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establishing specific weight loss goals, and follow-up appointments with healthcare providers prior to
scheduling surgery. Smoking cessation is mandatory and confirmed with nicotine tests on follow-up clinic
visits and prior to surgery. Glycemic control defined as a hemoglobin A1c less than 7.2% is used on the basis
of internal validation for risk calculations as well as international consensus [47-51] . All these interventions are
achieved through a healthcare network in conjunction with a multidisciplinary team involving the primary
care provider, dietician, bariatricians, bariatric surgeons, and other healthcare providers. Ultimately, these
efforts are geared towards preventing wound complications postoperatively, since obesity, active smoking,
and diabetes are all independent predictors for increasing wound complications and recurrence in AWR
patients [39,47-54] . In addition, patients also undergo preoperative screening to make sure all preoperative work
up is completed from a cardiopulmonary and anesthesia standpoint.

Patients who have had multiple hernia surgeries also undergo preoperative CT scans to assess hernia
defect size and better understand surgical anatomy. Often, prior meshes, as well as other abnormalities that
may impact the surgery are seen on CT and can be used for perioperative planning. In patients who have
large defect sizes and loss of domain that may make fascial closure difficult, they can be considered for
preoperative botulinum toxin injection and be counseled concerning the need for components separation.
Preoperative planning for success is perhaps the most important component to providing a successful
surgery. Appropriate patient selection, risk factor modification, and sound surgical planning prior to a
procedure is crucial to a successful index operation or durable recurrent hernia repair.

Institutional participation
Building a hernia COE requires many resources and buy in from all participants, most importantly from
the parent institution. Understanding the value of having a hernia COE and the additional value it brings to
an institution will allow the parent institution to participate, promote and use available resources to bring
[55]
recognition to the AWR center .
Creating visibility
Marketing and creating a presence through advertising by various means will help facilitate referrals
and increase patient volume. Additional promotion should include a dedicated website and social
media presence, featured articles in local media, press releases, distribution of brochures, peer-reviewed
publications, national conference presentation and recognition, and education of other healthcare providers
within the system to increase the referral base.

Dedicated ancillary support
Other keys to making a successful COE is having dedicated personnel specific to the program who can
espouse the key principles of the hernia center and who understand how to support the program and help
it grow. These are a team of advanced care practitioners (nurse practitioners and physician assistants) who
are trained to specifically take care of hernia patients, surgical schedulers with knowledge of operative
needs, insurance and billing specialists to help obtain coverage and payment for specific interventions that
are hernia specific. In an academic center, having designated research personnel and statisticians, as well as
staff assistants and coordinators are also important and can significantly improve care by simply associating
behavior and outcomes in the center.

Coordination of care
Having a nationally renowned AWR center with a wide referral base also means attracting patients from
a larger catchment area with patients traveling from out of state for consultation, perioperative care, and
surgery. Being able to coordinate alignment of clinic times for multiple consultants, operative scheduling
and travel plans, and allowing for smooth integration of care in a new healthcare system by obtaining prior
medical records and imaging are all tasks that will need to be completed for successful and streamlined
care.