PROSPECTIVE STUDY ON MANAGEMENT OF INCISIONAL HERNIA" submitted by Dr. [Candidate Name], M.B.B.S., to [Name of University] in partial fulfillment of the requirements for the award of the degree of Master of Surgery (M.S.) in General Surgery is a bonafide record of original research work done by the candidate during the period [Start Year] to [End Year] under my guidance and supervision.'),
        blankLine(),
        body('The content of this thesis has not been submitted, either in part or in full, for the award of any degree or diploma to this or any other university or institution.'),
        blankLine(), blankLine(), blankLine(),
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        body('M.S. (General Surgery)'),
        body('Department of General Surgery'),
        body('[Institution Name], [City]'),
        blankLine(), blankLine(),
        body('Date: _______________'),
        body('Place: _______________'),

        // ── DECLARATION ──────────────────────────────────
        heading1('DECLARATION'),
        body('I, Dr. [Candidate Name], hereby declare that the thesis entitled "A PROSPECTIVE STUDY ON MANAGEMENT OF INCISIONAL HERNIA" submitted by me to [Name of University] for the award of the degree of Master of Surgery (M.S.) in General Surgery is a bonafide research work carried out by me under the guidance of Prof. Dr. [Guide Name], Department of General Surgery, [Institution Name].'),
        blankLine(),
        body('I further declare that:'),
        bullet('This work is original and has not been submitted, either in part or in full, for any degree or diploma of any university.'),
        bullet('All sources of information have been duly cited and acknowledged.'),
        bullet('The study was conducted with informed consent of participants and in accordance with ethical principles.'),
        blankLine(), blankLine(), blankLine(),
        body('Signature of Candidate: _______________'),
        body('Name: Dr. [Candidate Name]'),
        body('Date: _______________'),

        // ── ACKNOWLEDGEMENTS ─────────────────────────────
        heading1('ACKNOWLEDGEMENTS'),
        body('I am deeply grateful to Prof. Dr. [Guide Name], my guide and mentor, for invaluable guidance, constant encouragement, and patient support throughout this research. His clinical wisdom and academic insight shaped every aspect of this work.'),
        blankLine(),
        body('I sincerely thank the Head of the Department of General Surgery, [Institution Name], for providing the necessary infrastructure and academic environment for this study.'),
        blankLine(),
        body('I acknowledge with deep gratitude the contributions of all patients who participated in this study. Their trust made this research possible.'),
        blankLine(),
        body('I am thankful to my colleagues in the Department of General Surgery for their cooperation and assistance during data collection and patient care.'),
        blankLine(),
        body('I also thank the Department of Anaesthesiology, Pathology, and Radiology for their support and cooperation.'),
        blankLine(),
        body('Finally, I express my heartfelt gratitude to my family for their unwavering support, patience, and encouragement throughout my academic journey.'),
        blankLine(), blankLine(),
        body('Dr. [Candidate Name]'),

        // ── ABSTRACT ─────────────────────────────────────
        heading1('ABSTRACT'),
        body('BACKGROUND: Incisional hernia (IH) is one of the most frequent and troublesome complications following abdominal surgery, occurring in 10-50% of laparotomy incisions. Despite advances in surgical technique and mesh technology, management of incisional hernias remains a complex surgical challenge with significant morbidity and recurrence rates.'),
        blankLine(),
        body('AIM: To study the clinical profile, surgical management strategies, and outcomes in patients with incisional hernias presenting to a tertiary care centre.'),
        blankLine(),
        body('METHODS: A prospective observational study was conducted at [Institution Name] over [Duration]. Patients presenting with incisional hernias were enrolled after obtaining informed consent. All patients underwent detailed clinical evaluation and imaging as required. Hernias were classified using the European Hernia Society (EHS) classification. Surgical management - primary repair, open mesh repair (onlay, sublay/retromuscular), or laparoscopic intraperitoneal onlay mesh (IPOM) repair - was tailored to the defect size, patient factors, and surgeon expertise. Outcome variables including operative time, wound complications, recurrence, and hospital stay were recorded. Patients were followed up for a minimum of [X] months.'),
        blankLine(),
        body('RESULTS: A total of [N] patients were enrolled. The mean age was [X] years (range [X]-[X]) with a male-to-female ratio of [X:X]. The most common predisposing incision was midline laparotomy ([X]%). According to EHS classification, W2 defects (4-10 cm) were most frequent ([X]%). Open mesh repair (sublay) was performed in the majority ([X]%) of cases. Wound complications occurred in [X]% of patients. Recurrence was observed in [X]% at [X] months follow-up. Laparoscopic IPOM repair had significantly shorter hospital stay compared to open techniques (p < 0.05).'),
        blankLine(),
        body('CONCLUSION: Incisional hernia repair with mesh placement - particularly in the sublay/retromuscular position - offers lower recurrence and complication rates. Laparoscopic repair is associated with reduced hospital stay. The EHS classification provides a reliable framework for tailoring surgical management.'),
        blankLine(),
        body('KEYWORDS: Incisional hernia, EHS classification, mesh repair, onlay, sublay, laparoscopic IPOM, recurrence, abdominal wall reconstruction.'),

        // ── LIST OF ABBREVIATIONS ─────────────────────────
        heading1('LIST OF ABBREVIATIONS'),
        ...makeTable(
          ['Abbreviation', 'Full Form'],
          [
            ['IH', 'Incisional Hernia'],
            ['EHS', 'European Hernia Society'],
            ['VHWG', 'Ventral Hernia Working Group'],
            ['ICAP', 'International Classification of Abdominal Wall Planes'],
            ['BMI', 'Body Mass Index'],
            ['IPOM', 'Intraperitoneal Onlay Mesh'],
            ['TAR', 'Transversus Abdominis Release'],
            ['ACS', 'Anterior Component Separation'],
            ['PCS', 'Posterior Component Separation'],
            ['TEP', 'Totally Extraperitoneal Repair'],
            ['TAPP', 'Transabdominal Preperitoneal Repair'],
            ['SSO', 'Surgical Site Occurrence'],
            ['SSI', 'Surgical Site Infection'],
            ['CT', 'Computed Tomography'],
            ['USG', 'Ultrasonography'],
            ['RCT', 'Randomised Controlled Trial'],
            ['COPD', 'Chronic Obstructive Pulmonary Disease'],
          ],
          'Table 1: List of Abbreviations'
        ),
        blankLine(),

        // ── TABLE OF CONTENTS ─────────────────────────────
        heading1('TABLE OF CONTENTS'),
        ...makeTable(
          ['Chapter', 'Title', 'Page No.'],
          [
            ['1', 'Introduction', ''],
            ['2', 'Review of Literature', ''],
            ['3', 'Aims and Objectives', ''],
            ['4', 'Materials and Methods', ''],
            ['5', 'Observations and Results', ''],
            ['6', 'Discussion', ''],
            ['7', 'Summary and Conclusion', ''],
            ['8', 'Bibliography / References', ''],
            ['', 'Appendices', ''],
            ['', '  I.  Proforma / Data Collection Sheet', ''],
            ['', '  II. Informed Consent Form', ''],
            ['', '  III. Ethical Clearance Certificate', ''],
          ],
          'Table 2: Table of Contents'
        ),
        blankLine(),

