B. Stephan, B. Ramshaw, B. Forman

Published: Surg Technol Int. 2015 May;26:135-42.


Patients with complex ventral/incisional hernias often undergo an abdominal wall reconstruction (AWR). These operations have a high cost of care and often result in a long hospital stay and high complication rates. Using the principles of clinical quality improvement (CQI), several attempts at process improvement were implemented in one hernia program over a 3-year period. For consecutive cases of patients undergoing (AWR) process improvement attempts included the use of a long-term resorbable synthetic mesh (TIGR Resorbable Matrix, Novus Scientific, Uppsala, Sweden) in place of a biologic mesh, the use of the transversus abdominis release approach in place of an open or endoscopic component separation (external oblique release) technique, and the use of a preoperative transversus abdominis plane (TAP) block using a long-acting local anesthetic (Exparel, Pacira Pharmaceutical, Parsippany NJ) as part of perioperative multi-modal pain management and an enhanced recovery program. After over 60 cases, improvement in materials costs and postoperative outcomes were documented. No mesh-related complications occurred and no mesh removal was required. In the real-world, value-based application of CQI, several attempts at process improvement led to decreased costs and improved outcomes for patients who underwent abdominal wall reconstruction for complex ventral/incisional hernias. Value-based CQI could be a tool for improved health care value globally.

Our hernia program has focused on implementing CQI for patients undergoing AWR as well as other hernia patient care processes. The specific process improvement ideas we have implemented include the use of preoperative transversus abdomius plane (TAP) block with a long-active local anesthetic (Exparel, Pacira Pharmaceuticals, Parsippany, NJ), use of long-term resorbable mesh (TIGR Resorbable Matrix, Novus Scientific, Uppsala, Sweden), the use of the transversus abdominus release (TAR) approach for AWR, and several other process improvement ideas.

39 patients from a very complex patient group were initially evaluated with a mean follow-up of 12 months. An additional 24 patients with mean follow–up between 4 and 14 months were included.

The impact of several attempts at process improvement for AWR patients, including the use of a long-term resorbable mesh as an attempt at value-based process improvement, are demonstrated.

Implementing the principles of CQI can improve the value of care in a dynamic way because improvement measures are applied in real time with real patients.

For AWR, use of long-term resorbable mesh demonstrated better value in this CQI project compared with published use of biological mesh based on measures that define value similar outcomes with decreased costs. Resorbable synthetics reduce costs by 66%, compared with biologic meshes.

Because of relatively high recurrence rates with biologics, resorbable synthetic meshes have become more widely utilized for large ventral hernia repair and abdominal wall reconstruction. Unlike biologic mesh, resorbable mesh have predicable mechanical properties.