Hernia Center BTK

Thank you for joining us for another episode of Behind the Knife. We are pleased to be back for our second journal review episode and our fourth total episode focusing on hernia repair. I'm Sully Ayuso, graduating chief resident at Carolinas Medical Center. Once again, I am joined by professors Todd Henniford both of whom are abdominal wall and foregut surgeons here in Charlotte.

In addition, we have Dr. Monica Pultz, who is an attending surgeon at Baptist Health in Miami, Florida, and trained here with us. Today, we are also lucky enough to be joined for the 1st time by current advanced G. I. and M. I. S. fellow at Carolinas. Dr. Brittany need. Dr. me will be graduating here in a couple of months and returning to Chicago, or she will be a hernia surgeon at rush and involved in developing a new hernia center there.

The topic for the episode today is just that, hernia centers, what are they and why do they matter in a field that is relative emphasy compared to other surgical subspecialties, the centralization of resources and the development of specialized centers is a new and evolving concept. Thus far,

the definition of a hernia center is somewhat subjective and has mostly been a label that is applied by a designated individual center, or at least domestically here in the United States, that's been the case.

Given this ambiguity, we believe that is very important to discuss this on another hernia edition of Behind the Knife. So, Brittany, I'm going to let you kind of kick things off for us here this morning. Awesome. Well, before we get started with reviewing our two articles, we first wanted to briefly touch on the meaning of hernia center to our individual team members and then discuss the formation of a hernia center here in Charlotte at Carolina's Medical Center.

So with that being said, I want to briefly ask each of you, what are, what thoughts come to mind when I mentioned the term hernia center? Dr. Henniford, let's start with you. Thanks, Brittany. And thanks, Sully, as always. And thanks, Behind the Knife. A hernia center, it's, the concept of a hernia center is not new, but I will say as well, it's not old.

The first group that I know of that

actually talked about a hernia center and when you focus care and when you really specialize Do something over and over again. The first time that was actually described that I've ever seen was the Lichtenstein clinic in the 1950s. And it was, the concept was brought up again in the, I guess, late 2000s, 2008, 9, 10, and then there was an article.

Mike Rosen was actually quoted in general surgery news saying it was time for a hernia center, but the response was not great and that surgeons actually said, you know, what are you going to do? Take hernias away from us? First and foremost, I wanna say that a hernia center and even a tertiary hernia center couldn't perform all the hernias if we wanted to.

So that's, let's just take that off the table. General surgeons have to be able to perform hernias, and the best operations are performed in people's communities. They're performed by good general surgeons at home. So patients don't have to travel.

And again, if you take all the hernias, quote unquote specialists in the country, we couldn't perform other hernias.

And quite honestly, I don't want to. So first and foremost, you don't have to have a hernia center to do hernias. When I say think of a hernia center, I do think of specialists and I have an S on that because if you're gonna do something special and you often, you can't cover the waterfront. Now we, when we started a hernia center, we had a plastic surgeon in two general surgeons in the very early two thousands, and we wanted to specialize in hernias to deliver specialty care.

And with that, we wanted to grow and growth would mean to improve the science of what we did, but very quickly we started working with. Our radiologist, our infectious disease doctors, physical therapist, sports medicine. We had a number of people that we had to bring in to supplement what we could do so we could cover the waterfront.

And the greatest thing that I am proud of what we have done in our program is one is we've trained the next generation of hernia leaders, and those people who've gone out and formed their own hernia centers as they see it. And again, as they see it, not as the way we saw it. But the next thing was our constant quality improvement.

Now, do you have to do constant quality improvement in science to have a hernia center? My answer to that is no, but I think it certainly is a breeding ground for improvement. Sometimes success can be an inhibitor of growth or change, or admitting that you can improve. I've always considered our hernia center as a place where growth really happens.