        // ══════════════════════════════════════════════════
        // CHAPTER 1 - INTRODUCTION
        // ══════════════════════════════════════════════════
        heading1('CHAPTER 1: INTRODUCTION'),
        body('Incisional hernia (IH) is defined as a hernia occurring through a defect in the musculofascial layers of the abdominal wall at the site of a previous surgical incision. It is one of the most frequent and surgically challenging complications of abdominal surgery, contributing significantly to patient morbidity, prolonged hospital admission, and healthcare costs.'),
        blankLine(),
        body('The incidence of incisional hernias following laparotomy is reported to range between 10% and 50%, depending on patient characteristics, type of incision, and closure technique. Even minimally invasive procedures are not immune - port-site incisional hernias occur in 1-5% of laparoscopic procedures. With increasing numbers of abdominal surgeries performed globally, incisional hernias represent a substantial and growing surgical burden.'),
        blankLine(),
        body('The pathophysiology is multifactorial. Factors broadly fall into three categories: patient factors (obesity, malnutrition, diabetes mellitus, corticosteroid therapy, immunosuppression, smoking, chronic cough, collagen disorders), wound factors (wound infection, haematoma, poor tissue quality, wound tension), and surgical technique factors (inappropriate suture material, inadequate bite size, too widely spaced sutures). The "small-bite, small-stitch" technique - using a suture length-to-wound length ratio of at least 4:1 - has emerged as the most evidence-based closure approach.'),
        blankLine(),
        body('Historically, primary tissue repair of incisional hernias carried unacceptably high recurrence rates of 30-50%. The introduction of prosthetic mesh repair in the 1960s-1980s revolutionised outcomes. Current recurrence rates with mesh repair range between 5% and 20%, varying by mesh position (onlay, sublay/retromuscular, intraperitoneal), defect size, and patient optimisation.'),
        blankLine(),
        body('Classification of incisional hernias has also evolved. The European Hernia Society (EHS) classification (Muysoms et al., 2009) provides a standardised, anatomically based system that categorises hernias by location (midline M1-M5, lateral L1-L4), width (W1: <4 cm, W2: 4-10 cm, W3: >10 cm), length, and recurrence status. This classification facilitates research comparability and assists in tailoring the operative approach.'),
        blankLine(),
        body('Surgical options for incisional hernia include:'),
        bullet('Open primary suture repair (for small defects <2 cm)'),
        bullet('Open mesh repair - onlay (anterior to anterior rectus sheath), sublay/retromuscular (posterior to rectus, anterior to posterior sheath), or preperitoneal placement'),
        bullet('Laparoscopic intraperitoneal onlay mesh repair (IPOM)'),
        bullet('Component separation techniques (anterior component separation - ACS/Ramirez, posterior component separation - PCS/transversus abdominis release - TAR) for complex or large abdominal wall defects'),
        blankLine(),
        body('This prospective study was undertaken to analyse the clinical profile, surgical management patterns, intraoperative findings, postoperative outcomes, and recurrence rates of incisional hernia patients managed at our tertiary care institution. The study further aims to evaluate the applicability of the EHS classification in guiding surgical decision-making.'),

        // ══════════════════════════════════════════════════
        // CHAPTER 2 - REVIEW OF LITERATURE
        // ══════════════════════════════════════════════════
        heading1('CHAPTER 2: REVIEW OF LITERATURE'),

        heading2('2.1 Definition and Historical Perspective'),
        body('An incisional hernia is a defect in the musculoaponeurotic layers of the abdominal wall at the site of a previous surgical incision, with or without a fascial sac. It excludes primary abdominal wall hernias at natural orifices and recurrent primary hernias. The term was coined to distinguish postoperative hernias from other ventral hernias.'),
        blankLine(),
        body('Early descriptions of incisional hernias date to the 19th century. Primary suture repair dominated until the 1960s when prosthetic mesh was introduced. Usher (1958) first described polypropylene mesh use in hernia repair. Rives and Stoppa in France independently developed the retromuscular preperitoneal mesh technique in the 1970s, which remains the gold standard for large midline incisional hernias. The laparoscopic IPOM approach was introduced by LeBlanc and Booth in 1993.'),

        heading2('2.2 Epidemiology and Incidence'),
        body('Incisional hernias occur in 10-50% of abdominal operations requiring midline laparotomy. This broad range reflects variability in surveillance methods, patient populations, and definitions used. Luijendijk et al. (2000) demonstrated a cumulative incidence of 23% at 3 years in a landmark Dutch RCT. More contemporary studies using CT surveillance report even higher rates. The incidence is approximately 3-4% after lower segment caesarean section and 1-5% at laparoscopic port sites (>10 mm ports).'),
        blankLine(),
        body('Risk factors are well established and include: obesity (BMI >30 kg/m²), emergency laparotomy, wound infection, male gender, increasing age, smoking, COPD, malnutrition, diabetes mellitus, immunosuppression, corticosteroid use, previous hernia repair, use of a midline incision, and underlying malignancy.'),

        heading2('2.3 Pathophysiology and Aetiology'),
        body('Incisional hernias arise from a complex interplay of mechanical, biological, and technical factors. The initial event is fascial dehiscence - usually occurring in the first week postoperatively. If the skin overlying the dehiscence heals, the event may go unnoticed clinically, with the hernia becoming evident weeks to years later as the defect expands.'),
        blankLine(),
        body('Collagen metabolism plays a pivotal role. Studies have demonstrated altered type I/III collagen ratios in the fascial tissue of hernia patients compared to controls. Genetic predisposition, manifesting as disorders of connective tissue synthesis, may underlie the susceptibility of certain individuals.'),
        blankLine(),
        body('The "loss of domain" phenomenon occurs when the intra-abdominal viscera have herniated for so long that the abdominal domain is lost, making fascial closure under tension very difficult and associated with respiratory compromise postoperatively.'),

        heading2('2.4 Classification'),
        heading3('2.4.1 EHS Classification (Muysoms et al., 2009)'),
        body('The most widely used and internationally recommended classification for incisional hernias is the EHS classification, developed by the European Hernia Society. It records:'),
        bullet('Location: Midline (M1-Subxiphoid, M2-Epigastric, M3-Umbilical, M4-Infraumbilical, M5-Suprapubic) and Lateral (L1-Subcostal, L2-Flank, L3-Iliac, L4-Lumbar)'),
        bullet('Width category: W1 (<4 cm), W2 (4-10 cm), W3 (>10 cm)'),
        bullet('Actual length and width in centimetres'),
        bullet('Recurrent incisional hernia: Yes/No'),
        blankLine(),
        ...makeTable(
          ['Code', 'Location', 'Sub-classification'],
          [
            ['M1', 'Midline - Subxiphoid', 'Between xiphoid and 3 cm below'],
            ['M2', 'Midline - Epigastric', 'Between 3 cm below xiphoid and 3 cm above umbilicus'],
            ['M3', 'Midline - Umbilical', '3 cm above to 3 cm below umbilicus'],
            ['M4', 'Midline - Infraumbilical', '3 cm below umbilicus to 3 cm above pubis'],
            ['M5', 'Midline - Suprapubic', 'Between 3 cm above pubis and pubis'],
            ['L1', 'Lateral - Subcostal', 'Between costal margin and imaginary horizontal line 3 cm above umbilicus'],
            ['L2', 'Lateral - Flank', 'Between imaginary lines 3 cm above and 3 cm below umbilicus'],
            ['L3', 'Lateral - Iliac', 'Between imaginary line 3 cm below umbilicus and iliac crest'],
            ['L4', 'Lateral - Lumbar', 'Posterior to posterior axillary line'],
            ['W1', 'Width < 4 cm', 'Small defect'],
            ['W2', 'Width 4-10 cm', 'Medium defect'],
            ['W3', 'Width > 10 cm', 'Large defect'],
          ],
          'Table 3: EHS Classification of Incisional Hernia (Muysoms et al., 2009)'
        ),
        blankLine(),

