Annual Quality Improvement Summit
- The goal of AHSQC Quality Improvement Summit is to create a different kind of meeting for practicing surgeons, industry partners, and the AHSQC team to improve the quality of care we deliver to our hernia patients.
- This focused meeting is centered around high-quality information obtained by AHSQC surgeons and their clinical teams about hernia patients and their experiences for quality improvement purposes.
- We learn lessons from high performing surgeons and surgical teams to improve the quality of care for the collaborative as a whole. This collaborative approach to quality improvement can transform healthcare in a very real way.
- After the Summit, surgeons are expected to take away at least 3 things that can be used to improve quality of care delivered to their patients back home.
- Surgeons participating in the AHSQC and the Quality Improvement Summit represent a unique type of practitioner who is dedicated to continually improving the quality of care delivered to their patients and to patients across the country with similar problems.
Highlights from the 2018 AHSQC Quality Improvement Summit
Use of prehospital chlorhexidine gluconate (CHG) to reduce surgical site infection (SSI) in ventral hernia repair
- A previous AHSQC study (https://www.journalacs.org/article/S1072-7515(16)31704-5/abstract) showed that use of prehospital CHG is a risk factor for surgical site infection after ventral hernia repair.
- Many surgeons found it difficult to stop using CHG due to institutional policies.
- A follow up analysis presented at the QI Summit showed that surgeons that discontinued the use of prehospital CHG scrub did not see a significant change in the clinical outcomes or surgical site infections over the last 2 years.
- QI Summit Consensus: The use of prehospital CHG should be optional for ventral hernia repair as the results are equivocal at best for any benefit, with additional cost incurred with CHG use.
Reduction of deep venous thrombosis (DVT) and pulmonary embolism (PE)
- High performers routinely use pharmacologic prophylaxis for reducing postoperative DVT/PE.
- Protocol used by CCF surgeons may reduce incidence of DVT/PE and will be adopted and tracked by the AHSQC: CCF Protocol
- QI Summit Consensus: The use of the AHSQC protocol may reduce DVT/PE rates after ventral hernia repair. Complete use of all components of the protocol will be tracked in the AHSQC.
Fascial closure technique during ventral hernia repair
- No difference was shown in short term wound events among different fascial closure techniques.
- More data is needed to assess impact on recurrence rates.
- QI Summit Consensus: Any method of fascial closure can be used during ventral hernia repair paying close attention to technique. This technique involves approximation of fascial layers only while avoiding inclusion of subcutaneous fat or muscle in the closure.
Reducing enterotomy rates during ventral hernia repair
- Careful technique minimizes the risk of enterotomy; fresh dissection with a #15 blade can facilitate difficult dissection.
- Changing planes of dissection can help avoid enterotomy.
- Early recognition of enterotomy with resection and anastomosis is recommended when feasible.
- Staging the repair may be the best option in very difficult situations.
- QI Summit Consensus: Multiple technical points can be used to minimize the risk of enterotomy. Bowel resection and anastomosis are favored compared to primary repair in more complex cases.
Opioid reduction after ventral hernia repair
- AHSQC should strive to minimize use of opioids through strategic data collection, analysis, and continuous quality improvement.
- QI Summit Consensus: Optional, comprehensive data collection will be instituted to evaluate opioid use after ventral hernia repair.
AHSQC registry based randomized controlled trials
- Efficient prospective research can be performed within the AHSQC.
- Three key elements for implementation include the informed consent process for patient participation, randomization, and collection of a small amount of additional data for trial support.
- Great care should be taken to minimize the need for collection of additional information beyond what is collected within the AHSQC.
- QI Summit Consensus: Each year, suggestions will be made for topics amenable to the performance of a registry based randomized controlled trial.
Surgical Coaching within the AHSQC
- University of Wisconsin has obtained federal funding from the Agency for Healthcare, Research, and Quality to implement a surgical coaching program within the AHSQC.
