Abdominal wall Surgery

Abdominal wall Surgery

Presentation

Abdominal Wall Surgery (AWS) is a “transferable competency” which requires the acquisition of “knowledge” in basic clinical sciences and operative skills as well as specialised “knowledge and skills” in the prevention and treatment of all types of hernias and abdominal wall defects.

The “transferable competency” AWS covers acute, traumatic and non-acute diseases and injuries, and acute and elective procedures in patients of all ages.

The “transferable competency” AWS provides the “knowledge and skills” for the non-operative and operative management of all types of hernias and abdominal wall defects, i.e., diagnosis, evaluation, decision making, treatment, intensive care, rehabilitation of patients with pathological processes and acute and chronic pain treatment, as well as prevention of any abdominal wall defect when performing any surgical procedure.,
It also involves the necessary knowledge and expertise leading to referral to specialised centres when this is indicated and possible, and where this is not possible because of time or geographical considerations, to possess the multi-specialty skills to carry out these interventions safely.

Abdominal Wall Surgery cooperates with other surgical and medical specialties, e.g. anaesthesia and intensive care medicine, emergency surgery, gastroenterology, general surgery, plastic surgery,  internal medicine, radiology, neurology, endocrinology, paediatrics, urology and others in the management of patients.

The surgeons must have acquired and must maintain specialized “knowledge and skills” (precisely defined in an additional catalogue) relating to the diagnosis, preoperative, perioperative and postoperative management in the following areas of primary responsibility:

  • Anatomy and Physiology of the abdominal wall
  • Differentiated use of diagnostic procedures (clinical examination, CT, MRI, Ultrasound)
  • Indication for surgery under consideration of the current guidelines
  • Indication for surgery under consideration of the current guidelines
  • Prevention of incisional and parastomal hernias following open abdominal procedures by small-bite suture technique and / or prophylactic mesh
  • Prevention of trocar site hernias following any laparoscopic procedure ;
  • Laparo-endoscopic and open treatment of all inguinal hernias in the emergency and elective clinical setting according to the guidelines ;
  • Surgical skills for inguinal hernia repair according to the guidelines in Lichtenstein, open preperitoneal approach, TEP or TAPP and Shouldice techniques ;
  • Tailored approach in elective inguinal hernia repair under consideration of gender, patient clinical history, bi-laterality, size of the hernia, recurrence and other factors ;
  • Laparo-endoscopic and open treatment of all primary ventral hernias (umbilical, epigastric) in the emergency and elective clinical setting and under consideration of an additional rectal diastases ;
  • Surgical skills in laparoscopic IPOM, all different techniques for minimally invasive abdominal wall reconstruction, open suture, open sublay, open onlay and open and laparo-endoscopic component separation techniques for primary ventral hernia repair ;
  • Tailored approach in primary ventral hernia repair under consideration of obesity, risk factors, patient status and hernia findings ;
  • Laparo-endoscopic and open treatment of all types of incisional hernias (recurrent, medial, lateral, “swiss-cheese”, “loss of domain”) in the emergency and elective clinical setting ;
  • Surgical skills in laparoscopic IPOM, all different techniques for minimally invasive abdominal wall reconstruction, open sublay, open IPOM, open onlay and open and laparo-endoscopic component separation techniques for incisional hernia repair ;
  • Tailored approach in incisional hernia repair under consideration of obesity, risk factors, patient status and findings of the hernia ;
  • Complex ventral and incisional hernia repair in the contaminated surgical field ;
  • Treatment of mesh infections ;
  • Techniques for management and closure of open and burst abdomen ;
  • Conservative and operative management of all postoperative complications following abdominal wall surgery ;
  • Knowledge about the characteristics of the used medical technology products in hernia surgery, including prosthetic materials (synthetic, biological and biosynthetic meshes), mechanical fixation devices (absorbable and non-absorbable) and atraumatic fixation systems as glues and fibrin sealant (biologic and synthetic glues) ;
  • Knowledge about biology during the process of in-growths of prosthetic materials and the effect of different fixation devices on the integration ;
  • Treatment of patients with chronic pain following hernia surgery in cooperation with neurologists and pain experts.

The focus is on diagnosis, treatment and postoperative management, which comprises all non-instrumental and instrumental techniques including radiology, sonography, computer tomography and magnetic resonance imaging.

The abdominal wall surgeon must be capable of employing laparo-endoscopic and open techniques for therapeutic purposes and must have the opportunity to gain knowledge and experience in evolving technological methods.

The abdominal wall surgeon must be also capable of interpreting all types of surgery-related radiological examinations.

The AWS activity covers the pre-, peri- and postoperative period including the principles of enhanced recovery and follow-up of patients. The specialty also includes individual and general preventive activities, rehabilitation, and management of pain.

Abdominal wall surgery is often performed in specialised centres, especially in complex cases. When transferal is not possible because of time or geographical considerations, the abdominal wall surgeon should possess the multi-specialty knowledge and skills to carry out these interventions safely.

Additionally, abdominal wall surgeons are expected to have a knowledge of anatomy, physiology and biochemistry which enable them to understand the effects of common surgical disease and injuries upon the normal structure and function of the various systems of the body.
They are expected to have a knowledge of cell biology which enable them to understand normal and disordered function of tissues and organs.
They should have an understanding of the pathogenesis of the common correctable congenital abnormalities.
They are expected to know the actions and toxic effects of drugs commonly used in perioperative and intraoperative care and in the management of critically ill surgical patients.
They must also have an understanding of general pathology including the principles of immunology and microbiology in relation to surgical practice.

The abdominal wall surgeon should have certified knowledge in basic technology of the used laparo-endoscopic instruments, especially insufflation devices, monitors, cameras and light sources, ultrasound- and other energy-driven instruments and stapling and fixation devices.

The abdominal wall surgeon must be trained in the economics of health care, in the assessment of research methods and scientific publications and be given the option of research in a clinical and relevant field of further training in another related specialty.

Ferdinand Köckerling

Ferdinand Köckerling

Foundation Chairman, Working Group of AWS

Arthur Felice

Arthur Felice

President of the European Board of Surgery