You get a group of people together who appreciate new ideas, and We can take criticism of our own and we enjoy asking hard questions and it's been about the pursuit of knowledge and not the pursuit of being right. And quite honestly, if you look at all the quality improvement projects that we've done, and that we've

published, what that meant was.

Is that I could have been a better surgeon and that's probably been the favorite part of my growth as a, as an operating person, somebody who lives their life in the operating room, but back to hernia centers, I think having a focus in, in, in hernia repair, can you form a hernia center? Yes, but you need to do things special.

If you don't do specialized things, then don't call yourself a specialist. And I don't, you know, achieving good outcomes. I don't think you have a lot of, with what we know now, you don't have a lot of choice, you have to be dedicated to doing the right things for your patients. The right operations for the right reasons, but don't call yourself a specialist and don't form a hernia center.

Thanks. Dr. Hannaford. Dr. Augustine. What? How about you? What comes to mind when you think of hernia center? Thanks, Brittany. So, good to talk to all of you guys. So basically, I've been very fortunate that I did my fellowship actually at

this great Carolinas Medical Center. Hernia center to Dr Hanford created years ago, so just entering into something that was already created made it just kind of seem like it was a given.

And I didn't really realize how much work it took to actually get there only when I left for a brief period of time and trying to figure out. You know, how to get certain things done that I realize how difficult it is. So, to me, you know, coming back and then having all of that again, it just, it really is tremendous amount of work that's been put together to, you know, get statisticians that sit in your office, data collectors you know, having, different various specialists at hand from radiologists to geriatricians. And I know we're going to talk a lot about these. But that's, you know, I think hernia center. We all understand what we're trying to do and you don't have to keep explaining to the consultants why you need their help and everybody specialize and they understand that you're basically trying to get the best outcomes.

So in brief,

that's basically what it means to me. How about you? Dr bolts? So I think similar to you both, you know, as Sully mentioned, there's no yet formal definition or designation for a hernia center. But I think that the most important thing to remember is that a true hernia center is not just a fancy website or a quick marketing gimmick to try to increase referrals.

It's really an alliance. of multiple specialties and resources, a constant review of outcomes and quality improvement, and really a promise to patients that they're getting the highest level of care. For many years, we've been treating other surgical problems like cancer and organ failure very collaboratively and very scientifically with formally designated cancer centers and transplant centers that are held to certain quality benchmarks.

And though hernias may not be as life threatening, they certainly can be very life altering, and even a simple hernia, if not thoughtfully managed, can become very complex and difficult to treat. And these more complex patients can certainly benefit from being treated at a specialty center that sees a

higher volume of these challenging cases, or have surgeons who have received dedicated training in this area, like subspecialty.

So, I guess when I think about what a hernia center is, I think about it in 4 phases. I think about it before the operation. What are you doing for the patient to get them best prepared to undergo a complex abdominal wall procedure? So that's things like prehabilitation and optimizing patients in ways that we're able to prior to taking them into the operating room.

And then during the case, you want a surgeon who has performed a high volume of cases. You want someone who feels comfortable with the anatomy and is beyond their learning curve for a particular procedure. And then afterwards, you want to patient to be taken care of by a team of nurses and. therapists and people from other disciplines who are used to taking care of those patients and that there are protocols in place at our institution.

We have specific ERAS protocols that are designed for best outcomes for these patients. And then fourth, Dr. Hennifer touched on this briefly, but I

definitely think that at least to me, research and education is a large part of what makes a hernia center, transmitting knowledge from one generation to the next.

Dr. Henniford, you started to touch on, you know, what a hernia center means to you, but could you tell us a little bit about the inception of the hernia center here in Charlotte? We started the hernia center going on about 25 years ago, and the real reason we began it, it began with myself, Kent Kirchner, the general surgeon, and Stan Getz, the plastic surgeon, one, because we had a real interest in this.

