Hernia (2019) 23:185–203 https://doi.org/10.1007/s10029-018-1873-2 REVIEW Accreditation and certification requirements for hernia centers and surgeons: the ACCESS project F. Köckerling1 · A. J. Sheen2 · F. Berrevoet3 · G. Campanelli4 · D. Cuccurullo5 · R. Fortelny6 · H. Friis‑Andersen7 · J. F. Gillion8 · J. Gorjanc9 · D. Kopelman10 · M. Lopez‑Cano11 · S. Morales‑Conde12 · J. Österberg13 · W. Reinpold14 · R. K. J. Simmermacher15 · M. Smietanski16 · D. Weyhe17 · M. P. Simons18 Received: 13 August 2018 / Accepted: 11 December 2018 / Published online: 23 January 2019 © The Author(s) 2019 Abstract Introduction There is a need for hernia centers and specialist hernia surgeons because of the increasing complexity of hernia surgery procedures due to new techniques, more difficult cases and a tailored approach with an increasing public awareness demanding optimal treatment results. Therefore, the requirements for accredited/certified hernia centers and specialist her- nia surgeons should be formulated by the international and national hernia societies, while taking account of the respective health care systems. Methods The European Hernia Society (EHS) has appointed a working group composed of 18 hernia experts from all regions of Europe (ACCESS Group—Hernia Accreditation and Certification of Centers and Surgeons—Working Group) to formulate scientifically based requirements for hernia centers and specialist hernia surgeons while taking into consideration different health care systems. A consensus was reached on the key questions by means of a meeting, a telephone conference and the exchange of contributions. The requirements formulated below were deemed implementable by all participating hernia experts in their respective countries. Results The ACCESS Group suggests for an adequately equipped hernia center the following requirements: (a) to be accred- ited/certified by a national or international hernia society, (b) to perform a higher case volume in all types of hernia surgery compared to an average general surgery department in their country, (c) to be staffed by experienced hernia surgeons who are beyond the learning curve for all types of hernia surgery recommended in the guidelines and are responsible for educa- tion and training of hernia surgery in their department, (d) to treat hernia patients according to the current guidelines and scientific recommendations, (e) to document each case prospectively in a registry or quality assurance database (f) to perform follow-up for comparison of their own results with benchmark data for continuous improvement of their treatment results and ensuring contribution to research in hernia treatment. To become a specialist hernia surgeon, the ACCESS Group sug- gests a general surgeon to master the learning curve of all open and laparo-endoscopic hernia procedures recommended in the guidelines, perform a high caseload and additionally to implement and fulfill the other requirements for a hernia center. Conclusion Based on the above requirements formulated by the European Hernia Society for accredited/certified hernia centers and hernia specialist surgeons, the national and international hernia societies can now develop their own programs, while taking account of their specific health care systems. Keywords Hernia center · Specialist hernia surgeon · Guidelines · Certification requirements · Accreditation Introduction “Medicine is continuing to evolve and this is true more so than ever before with a notable direct relation to sev- eral possible major factors including substantial changes in the health care systems, progressive scientific advances, * F. Köckerling ferdinand.koeckerling@vivantes.de an accelerated pace of discovery in biomedical science, heightened public awareness and demands and consequently Extended author information available on the last page of the article 13 Vol.:(0123456789) 186 Hernia (2019) 23:185–203 expectations for transparency and accountability in health merit. Any subsequent data analysis of these respective care” [1]. “Considering this fundamental, dynamic and rapid centers and their results is compounded by the fact that no evolution, there could also be challenges to and changes in clear hernia centers are defined, but it is understood that the well-established structure of self-regulating functions arbitrary nomenclature is used such as “self-proclaimed” involving the medical profession” [1]. “Accrediting and hernia center with so-called hernia specialists. There is certifying organizations, such as surgical societies, can and therefore a need for accredited/certified hernia centers should play a major role in ensuring that society will con- where hernia surgery is practiced according to the guide- tinue to entrust self-governance to the medical profession lines set by specialist certified hernia surgeons. In addi- by directly promoting and supporting consistent excellence tion, these centers will be encouraged with specialization in the performance of physicians and health care organiza- to be coupled with a measurable mastery of hernia surgical tions” [1]. techniques as well as playing an active role in training The medical profession being charged with the remit of and continuing education in the field of science in hernia self-regulation may well create a relative disbalance with its surgery [5]. apparent, albeit responsible, governance presenting difficul- A credible accreditation/certification process for hernia ties for any laypersons who wish to scrutinize any such self- centers will involve definitions of requirements and their governed professional body. Good examples of such self- verification by hernia societies that are interested in assuring regulation include the governance seen in medical societies, the best possible quality of hernia surgery [5]. for example, in specialist breast and bariatric centers. The Examples of such accreditation are the introduction in European Society of Breast Cancer Specialists has continued 2014 of a three-stage accreditation/certification program for to produce updated and revised guidelines on the require- hernia centers in Germany conjointly by the German Hernia ments of a specialist breast center which are based on the Society and the German Society of General and Visceral advances and evidence-based changes in contemporaneous Surgery [5] and more recently in 2018 the Italian Society of clinical practice [2]. Hernia and Abdominal Wall Surgery which defines the char- As a consequence, there is now evidence of improved acteristics of accredited/certified hernia centers in Italy [21]. patient outcomes in bariatric surgery centers that have since In September 2017, the European Hernia Society (EHS) been accredited/certified according to the requirements of commissioned an expert group from across Europe to com- the German Society for General and Visceral Surgery [3]. pile evidence-based requirements for accredited/certified In a systematic review of the literature, there is clear evi- hernia centers. In the absence of any such evidence to date, dence which demonstrated that accreditation programs will the goal in this project was to seek an expert, transparent and improve clinical outcomes in a wide spectrum of clinical coherent consensus. conditions [4]. Each year some 20 million inguinal hernia operations are performed worldwide with 350,000 and 100,000 ventral her- nia operations in the US and Germany, respectively [5, 6]. Methods Hernia surgery has become increasingly more complex over the past 25 years because of the introduction of novel The EHS Board invited 18 hernia experts from across endoscopic, but also open, techniques and of the plethora Europe to convene in the ACCESS Group (Access Group— of medico-technical devices which are now available [5, 6]. Hernia Accreditation and Certification of Centers and Sur- Currently though, the lack of standardization for abdominal geons—Working Group). The group was entrusted with the wall hernia repair has led to the existence of a multitude of task of formulating evidence-based scientific requirements techniques and even more options are available for prosthetic for accredited/certified hernia centers and surgeons. Where mesh selection but with little high-level evidence to suggest evidence from systematic reviews and/or meta-analyses the type of technique and mesh to use [6]. existed, the Prisma Grading was used [22]. The ACCESS Despite this, numerous evidence-based guidelines pub- group based inclusion into the final script only on material lished by international hernia societies are endeavoring to that reached a firm expert consensus without in some cases keep abreast of these rapid developments [7–18]. the necessary evidence, as it was understood there will be However, analyses by hernia registries [19] demonstrate reliance on the very high expertise in the field of hernia that that the evidence-based guidelines compiled by the inter- was made available. Any recommendations were formulated national hernia societies are not always implemented [20]. as “suggestion” for weak and “recommendation” for strong Although hard evidence that specialist hernia centers evidence. perform better than surgeons and/or surgical teams in gen- Firstly; relevant key questions on this topic were for- eral practice is scarce, it seems obvious in a subjective mulated and collated