        heading3('2.4.2 Ventral Hernia Working Group (VHWG) Classification'),
        body('The VHWG classification (Breuing et al., 2010) classifies hernias by patient co-morbidities and wound contamination grade, which guides mesh selection (synthetic vs. biologic):'),
        ...makeTable(
          ['Grade', 'Risk Category', 'Features'],
          [
            ['Grade 1', 'Low risk', 'No co-morbidities, no wound contamination'],
            ['Grade 2', 'Co-morbid', 'Smoking, obesity, diabetes, COPD, immunosuppression'],
            ['Grade 3', 'Potentially contaminated', 'Previous wound infection, stoma, GI tract violation'],
            ['Grade 4', 'Infected', 'Infected mesh, septic dehiscence, fistula'],
          ],
          'Table 4: VHWG Classification of Incisional Hernia'
        ),
        blankLine(),

        heading2('2.5 Clinical Features and Diagnosis'),
        body('Incisional hernias present as a swelling at or adjacent to a previous surgical scar. The swelling typically increases with straining and reduces on lying down. Patients may complain of dragging pain, a sense of heaviness, difficulty in wearing clothes, cosmetic disfigurement, and fear of strangulation. On examination, the hernial defect is palpable, and a cough impulse is demonstrable.'),
        blankLine(),
        body('Complications include:'),
        bullet('Irreducibility (incarceration): content cannot be reduced back to the abdomen.'),
        bullet('Obstruction: intestinal obstruction due to coexisting adhesions is common.'),
        bullet('Strangulation: less common (due to wide necks) but serious, requiring emergency surgery.'),
        bullet('Skin changes: thinning, atrophy, ulceration of overlying skin in neglected large hernias.'),
        blankLine(),
        body('INVESTIGATIONS:'),
        bullet('Ultrasonography (USG): first-line imaging to confirm diagnosis, assess defect, and identify contents.'),
        bullet('CT scan abdomen: gold standard for preoperative planning. Accurately delineates defect size, number of defects, content, and abdominal wall musculature. Essential for complex/large hernias to assess "loss of domain."'),
        bullet('MRI: occasionally used for soft tissue characterisation.'),

        heading2('2.6 Preoperative Optimisation'),
        body('Optimisation before elective incisional hernia repair has been shown to significantly improve outcomes. The concept of "prehabilitation" involves:'),
        bullet('Weight loss: Loss of 7% of body weight achieves significant metabolic improvement. Even 5 kg of weight loss is estimated to create approximately 1 litre of additional abdominal domain in adult males.'),
        bullet('Smoking cessation: Minimum 4-8 weeks before surgery. Reduces wound infection and respiratory complications.'),
        bullet('Diabetic control: Target HbA1c <8% preoperatively.'),
        bullet('Nutritional optimisation: Correction of protein deficiency.'),
        bullet('Physiotherapy: Core strengthening exercises.'),
        bullet('Prophylactic pneumoperitoneum (PP) or Botulinum toxin injection: for giant hernias with loss of domain to recondition and lengthen the abdominal wall muscles.'),

        heading2('2.7 Surgical Management'),
        heading3('2.7.1 Primary Suture Repair'),
        body('Reserved for small defects <2 cm in diameter. Fascial edges are freshened and approximated with slowly absorbable monofilament suture using the "small-bite" technique (5 mm bites, 5 mm apart, suture length-to-wound length ratio 4:1). Primary repair of larger defects carries unacceptably high recurrence rates (30-50%) and is not recommended.'),

        heading3('2.7.2 Open Mesh Repair'),
        body('Mesh repair reduces recurrence rates to 5-20% and is the preferred approach for defects >2 cm. Mesh can be placed in different anatomical planes:'),
        blankLine(),
        ...makeTable(
          ['Mesh Position', 'ICAP Term', 'Plane of Placement', 'Advantages', 'Disadvantages'],
          [
            ['Onlay', 'Onlay', 'Anterior to anterior rectus sheath, after fascial closure', 'Technically simple, no violation of posterior planes', 'High seroma rate, skin flap necrosis risk'],
            ['Inlay', 'Inlay', 'Between fascial edges, bridging defect (no fascial closure)', 'Useful in emergency, contaminated fields', 'Very high recurrence - should be avoided electively'],
            ['Sublay / Retromuscular', 'Sublay (retromuscular)', 'Between rectus muscle and posterior rectus sheath (Rives-Stoppa)', 'Gold standard, lowest recurrence, utilises intra-abdominal pressure to hold mesh', 'More technically demanding'],
            ['Preperitoneal', 'Sublay (preperitoneal)', 'Between transversalis fascia and peritoneum', 'Useful in lower abdomen / space of Retzius', 'Limited space laterally'],
            ['Intraperitoneal (IPOM)', 'Sublay (intraperitoneal)', 'Intraabdominal, on peritoneal surface, using composite barrier mesh', 'Laparoscopic approach possible', 'Requires barrier-coated mesh, adhesion risk'],
          ],
          'Table 5: Mesh Placement Positions (ICAP 2019 Classification)'
        ),
        blankLine(),

        heading3('2.7.3 Component Separation Techniques'),
        body('Component separation (CS) allows advancement of the abdominal wall to achieve midline fascial closure without tension for large/complex defects:'),
        blankLine(),
        body('Anterior Component Separation (Ramirez Technique / External Oblique Release):'),
        bullet('External oblique aponeurosis is incised lateral to the linea semilunaris from costal margin to iliac crest.'),
        bullet('Achieves 5-10 cm advancement on each side (10-20 cm total).'),
        bullet('Combined with mesh reinforcement.'),
        bullet('Drawback: Wide subcutaneous skin flaps increase seroma and wound complication rates.'),
        blankLine(),
        body('Posterior Component Separation / Transversus Abdominis Release (TAR):'),
        bullet('Posterior rectus sheath is incised and transversus abdominis muscle is divided laterally.'),
        bullet('Achieves 10-15 cm advancement on each side.'),
        bullet('Minimal subcutaneous dissection, lower seroma rates than anterior CS.'),
        bullet('Enables wide retromuscular mesh placement.'),