- Ventral hernia will be the focus.
- Coaches will undergo mandatory training.
- QI Summit Consensus: AHSQC will partner with the University of Wisconsin to implement a surgical coaching program and to evaluate clinical outcomes as a result of the program.
Open retromuscular ventral hernia repair tips
- Aggressive prehabiliation should be employed: BMI <=40, hemoglobin A1C <=7%, strict blood glucose control for diabetic patients postop.
- Scar excision and resection of diseased fascia important prior to closure.
- QI Summit Consensus: Greater attention should be paid to prehabilitation and soft tissue handling techniques. Consideration should be given to the “no touch” mesh technique and antibiotic irrigation.
Open onlay ventral hernia repair tips
- Patient selection is key; avoid technique in obese patients (BMI >=35), active nicotine users, patients on immunosuppression.
- During dissection of the anterior abdominal wall, preserve lymphatics in Le Louarn’s fascia just anterior to the anterior rectus fascia and aponeurosis of the external oblique musculature.
- Use of fibrin glue and midweight macorporous mesh is critical to the technique.
- QI Summit Consensus: The open onlay ventral hernia repair using a modified Chevrel (The Voeller) technique is a useful extraperitoneal repair with minimal need for enterolysis.
Robotic retromuscular ventral hernia repair tips
- Good retromuscular method if reduction in length of stay is a primary goal.
- Fundamental understanding of retromuscular anatomy is critical to success.
- Hybrid approach may offer sizable cosmetic advantage over ‘traditional’ robotic retromuscular ventral hernia repair techniques.
- Mesh fixation probably less important than initially thought based on the robotic retromuscular experience.
- Growing experience with robotic eTEP in smaller less complex hernias has resulted in significant reduction in full robotic TAR procedures.
- QI Summit Consensus: Robotic retromuscular repairs should be performed by expert surgeons in well selected patients. Hybrid approaches may offer the best balance of a minimally invasive approach and optimal cosmesis. Consider Robotic eTEP for small less complex hernias being performed robotically.
Robotic IPOM ventral hernia repair tips
- Like all robotic approaches requires a comprehensive team to facilitate the procedure.
- Defect routinely closed robotically.
- Can consider peritoneal closure in selected cases over the mesh.
- QI Summit Consensus: Robotic IPOM offers another minimally invasive approach to routine ventral hernia repair with suture fixation perhaps avoiding some of the early post op discomfort of transfascial suture fixation in standard laparoscopic IPOMs. Ongoing randomized controlled trials within the AHSQC will provide further information on the actual reduction in pain with each approach.
Robotic inguinal hernia repair tips
- Appropriate patient selection is critical.
- Has been found to be more useful for preperitoneal mesh removals in chronic groin pain patients.
- QI Summit Consensus: The robot continues to show promise in allowing surgeons to perform a minimally invasive inguinal hernia. Further data is needed to understand the advantages over a standard laparoscopic inguinal hernia repair.
Laparoscopic inguinal hernia repair tips
- Should have a standardized approach to this procedure. Can consider avoiding balloon dissection to save time and money.
- Large piece of mesh is necessary to adequately cover the myopectineal orifice and reduce recurrence rates.
- QI Summit Consensus: Standardization of technique and adequately sized piece of mesh is necessary to reduce recurrence rates and improve outcomes.
Link to presentations coming soon!
"THIS IS THE FUTURE OF SURGICAL MEETINGS."
"SUCH A GREAT AND IMPORTANT INITIATIVE!"
"It was well coordinated and I'm happy to see the data is making a difference in the future of hernia surgery."
"Great initiative. I strongly encourage my colleagues to participate."
"Fantastic participation by attendees."
Join us next year for the 2019 AHSQC Quality Improvement Summit! Spotlight on Optimizing Umbilical Hernia Repair in 2019.
38,884 Enrolled Patients
312 Participating Surgeons