through email exchange within the analysis in various settings that this mere fact holds some ACCESS Group. Then, the individual key questions were 13 Hernia (2019) 23:185–203 187 distributed for processing among the members of the Group. surgery is almost certain to continue” [24]. “Numerous fac- The findings of literature analyses were then presented at tors such as advances in surgical knowledge, techniques, and meetings held by the Group, debated and the answer to each technology, as well as patient and physician preferences, key question compiled in the form of a consensual recom- have driven an increasing numbers of surgeons to speciali- mendation. A meeting was held on January 12, 2018 in Ber- zation” [25]. lin followed by a telephone conference on June 26, 2018. “Hernia surgery has become increasingly more complex The manuscript was circulated multiple times for corrections over the past 25 years because of the introduction of novel and proposals within the group. endoscopic and robotic, but also open techniques and of the At the end of the meeting and the telephone confer- plethora of medico technical devices” [26]. ence, the answers to the key questions were collated for “The consideration of a herniorrhaphy among most gen- publication. eral surgeons has changed. The past thinking “it’s just a her- nia” is passé and has been replaced with the science-based consideration of patient-related factors, patient selection, Results anatomic application, fixation strength requirements, and healing considerations of biomaterials as well as truthful and true physical world-based postoperative activity restric- Arguments for and against hernia centers tions” [26]. “This realm of greater understanding of abdominal wall Key questions 1, 2 problems and their repair has improved patient outcomes and delivered this form of surgery to a true specialty” [26]. Do we need hernia centers and specialist hernia surgeons? “Differentiated use of the various techniques has been What are the pros and cons of accredited/certified hernia adapted as a “tailored approach” program and requires centers? intensive engagement with, and extensive experience of, What are the risks? the entire field of hernia surgery. Eighty-two percent of experienced hernia surgeons are employing the “tailored Statement approach” in hernia surgery” [27]. “The overall domain of There is a need for accredited/certified hernia hernia surgery has become more demanding” [5]. “A com- centers and specialist hernia surgeons because of parative study demonstrated that regardless of the surgical the increasing complexity (availabilities of new technique (open anterior mesh technique, plug technique, techniques, an increase in surgical devices and the open posterior mesh technique, endoscopic technique), the presence of more complex cases requiring tailored recurrence rate is significantly higher for general surgeons approach) of hernia treatment with an increasing who are not specialists in hernia surgery compared with her- public awareness and expectation in treatment nia specialists (p < 0.0001)” [28]. “Therefore, there is a need results. for hernia centers and hernia specialists” [29]. The ACCESS Group is, of course, aware of the fact that in the future, too, the vast majority of hernia operations will be Most patients worldwide presenting with hernias are man- performed by non-specialist general surgeons. It is precisely aged in general hospitals but because of a lack of definitions because the number of hernia operations is so great that the of specialist centers and/or surgeons, the exact percentages findings of the ACCESS project should motivate as many of those that are managed by “specialists” are almost impos- general surgeons as possible to focus intensively on hernia sible to obtain. For example, in the Netherlands, 645 out of surgery. That applies equally for primary care providers as 1500 surgeons performed inguinal hernia repair in 2016. well as for secondary/tertiary referral centers. Different lev- The treatment was offered in all 87 hospitals with a range els of accredited/certified hernia centers (see “Key question of 5–1200 repairs per year. 23/87 hospitals performed fewer 4” section) make it easier for all hospital levels to join the than 200 repairs per year [23]. In Germany, there are more Hernia Center Program. than 1200 hospitals with a department of general surgery, However, accreditation/certification as a hernia center of which 82 are accredited/certified hernia centers with 2–3 cannot, on the one hand, guarantee optimum treatment for accredited/certified hernia surgeons per center. each hernia patient and, on the other hand, excellent hernia “General surgery has become increasingly fragmented surgery can also be carried out without accreditation/certi- into subspecialties and diseases previously treated by gen- fication as a hernia center. Therefore, as far as the quality of eral surgeons are now managed by specialists” [24]. “The hernia surgery is concerned, accreditation/certification of etiology of this evolution to sub-specialization in surgery hernia centers should not have medico-legal implications. is multifunctional, and this paradigm shift toward specialty 13 188 Hernia (2019) 23:185–203 Definition of a hernia center The Accreditation/Certification Program of the German Hernia Society (DHG) and the German Society of General Key question 3 and Visceral Surgery [5] provides for three levels: What is the definition of an accredited/certified hernia • The German Hernia Society Seal of Participation in a center? hernia registry with presentation of one’s own results in What could a definition be? comparison with existing benchmark data. • The Competence Center which ensures compliance with Suggestions for definition of a general surgery structural and clinical requirements, case numbers as department accredited/certified as Hernia well as benchmark findings. Center • The Reference Center which, in addition to meeting the An adequately equipped hernia center is suggested: requirements of the Competence Center, undertakes tasks (a) to be accredited/certified by a national or in science, education and training for external surgeons. international hernia society This system has the advantage that those hospitals and (b) to perform a higher case volume in all types of surgeons who are particularly active in hernia surgery hernia surgery compared to an average general can gradually implement and expand the requirements surgery department in their country for a Reference Center. Requirements for the German (c) to be staffed by experienced hernia surgeons Hernia Society Seal of Participation in a hernia registry who are beyond the learning curve for all types of are kept relatively low, so the use of the barest not so high hernia surgery recommended in the guidelines and requirements has enabled relatively high motivation of are responsible for education and training of hernia surgeons to participate in the hernia registry. surgery in their department of general surgery (d) to treat hernia patients according to the current The Italian Society of Hernia and Abdominal Wall Sur- guidelines and scientific recommendations gery also propose three levels of accreditation/certification (e) to document each case prospectively in a [21]. registry or quality assurance database (f) to perform follow-up for comparison of their • First level certification is restricted to single surgeons. own results with benchmark data for continuous • Second level certifications are referral centers for abdom- improvement of their treatment results and ensuring inal wall surgery contribution to research in hernia treatment • Third level certifications are for highly specialized cent- ers for abdominal wall surgery [21]. The establishment of a hernia center in accordance with Definition of a hernia specialist the aforementioned requirements calls for, in addition to the choice and qualification of the responsible surgeons, appro- Key questions 5, 6 priate support from the hospital administration to meet all the structural, equipment and personnel requirements. Should the accreditation/certification process also be extended to specialist hernia surgeons particularly trained and experienced in hernia surgery? Key question 4 What are the criteria that an accredited/certified specialist hernia surgeon needs to fulfill? Do we need different levels of accredited/certified hernia centers? Suggestion A general surgeon can be trained to become a Statement specialist hernia surgeon by mastering the learning Different levels of accredited/certified hernia curve of all open and laparo-endoscopic hernia centers make it easier to join the Hernia Center procedures that are recommended in the guidelines Program and gradually upgrade to a high(er) level and should additionally implement and fulfill the hernia center. ACCESS suggests to offer other requirements for a hernia center and perform requirements which allow for a gradual a minimal yearly caseload. implementation 13 Hernia (2019) 23:185–203 189 Accredited/certified hernia centers can offer an optimal “The mission of the professional societies is primarily to environment for the education and training of hernia sur- provide education through information guided by evidence geons. If a surgeon works in a general surgery department and considered best practice. Their relative influence flows and wants to become a specialist hernia surgeon, he/she from their continuing, highly visible function and moreo- should intend to perform at least 100 hernia operations per ver compulsory membership: this influence is necessary to year, including assisting, and in addition assisting in several steer publications in peer-reviewed journals, professional complex hernia repairs. General surgeons will be encour- excellence, to raise public awareness and to make awards. aged to undertake further training as hernia specialists in Through their work, they help to define and set standards high-volume hernia institutions. In an accredited/certified for their professional fields and to promote high standards hernia center, a surgeon should have played a ‘key role’ in of quality” [30]. “Medical societies play an important role at least 300 hernia surgical procedures within a period of in improving leadership in medicine” [31]. 