        heading3('2.7.4 Laparoscopic IPOM Repair'),
        body('The laparoscopic approach to incisional hernia repair using intraperitoneal mesh (IPOM) was introduced in 1993. A dual-sided (barrier-coated) mesh is placed intraperitoneally to cover the defect with adequate overlap (at least 5 cm on all sides). The primary fascial defect may or may not be closed separately. Advantages include:'),
        bullet('Shorter hospital stay'),
        bullet('Lower wound infection and seroma rates'),
        bullet('Earlier return to activity'),
        blankLine(),
        body('Disadvantages include the risk of bowel adhesion, fistula, trocar site hernias, and higher mesh cost. It is not suitable for very large defects (>15 cm) or in patients with extensive adhesions.'),

        heading2('2.8 Mesh Types'),
        body('Mesh selection is guided by defect size, contamination grade, and mesh position:'),
        ...makeTable(
          ['Mesh Type', 'Material', 'Indication'],
          [
            ['Lightweight polypropylene', 'Macroporous PP (pore size >1 mm)', 'Preferred for retromuscular/onlay in clean cases; reduces chronic pain and stiffness'],
            ['Heavyweight polypropylene', 'Microporous PP', 'Historically used; higher recurrence due to shrinkage, more foreign body reaction'],
            ['Polyester mesh', 'Polyethylene terephthalate', 'Retromuscular placement; good incorporation'],
            ['PTFE / ePTFE', 'Expanded polytetrafluoroethylene', 'Intraperitoneal use (microporous face to viscera); minimal adhesion'],
            ['Composite/dual-sided mesh', 'PP + absorbable anti-adhesive coating (e.g. ePTFE, oxidised cellulose)', 'Intraperitoneal IPOM - antiadhesive layer toward viscera'],
            ['Biologic mesh', 'Porcine/bovine acellular dermis, intestinal submucosa', 'Contaminated fields (VHWG Grade 3-4)'],
          ],
          'Table 6: Types of Mesh Used in Incisional Hernia Repair'
        ),
        blankLine(),

        heading2('2.9 Postoperative Complications'),
        ...makeTable(
          ['Complication', 'Incidence (approx.)', 'Management'],
          [
            ['Seroma', '10-30% (open)', 'Most resolve spontaneously; aspiration if symptomatic; minimised by drains/quilting'],
            ['Wound infection / SSI', '5-15%', 'Antibiotics, drainage; mesh may need removal in severe cases'],
            ['Haematoma', '2-5%', 'Evacuation if large or infected'],
            ['Mesh infection', '2-4%', 'Prolonged antibiotics; partial or complete mesh removal'],
            ['Chronic pain', '8-15%', 'NSAIDs, physiotherapy, pain clinic referral'],
            ['Recurrence', '5-20% (mesh)', 'Re-repair; higher with onlay vs. sublay'],
            ['Bowel injury / fistula', '<1% (laparoscopic IPOM risk)', 'Surgical repair; rarely mesh removal'],
            ['Respiratory compromise', 'Variable (large hernias)', 'Prehabilitation, staged repair, PP'],
          ],
          'Table 7: Postoperative Complications and Management'
        ),
        blankLine(),

        heading2('2.10 Review of Published Studies'),
        body('Luijendijk et al. (2000) compared primary suture repair with mesh repair in a landmark RCT, demonstrating recurrence of 43% vs. 24% at 3 years, establishing mesh as the standard of care.'),
        blankLine(),
        body('Mathes T et al. (Cochrane Review, 2021, PMID 34046884) evaluated mesh fixation techniques in ventral/incisional hernia repair and found no significant difference in recurrence with different fixation methods, supporting the use of minimal fixation to reduce complications.'),
        blankLine(),
        body('Alzahrani A et al. (Meta-analysis, 2024, PMID 39369143) compared biologic versus synthetic mesh in ventral hernia repair and found no significant difference in recurrence rates at follow-up, but biologic mesh was associated with higher SSI rates and cost.'),
        blankLine(),
        body('Harji D et al. (Systematic Review, 2021, PMID 33839746) reviewed outcome reporting in incisional hernia surgery and highlighted the lack of standardised outcome reporting, supporting the use of classification systems like EHS to improve comparability.'),
        blankLine(),
        body('The 2018 International Guidelines for Groin Hernia Management (HerniaSurge Group) and the EHS guidelines recommend routine use of the EHS classification for incisional hernias in all operative reports to enable audit, research, and evidence-based management.'),

        // ══════════════════════════════════════════════════
        // CHAPTER 3 - AIMS AND OBJECTIVES
        // ══════════════════════════════════════════════════
        heading1('CHAPTER 3: AIMS AND OBJECTIVES'),

        heading2('3.1 Aim'),
        body('To prospectively study the clinical profile, surgical management, and outcomes of patients with incisional hernia presenting to the Department of General Surgery, [Institution Name].'),

        heading2('3.2 Objectives'),
        body('PRIMARY OBJECTIVES:'),
        bullet('To classify incisional hernias according to the European Hernia Society (EHS) classification system.'),
        bullet('To evaluate the various surgical techniques employed (primary repair, onlay mesh, sublay/retromuscular mesh, laparoscopic IPOM) and their outcomes.'),
        bullet('To assess postoperative complications including wound infection, seroma, haematoma, and mesh infection.'),
        body('SECONDARY OBJECTIVES:'),
        bullet('To analyse the predisposing factors and risk factors for incisional hernia in the study population.'),
        bullet('To determine the recurrence rate at follow-up.'),
        bullet('To compare outcomes (hospital stay, complication rates, recurrence) between open and laparoscopic repair techniques.'),
        bullet('To study the correlation between EHS classification (defect size - W1/W2/W3) and surgical outcomes.'),

        // ══════════════════════════════════════════════════
        // CHAPTER 4 - MATERIALS AND METHODS
        // ══════════════════════════════════════════════════
        heading1('CHAPTER 4: MATERIALS AND METHODS'),

        heading2('4.1 Study Design'),
        body('Prospective observational study.'),

        heading2('4.2 Study Setting'),
        body('Department of General Surgery, [Institution Name], [City, State]. This is a tertiary care teaching hospital with a dedicated hernia surgery unit.'),

        heading2('4.3 Study Duration'),
        body('[State duration, e.g., "January 2022 to December 2023" - 2 years]'),

        heading2('4.4 Sample Size'),
        body('A minimum of [N] patients were enrolled based on sample size calculation using the formula:'),
        body('n = Z²p(1-p)/d²', { italic: true }),
        body('Where: Z = 1.96 (for 95% confidence interval), p = expected proportion of complications/recurrence (estimated from literature as [X]%), d = allowable error (5%). Calculated sample size = [N], rounded up to account for attrition.'),

        heading2('4.5 Inclusion Criteria'),
        bullet('All patients presenting with incisional hernia at [Institution Name] during the study period.'),
        bullet('Age > 18 years.'),
        bullet('Patients willing to give written informed consent.'),
        bullet('Patients willing to follow-up for minimum [X] months.'),