And most, I guess the most important thing is that we saw there was something missing, not only in our community, but also nationally, there was an area of specialty, an area of engagement for complex patients that just really didn't exist. And also, too, we saw a huge research opportunity. There were very few real science papers that were being published in hernia and the science was, I mean, it really was the scattergram of care.

It made me think about, like, the concept of lean that came

over from Toyota by our professor, and it's been misconstrued in the United States as a means for efficiency. And that's not what it's about. It's about constant quality improvement. That's what lean actually is. And that why Toyota really grew so quickly and made such great cars that lasted so long, quite honestly, but we saw that we could give ourselves a report card, honestly, track our patients.

And if we did, you know, we could really grow what we do and change how we did it, change the meshes that we use, change the placement that we did. And we absolutely did. We also saw there was a huge missing component of in training. And if we had great residents, and if you look at some of the people and fellows and some of the people that we've trained, I mean, like you're into this key micros and Christie Herald Gita, Purdue ego belly.

I mean, will Cobb, Alfie Carbonell. These guys would have done great no matter what they did in their whole life. But we had a training

opportunity, and these people latched on and saw the huge potential in developing hernia centers, hernia science, hernia specialization, and they have grown it much more than we ever did.

We also saw the opportunity for collaboration. As I mentioned earlier, in working with sports medicine, working with infectious disease, with radiology, we couldn't do this by ourselves. The veteran mentioned like geriatrics, geriatrics has changed our practice. And we saw that we didn't, we didn't, the patients who stayed the longest in the hospital or our older patients for every 5 years.

Over the age of 60, you increase length of stay. Those guys have, I mean, over the last 3 years working with them, they have changed their practice to made us such as so much better. And we also have established. ourselves with our primary care doctors and also our surgeons in the area and the region and also nationally that they can just call us and say, can you help us with this?

Can I send you this CT scan? And I'll tell you, there's, there

is, I love that. You know, I don't need to take care of all the patients. I don't want to take care of all those patients. But being able to become a specialist and develop this center we fall back and can help people in our community, you know, do better by this specialization.

And I love it that we have a once a month video conference where we discuss patients with ourselves. So you can it's like going to tumor board. You get 4 surgeons that talk about patients. We have, you know, radiology will be there. We have other specialists that show up. And we can talk about specific patients in a very organized manner.

And also it builds team building and it allows us to be able to talk to patients with an effective voice from the whole center, from a group of physicians. When you can see how excited I still am about this a quarter of a century later, this still drives me and I love the future considerations of hernia centers.

Yeah, thanks for that question, Sully. Thank you so much, Dr. Henniford. All great points. So, I think

theme in every episode that we've done to this point has been what surgical depend surgical outcomes are dependent on. And I think it's extremely important. If you're going to have a hernia center that you have people who know how to fix hernias and, you know, not just 1 way of fixing them, but you have the full toolbox that you're able to do lots of different ways.

As you guys know, hernias a lot of times, you never know what you're going to get until you're in there. So I think surgical technique is extremely important. If you're going to have a hernia center, you have to have not just 1, but several people. Probably. They're going to be very good at different techniques and then also while surgical technique is also important.

We you know, looking at patient outcomes, prehabilitation, preoperative care is also a central portion of practice at our hernia center. So every patient that comes into our office to get seen today in office, Todd and I have clinic every 1 of these patients is going to be comprehensively reviewed for Some comorbidities.

So what we look at is we know what things are going to

cause complications and problems. So we look at patients and then if they need to lose weight, we already have a pre printed worksheet. And we talk to our patients about how to go on a low carb diet and how to change what they're doing. Also, if they're pre diabetic, or if they've never actually even had their hemoglobin a 1c checked.

We also check that if a patient is a smoker, we also will talk to them and give them resources on how to. Smoking cessation preoperatively. And then we will test them preoperatively. We may test them preoperatively for urine coine levels and this will determine if we operate on them or not.