3 years and have met the other requirements to fulfill the There are numerous examples that surgical societies prerequisites for a specialist hernia surgeon. implemented accreditation/certification programs for sub- An example of caseload and volume can be found in specialties in surgery. the recommendations laid out for the attainment of a first The American College of Surgeons (ACS) and the Ameri- level certification of a specialist hernia surgeon by the Ital- can Society for Metabolic and Bariatric Surgery (ASMBS) ian Society of Hernia and Abdominal Wall Surgery: 120 combined their respective national bariatric surgery accredi- inguinal hernia repairs (60 by open approach, 60 laparo- tation programs into a single unified program to achieve one endoscopic, optional open preperitoneal) and 40 abdominal national accreditation standard for bariatric surgery cent- wall repairs (20 open, 20 laparoscopic) need to be performed ers: The Metabolic and Bariatric Surgery Accreditation and with an annual caseload of 50 inguinal hernia repairs (25 Quality Improvement Program [32]. open/25 laparo-endoscopic) and 50 incisional hernia repairs The National Accreditation Program for Rectal Cancer (25 open/25 laparoscopic) [21]. is a newly developed initiative formed in collaboration with The numbers are representative of findings in the current The OSTRICH Consortium (Optimizing the Surgical Treat- literature pertaining mainly to the learning curve seen for the ment of Rectal Cancer) and the Commission on Cancer, a different procedures [21]. It is recommended and understood quality program of the American College of Surgeons [33]. that to manage all eventualities in various clinical scenar- “The Key to maintaining the highest standards of multidisci- ios and perioperative complications, additional experience plinary care is accreditation of centers specializing in rectal remains advisable. cancer” [33]. Therefore, an accredited/certified specialist hernia sur- The National Accreditation Program for Breast Centers geon should intend to have experience of at least 300 her- represents a consortium of national, professional organiza- nia operations, including 100 ventral and incisional hernia tion (e.g., American College of Surgeons, American Can- repairs. cer Society, American Society of Clinical Oncology and others) dedicated to the improvement of the quality of care Institution for accreditation/certification of hernia and monitoring of outcomes of patients with diseases of the centers breast [34]. In 2014, the German Hernia Society (DHG) and the Ger- Key question 7 man Society for General and Visceral Surgery introduced an accreditation/certification program for hernia centers [5]. A Should the national and international hernia societies be basic requirement for a credible certification process for her- responsible for the accreditation/certification of hernia nia centers involves definition of the defined requirements centers? and its subsequent verification by hernia societies [5]. In addition, in 2018, the Italian Society of Hernia and Abdomi- Suggestion nal Wall Surgery created a commission to define principles Hernia center accreditation/certification is and structure of an accredited/certified hernia center [21]. suggested to be undertaken by national hernia Therefore, it is important that national and international societies guided by international hernia bodies or hernia societies should be responsible for the accreditation/ by international hernia organizations, especially in certification of hernia centers. cases where national hernia societies do not offer ACCESS (on behalf of the European Hernia Society) hernia center accreditation/certification. offers guidelines to develop and implement hernia centers and specialist hernia surgeons. National societies should be able to ensure that they take into consideration existing local factors. 13 190 Hernia (2019) 23:185–203 Auditing/re‑auditing of a hernia center indicating the name, title, and contact information of the new program director along with the effective date of the Key question 8 appointment and whether the appointment is on an interim basis or permanent. The program must include documen- What is the qualification of the auditors in the accreditation/ tation about the new program director’s qualifications and certification process of hernia centers? credentials which will be reviewed to ensure that the indi- vidual meets the requirements outlined in Standard 1.1 level Suggestion of Responsibility and Accountability. The notice also must An auditor for the accreditation/certification include the justification for the change [38]. process of hernia centers should be an expert hernia surgeon nominated by the respective national or Equipping a hernia center international hernia societies. Key question 11 The importance of using a “reviewing/auditing” proce- Which diagnostic tools need to be available in an accredited/ dure that ratifies the requirements of the center and that it certified hernia center? functions at the desired level depicting the adequate quality and standard is an unequivocal fact [35]. Suggestion An accredited/certified hernia center must have the Key question 9 possibility to access ultrasound, CT scan and [dynamic] MRI. How long is the time interval after accreditation/certification of a hernia center for re-accreditation/re-certification? Inguinal hernia Suggestion An accredited/certified hernia center is suggested to Using current best evidence in clinical decision making is be re-accredited/re-certified every 3–5 years. always considered the gold standard. One way of present- ing evidence to clinicians is through systematic reviews In the Quality Programs of the American College of Sur- with summaries highlighting the highest impact on current geons (Breast Center, Bariatric Surgery Center), the accred- evidence available. A key strategy to integrate the infor- ited/certified centers must completing a site visit every 3 mation of systematic reviews is through the development years for re-accreditation/re-certification [36, 37]. of clinical practice guidelines [7–18]. Recently, the Inter- national Guidelines for Groin Hernia Management have been published by the HerniaSurge Group [12] and in these Key question 10 guidelines four key questions (KQ) are put forward question- ing the diagnostic modalities used for an inguinal hernia What happens with the accreditation/certification of a hernia (Chap. 3). center, if a personnel or structural change occurs? The first KQ was which diagnostic modality is the most suitable for diagnosing groin hernias? The answer and rec- Suggestion ommendation is that clinical examination (CE) alone is If a personnel or structural change in adequate for providing evidence of a groin hernia. The level accredited/certified hernia center occurs, the of evidence was low, however, a strong recommendation program is suggested to submit notification about upgraded by the group was undertaken largely due to the the changes to the responsible national or fact that the history and clinical examination are all that international hernia society, which monitors and are usually required to confirm the diagnosis of a clinically determines the requirement of a re-accreditation/re- evident groin hernia. certification. The second KQ was which diagnostic modality is the most suitable for diagnosing patients with obscure pain or a ‘doubtful’ swelling? CE and ultrasound (US) used in com- Quality program director changes must be notified to the bination is recommended for diagnosing patients with vague American College of Surgeons 2018 [38]. The program must groin swelling or a possible occult groin hernia(s). Dynamic submit notification to the American College of Surgeons magnetic resonance image (MRI) or computed tomography 13 Hernia (2019) 23:185–203 191 (CT) can be considered for further evaluation if US is nega- Key question 12 tive or non-diagnostic. The level of evidence was moderate and a strong recommendation upgraded by the group was Does an accredited/certified hernia center require an inten- undertaken. sive care unit? The third KQ was which diagnostic modality is the most suitable for diagnosing recurrent groin hernias? CE and US Recommendation combined is suggested as most suitable for confirming the An accredited/certified [high-level] hernia center diagnosis of