Establishing a robust multidisciplinary team process in complex abdominal wall reconstruction within a colorectal surgical unit

There is an increasing disease burden of complex abdominal wall herniation [1]. This is likely secondary to improved survival following intra-abdominal catastrophe, an ageing population and failure of primary hernia repair (both open and minimal access techniques). Colorectal surgeons continue to contribute to the problem; incisional hernia rates following midline laparotomy remain high at 22.4% at 3 years [2], and controversy remains regarding the best method of primary closure to prevent future herniation [3]. Even when strong evidence exists to support one type of primary closure over another, uptake of new techniques remains poor. Due to the nature of the pathologies and the procedures that often create the initial problem, these patients frequently find themselves in the colorectal surgical clinic. Traditionally patients with complex abdominal wall defects have been managed by single-handed enthusiasts developing expertise, often in isolation, over a prolonged time period. Similar to cancer surgery a few decades ago, transparency with regard to activity levels, outcomes and resource utilisation has often been lacking. This despite major abdominal wall reconstruction (AWR) surgery necessitating complex decision making, frequently involving different surgical specialities, and being resource intensive with prolonged theatre times and hospital stays, and the use of expensive implants [4]. There is also increasing evidence that recording of surgical approach, mesh implant type and position, and patient outcomes within formal registries improve care [4]. Multidisciplinary team (MDT) management is increasingly the standard of care in many colorectal pathologies, both malignant and benign (e.g., inflammatory bowel disease). MDT management is not yet routine practise in complex AWR. We describe below our initial experience in establishing an MDT in complex AWR and propose a structure and some process and outcome measures to support any colorectal unit keen to do so.