So it's unclear about the exact. Sustainability of these prehabilitation efforts post operatively, but we actually do have some really good news that hopefully our studies that we're going to show you guys in the near future is going to be very helpful that I think patients are really sticking to these prehabilitation efforts.

Even after many years after their hernia repair, so maybe just

getting ready for this hernia repair actually is changing their lives. As far as making sure that they keep their weight off and are just healthy individuals intraoperatively. We work with our staff, both nursing and anesthesia who are incredibly familiar with how complex our patient population is.

We also have a nursing liaison on the floor who helps coordinate care of our patients. So they know a lot about the drains, incisional backs and things like that. We also involve physical therapy. So then patients are taking care of postoperatively as far as their mobility right after surgery.

And then we also have, physicians like geriatricians who are also involved in seeing all the geriatrics patient. We operate on preoperatively and then also postoperatively wonderful. Thank you. Dr Augustine. That was perhaps a little bit of a long preamble prior to us jumping into the 2 articles.

But one that I think was necessary for setting the stage for all of our listeners to understand the information that we're going to present. So the first

article that we're gonna be discussing comes from the Hernia Journal. The title of the article is Characterizing Hernia Centers in the United States.

What Defines a Hernia Center? This article comes to us from the group of the University of Pennsylvania. Dr. Fisher is the principal investigator in this group. He's a plastic surgeon by trade, but focuses on abdominal wall reconstruction. The author's motivation to write this paper, as they state, is stemmed from the fact that, like we've already talked about, there's no universal definition for a hernia center.

or what factors are common to hernia centers. And so with over 600, 000 hernia repairs that are performed each year, this is obviously very important not only to individual patients, but to the health care system at large. However, currently there's no certification process or defined pathway to becoming a hernia center in the United States.

So the authors did a web based search for all institutions with an ACGME general surgery training program. This represented nearly 320 programs nationally. They then identified any institution that called

itself a hernias center, and they reviewed these centers and performed a further web based search in order to assess the characteristics of the program.

program. They evaluated research productivity, faculty demographics and composition, and the content of the center's website, and whether or not the programs had a mission statement on the website. So Monica, what did the authors find? Thanks, Sally. So out of the 320 programs, there were 36 self identified hernia centers.

They also classified non hernia centers as those that performed ventral hernia repairs, but did not specifically identify themselves as a hernia center. As Sally mentioned, the authors really did a deep dive on things like research productivity and funding, society participation, types of training programs, and more.

And they found that the majority of hernia centers, about 90%, were local. Located in urban areas and perhaps not unexpectedly hernia centers were more likely to be associated with a university type programs at 61 percent versus 34 percent for non hernia centers.

Only 5. 6 percent of hernia centers were affiliated with the abdominal core health quality collaborative, which is a multi center hernia specific outcomes data registry.

But 19 percent carried a Center of Excellence designation by the Surgical Review Corporation, which is an accreditation that can be obtained online, and it's associated with a fee and minimum case volume, but there's no specific research, training, or outcomes criteria, nor requirement for multidisciplinary care for this certification.

With regard to participation in research, 72 percent of hernia centers had active clinical trials compared to only 27 percent of non hernia centers, but most were industry sponsored. NIH funding was Very low in both groups at 2. 8%. When evaluating faculty characteristics at hernia centers, 39 percent had completed fellowship training, a number that we anticipate will increase over time.

Faculty at hernia centers had an average of 50 publications. Most faculty were general surgeons, but over 50 percent of centers also had

plastic surgeons on faculty. A review of the websites for these hernia centers revealed a mostly clinical focus. Almost all described the types of hernias treated and techniques with only 39 percent mentioning anything about research.

Many centers also included mission statements, which most frequently highlighted concepts like multidisciplinary care and individualized care plans. I think that this is a really interesting paper, because while it does reveal some common underlying themes of a hernia center, it also really does highlight the lack of uniformity as to what exactly defines a hernia center in the U.