a recurrent groin hernia. Dynamic MRI or CT should have available an intensive care unit setting can be considered for further evaluation if US is negative or if required. non-diagnostic. The level of evidence was low and grade of recommendation was weak. The fourth KQ was which diagnostic modality is the Below are listed the relevant citations in the literature most suitable for investigating the cause of chronic pain which recommend the use of an intensive care unit in the after groin hernia surgery? Use of US-guided nerve blocks care of patients undergoing hernia surgery. is suggested as helpful for investigating the cause of chronic In a prospective randomized trial comparing laparoscopic pain after inguinal hernia surgery. US, CT or MRI scans are vs open incisional hernia repair, patients not amenable to also helpful in identifying non-neuropathic causes of chronic extubation were admitted to the intensive care unit for obser- groin pain (i.e., mesh-related pathologies, recurrent hernias vation and ventilator support [40]. and neuromas). The level of evidence was low and grade of In a study by Clarke [41] reporting about incisional hernia recommendation was weak. repair by fascial component separation, routine postoperative An accredited/certified hernia center must have available management entailed intensive care unit monitoring where a variety of diagnostic modalities (i.e., expert clinical exam, appropriate. US, CT and MRI) to cover the spectrum of investigations Farooque et al. [42] presented a series with preoperative required to diagnose a groin hernia. abdominal muscle elongation with botulinum toxin A for In the context of primary ventral and incisional hernias, complex incisional ventral hernia repair. Postoperatively, preoperative imaging provides essential information for patients required a period of ventilation in an intensive care decision making [13, 17, 39]. One of the preoperative deci- unit. sions that the surgeon needs to know is the feasibility of The Accreditation/Certification Program of the Italian repair in terms of size of the defect and anterior abdominal Society of Hernia and Abdominal Wall Surgery ask for wall, volume abdominal cavity/volume hernia, degree of availability of an intensive care unit in a high-level hernia central adiposity, grade of obesity and how effective weight center [21]. loss would be, morphemic analysis (e.g., osseous margin, It is recognized that the management of large incisional muscle contour), liquid collections, multiple defects, quality/ hernia patients requires an intensive care unit. quantity abdominal wall muscles and potential adherences. All these aspects should help the surgeon select which sur- Key question 13 gical approach will be required. Also, postoperative imag- ing provides essential information regarding any potential Should an accredited/certified hernia center offer special complications and possible recurrences [13, 17, 39]. In consultation hours for hernia patients? our learned opinion and in the context of primary ventral and incisional hernias, preoperative and postoperative (if needed) cross-sectional imaging (especially CT) play a criti- Suggestion cal role in assessing the likelihood of successful repair and An accredited/certified hernia center is suggested to by aiding in determining the optimal surgical approach. offer dedicated consultation hours for hernia In summary, an accredited/certified hernia center must patients. therefore have available a variety of diagnostic modalities such as US, CT and MRI to cover the whole spectrum of pre- “Effective communication between primary care physi- operative and postoperative assessments of all the types of cians and specialists regarding patient referrals and consul- hernias that can present. It is also advisable that an abdomi- tations is necessary for coordinated care, is important to nal wall surgeon work alongside a radiologist with special patients and physicians and improves patient outcomes and dedication to abdominal wall pathology. physician satisfaction” [43] “Interspeciality communication is increasingly important because medical subspecialization and technological advances fragment care across numerous 13 192 Hernia (2019) 23:185–203 physicians” [43]. “The need for better dialogue and engage- Key question 15 ment between doctors and patients was also stressed though, together with the potential for a more collaborative rela- Does a certified hernia center need to follow a special post- tionship” [44]. To fulfill the demands of the primary care operative pain treatment regimen? physicians and their hernia patients, regular pre- and postop- erative visits in special consultation hours with the special- Suggestions ized surgeon are of great importance and value. An example An accredited/certified hernia center is suggested to of this system is noted in the requirements for the German offer every patient an individualized optimal pain and Italian certification programs for hernia centers which treatment regimen on the basis of a recommended include weekly ‘dedicated’ consultation hours and outpatient postoperative pain algorithm. clinics [5, 21]. It is well-recognized that for an inguinal hernia repair, Key question 14 risk factors for chronic postoperative inguinal pain are pre- sent that include young age, female gender, high preopera- Are regular morbidity conferences necessary for an accred- tive pain, early increased postoperative pain, recurrent and ited/certified hernia center? an open hernia repair [11]. Overall, the incidence of clini- cally significant chronic pain is in the 10–12% range, which Recommendations decreases over time [11]. Debilitating chronic pain affecting Morbidity/mortality conferences appear to normal daily activities or work ranges from 0.5 to 6% [11]. significantly improve the quality of care, so they The intensity of perioperative pain has been suggested as should be held. A preoperative multidisciplinary a key risk factor [50]. Several other surgical, psychosocial assessment of complex cases is mandatory. and patient-related genetic and environmental risk factors have also been identified [50]. The use of multimodal analgesia (opioids, paracetamol, “Morbidity and mortality conferences have already been non-steroidal anti-inflammatory agents, gabapentinoids) is a representative example of both education and quality a recognized strategy and relied on the use of more than assurance within surgical departments” [45]. In a survey, one class of analgesic agent and this has been advocated as there was a general agreement that surgical morbidity and a means to improve analgesia through either their additive mortality conferences are of good educational value as well or synergic effects, while reducing the opioid-related side as being effective in reducing potential errors [45]. “The effects [50]. majority of respondents expressed that evidence-based Multimodal analgesia can be defined as a combination of literature should be the primary basis of discussion, with an opioid and a non-opioid analgesia [50]. Whenever pos- comprehensive presentations that focus primarily on the sible, multimodal pain management should be used [51]. analyses of the error” [45]. “The potential for learning from Dosing regimens should be administered to optimize effi- medical errors, complications and unanticipated outcomes is cacy while minimizing the risk of adverse events [51]. The immense” [46]. “One basic premise is that greater recogni- choice of medication, dose, route and duration of therapy tion of prior mistakes offers the opportunity, in the future, should ideally be individualized [51]. to consequently avoid them if possible” [47]. Notwithstanding the value of learning from postoperative Quality assurance in a hernia center morbidity and mortality meetings, the preoperative assess- ment of a patient as well as prehabilitation has been shown Key question 16 to have a great influence on the inevitably preferred posi- tive outcome for patients. “Pre-operative assessment should Should an accredited/certified hernia center follow the refer the patient, if necessary, for optimization of their health guidelines of the international hernia societies? before surgery, e.g. to a primary care and/or a secondary care specialist” [48]. “Preoperative assessment of large ventral hernia defects is the cornerstone of success” [49]. “It allows for identification of factors that may preclude certain opera- tive interventions and promotes presurgical steps to optimize a patient’s status before undergoing such a repair” [49]. 