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1. Establishing a Hernia Program and Follow-Up Regimen…
Fig. 1.3. ( a ) The list and basic diagram for hernia program dynamic care
processes representing all groups of patients cared for by our hernia program and
the design of the care processes to de fi ne the patient’s entire cycle of care. ( b )
The early stages of developing a dynamic care process for a complex abdominal
wall patient group. ( c – f ) A more complete example of the dynamic care process
for a patient group with uncomplicated ventral hernia disease. Within many of
these steps, there are data collection forms that will travel with the patient and
team through the entire cycle of care and outcome measures that will be used to
determine value and help to improve the process over time.
Types of Hernia Dynamic Care
Processes
a
b
• Inguinal hernia (uncomplicated and complicated)
• Ventral hernia (uncomplicated and complicated)
• Complex abdominal wall reconstruction
• Sports hernia (chronic groin pain without hernia)
• Chronic pain after prior hernia repair
• Chronic pelvic pain in females
Pre-Clinic Clinic
Pre-Op Procedure
Post-Op
Discharge /
Follow-up
Elective Dynamic Care Processes
10
B. Ramshaw
Fig. 1.3. (continued).
11
1. Establishing a Hernia Program and Follow-Up Regimen…
Fig. 1.3. (continued).
12
B. Ramshaw
Fig. 1.3. (continued).
13
1. Establishing a Hernia Program and Follow-Up Regimen…
cycle are determined, and value is also determined as part of the analysis.
This data is critical for the analysis of the true value as measured by
outcomes, satisfaction, and cost.
A critical aspect of all care is the technology involved in providing
the care, including the medical records software (electronic medical
records or EMR). The majority of medical and health record software
used by hospitals is proprietary and expensive. This makes having
different software systems and software systems that might be
implemented in different areas of care dif fi cult to integrate. Software
Fig. 1.3. (continued).
14
B. Ramshaw
users are locked into the interfaces and capabilities of the software and
do not have the ability to customize the software to their speci fi c needs.
This makes it dif fi cult to track the patient in a person-centered model and
can contribute to medical error and increased costs [ 16 ] . As part of the
Transformative Care Institute (our academic medical center designed in
a complex system model), the Advanced Hernia Solutions team will
design software around the care processes and outcome measurements in
collaboration with the larger hernia care community. This software will
be open source and freely available. It will be capable of interfacing with
software that is currently in use within hospitals and health care systems
using the protocols being developed as part of the health information
exchange (HIE) effort.
In summary, the care team outlined in this chapter for an academic
hernia program follows patients throughout their entire cycle of care.
The team will provide local management for the care processes,
measuring and being accountable for costs, quality, satisfaction, and
other outcome measures throughout this entire care cycle. The data
collected will allow for better decision making within this full cycle of
care. An example of the use of CCQI and patient process documentation
would be the selection of hernia mesh for hernia repair. Currently, there
are no clear documented guidelines for the selection of hernia mesh. By
being able to look at full patient cycles of care for multiple patients,
better decisions in the selection of hernia mesh can be made. This can
potentially reduce complications such as recurrence, chronic pain, and
mesh infections which could require reoperation and removal of the
mesh. Through the continuous learning and improvement of a CCQI
model, the quality and satisfaction of care can be improved at the same
time that the overall cost of care can be lowered. Because of the increasing
complexity and pace of change in health care, and our world, this is a
never-ending iterative process.
Adapting These Concepts to the Community
Setting
It is clear that in a small private- or hospital-based practice, a general
surgeon will not have the resources to implement a hernia program using
the academic model described in this chapter. However, many of the
principles of care coordination and continuous clinical quality
improvement can be implemented over time. One goal of our hernia
15
1. Establishing a Hernia Program and Follow-Up Regimen…
program is to develop software for hernia care processes that can be
freely available to surgeons and hospitals. This software, which will be
adaptable to the local environment, will help facilitate its implementation
for hernia care. Until the software is available, surgeons who desire to be
leaders of a hernia team can identify potential team members. These
individuals might be current of fi ce staff, hospital employees, former
patients, family members, or others within the community (several of our
team members are former patients who volunteer their time). With a
team identi fi ed, the dynamic care processes can be de fi ned. These
evidence-based care processes and outcome measures that determine
value (quality, satisfaction, fi nancial, etc.) will be the starting point for
offering care to hernia patients in this model. When patients are cared for
guided by these processes, the data that is generated can then be used to
learn and to improve these processes.