S. Dr. Hennifer, you were actually one of the co authors on this paper. What about these results really surprised or stood out to you? Well, this really wasn't surprising, but I actually started looking back just recently. So this article was published a couple, three years ago, and that's just started looking back at some of this for a recent lecture that I gave instead of the number that you saw in this article.

Now, whether it's 36 hernia centers,

I've found over 60. Just recently, so the thing that's surprising is how hurting centers are now really taking off and indeed the qualification of becoming a hernia center. We really have known in the United States. I know that you're in a biscuit through the America's hernia society and a group that that was part of that's working with Yuri or working to put some parameters around this.

I think that the group in the world that's really led. This is in Germany, and they have an article that came out in 2014 about what qualifies as a hernia center in Germany, and they actually have qualifications. It's also done in Italy and some in some other countries, but it's not very stringent. And like, in the United States, we have nothing you can go to the surgical review corporation and you can pay 2800 and 25.

you have a minimum of 125 lifetime cases, no research criteria, no special training, no measure of outcomes and in 2 weeks, you can get kind of an urgent, You know, mastery master and hernia repair special

qualification from them, which really doesn't mean anything, but you can hang something on your wall.

I think we need some to meet on this. If there's going, if we're going to have qualifications for a hernia center, then there should be specific qualifications. And I look forward to what the American Hernia Society, Vedra, and also Yuri come up with. Great, so the second article that we're going to be reviewing provides us with scientific and focused recommendations for what may define a hernia center.

This is the article that Dr. Hennifer just referred to entitled Accreditation and Certification Requirements for Hernia Centers and Surgeons, the ACCESS Project. As he stated, the first author of this paper is Dr. Ferdinand Kockerling of Berlin, Germany. So, the European Hernia Society board selected 18 members to perform a working to form a working group and review key questions on the topics of hernia center.

At the time of publication, there were designation for hernia centers that already existed in 2 European countries. Those were Germany and Italy. Each of these countries recognizes different tiers of hernia centers from

least to most complex. The working group first formulated key questions on this topic, and then performed a literature review for each of these, and presented their recommendations as suggestions if they had weak level of evidence to support them, and true recommendations for those that had strong evidence to support them.

There was an in person meeting in Berlin prior to the finalization of these recommendations and the drafting of the paper. In total, there were 32 key questions that the group formulated. For the purposes of our discussion, we'll focus on the definition of hernia center that was developed as well as the strong recommendations and relevant points.

So, for the designation of hernia center, the group proposed a 6 part definition and a lot of these things we've talked about already today. A hernia center should be accredited by a national or international hernia society. B, in comparison to an average surgical department, a hernia center would perform a higher volume of cases in all types of hernia surgery.

C,

a hernia center is staffed by hernia surgeons who are beyond their learning curve in all types of hernia surgery and are responsible for education and training in their department. D, hernia patients at hernia centers are treated according to current guidelines and recommendations. E, it is necessary to document each case prospectively in a registry or quality assurance database.

And lastly, hernia centers should perform follow up comparison of their own results with benchmark data for continuous improvement of their treatment results and contribute to research and hernia related care. There were a handful of other strong recommendations that were made by this group. For instance, hernia centers should have high level of care available, like an ICU.

They should also have M& M conferences that focus on clinical shortcomings. Hernia centers should work towards developing clinical practice guidelines. And members of hernia centers should participate in national and international meetings in order to help advance hernia care across the world. In regards to becoming a hernia specialist, the group

suggests that a surgeon have certain surgical volume, master the learning curve for the gold standard operations, be proficient in open and minimally invasive techniques, and work towards fulfilling the other aforementioned requirements for a hernia center.

While the ACCESS group recognizes that the data behind some of their suggestions and recommendations could be based on stronger data, their study provides a blueprint for the development of hernia centers in countries across the world. So Dr. Augenstein, as a current board member of the American Hernia Society, what do you think we can take away from the recommendations and suggestions outlined in this paper and what steps is the AHS currently taking towards recognizing specialty centers in the U.