13 Hernia (2019) 23:185–203 193 instance, as an important tool to monitor and improve qual- ity of care or as a resource for research” [57]. Recommendations “Establishing a nationwide groin hernia database leads to In accredited/certified hernia centers treatment general improvement in outcomes and, due to the large num- protocols and algorithms should be as per the ber of patients on the dataset will allow analyses of specific published guidelines concerning hernia sub-groups or complications which otherwise could not be management. obtained with the added objectivity as from single centers” [58]. “One cannot deny that the sharing and comparing data with similar colleagues and a measurement of one’s per- “Advances in medical, biomedical and health services formance relative to the collective benchmark is likely to research have reduced the level of uncertainty in clinical improve the safety and quality of health care rendered” [59]. practice” [52]. “Clinical practice guidelines complement this “Registries can provide sound data needed by clinicians and progress by establishing standards of care backed by strong organization to improve patient safety and quality of care” scientific evidence” [52]. “Clinical practice guidelines are [60]. “Clinical registries do provide a clinically credible statements that include recommendations intended to opti- means of monitoring health care processes and outcomes” mize care” [52]. “These statements are based on a systematic [61]. Registries are in particular suitable for evaluation of review of evidence and an assessment of the benefits and actual standard surgical practice examining both the level of costs of alternative care options” [52]. “Clinical practice an individual institution or on a national basis [62]. “While guidelines do examine the current state of clinical guide- the seven hernia registries worldwide may differ in struc- lines and consequently used to improve, enhance health care ture, together they contribute to raising the quality of hernia quality and inevitably patient outcomes” [52]. “Guidelines surgery” [19]. are designed as documents that help doctors understand the “Many hospitals unfortunately do not collect reliable data best way to diagnose, treat and even prevent diseases and on their own adverse events, and you understandably can- conditions” [53]. “Clinical practice Guidelines can enhance not improve a hospital’s surgical quality if you are unable both clinician and patient decisions –by translating complex to measure it” [63]. scientific research findings into recommendations for clinical For improvement in hernia patients and participation in practice that are relevant to the individual patient encoun- research projects, it is recommended that accredited/certi- ter, instead of implementing a ‘one size fit all’ approach fied hernia centers should participate in a quality assurance to patient care” [52]. “Clinical practice guidelines are now program or a defined registry. With widespread growing rec- ubiquitous in our healthcare system” [52]. In the field of ognition that surgical outcomes vary by any one provider, hernia surgery, numerous guidelines have been already surgeons and hospitals are increasingly being asked to pro- published by respective responsible international hernia vide evidence of the quality of care that they deliver [64]. societies since 2009, which are also regularly validated and On all levels of the accreditation/certification program of updated [7–18, 54–56]. the German Hernia Society (DHG) and the German Society In conclusion, to improve the quality of treatment in her- of General and Visceral Surgery (DGAV), participation in nia patients and their outcomes, accredited/certified hernia a hernia registry is a fundamental requirement with regular centers should intentionally and conscientiously follow these audit and presentations of the outcome measures [5]. The peer-reviewed guidelines. Italian program of accreditation/certification hernia centers does not appear to contain an obligatory participation in Key question 17 a hernia registry, but relies more so on trials arising from international centers [21]. Is it a must for an accredited/certified hernia center to par- ticipate in a hernia quality assurance program or a defined registry? Clinical spectrum in a hernia center Recommendations Key question 18 An accredited/certified hernia center should participate in a quality assurance program or In which techniques for inguinal hernia repair should an preferably a registry. accredited/certified hernia center be proficient? “Medical registries can serve different purposes but most are to the advantage of both patients and clinicians—for 13 194 Hernia (2019) 23:185–203 retromuscular), open IPOM (intraperitoneal or underlay), inlay (bridged or spanning the defect) [16]. An expert panel Suggestion agreed on the basis of a systematic review that for open elec- For optimal treatment of the variety of different tive ventral and incisional hernia repair sublay mesh location cases of inguinal hernia repair using a tailored is preferred [16]. However, open IPOM with intraperitoneal approach, an accredited/certified hernia center is or underlay mesh positioning and also an onlay mesh posi- suggested to be proficient in the Lichtenstein open tioning may be useful in certain settings [16]. Bridged open anterior mesh technique, the laparo-endoscopic and inlay repairs should be avoided where possible, as these TEP or TAPP techniques, ideally both, and the are associated with a higher rate of complications and recur- Shouldice non-mesh technique. A tailored approach rence [16]. Considering all the various types of component to hernia patients is required. separation that are available with the endoscopic anterior and posterior approaches, using a mesh is recommended In the recently published new International Guidelines because of a lower recurrence rate and subsequent wound for groin hernia management of the HerniaSurge Group, a complications [16]. strong upgraded recommendation for a mesh-based repair of inguinal hernias is provided [12]. Key question 20 “Since a generally accepted technique which is suitable for all inguinal hernias does not exist, it is recommended that What is the spectrum of hernia types treated in an accred- surgeons/surgical services provide an option of both anterior ited/certified hernia center? and posterior approaches” [12]. For an open anterior approach, the use of other implants Statement (plug and patch, PHS, preperitoneal mesh) to replace the Ideally an accredited/certified [high-level] hernia standard flat mesh in the Lichtenstein technique is currently center should treat all types of hernias. Specialized not recommended [12]. In laparo-endoscopic posterior centers for inguinal hernia repair or complex inguinal hernia repair, as TAPP and TEP have comparable abdominal wall hernias do already exist. Such outcomes, it is recommended that the choice of the tech- centers should therefore treat all types of hernias in nique should be based primarily on the surgeon’s skills, their respective chosen specializations. education and experience [12]. The Shouldice technique is recommended as the best non-mesh inguinal hernia repair, Rosen [65] focused on a team approach for providing the especially in cases where the patient refuses a mesh and/or best care possible for patients with all types of hernias as his after shared decision making [12]. vision and strategic plan for the Digestive Disease Institute’s Hernia Center. “We see a wide spectrum of cases at our Hernia Center—from inguinal hernias that can be repaired Key question 19 laparoscopically on an outpatient basis, to incisional hernias with a 1–2 day length of stay, to ventral hernias that can be In which ventral and incisional hernia repair technique repaired with minimally invasive techniques if done right should an accredited/certified hernia center be proficient? the first time” [65]. “We also specialize in complex open and repeat surgeries—including complex abdominal wall Suggestion reconstruction—which are referred to us from all over the An accredited/certified hernia center is suggested to country and the world” [65]. be proficient in generally all accepted (evidence- The Hernia Institute of the University of Southern Cali- based) open (sublay, onlay, open IPOM, component fornia delivers a high-quality interdisciplinary specialty care separation) and laparoscopic (lap. IPOM) hernia for patients with abdominal hernias, ranging from the sim- repair techniques involving mesh. ple to the most complex defects [66]. In addition mirroring this effect, the comprehensive Hernia Center of the Univer- sity Hospitals Cleveland Medical Center, which is a team As laparoscopic ventral hernia repair has a lower rate of of highly skilled specialists provide today’s most advanced wound complications compared with open repair, numerous management of all types of hernias [67]. guidelines recommend that this technique is mainly reserved The comprehensive Hernia Center of Memorial Hospital for defects not larger or less than 10 cm [13–15, 17, 18]. of Rhode Island offers highly specialized care for people For open ventral and incisional hernia repairs, there with all types of hernias, including all the latest treatments are a number of options including sublay (retro-rectus, in hernia surgery, to ensure the best possible outcomes [68]. 