There are a number of principles for implementing this locally. One
of the most critical principles is to develop a true team environment. As
a surgeon and leader of a hernia team, it will be necessary to cultivate a
safe environment for the team in order to allow all team members to
speak freely, without risk of being treated inferiorly. Clearly, each
member of the team will have different levels of medical knowledge;
however, each member’s perspective should be treated as valuable. The
ability for all members of the team to speak up can have signi fi cant
bene fi ts for patient safety and opportunities for innovation. The patient
and family perspectives are especially important because of the unique
experience of actually going through the cycle of care. It is important to
have an open mind and be driven by the outcomes rather than preconceived
beliefs. This will not necessarily be easy and will take time.
Another important principle is to not make reactionary decisions. If
the fi rst time a new mesh is used and the patient has a recurrence, it is not
necessarily a bad mesh. There might be technical issues (learning curve
with a new product), patient selection issues, or other factors that
generated a poor outcome. Looking at the outcomes with the team will
help to prevent reactionary decisions. Most importantly, whatever
decisions are made to change processes, they should be measured by
looking at the outcomes after the process change has been made.
The following steps can be used to implement a hernia program:
1. Identify a core team.
2. De fi ne dynamic care processes and outcome measures – the
types of hernia patients your program will care for, procedure to
offer, and types of patients and hernia complications (such as
16
B. Ramshaw
chronic pain after hernia repair) your program will refer (it will
be helpful to identify appropriate surgeons and other hernia
programs to which the team can refer patients that your hernia
program decides not to care for).
3. Begin to see patients in this hernia program model—allow
patients to view the processes and outcomes as they are
generated to help them make decisions throughout their cycle
of care (shared decision process).
4. Generate outcomes data and identify errors, complications, and
anomalies (good and bad) during the patients’ cycle of care.
5. Have regular team meetings to review these outcomes and look
for opportunities to improve the care processes. These CQI
meetings have replaced traditional M&M conference at our new
academic medical center.
6. Develop and support extended team members (in the OR, on the
fl oor, etc.) and care communities (former patients and others
interested in your hernia program) that can help support the
care coordination and continuous learning and improving which
are the foundations of this model for hernia care.
7. Have fun! Building a team and a community that cares for each
other can be an incredibly rewarding experience. When
implemented, this model has the potential to not only improve
the value of patient care but also improve the working
environment and behavior of the entire care team.
Summary
The decision to implement a hernia program should be made as a
commitment to care for patients with hernia problems. No hernia
program, ours included, can serve all hernia patients and provide every
option for care. It will be important to identify a core hernia team and
de fi ne the care processes that your team will offer to patients. These care
processes should be evidence-based. Outcome measures should be
identi fi ed and collected that will determine the value of care provided.
These will need to be measured not only for a portion of care but also for
the entire cycle of care. Applying continuous learning and clinical quality
improvement principles will ensure that the care provided by your
program will generate better outcomes and better value over time.
17
1. Establishing a Hernia Program and Follow-Up Regimen…
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B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_2,
© Springer Science+Business Media New York 2013
2. Prosthetic Choice in Open Inguinal
Hernia Repair
Lisa C. Pickett
While non-mesh repairs can be performed safely in experienced hands
with standardized technique, such as the Shouldice ( 1 ) , tension-free repairs
with mesh placement have become the gold standard for the open repair of
inguinal hernias ( 2 ) . Traditionally, there has been concern about the
placement of mesh in an acute/incarcerated hernia, but this appears to be
safe ( 3 ) , even in the context of bowel necrosis ( 4 ) . Internet search of hernia
mesh reveals countless brands and types of mesh for the repair of inguinal
hernias. Mesh materials vary by source. There are absorbable and
permanent synthetic meshes, allograft material, and xenograft material.
In addition, mesh is sold in fl at sheets, precut segments, and three-
dimensional forms. Some mesh products include additional components to
resist adhesions, to allow for fi xation, or to prevent infection.
Webster’s dictionary de fi nes mesh as “that which entangles us” ( 5 ) .
This is not truer than in inguinal hernia repair. Millions of inguinal hernia
repairs are performed in the world annually, predominantly open, with
every variety of prosthetic, from polyester and polypropropylene to
mosquito netting in some parts of the world ( 6 ) . In fact, a recent study
demonstrates no signi fi cant difference in outcomes between sterile
mosquito nets and standard commercial mesh, which cost 1,000 times
more! ( 7 )
History
Initial management of inguinal hernias required external management
with bandages, then trusses, fi rst created by French surgeon Guy de
Chauliac and then by Ambroise Pare, and subsequently a variety of plugs