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AWR allows for quality improvement as institutions can follow their own long-term outcomes for self-
evaluation, and eventual growth and improvement.

KEY COMPONENTS OF A SUCCESSFUL HERNIA CENTER
There are several key components that all successful tertiary care AWR COEs will require: surgeon
experience and expertise, support of parent institution, interdisciplinary collaboration, commitment to
current evidence-based practice and continual outcome assessment, and financial stability.

Surgical expertise
Operative technique and anatomical mastery
Education and specialization in AWR and hernia surgery with good operative technique is a foundational
building block of a successful hernia center. As with many other experts in their respective fields, practice
makes perfect and having the appropriate experience and training is important in AWR [27,28] . Surgeons
specializing in AWR may have training in general, minimally invasive, robotic, and plastic surgery, or a
combination of all these techniques in their armamentarium. Proper knowledge of the relevant anatomy
and of the appropriate surgical technique and tissue planes cannot be understated to perform the optimal
surgery, and the ability to innovate and create new techniques for hernia repair is also important. Once
mastery is achieved, continued education and involvement in academic research and conferences are also
important to sustain a level of high-quality care. Having surgical fellows and training programs also fosters
excellence within a center and improves outcomes [29-31] . Attending and hosting AWR courses can also be
utilized as a tool for maintaining expertise.

Perioperative management
In addition to the appropriate technical skills, surgeons must also possess the clinical acumen to provide
appropriate perioperative care for complex AWR patients. Being able to successfully navigate complex
patient records with multiple prior abdominal surgeries, complications, and hernia repairs is very helpful
in formulating the next clinical care steps. Routinely, outside hospital records and CT scans are obtained.
Once an assessment has been made, along with a thorough history and physical examination, identification
[39]
of the patient’s specific risk factors is made, and pre-habilitation as needed precedes surgery . Sometimes,
a patient may not be ready for surgery for several months after their initial consultation to optimize their
specific comorbidities.

Risk models commonly used include the Ventral Hernia Risk Score, the Ventral Hernia Working Group
Grade, Centers of Disease Control and Prevention Wound Class, and Hernia Wound Risk Assessment
tool. An application designed by our institution known as the Carolinas Equation for Determining
Associated Risks is commonly employed to calculate a patient’s postoperative cost and risk of wound
complications [41-45] . Utilization of this application has decreased cost and wound complications specific to
[46]
our center and has been recognized across the world as an accurate predictor of risk .
Specifically, the risk factors and comorbidities addressed by the assessments are geared towards prevention
of hernia recurrence, need for additional surgery, prevention of complications, and decreasing costs [39,45,46] .
To accomplish this goal, associated complications or comorbidities that contribute to recurrence such as
infection, obesity, tobacco use, and diabetes are factors that warrant careful attention. Having a comprehensive
approach to patient care and tailored patient counseling prior to surgery is an important keystone in the
patients’ postoperative course and outcomes. Optimization is not limited to informing patients about their
risk, it also includes patient-specific interventions and confirmation of success.

2
Strategies for optimization include weight loss for patients who are obese with BMI ≥ 30 kg/m by not only
providing patient education, but also dietary plans, multidisciplinary follow-up with bariatric dieticians,