13 Hernia (2019) 23:185–203 195 These above examples are both relevant and contempo- in-hospital mortality was 0.14% [71]. Using 10 cases per raneous depictions of high-volume centers providing hernia year as the volume threshold, low-volume hospitals had care to all comers in terms of location, size and distribution almost a twofold higher mortality compared to high-volume of the abdominal wall defect. hospitals (0.23 vs 0.12%, respectively, p = 0.02). The authors concluded that there was a small but significant inverse rela- tionship between the hospital’s case volume and mortality in Caseloads in a hernia center laparoscopic diaphragmatic hernia repair [71]. The volume required in the German program for accredi- Key question 21 tation/certification of a high-level hernia center by the DHG and DGAV is at least 250 hernia operations per year, of Should there be a minimum caseload per center per year? which at least 50 must be incisional hernia operations, five If so, what should be the total caseload in an accredited/ complex hernias (e.g., parastomal hernia, component sepa- certified hernia center? ration technique) and five hiatal hernias [5]. In the accredi- tation/certification program of the Italian Society of Her- Suggestion nia and Abdominal Wall Surgery for the third tier ‘High In an accredited/certified [high-level] hernia center, Specialization for Abdominal Wall Surgery’, the volume it is suggested to perform a significantly higher case requirements for inguinal hernia repair are 150 procedures volume in all types of hernia surgery compared to with 20 recurrent or scrotal hernias and 50 abdominal wall an average general surgery department in their repairs with 20 complex cases [21]. country. National societies should develop minimal caseload numbers that can be increased gradually if Key question 22 required. Should there be a minimum caseload per surgeon? What should be the caseload per surgeon in an accredited/ Surgeon volume is recognized as a net positive con- certified hernia center? tributing factor for procedures that have a short length of stay, predominantly day case operations such as inguinal Suggestion hernia surgery. But hospital factors, such as infrastructure In an accredited/certified hernia center it is and intensive care facilities become a more important prog- suggested that the experienced hernia surgeons nostic denominator in procedures that are more complex perform a minimum caseload per year according to and so require a more prolonged length of stay [69]. An the literature including education and training of observational study using data from 2009 to 2014 from inpa- hernia surgery in their department. National tient treatment in German hospitals depicted this volume societies are encouraged to offer minimal caseload outcome trend for inguinal and femoral hernia repair with a numbers. greater volume resulting in reduced mortality (n = 897,000) with odds ratios of in-hospital death according to volume quintile of 1.00 for median annual volume of 68 cases, 0.94 In a study from the Swedish Hernia Registry in 86,409 (0.77–1.4) for median annual volume of 120 cases, 0.90 patients over a 15 year period, the re-operation rate for recur- (0.72–1.11) for median annual volume of 160 cases, 0.83 rence was significantly higher for surgeons who carried out (0.66–1.04) for median annual volume of 208 and 0.66 1–5 repairs a year than for surgeons who carried out more (0.51–0.86) for median annual volume of 312 [70]. Mortal- repairs [72]. ity in the very high-volume quintile was in the trend lower In a retrospective review, a greater annual surgeon vol- (0.07%, 95% CI 0.06–0.08) than in the very low-volume ume (> 30 vs 15–30 vs < 15) for inguinal hernia repair in quintile (0.10%, 95 CI 0.09–0.12) [70].Based on complete totally extraperitoneal patch plasty technique was associated national hospital discharge data for 25 types of inpatient with improved outcomes as shown by the respective rates treatments, the results confirmed the trends described above for intra- (1% vs 2.6% vs 5.6%) and postoperative (13% vs in volume–outcome relationships for many complex surgical 27% vs 36%) complications, need for overnight stay (17% procedures, as well as for some emergency conditions and vs 23% vs 29%) and hernia recurrence (1% vs 4% vs 4.3%) low-risk procedures [70]. (all p < 0.05) [73]. A review of the National Inpatient Sample database An analysis of the Herniamed Registry with 16,290 between 2008 and 2012 analyzed a total of 31,228 lapa- patients highlighted that low-volume surgeons (< 25 cases/ roscopic diaphragmatic hernia operations [71]. Pediat- year) had a significantly higher recurrence rate compared ric, emergent, and open cases were excluded. The overall 13 196 Hernia (2019) 23:185–203 with high-volume surgeons (≥ 25 cases/year) following complications and < 2% rate for any complication-related laparo-endoscopic inguinal hernia repair [74]. reoperations [77]. An analysis of the Statewide Planning and Research The expected outcome according to the accreditation/ Cooperative System among 78,267 ventral hernia repairs certification program of the Italian Society of Hernia and and 124,416 inguinal hernia repairs demonstrated that the Abdominal Wall Surgery is a morbidity < 10% and an infec- majority of variation in hernia recurrence was attributable tion rate of < 3% following inguinal hernia repair [21]. to surgeon-level variation [75].This suggests that hernia recurrence may be an appropriate surgeon quality assurance metric [75]. Key question 24 In the first level certification of single surgeons in the certification program of the Italian Society of Hernia and What outcome should be attainable for a primary ventral Abdominal Wall Surgery, the volume requirements per year hernia repair in an accredited/certified hernia center? are defined as 50 inguinal hernia repairs (25 open, 25 laparo- endoscopic) and 50 incisional hernia repairs (25 open and Suggestion 25 laparoscopic) [21]. In an accredited/certified hernia center for primary ventral hernia repair the postoperative complication rate and follow-up outcome generated by a quality Results in a hernia center assurance program or registry data is suggested to be in accordance with benchmark data provided by Key question 23 national and international hernia societies. What inguinal hernia repair results should be achieved in an accredited/certified hernia center? The 30-day postoperative complications after elective umbilical and/or epigastric hernia repair presented in non- Suggestion nationwide and very heterogeneous studies are varied at In an accredited/certified hernia center for inguinal 3–23% [78]. The national risk in Denmark of 30-day read- hernia repair the postoperative complication rate mission following umbilical and epigastric hernia repair and follow-up outcome generated by a quality mainly due to the occurrence of a wound infection, hema- assurance program or registry data is suggested to toma, seroma, and pain is 5% with a complication-related re- be in accordance with benchmark data provided by operation rate of 0.3% [78]. In the Herniamed Registry, the national and international hernia societies. 30-day postoperative surgical complication rates in 16,206 umbilical hernias was found to be 3.2% and in 3,757 epi- gastric hernias 3.5% [79]. The corresponding complication- In a systematic review, the overall postoperative compli- related re-operation rates for umbilical and epigastric hernias cation rate in 39 studies with 571,445 inguinal hernia repairs were 1.0% and 1.2%, respectively [79]. were evaluated [76]. Overall, 16,482 (2.9%) perioperative complications were reported [76]. The most commonly reported complications are bleeding (0.9%), wound infec- Key question 25 tion (0.5%) and pulmonary and cardiovascular complica- tions (0.2%), with 22% needing some form of re-intervention What incisional hernia repair results should be achieved in (Clavien-Dindo grade > IIIa) [76]. an accredited/certified hernia center? A registry-based, propensity score-matched comparison of 57,906 patients showed for the Lichtenstein technique Suggestion a postoperative surgical complication rate of 3.4% with a In an accredited/certified hernia center for complication-related re-operation rate of 1.1%, for the TEP incisional hernia repair the postoperative technique of 1.7% and 0.8%, respectively, and for the TAPP complication rate and follow-up outcome generated technique 3.3% and 0.9%, respectively [77]. by a quality assurance program or registry data is In the accreditation/certification program of hernia cent- suggested to be in accordance with benchmark data ers by the German Hernia Society (DHG) and the Ger- provided by national and international hernia man Society of General and Visceral Surgery (DGAV), societies. the recommended perioperative outcome 30 days postop- eratively is < 5% rate for the total number of postoperative 13 Hernia (2019) 23:185–203 197 In a meta-analyses and systematic review of laparo- those in a standard practice residency program (34 ± 8 min scopic vs. open mesh repair for elective incisional hernia, vs 48 ± 14 min; p < 0.001) [83]. Intraoperative complica- the wound infection rates were 5.9% for laparoscopic and tions (peritoneal tear, procedure conversion), postoperative 8.5% for open [80]. complications (urinary retention, seroma) and the need for A registry-based, propensity score-matched comparison overnight stay were less likely in the simulation-based mas- of 9.907 patients with elective incisional hernia repairs the tery learning group adjusted odds ratio 0.14, [0.04–0] all surgical postoperative complication rate within 30 days was p < 0.05 [83]. In conclusion, a simulation-based mastery 3.4% for laparoscopic IPOM and 10.5% for open sublay [81]. learning curriculum decreased operative time, improved The complication-related re-operation rates were 1.5% for trainee performance and decreased intra- and postoperative laparoscopic IPOM and 4.7% for sublay repair [81]. complications as well as incidents needing overnight