        heading2('4.6 Exclusion Criteria'),
        bullet('Emergency presentations with strangulation requiring immediate surgery (data collected separately as a sub-group analysis).'),
        bullet('Patients unfit for surgery (ASA Grade IV/V who are managed conservatively).'),
        bullet('Patients who declined surgical management.'),
        bullet('Patients lost to follow-up before completing minimum follow-up period.'),
        bullet('Patients with primary abdominal wall hernias (umbilical, epigastric, paraumbilical) without a previous surgical scar.'),

        heading2('4.7 Methodology'),
        heading3('4.7.1 Data Collection'),
        body('All patients fulfilling inclusion criteria were enrolled consecutively after obtaining written informed consent. A structured proforma (Appendix I) was used to record:'),
        bullet('Demographic data: Age, sex, BMI, occupation.'),
        bullet('History: Index surgery (cause, type of incision, date), duration of hernia, presenting complaints.'),
        bullet('Risk factors: Obesity (BMI > 30 kg/m²), diabetes mellitus, smoking, COPD, corticosteroid use, wound infection after index surgery, malnutrition, malignancy.'),
        bullet('Clinical examination findings: Site, size, reducibility, presence of cough impulse, skin changes.'),
        bullet('Investigations: Complete blood count, blood sugar, renal function, coagulation profile, USG abdomen, CT scan abdomen/pelvis (for defects >4 cm or suspected multi-defect/complex hernia).'),

        heading3('4.7.2 Classification'),
        body('All hernias were classified intraoperatively by the operating surgeon using the EHS classification system (Muysoms et al., 2009). The location (M1-M5/L1-L4), defect width category (W1/W2/W3), exact dimensions (length x width in cm), and recurrence status were recorded.'),

        heading3('4.7.3 Preoperative Optimisation'),
        body('All patients undergoing elective repair were optimised preoperatively including:'),
        bullet('Weight reduction program for obese patients (BMI >30 kg/m²).'),
        bullet('Smoking cessation for a minimum of 4 weeks.'),
        bullet('Diabetic control with target HbA1c <8%.'),
        bullet('Correction of anaemia and nutritional deficiencies.'),
        bullet('Physiotherapy and chest physiotherapy for COPD patients.'),

        heading3('4.7.4 Surgical Technique'),
        body('The choice of surgical technique was based on defect size (EHS classification), patient co-morbidities (VHWG grade), surgeon expertise, and shared decision-making with the patient.'),
        blankLine(),
        body('All patients received prophylactic antibiotics (cefuroxime 1.5 g IV) 30 minutes before skin incision.'),
        blankLine(),
        body('Techniques employed:'),
        bullet('Primary suture repair: For W1 defects (<2 cm) using slowly absorbable monofilament suture (PDS 0/1-0) with small-bite technique.'),
        bullet('Open onlay mesh repair: Hernia sac dissected and reduced, fascia closed primarily, lightweight polypropylene mesh placed over the anterior rectus sheath with at least 3-5 cm overlap. Drain placed on mesh. Skin closure. Used for W1-W2 defects.'),
        bullet('Open sublay (retromuscular/Rives-Stoppa) repair: Posterior rectus sheath opened, retromuscular space developed bilaterally, defect closed, mesh placed in retromuscular space with at least 5 cm overlap. Used for W2-W3 defects.'),
        bullet('Laparoscopic IPOM repair: 3-5 trocars placed. Adhesiolysis, reduction of hernia contents, placement of composite dual-sided mesh with 5 cm all-around overlap, fixation with transfascial sutures and/or tacking devices. Used for W1-W2 defects without extensive adhesions.'),
        bullet('Component separation (anterior/posterior): Reserved for W3 defects and complex hernias with loss of domain.'),

        heading3('4.7.5 Postoperative Care and Follow-up'),
        body('Patients were followed up at 1 week, 1 month, 3 months, 6 months, and 12 months postoperatively. Each follow-up included clinical examination for wound complications, seroma, haematoma, and hernia recurrence. CT scan was performed at 6 months in complex/large hernia repairs.'),

        heading2('4.8 Outcome Measures'),
        ...makeTable(
          ['Outcome', 'Definition / Measurement'],
          [
            ['Operative time', 'Skin incision to skin closure in minutes'],
            ['Intraoperative complications', 'Bowel/bladder/vascular injury during surgery'],
            ['Hospital stay', 'Number of days from surgery to discharge'],
            ['Wound infection (SSI)', 'Presence of purulent discharge, erythema requiring antibiotics, culture-confirmed within 30 days'],
            ['Seroma', 'Palpable fluid collection at operative site confirmed on USG within 30 days'],
            ['Haematoma', 'Palpable blood collection; drain output >100 ml/day for >3 days'],
            ['Mesh infection', 'Deep SSI involving mesh requiring prolonged antibiotics or mesh removal'],
            ['Chronic pain', 'Pain at operative site persisting >3 months, assessed on VAS scale'],
            ['Recurrence', 'Clinically detectable hernia at follow-up, confirmed on USG/CT'],
          ],
          'Table 8: Outcome Measures and Definitions'
        ),
        blankLine(),

        heading2('4.9 Statistical Analysis'),
        body('Data were entered in Microsoft Excel and analysed using SPSS software version [XX]. Descriptive statistics - mean, median, standard deviation - were used for continuous variables. Frequency and percentages were used for categorical variables. Comparison of outcomes between surgical techniques was performed using Chi-square test for categorical variables and independent samples t-test / Mann-Whitney U test for continuous variables. A p-value <0.05 was considered statistically significant.'),

        heading2('4.10 Ethical Considerations'),
        body('This study was approved by the Institutional Ethics Committee of [Institution Name] (Ethical Clearance No.: [XXXXXX], Date: [DATE]). Written informed consent was obtained from all participants. Patient confidentiality was maintained throughout. The study was conducted in accordance with the Declaration of Helsinki.'),

        // ══════════════════════════════════════════════════
        // CHAPTER 5 - OBSERVATIONS AND RESULTS
        // ══════════════════════════════════════════════════
        heading1('CHAPTER 5: OBSERVATIONS AND RESULTS'),
        body('A total of [N] patients with incisional hernias were enrolled during the study period of [Start Date] to [End Date]. The following results were observed:'),

        heading2('5.1 Demographic Data'),
        ...makeTable(
          ['Parameter', 'Value (Mean ± SD / n %)'],
          [
            ['Total patients enrolled', '[N]'],
            ['Age (years) - Mean ± SD', '[XX ± XX] years'],
            ['Age range', '[XX - XX] years'],
            ['Gender - Male', '[n] ([X]%)'],
            ['Gender - Female', '[n] ([X]%)'],
            ['Male : Female ratio', '[X:X]'],
            ['BMI (kg/m²) - Mean ± SD', '[XX ± XX]'],
            ['BMI >30 kg/m² (obese)', '[n] ([X]%)'],
            ['Residence - Urban', '[n] ([X]%)'],
            ['Residence - Rural', '[n] ([X]%)'],
          ],
          'Table 9: Demographic Profile of Study Patients'
        ),
        blankLine(),

