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Page 6 of 10 Shao et al. Plast Aesthet Res 2020;7:21 I http://dx.doi.org/10.20517/2347-9264.2020.04

Interdisciplinary collaboration
Building a network of specialists
Surgery alone is not enough for success in complex AWR patients who often will require a multi-faceted
approach to ensure they are prepared, optimized, and ultimately ready to undergo surgery. As previously
discussed, having a support network of ancillary staff and physicians with aligned goals in a coordinated
effort is essential. Building a network of physicians who intimately understand the unique challenges that
AWR patients face and how to intervene in these problems will be beneficial.

Potential areas of collaboration
Much of specialist collaboration is planned prior to the operation by recognizing areas of improvement.
Preoperative consultation of bariatricians, dieticians, primary care doctors, and endocrinologists to
help with management of comorbidities including weight loss, glycemic control, and smoking cessation
is important. There should be consideration of a prior history of thromboembolism and the use of
anticoagulation medications. This would would lead to decisions concerning which patients would
benefit from an inferior vena cava filter and the management of anticoagulated medications to limit the
risk of adverse events including stroke, pulmonary embolism, while attempting to mitigate the chance of
postoperative bleeding or hematoma. Consulting with radiology regarding CT scan findings can be helpful
[56]
to decide which patients with larger hernia defects would benefit from preoperative Botox injection .
Radiologists can also participate greatly in drain placement, injection of steroids or other drugs in specific
areas, and diagnosis and management of pain in patients. Patients might also benefit from a consult with
plastic surgery regarding advancement flaps or perhaps the need for concomitant panniculectomy during
the hernia repair itself. Some patients may also need simultaneous intraabdominal procedure such as
enterocutaneous fistula takedown, biliary surgery, colon resection, ostomy revision or reversal, etc., and
having the appropriate consulting surgeons available is necessary. Other patients who have had prior hernia
repairs with complications of prior or existing infection or have extensive antibiotic allergies may also
benefit from an infectious disease consult.

Intraoperatively, having an anesthesia team focused on multimodal pain management is extremely helpful
to limit postoperative narcotic requirement, improve postoperative mobility, and ultimately reduce the
length of hospital stay [57-59] . Setting forth an intraoperative protocol for pain management including the use
of a lidocaine drip, dexmedetomidine, and liposomal bupivicaine by performing transversus abdominis
plane blocks will be helpful in terms of limiting overall narcotic use (ERAS). Postoperative use of patient-
controlled analgesia, early mobility, and introduction of scheduled Tylenol, gabapentin, and ibuprofen will
also be key to decreasing ileus, decreasing narcotic use, and decreasing hospital length of stay [57-59] .

Postoperative consultation with geriatricians to manage older patients with frailty, limited mobility,
declining mental status, and polypharmacy can significantly improve the postoperative recovery process
[60]
for that subset of patients . Managing inpatient and outpatient complications will also be important
as the need arises. Also necessary will be utilizing resources of interventional radiology to drain any
postoperative fluid collection, consultation with infectious disease physicians for treatment of surgical site
occurrences, the need for physical therapy and social work, and rarely the need for intensivist care or other
subspecialists.

The underlying vital concept is to generate harmony between care teams, and that predominantly relies
on leadership, adequate communication of ideas and responsibilities, and a healthy relationship between
all members of the healthcare network. Indeed, identifying experts and leaders in each field will influence
the success of a patient’s ultimate outcome and success of the AWR center. Great teamwork with careful
coordination is indispensable in a well-run and organized complex AWR COE.