S. and North America? Thank you, Rebecca. Yeah, so, thanks, Brittany. I think all of these recommendations are really great. And I know that Todd has already mentioned. Dr. Novitsky has selected a group of people who are all America's hernia society members who are actually working. It's a group that has been working on a document, which tells us basically what a center of

excellence for hernia should be.

So I know that this document has been developed and it's waiting to be circulated to the board and then hopefully soon we're going to see What the recommendations are of the American Hernia Society, but I think it's going to be very inclusive of many of these topics in here that you already mentioned.

Dr. Henniford, with these discussion of the 2 papers that we've had, do you have any final thoughts about the future of hernia centers, both domestically and abroad that the listeners should take away? Well, I think those two papers actually cover it pretty well. One is the lack of uniformity in the United States.

Second would be how we were being led by Ferdinand Koechlin and the group from Germany and also the European Herring Society believe that If you break down what we're doing in hernia repair, first, have our techniques significantly improved, our understanding of anatomy our grading of our

outcomes, both surgical and outcomes as well as quality of life outcomes, the answer to that is all yes and outstandingly yes, we've really improved our ability to take care of patients.

Part of the, what's been driving to the attractiveness of the bowel reconstruction is the amount of science that's being produced. If you look at what we were producing 15, 17 years ago, last year, we wrote four times as many peer reviewed papers. The science is truly growing the application of new technology, and that's not just robotics, the growth of technology and the understanding of even how to close the abdominal wall, prevent hernias.

There's this huge growth in all of this, which makes it super attractive for young surgeons. If we have, they have great mentors, they have approachable heroes. They have science, they can actually become an expert, and then if you add even like board certification, and they're doing that now in Europe, the European Board of Surgery, you can become a

fellow in the European Board of Surgery in abdominal wall surgery.

They have a, essentially, a, its own specialty, and even Americans. Can actually take that exam, which is given every year at the European Hurting society and become a specialist through the European board. They allow people from outside of Europe to do it. You combine all of that. And our ability now, truly to give ourselves an honest report card.

And when I say that, if you look at the data that's now being published, we have increasing recurrence rates, increasing complication rates. And I don't think that's because we're the patients are worse necessarily. And I don't think we have worse surgeons. I believe what we're doing is we're allowing ourselves to give her a true report card so we can improve.

But the combination of that makes it our environment very ripe. For young people to step in and actually drive this forward and provide additional energy and eventually become true

specialist and develop printing centers. And I will just say, I believe that every major institution. Every big city in this country will have a center and we'll have specialization.

We just have to decide. Are there specific criteria to actually, or in a governing board and an approval board to say, yes, like you would do with cancer and you would do with trauma and things like that to call yourself a true hernia center and with the designation be a level 1, level 2, level 3 hernia center, like you might have with with trauma.

Is it going to happen? I absolutely believe it will happen because it's being driven by all the factors and the excitement that I just mentioned. Sully, thank you so much. Thank you guys so much for the conversation today. I'm going to transition to our quick hits for this discussion. So first, there is not a universal definition for a hernia center that currently exists.

Being a hernia center encompasses more than just technical skill and hernia surgery. Rather, it refers to a center that offers

multidisciplinary care, Focuses on research and training, quality improvement, and seeks to address the optimization of its patients. Most of the hernia centers that do exist in the U.

S. are self appointed, located in urban university settings, and have industry related sponsorship. The European Hernia Society Access Working Group has provided us recommendations for defining a hernia center that may help pave the way to create standards for defining hernia related care in the United States.

And lastly, at present, there is a significant room for improvement in defining hernia centers and the quality of hernia related care in this country. Just a reminder that the articles that have been discussed in this episode will be made available in the show notes, which can be accessed on the BTK app and the BTK website.

So for now, this is the BTK hernia team from Carolina's Medical Center reminding you to dominate the day.