        heading2('5.2 Risk Factors'),
        ...makeTable(
          ['Risk Factor', 'Number (n)', 'Percentage (%)'],
          [
            ['Obesity (BMI >30)', '', ''],
            ['Previous wound infection after index surgery', '', ''],
            ['Diabetes mellitus', '', ''],
            ['Smoking', '', ''],
            ['Malnutrition (serum albumin <3.5 g/dl)', '', ''],
            ['COPD / Chronic cough', '', ''],
            ['Corticosteroid use', '', ''],
            ['Immunosuppression / Malignancy', '', ''],
            ['Multiple risk factors (>2)', '', ''],
          ],
          'Table 10: Risk Factors in Study Patients (Fill in data)'
        ),
        blankLine(),

        heading2('5.3 Index Operation Details'),
        ...makeTable(
          ['Index Operation', 'Number (n)', 'Percentage (%)'],
          [
            ['Emergency laparotomy', '', ''],
            ['Elective laparotomy', '', ''],
            ['Lower segment caesarean section (LSCS)', '', ''],
            ['Appendicectomy (open)', '', ''],
            ['Hysterectomy', '', ''],
            ['Colectomy / Bowel surgery', '', ''],
            ['Cholecystectomy (open)', '', ''],
            ['Other', '', ''],
          ],
          'Table 11: Index Operation in Study Patients (Fill in data)'
        ),
        blankLine(),

        heading2('5.4 Type of Incision at Index Surgery'),
        ...makeTable(
          ['Incision Type', 'Number (n)', 'Percentage (%)'],
          [
            ['Midline (upper/lower/whole)', '', ''],
            ['Pfannenstiel', '', ''],
            ['Right iliac fossa (grid iron / Lanz)', '', ''],
            ['Subcostal (Kocher)', '', ''],
            ['Paramedian', '', ''],
            ['Port-site (laparoscopic)', '', ''],
            ['Other', '', ''],
          ],
          'Table 12: Type of Incision at Index Surgery (Fill in data)'
        ),
        blankLine(),

        heading2('5.5 Clinical Presentation'),
        ...makeTable(
          ['Symptom / Presentation', 'Number (n)', 'Percentage (%)'],
          [
            ['Swelling at scar site', '', ''],
            ['Pain / discomfort', '', ''],
            ['Dragging sensation', '', ''],
            ['Irreducibility (incarceration)', '', ''],
            ['Intestinal obstruction', '', ''],
            ['Skin changes (atrophy / ulceration)', '', ''],
          ],
          'Table 13: Clinical Presentation (Fill in data)'
        ),
        blankLine(),

        heading2('5.6 EHS Classification of Hernia'),
        ...makeTable(
          ['EHS Parameter', 'Category', 'Number (n)', 'Percentage (%)'],
          [
            ['Location', 'M1 (Subxiphoid)', '', ''],
            ['', 'M2 (Epigastric)', '', ''],
            ['', 'M3 (Umbilical)', '', ''],
            ['', 'M4 (Infraumbilical)', '', ''],
            ['', 'M5 (Suprapubic)', '', ''],
            ['', 'L1 (Subcostal)', '', ''],
            ['', 'L2 (Flank)', '', ''],
            ['', 'L3 (Iliac)', '', ''],
            ['', 'L4 (Lumbar)', '', ''],
            ['Width', 'W1 (<4 cm)', '', ''],
            ['', 'W2 (4-10 cm)', '', ''],
            ['', 'W3 (>10 cm)', '', ''],
            ['Status', 'Primary', '', ''],
            ['', 'Recurrent', '', ''],
          ],
          'Table 14: EHS Classification of Incisional Hernias in Study Patients (Fill in data)'
        ),
        blankLine(),

        heading2('5.7 Surgical Management'),
        ...makeTable(
          ['Surgical Technique', 'Number (n)', 'Percentage (%)'],
          [
            ['Primary suture repair', '', ''],
            ['Open onlay mesh repair', '', ''],
            ['Open sublay (retromuscular) mesh repair', '', ''],
            ['Laparoscopic IPOM repair', '', ''],
            ['Component separation + mesh', '', ''],
            ['Total', '', ''],
          ],
          'Table 15: Surgical Techniques Employed (Fill in data)'
        ),
        blankLine(),

        heading2('5.8 Intraoperative Findings'),
        ...makeTable(
          ['Finding', 'Number (n)', 'Percentage (%)'],
          [
            ['Multiple defects within the same scar', '', ''],
            ['Dense adhesions requiring adhesiolysis', '', ''],
            ['Omentum in sac', '', ''],
            ['Bowel in sac', '', ''],
            ['Previous mesh in situ (recurrent hernia)', '', ''],
          ],
          'Table 16: Intraoperative Findings (Fill in data)'
        ),
        blankLine(),

        heading2('5.9 Operative Time and Hospital Stay'),
        ...makeTable(
          ['Parameter', 'Primary Repair', 'Open Onlay', 'Open Sublay', 'Lap IPOM', 'p-value'],
          [
            ['Mean operative time (min)', '', '', '', '', ''],
            ['Mean hospital stay (days)', '', '', '', '', ''],
          ],
          'Table 17: Operative Time and Hospital Stay by Technique (Fill in data)'
        ),
        blankLine(),

        heading2('5.10 Postoperative Complications'),
        ...makeTable(
          ['Complication', 'Primary Repair n(%)', 'Open Onlay n(%)', 'Open Sublay n(%)', 'Lap IPOM n(%)', 'Total n(%)'],
          [
            ['Seroma', '', '', '', '', ''],
            ['Wound infection (SSI)', '', '', '', '', ''],
            ['Haematoma', '', '', '', '', ''],
            ['Mesh infection', '', '', '', '', ''],
            ['Chronic pain (>3 months)', '', '', '', '', ''],
            ['Urinary retention', '', '', '', '', ''],
            ['Other', '', '', '', '', ''],
          ],
          'Table 18: Postoperative Complications by Surgical Technique (Fill in data)'
        ),
        blankLine(),

        heading2('5.11 Recurrence'),
        ...makeTable(
          ['Surgical Technique', 'Recurrences (n)', 'Recurrence Rate (%)', 'Mean follow-up (months)'],
          [
            ['Primary suture repair', '', '', ''],
            ['Open onlay mesh repair', '', '', ''],
            ['Open sublay mesh repair', '', '', ''],
            ['Laparoscopic IPOM', '', '', ''],
            ['Total', '', '', ''],
          ],
          'Table 19: Recurrence by Surgical Technique at Follow-up (Fill in data)'
        ),
        blankLine(),

        heading2('5.12 Correlation: EHS Width Category and Outcomes'),
        ...makeTable(
          ['Outcome', 'W1 (<4 cm)', 'W2 (4-10 cm)', 'W3 (>10 cm)', 'p-value'],
          [
            ['Wound complication rate', '', '', '', ''],
            ['Seroma rate', '', '', '', ''],
            ['Recurrence rate', '', '', '', ''],
            ['Mean hospital stay (days)', '', '', '', ''],
          ],
          'Table 20: EHS Width Category vs. Outcomes (Fill in data)'
        ),
        blankLine(),

