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ventral hernia repair, it is estimated that as many as 12%-52% will have a hernia recurrence, which
ultimately leads to more surgery, reduced quality of life, prolonged recovery, a greater chance of future
failure, and increasing healthcare costs [8-12] . It is estimated that each failed hernia repair results in higher
morbidity, cost, and risk of recurrence for each subsequent repair [13-15] . All these factors combined make
a compelling argument for optimizing the index hernia repair for patients to decrease recurrence rates
and cost, ultimately improving patient outcomes. This leads to preoperative optimization of modifiable
patient comorbidities, increasing patient education, and streamlining operative and postoperative factors to
provide the best care.

BUILDING A CENTER OF EXCELLENCE
What does it mean to be a center of excellence?
The trend towards building “centers of excellence” is not a new concept in surgery. Within recent years,
driven by national policies considering outcome measures, there has been a drive towards improved
outcomes and decreased complications, length of hospital stay, and hospital readmissions [16,17] . This is backed
by data and evidence from across many surgical specialties, including oncologic, bariatric, orthopedic, and
cardiovascular surgery, in which better surgical outcomes are seen at established high-volume specialized
centers [18-28] . The trend of improved outcomes at high-volume specialty centers is especially noticeable for
complex procedures. While the current literature does not provide a full explanation for this association,
the improvement in outcomes is likely linked to an increased surgical skill set from high-volume repetition
(practice makes perfect model), selective-referral patterns, and accessibility to additional specialized
[27]
resources for more comprehensive perioperative care . The literature also demonstrates that associated
surgical fellowships also improve surgical outcomes [29-31] . This is most ardently demonstrated in bariatric
surgery, which has reinforced the development of a bariatric center of excellence (COE) [32,33] . The term COE
has been widely adopted by many fields of surgery, but what does it truly mean to be a COE? This article
will describe the foundations of a COE for complex abdominal wall reconstruction (AWR) and the key
components needed to build a multidisciplinary practice centered on improvement of patient outcomes
and development of new techniques for advancement of surgical practice.

Establishing a multidisciplinary AWR center
Establishing a tertiary referral and care center for AWR is a concept that has solidified in the past decade [17,34-36] .
Recognition of hernia surgery as a challenging endeavor fraught with unique challenges has led to the
development of several specialized AWR centers [34-36] . There is a paucity of literature available regarding
which healthcare systems would qualify as a COE. From the literature, we see how the German Hernia
Society has created a 3-tier accreditation system for hernia repair centers, stratifying centers based on
volume, outcome evaluation, academic involvement, hernia research, and participation in multicenter
[37]
databases . In addition to traditional measures of success, such as hernia recurrence and pure clinical
outcomes, there is a push to include patient quality of life, focus on research, and continual participation
[37]
[35]
in ongoing academics to bolster the current advancements in surgery . Williams et al. described the
establishment of a hernia referral center, which led to an increase in the complexity of the patients referred,
including a 48% increase in recurrent hernias, increasing patient comorbidities, and overall complexity.
[36]
Raigani et al. describe a similar trend of increasing complexity in 2014, in which patients traveling
over 100 miles were more likely to have active mesh infections and increased length of stay. Both studies
highlight that increasing hernia complexity combined with patient comorbidity and operative difficulty
should lead to increasing postoperative complications. However, in practice, complex patients treated at
tertiary referral centers do not have a proportional increase in adverse outcomes or complications due to
expertise provided at these centers [35,36] .

The European Hernia Society has also developed an expert consensus comprising 18 surgeons across
Europe to form the ACCESS Group (Hernia Accreditation and Certification of Centers and Surgeons -