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Shao et al. Plast Aesthet Res 2020;7:21 I http://dx.doi.org/10.20517/2347-9264.2020.04 Page 3 of 10
[38]
Working Group) to formulate scientifically based requirements for hernia centers and hernia specialists .
They propose that an adequately prepared hernia center will have the following components: accredited/
certified by a national or international hernia society, perform higher case volume hernia surgery compared
to average, experienced surgeons beyond their learning curve, evidence-based clinical treatment, document
outcomes in hernia registry or database, and perform follow-up comparisons of outcomes with benchmark
[38]
data for continual improvement . These recommended requirements have been put forth so that
healthcare systems can develop their own programs, while taking into account specific healthcare system
[38]
constraints .

At the authors’ own institution, a hernia center has been established since 2004, due to increasing
patient numbers, complexity of abdominal wall hernias, and outside referrals. Since that time, a growing
network of general surgeons, plastic surgeons, infectious disease specialists, allergists, radiologists,
orthopedic surgeons, geriatricians, and sports medicine, research, and support staff have been recruited
in a multidisciplinary fashion to coordinate complex care for patients. This coordinated problem-solving
approach has allowed the hospital system to increase annual case volume by 234%, annual billing by 713%,
[35]
in-state referrals by 340%, and out of state referrals by 540% . Using a model of concentrated, high-quality
patient-centered, patient-specific care in both the inpatient and outpatient setting has led to a streamlined
perioperative process that reduces preoperative modifiable comorbidities, increases patient education
and high-volume technical operations, combined with specific goal-oriented postoperative management
strategies, and ultimately smooth transitions of care. All these combined efforts have led to decreasing
[39]
recurrence rates and improved patient outcomes and quality of life . This comprehensive care has also
allowed for continued academic improvement and research, to analyze outcomes for further improvement.

Regardless of the approach, whether a government-driven model like the one in Germany or a surgeon-
driven model such as at the authors’ institution, they both emphasize similar core characteristics
encompassing high-quality, financially sustainable, multidisciplinary care, with the ability for continual
improvement through academic research and outcomes analysis. An AWR COE should be able to confer
the benefits of the institution to the patient in a standardized manner with reproducible and reliable
[40]
outcomes for complex hernia patients. Cherla et al. described a significant reduction in surgical site
infections in over 600 patients from 13.5 to 1.5% over a period of one year, despite increasing complexity of
cases, due to appropriate patient referral, improved preoperative management of patient comorbidities, and
internal consistency of treatment principles across all surgeons participating in AWR. The true hallmark
of a COE is the ability to mitigate increasing risk factors in complex patients and still provide successful
clinical outcomes with low hernia recurrence, infections, length of stay, and cost, while simultaneously
improving quality of life.

While no strict criteria exist indicating which patients should be referred to a AWR COE, some general
considerations that may warrant referral are: surgeon experience and comfort performing hernia
operations, patient complexity including presence of mesh infections or fistulas, loss of domain, need
for components separation technique, lack of hospital resources such as Botox and plastic surgery, and
multiple recurrent hernias with many prior operations. Ultimately, referral is dependent on a recognition
for a higher level of care due to increasing patient complexity and the ability of a COE to provide patient-
specific care with improved hernia outcomes and decreased recurrence rates [27,35,36,39,40] .

Having a COE is beneficial not only to patients but to parent institutions as well by increasing surgical
volume, complexity, and reputational benefits, which will draw additional resources and talent and expand
the infrastructure already implemented. Additionally, the treatment of a large volume of patients, as seen
at our institution, can be and has been the driving force for innovative research focusing on preoperative
optimization, operative techniques, and postoperative quality of life. Integration of academic research in