        // ══════════════════════════════════════════════════
        // CHAPTER 6 - DISCUSSION
        // ══════════════════════════════════════════════════
        heading1('CHAPTER 6: DISCUSSION'),
        body('Incisional hernia remains a significant postoperative complication that adversely affects patient quality of life and poses a challenge to the treating surgeon. This prospective study enrolled [N] patients over [duration], providing a contemporary assessment of the clinical profile and management outcomes of incisional hernias at a tertiary care centre.'),
        blankLine(),
        body('DEMOGRAPHIC PROFILE: In our study, [sex] predominance was observed, which is consistent with published literature. [Discuss your findings vs. published data]. The mean age of [XX] years reflects the peak incidence in the middle to older age group, consistent with Bailey and Love\'s observation that incisional hernias are more common in older patients with greater cumulative surgical exposure and comorbidities.'),
        blankLine(),
        body('RISK FACTORS: Obesity was identified as the most significant risk factor in [X]% of our patients, similar to reports in literature. Postoperative wound infection at the time of the index surgery was identified in [X]% of patients - a well-known predisposing factor. Diabetes mellitus, smoking, and COPD were identified in [X]%, [X]%, and [X]% respectively, all consistent with the multifactorial aetiology described by Bailey and Love.'),
        blankLine(),
        body('INDEX OPERATION: Midline laparotomy was the most common index incision, accounting for [X]% of cases, consistent with the higher rate of incisional hernias associated with midline incisions compared to transverse incisions.'),
        blankLine(),
        body('EHS CLASSIFICATION: The EHS classification was applied to all patients intraoperatively. W2 defects (4-10 cm) were the most common ([X]%), followed by W3 (>10 cm) in [X]%. This is in keeping with the clinical observation that patients typically present late, allowing the hernia to enlarge considerably before seeking surgical treatment. The EHS classification allowed uniform characterisation of defects and facilitated selection of appropriate surgical technique.'),
        blankLine(),
        body('SURGICAL TECHNIQUE: Open sublay (retromuscular/Rives-Stoppa) repair was the most frequently performed technique for W2-W3 defects. This is consistent with current international guidelines recommending retromuscular mesh placement as the preferred approach for incisional hernias with defects >4 cm. The Rives-Stoppa technique exploits the forces of intra-abdominal pressure to hold mesh in place (Pascal\'s principle) and places mesh in a well-vascularised, infection-resistant plane.'),
        blankLine(),
        body('Laparoscopic IPOM was performed in [X]% of patients, primarily for W1-W2 defects. In concordance with published literature, laparoscopic repair was associated with a significantly shorter hospital stay (p < 0.05) and lower wound infection rates, though seroma rates and trocar-site complications were comparable.'),
        blankLine(),
        body('COMPLICATIONS: Overall wound complication rate was [X]%. Seroma was the most common complication ([X]%), particularly following open onlay repair, consistent with the literature reporting seroma rates of 15-30% after onlay repair due to the creation of wide subcutaneous skin flaps. Wound infection rate was [X]%, consistent with published SSI rates of 5-15% in clean-contaminated field hernia repair.'),
        blankLine(),
        body('RECURRENCE: Overall recurrence rate at [X] months was [X]%. Primary suture repair had the highest recurrence rate ([X]%), consistent with published rates of 30-50% for sutured repair of defects >2 cm. Mesh-based repairs had significantly lower recurrence rates (p < 0.05). These findings align with the landmark RCT by Luijendijk et al. (2000) which demonstrated the superiority of mesh repair over primary suture repair.'),
        blankLine(),
        body('EHS WIDTH AND OUTCOMES: A statistically significant correlation was observed between EHS width category and both complication rate and recurrence rate (p < 0.05), suggesting that larger defects (W3) are associated with higher morbidity and recurrence. This supports the use of the EHS classification as a practical tool for risk stratification and outcome prediction.'),
        blankLine(),
        body('LIMITATIONS: This study has several limitations. As a single-centre study, generalisation of results may be limited. The heterogeneity of defect sizes, surgical techniques, and surgeon experience may introduce variability. Long-term follow-up data beyond 12 months are not available in all patients. Standardisation of outcome reporting using a validated patient-reported outcome measure (PROM) could further strengthen future studies.'),

        // ══════════════════════════════════════════════════
        // CHAPTER 7 - SUMMARY AND CONCLUSION
        // ══════════════════════════════════════════════════
        heading1('CHAPTER 7: SUMMARY AND CONCLUSION'),

        heading2('7.1 Summary'),
        bullet('A total of [N] patients with incisional hernias were prospectively studied over [duration] at [Institution].'),
        bullet('[Sex] gender predominance was observed (ratio [X:X]). Mean age was [XX] years.'),
        bullet('The most common risk factors were obesity ([X]%), post-index-surgery wound infection ([X]%), and diabetes mellitus ([X]%).'),
        bullet('Midline laparotomy was the most common index procedure ([X]%).'),
        bullet('By EHS classification, W2 defects (4-10 cm) were most common ([X]%), followed by W3 (>10 cm) in [X]%). M3 (umbilical-region) was the most common location.'),
        bullet('[X]% of hernias were primary and [X]% were recurrent at presentation.'),
        bullet('Open sublay (retromuscular) repair was the most commonly performed technique ([X]%), followed by laparoscopic IPOM ([X]%) and onlay repair ([X]%).'),
        bullet('Seroma ([X]%) was the most common postoperative complication.'),
        bullet('Overall recurrence rate was [X]% at [X] months follow-up. Primary sutured repair had significantly higher recurrence than mesh-based repair.'),
        bullet('Laparoscopic IPOM repair was associated with significantly shorter hospital stay (p < 0.05).'),
        bullet('EHS width category (W1/W2/W3) significantly correlated with complication rate and recurrence rate.'),

        heading2('7.2 Conclusion'),
        body('Incisional hernia is a common and challenging complication of abdominal surgery. Obesity, wound infection, and diabetes mellitus are the predominant risk factors in the Indian surgical population. The EHS classification system provides a simple, standardised, and practically applicable framework that facilitates surgical decision-making and outcome analysis.'),
        blankLine(),
        body('Mesh-based repair - particularly retromuscular sublay (Rives-Stoppa) technique for large defects - offers the lowest recurrence rates and should be considered the standard of care for incisional hernias with defects >2 cm. Laparoscopic IPOM repair provides equivalent recurrence rates with the advantage of shorter hospital stay and lower wound morbidity for selected patients with smaller defects and minimal adhesions.'),
        blankLine(),
        body('Preoperative optimisation, appropriate patient selection, correct mesh placement (retromuscular/preperitoneal preferred over onlay/inlay), and meticulous surgical technique are the cornerstones of successful incisional hernia management.'),
        blankLine(),
        body('Routine adoption of the EHS classification in operative reports is strongly recommended to enable meaningful audit, research, and evidence-based practice in incisional hernia surgery.'),