stay For the accreditation/certification program of hernia after laparoscopic TEP inguinal hernia repair [83]. centers by the German Hernia Society (DHG) and the Ger- According to the international guidelines for groin her- man Society for General and Visceral Surgery (DGAV), the nia management of the HerniaSurge Group, a goal-directed required outcome rates for incisional hernia repair are less curriculum including review of the anatomy, procedure than 10% wound infection rate for open and less than 3% for steps, intraoperative decision making and technical skills laparoscopic repair with re-intervention rates of less than training shortens the learning curve for laparoscopic hernia 10% for open and less than 3% for laparoscopic [5]. In the repair and consequently will have a net benefit by improving Italian certification program, the infection rate for abdominal patient outcomes [12]. wall hernia repair should also be lower than 10% and the The update of guidelines on laparoscopic (TAPP) and recurrence rate at the first follow-up below 5% [21]. endoscopic (TEP) treatment of inguinal hernia by the Inter- national Endohernia Society recommends the availability of Education and training in a hernia center a simulation trainer to all surgical trainees to help improve their operative performance [10]. Currently, the trend is Key question 26 towards the use of box trainers over computer-assisted simu- lation for inguinal hernia repair training [10]. A proficiency- Does an accredited/certified hernia center need special train- based curriculum for the available trainer tool should be ing facilities with simulations to train hernia surgery? established to improve patient outcomes [10]. There is also a positive correlation between laparoscopic Suggestion ventral hernia repair simulation training and performance in For an accredited/certified hernia center it is the operating room [15]. strongly recommended to offer its trainees participation in simulation-based training courses. Key question 27 In a systematic review examining simulation-based Is access to the important hernia journals important for an training for laparoscopic surgery, 219 studies with 7138 accredited/certified hernia center? trainees and 91 (42%) randomized controlled trials were included. For comparison with no intervention (n = 151 stud- Suggestion ies) pooled effect size favored simulation for outcomes of Surgeons of an accredited/certified hernia center knowledge, skills time, skills process, skills product, behav- should ensure regular reading and familiarization of ior time, behavior process and patient effects (all p < 0.05) important hernia journals and articles for their [82]. The authors concluded that simulation-based training continuing medical education (CME). for laparoscopic surgery of health professionals demonstrate large benefits when compared with no intervention and is also moderately more effective than non-simulation instruc- “Practicing medicine without reading is unthinkable and tions [82]. reading of contemporaneous journals and relevant research In a randomized controlled trial, general surgery residents articles is extensively used in searching for information were randomized to mastery learning on standard practice to solve clinical problems” [84]. “Journal reading is well after performing a baseline total extraperitoneal patch plasty established as an important source of continuing medical (TEP) and reassessed during subsequent TEPs. Fifty resi- education of physicians, at least at the level of knowledge dents performed 219 TEPs on 146 patients [83]. After train- development” [85]. ing, TEPs performed by simulation-based mastery residents in training were undertaken with greater expediency than 13 198 Hernia (2019) 23:185–203 A meta-analysis suggests though that the effect of con- The potential providers of surgical education are surgical tinuing medical education on a physician’s knowledge is of centers in their sub-specialty which have been identified as a medium one [86]. an accredited/certified center by their respective scientific Subscription to the journal “Hernia” is therefore consid- societies [88]. Considered tertiary or high-level hernia cent- ered obligatory for all levels of an accredited/certified hernia ers that are accredited/certified by national or international center in the German program [5]. hernia societies should be providers of external education and training of surgeons in hernia surgery. The accred- ited/certified high- or tertiary-level hernia centers must be Key question 28 actively involved in education and training of surgeons of external institutions [5, 21]. Should the surgeons of an accredited/certified hernia center Accredited/certified (high level) hernia centers should regularly attend national and international meetings about help non-hernia specialists/centers to develop by coopera- hernia treatment? tion, teaching, education and mentoring. Suggestion Scientific activities of a hernia center Surgeons of an accredited/certified hernia center should regularly attend national and international Key question 30 meetings either directly related to or with a sub- section on hernia treatment. Should leading surgeons of accredited/certified hernia cent- ers be members of the relevant scientific national and inter- national hernia societies? “The congresses enable health-care professionals to keep up-to-date with important research, learn directly from expe- Suggestion riences and “trials and errors” of others, share best prac- Leading surgeons of accredited/certified hernia tices, and develop new skills and techniques. All of these centers must be members of the relevant scientific have a direct impact on our daily clinical practice, helping national and international hernia societies which us to improve safety and equality of care” [87]. “Exposure to will demonstrate their dedication to the other professionals may motivate the physicians to improve development of professional excellence. their performance and adapt continuous learning through the course of their careers” [87]. Demonstration of regular attendance at conferences is therefore to be considered an “Many scientific societies were founded to support the obligatory requirement for surgeons in an accredited/certi- single disciplines for which they are named” [89]. fied hernia center [5, 21]. “The mission of the scientific societies is primarily pro- viding information through education, to publish in scientific journals, to develop professional excellence, to raise public Key question 29 awareness and to make awards” [89]. “Through this work, they help to define and set standards for their professional Should an accredited/certified [high-level] hernia center fields and to promote high standards of quality through actively participate in external education and training of awards and other forms of recognition”, for example, guide- surgeons in hernia surgery? lines [89]. “Professional medical societies serve several functions Suggestion that may benefit society, the medical profession, and indi- An accredited/certified [high-level] hernia center vidual members” [90]. should be seen to be and demonstrate active “Participation can vary from membership to leadership” participation in the external education and training [90]. “Members may want to seek advice from senior col- of surgeons in hernia surgery. leagues to guide them in their research or for their own aca- demic advancements” [31]. Accredited/certified hernia centers of all levels in the “Surgical education is by definition a lifelong process German program must be full members of the German Her- which starts with a solid training period and should be fol- nia Society (DHG) and the European Hernia Society (EHS) lowed by high-quality continuing medical education (CME)” [5]. In the Italian program, all certified hernia surgeons [88]. and the leading surgeons of an accredited/certified hernia center must be members of the Italian Society of Hernia and 13 Hernia (2019) 23:185–203 199 Abdominal Wall Surgery, which is the Italian chapter of the “The need for continuing self-improvement is the one European Hernia Society [21]. element that is consistently seen as being central to profes- The leading surgeons of an accredited/certified hernia sionalism across all disciplines” [85]. center should therefore be at least a member of the inter- A meta-analysis of continuing medical education effec- national hernia society if there is no national equivalent tiveness demonstrated a better effect of active vs. passive organization. participation in conferences [86]. Continuous medical edu- cation, especially in the active form, is likely to have an effect on a physician’s knowledge, performance and may Key question 31 also help improve patient outcomes [86]. Therefore, sur- geons of accredited/certified hernia center should give—at Should an accredited/certified [high-level] or tertiary her- least once a year—oral presentations or present videos/post- nia center participate actively in scientific projects of hernia ers at national and/or international hernia conferences. In the treatment? Italian certification program considered high-level or tertiary hernia centers must participate at the annual congress of Suggestion the European Hernia Society with abstracts and presenta- An accredited/certified [high-level] or tertiary tions [21]. For the German certification program, at least hernia center is suggested to participate in scientific two papers or posters at national and international hernia hernia projects and evaluation of new technologies. conferences must be presented by high-level or tertiary her- nia centers per year [5]. “Cooperation among a diverse group of stakeholders— including research sponsors (industry, academia, govern- Conclusions ment, nonprofit organizations, and patient advocates), clinical investigators, patients, payers, physicians, and reg- Within the framework of the ACCESS project, a group of 18 ulators—is necessary in conducting a clinical trial today” hernia experts nominated by the European Hernia Society [91]. “The fewer physicians are involved in developing and have formulated consensual recommendations and sugges- implementing clinical trials, the less scientific the practice of tions of requirements for accredited/certified hernia centers medicine will be” [91]. “There is data to reflect that there is and specialist hernia surgeons. Even if the scientific evi- a disappointing trend that fewer professionals are undertak- dence for these requirements is relatively low, experiences ing research than in the past” [91]. Therefore, hernia cent- from other areas of medicine can be extrapolated to hernia ers accredited/certified by national or international hernia surgery. This means that sufficient valid recommendations societies as high-level or tertiary institution should ideally and suggestions are available for all key questions. Because be encouraged to actively participate in the scientific evalu- of the differences in the health care systems of the vari- ation of their specific field with quality audit and research. In ous countries from which the participating hernia experts the German and Italian accreditation/certification programs, come, it is not possibly to stipulate specific numbers in the high level hernia centers are obliged to participate in hernia requirements. The view among working group members was studies and research projects [5, 21]. that framework recommendations and suggestions should be agreed for the requirements, whereby the requirements Key question 32 would then be later supplemented with actual figures by the national and international hernia societies for the individual Should surgeons of an accredited/certified [high-level] or countries or continents. Hence, the recommendations and tertiary hernia center regularly attend national and inter- suggestions presented here are minimal requirements which national meetings about hernia treatment, and present oral, can later be expressed in more concrete terms and expanded video or poster presentations? by the national and international hernia societies. However, already observance of the minimal requirements set out here Recommendation for accredited/certified hernia centers and specialist hernia Surgeons of accredited/certified hernia center surgeons is likely to improve the quality of hernia surgery should actively participate in national and/or due to the experiences gained in other areas of surgical med- international hernia conferences [at least once a icine. In view of the increasing complexity of hernia surgery, year]. this development should be driven forward as far as possible by all national and international hernia societies. Therefore, based on the minimum requirements formulated here, all 13 200 Hernia (2019) 23:185–203 national and international hernia societies are called upon Hernia [International Endohernia Society (IEHS)]. Surg Endosc to develop and implement programs in their own countries 25:2773–2843. https​://doi.org/10.1007/s0046​4-011-1799-6 10. Bittner R, Montgomery MA, Arregui E et al (2015) Update for the accreditation/certification of hernia centers and spe- of guidelines for laparoscopic (TAPP) and endoscopic (TEP) cialist hernia surgeons. This also helps to meet the public treatment of inguinal hernia [International Endohernia Society expectation invested by the national and international hernia (IEHS)]. Surg Endosc 29:289–321. https​://doi.org/10.1007/s0046​ societies for optimization of patient treatment. 4-014-3917-8 11. Poelman MM, van den Heuvel B, Deelder JD (2013) EAES con- sensus development conference on endoscopic repair of groin her- nias. Surg Endosc 27:3505–3519. https​://doi.org/10.1007/s0046​ Compliance with ethical standards 4-013-3001-9 12. The HerniaSurge Group (2018) International guidelines for Conflict of interest All authors declare no conflicts of interest. groin hernia management. Hernia. https​://doi.org/10.1007/s1002​ 9-017-1668-x Ethical approval This article does not contain any studies with human 13. Bittner R, Bingener-Casey J, Dietz U et al (2014) Guidelines for participants or animals performed by the authors. laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-part 1. Surg Statement on human and animal rights This article does not contain Endosc 28(1):2–29. https​://doi.org/10.1007/s0046​4-013-3170-6 any study with animals performed by any of the authors. 14. Bittner R, Bingener-Casey J, Dietz U et al (2014) Guidelines for laparoscopic treatment of ventral and incisional abdominal Informed consent For this type of article informed consent is not wall hernias (International Endohernia Society (IEHS))-part required. 2. Surg Endosc 28(2):353–379. https​://doi.org/10.1007/s0046​ 4-013-3171-5 15. Bittner R, Bingener-Casey J, Dietz U et al (2014) Guidelines for Open Access This article is distributed under the terms of the Crea- laparoscopic treatment of ventral and incisional abdominal wall tive Commons Attribution 4.0 International License (http://creat​iveco​ hernias ((International Endohernia Society (IEHS))-Part III. Surg mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribu- Endosc 28:380–404. https​://doi.org/10.1007/s0046​4-013-3171-5 tion, and reproduction in any medium, provided you give appropriate 16. Liang MK, Holihan JL, Itani K et al (2017) Ventral hernia man- credit to the original author(s) and the source, provide a link to the agement: expert consensus guided by systematic review. Ann Surg Creative Commons license, and indicate if changes were made. 265(Issue 1):80–89. https​://doi.org/10.1097/SLA.00000​00000​ 00170​1 17. Earle D, Roth JS, Saber A et al (2016) SAGES guidelines for laparoscopic ventral hernia repair. 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Köckerling F, Schug-Paß C, Adolf D et al (2015) Is pooled data jurisdictional claims in published maps and institutional affiliations. analysis of ventral and incisional hernia repair acceptable? Front Surg 2:15 Affiliations F. Köckerling1 · A. J. Sheen2 · F. Berrevoet3 · G. Campanelli4 · D. Cuccurullo5 · R. Fortelny6 · H. Friis‑Andersen7 · J. F. Gillion8 · J. Gorjanc9 · D. Kopelman10 · M. Lopez‑Cano11 · S. Morales‑Conde12 · J. Österberg13 · W. Reinpold14 · R. K. J. Simmermacher15 · M. Smietanski16 · D. Weyhe17 · M. P. Simons18 1 4 Department of Surgery, Center for Minimally Invasive General and Day Surgery Unit, Center of Research and High Surgery, Academic Teaching Hospital of Charité Specialization for the Pathologies of Abdominal Wall Medical School, Vivantes Hospital, Neue Bergstrasse 6, and Surgical Treatment and Repair of Abdominal Hernia, 13585 Berlin, Germany Milano Hernia Center, Instituto Clinico Sant’Ambrogio, 2 University of Insurbria, Milan, Italy Associate Clinical Head of Division (Surgery), Manchester 5 University NHS Foundation Trust, Manchester, UK Chief Week Surgery Departmental Unit, Department 3 of General, Laparoscopic and Robotic Surgery, A.O. Dei General and HPB Surgery and Liver Transplantations, Colli Monaldi Hospital Naples, Naples, Italy Pancreas and Abdominal Wall Specialist, Universitair 6 Ziekenhuis Gent, C. Heymanslaan 10, 9000 Ghent, Belgium Department of General, Visceral and Oncological Surgery, Wilhelminenspital, 1160 Vienna, Austria 13 Hernia (2019) 23:185–203 203 7 13 Surgical Department, Horsens Regional Hospital, Horsens, Department of Surgery, Mora Hospital, 79285 Mora, Sweden Denmark 14 Wilhelmsburger Krankenhaus Gross-Sand, Gross‑Sand 3, 8 Unité de Chirurgie Viscérale, Hôpital Privé d’Antony, 1, Rue 21107 Hamburg, Germany Velpeau, 92160 Antony, France 15 Department of Surgery, University Medical Center Utrecht, 9 Department of Surgery, Krankenhaus der Barmherzigen Heidelbergglaan 100, Utrecht, The Netherlands Brüder, Spitalgasse 26, 9300 St. Veit an der Glan, Austria 16 Department of General Surgery and Hernia Centre, Hospital 10 Department of Surgery Emek Medical Center, Afula in Puck, Medical University of Gdansk, Gdańsk, Poland and the Rappaport Faculty of Medicine, Technion-Israel 17 School of Medicine and Health Sciences, University Institute of Technology, Haifa, Israel Hospital for Visceral Surgery, Pius‑Hospital Oldenburg, 11 Abdominal Wall Surgery Unit, Department of General Medical Campus University of Oldenburg, Georgstrasse 12, Surgery, Hospital Universitari Vall d’Hebron, Universitat 26121 Oldenburg, Germany Autònoma de Barcelona, Passeig Vall d’Hebron, 119‑129, 18 Department of Surgery, OLVG Hospital, Oosterpark 9, 08035 Barcelona, Spain 1091 AC Amsterdam, The Netherlands 12 Unit of Innovation in Minimally Invasive Surgery, University Hospital Virgen del Rocío, Av. Manuel Siurot, s/n, 41013 Seville, Spain 13