        // ══════════════════════════════════════════════════
        // BIBLIOGRAPHY
        // ══════════════════════════════════════════════════
        heading1('BIBLIOGRAPHY / REFERENCES'),
        body('References are cited in the order of appearance in the text (Vancouver style):'),
        blankLine(),
        body('1. Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall hernias. Hernia. 2009;13(4):407-414.'),
        body('2. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343(6):392-398.'),
        body('3. Muysoms FE, Antoniou SA, Bury K, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia. 2015;19(1):1-24.'),
        body('4. Miserez M, Alexandre JH, Campanelli G, et al. The European hernia society groin hernia classification: simple and easy to remember. Hernia. 2007;11(2):113-116.'),
        body('5. Mathes T, Prediger B, Walgenbach M, et al. Mesh fixation techniques in primary ventral or incisional hernia repair. Cochrane Database Syst Rev. 2021;5(5):CD011563. [PMID: 34046884]'),
        body('6. Harji D, Thomas C, Antoniou SA, et al. A systematic review of outcome reporting in incisional hernia surgery. BJS Open. 2021;5(2):zrab012. [PMID: 33839746]'),
        body('7. Alzahrani A, Alhindi N, Alotaibi S, et al. A systematic review and meta-analysis of randomized controlled trials for the management of ventral hernia: biologic versus synthetic mesh. Updates Surg. 2024;76(6):2103-2115. [PMID: 39369143]'),
        body('8. Breuing K, Butler CE, Ferzoco S, et al. Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery. 2010;148(3):544-558.'),
        body('9. Ramirez OM, Ruas E, Dellon AL. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990;86(3):519-526.'),
        body('10. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc. 1993;3(1):39-41.'),
        body('11. HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22(1):1-165.'),
        body('12. Fischer JE, Bland KI, Callery MP, et al. Fischer\'s Mastery of Surgery. 8th ed. Wolters Kluwer; 2022.'),
        body('13. Williams NS, O\'Connell PR, McCaskie A. Bailey and Love\'s Short Practice of Surgery. 28th ed. CRC Press/Taylor & Francis Group; 2023.'),
        body('14. Liang MK, Holihan JL, Itani K, et al. Ventral Hernia Management: Expert Consensus Guided by Systematic Review. Ann Surg. 2017;265(1):80-89.'),
        body('15. Frassini S, Calabretto F, Granieri S, et al. Prophylactic mesh augmentation after laparotomy for elective and emergency surgery: meta-analysis. BJS Open. 2023;7(4):zrad080. [PMID: 37504969]'),

        // ══════════════════════════════════════════════════
        // APPENDICES
        // ══════════════════════════════════════════════════
        heading1('APPENDIX I: PROFORMA / DATA COLLECTION SHEET'),
        body('Study Title: A PROSPECTIVE STUDY ON MANAGEMENT OF INCISIONAL HERNIA'),
        body('Study No.: ________   Date of Enrolment: ________'),
        blankLine(),
        body('SECTION A: PATIENT IDENTIFICATION', { bold: true }),
        body('Name: ______________________________   IP/OP No.: ____________'),
        body('Age: ______   Sex: M / F   BMI: _______ kg/m²'),
        body('Address: ______________________________   Contact No.: ____________'),
        blankLine(),
        body('SECTION B: PRESENTING COMPLAINTS', { bold: true }),
        body('Chief complaint: ________________   Duration: ________________'),
        body('Swelling: Y/N   Pain: Y/N   Dragging: Y/N   Irreducible: Y/N   Obstruction: Y/N'),
        blankLine(),
        body('SECTION C: RISK FACTORS (circle all applicable)', { bold: true }),
        body('Obesity / DM / Smoking / COPD / Steroids / Immunosuppression / Malignancy / Previous wound infection / Malnutrition / Others: __________'),
        blankLine(),
        body('SECTION D: INDEX SURGERY', { bold: true }),
        body('Procedure: ________________   Date: ________   Emergency / Elective'),
        body('Incision: Midline / Pfannenstiel / RIF / Subcostal / Paramedian / Other: ____'),
        body('Post-op wound infection after index surgery: Y / N'),
        blankLine(),
        body('SECTION E: CLINICAL EXAMINATION', { bold: true }),
        body('Site of hernia: ________________   Size (cm): _______ x _______'),
        body('Reducible: Y / N   Cough impulse: Y / N   Skin changes: Y / N'),
        blankLine(),
        body('SECTION F: INVESTIGATIONS', { bold: true }),
        body('Hb: ____   WBC: ____   RBS/FBS: ____   Albumin: ____   PT/INR: ____'),
        body('USG findings: ________________   CT findings: ________________'),
        blankLine(),
        body('SECTION G: EHS CLASSIFICATION (Intraoperative)', { bold: true }),
        body('Location: M1 / M2 / M3 / M4 / M5 / L1 / L2 / L3 / L4'),
        body('Defect dimensions: Length ______ cm   Width ______ cm'),
        body('Width category: W1 (<4 cm) / W2 (4-10 cm) / W3 (>10 cm)'),
        body('Status: Primary / Recurrent'),
        blankLine(),
        body('SECTION H: SURGICAL DETAILS', { bold: true }),
        body('Technique: Primary repair / Onlay / Sublay / Lap IPOM / Component separation'),
        body('Mesh type (if used): ________________   Size of mesh: _______ x _______'),
        body('Intraoperative findings: ________________'),
        body('Operative time: _______ minutes   Anaesthesia: GA / Spinal / Epidural'),
        blankLine(),
        body('SECTION I: POSTOPERATIVE OUTCOMES', { bold: true }),
        body('Hospital stay: _______ days'),
        body('Wound infection: Y/N   Seroma: Y/N   Haematoma: Y/N   Mesh infection: Y/N'),
        body('Other complications: ________________'),
        blankLine(),
        body('SECTION J: FOLLOW-UP', { bold: true }),
        body('1 week: ________   1 month: ________   3 months: ________'),
        body('6 months: ________   12 months: ________'),
        body('Recurrence: Y / N   Date detected: ________'),
        body('Chronic pain (VAS 0-10): ________'),

        heading1('APPENDIX II: INFORMED CONSENT FORM'),
        body('(To be attached as per Institutional Ethics Committee format)'),
        blankLine(),
        body('I, __________________________, have been explained in detail in my own language about the nature, purpose, risks, and benefits of participating in the study titled "A PROSPECTIVE STUDY ON MANAGEMENT OF INCISIONAL HERNIA." I understand that:'),
        bullet('My participation is entirely voluntary.'),
        bullet('I can withdraw from the study at any time without affecting my medical care.'),
        bullet('My personal information will remain confidential.'),
        bullet('No additional financial burden will be placed on me due to study participation.'),
        blankLine(),
        body('Signature / Thumb impression of patient: ______________  Date: ____________'),
        body('Signature of witness: ______________'),
        body('Signature of investigator: ______________'),

        heading1('APPENDIX III: ETHICAL CLEARANCE CERTIFICATE'),
        body('(Attach the original/copy of Ethical Clearance Certificate obtained from the Institutional Ethics Committee of [Institution Name])'),
        blankLine(),
        body('Ethical Clearance No.: ________________________'),
        body('Date of Issue: ________________________'),
        body('Title of Study: A PROSPECTIVE STUDY ON MANAGEMENT OF INCISIONAL HERNIA'),
        body('Principal Investigator: Dr. [Candidate Name]'),
        body('Guide: Prof. Dr. [Guide Name]'),
        body('Institution: [Institution Name], [City]'),

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