Mr Srinivas Chintapatla provides an insight into how the York Abdominal Wall Unit (YAWU) has put the patient at the centre of decision making, transformed the care pathway, and improved outcomes.
At York Abdominal Wall Unit (YAWU) we are continuously striving to improve patients’ quality of life and their experience when undergoing treatment for complex abdominal wall hernia (CAWH). When I trained two decades ago, Abdominal Wall Reconstruction (AWR) was referred to as Incisional Hernia Repair. A lot has changed in the intervening time, and how we approach repairing CAWH has improved.
There are new surgical techniques, meshes coupled with a better understanding of how to reduce wound breakdown, and Surgical Site Infections (SSIs). We have a better understanding of monitoring recurrences and all of these measures have led to a focus on improving quality of experience for the patient. The focus is on the patient returning to optimum function in terms of abdominal wall and their life. We have to think outside of the hernia itself.
Surgical techniques to repair the abdominal wall defect is a key aspect, but so is returning the abdominal wall function including returning form of the skin, subcutaneous tissue, and the muscles to an anatomical correction that is good for them. Correcting the anatomy improves the function – and that is the key of AWR.
AWR service developments and patient pathways
At YAWU, we see this as a service which keeps the patient at the centre of the process and pathway. These are very complex journeys for the patient which is why it is split into 12 stages. At YAWU we have approached this as a patient journey from stage 1 (when the patient is referred) to stage 12 (when the patient is discharged, and the outcomes are audited)
Multi-disciplinary approach for patients and guidance
We have developed a variety of information leaflets,1 as patients can find this process daunting. Each leaflet has bite-sized information to support a different stage of the pathway. However, patients have different needs and different opinions on the amount of information they require. Some just want the information pared back, whereas others prefer to know and understand the details.
There is no right or wrong approach here. Again, we are listening to the individual patient and responding to their needs and wants. At YAWU we have published all ten leaflets on the website of the hospital site for patients to be able to view them.
However, we believe the most effective way to make sure information is truly understood is through two-way communication. We invest time in our patients. All our AWH clinics are multidisciplinary. We start with a combined clinic where a gastrointestinal surgeon and a plastic surgeon sit together in the consultation.
We have a dietician in a parallel clinic to provide a consultation for those who need advice. We set up a pre-habilitation clinic for those who need a more intensive set up and long-term intervention. Our approach to a Complex Abdominal Wall Hernia is to carefully assess the past story. To do this we need to gather the story and allow patient some thinking time to get all the facts. We have devised a 10-page health questionnaire which we send to the patient.
They get to spend some time in their home to gather and record their thoughts. Time is the key here, and the preparation by the patient is an asset. This exercise helps in gathering the past story and on the day of the consultation, it speeds up this part of the appointment. We spend time clinically assessing the hernia and making a plan for the future with agreed goals and agreed investigations, if needed. Agreed goals have patient buy-in towards modifying behaviours to overcome issues like smoking, obesity, and nutrition, and sets the patient on the pathway to getting healthier.
We help with an information leaflet which has several behaviour modification tools and practical advice. This sets the ground for pre-habilitation work. Once the patient has successfully achieved the goals set out, we meet again to discuss the details about the surgery and post-surgery rehabilitation.
We talk about what the surgery involves. This is the time to consider how to anticipate the issues that will rise in life after surgery. We plan for what has to be done while on the wards and for after discharge from the hospital. Success comes from improving the patient’s fitness, choosing the right operation and carrying it out with a focus on reducing surgical complications including reducing wound breakdowns. We use different checklists to reduce wound complications such as theatre protocols shown in Fig 2. At YAWU, this focus on process has allowed us to improve the complexity of surgery safely.
Quality of life issues
At YAWU, we care about improving the patient’s quality of life (QoL). BD provided support for an AWR research fellow post to look into this aspect of this complex disease. This is crucial to a successful outcome for the patient. We experimented with different QoL tools and questionnaires and were disappointed with many of them.
Many of them had been constructed by professionals and the patient voice seemed missing in their genesis. At our institution, we constructed a two-year study where we asked patients how their AWH had affected their QoL. Then we analysed all the interviews and their transcripts. We gathered the combined information into an infographic which we believe covers the themes in terms of how these affect the QoL. Further work still remains but we can share the latest infographic (Fig.4).
The ultimate aim is to improve the patient’s functionality of the abdominal wall and, in so doing, attempt to improve their quality of life. To achieve this, the patient’s needs and desires must be at the centre of the process and pathway goals. The package of care created must take the form of multi-disciplinary teams working at different stages of the individual’s journey with overall quality of life being the outcome that one focuses on throughout.
Seeking improvements to achieve marginal gains
The YAWU team are continually looking for small improvements to get those 1% gains. We hold regular time-out meetings to discuss next steps and actions. These actions may be only small changes and tweaks to our process and pathway. We believe in Brailsford’s concept of aggregating marginal gains (even 1% gains) bringing a considerable improvement.
Every little idea from all our extensive team members is noted down and a smaller core team discuss it and implement it, and then re-evaluate it after a period of time. It is a labour of love for the profession and hopefully seeps through into the results for our CAWH patients.
About the author
Mr Chintapatla, a consultant surgeon, initially trained in India. After completing his Masters in Surgery and Diplomate of National Board in General Surgery, he went through higher surgical training in the UK and a fellowship in Germany. It was during this period that he learnt how to do a Stoppa retrorectus and a preperitoneal repair in 2002. He went on to acquire an Intercollegiate Fellowship of Royal College of Surgeons of Edinburgh. He also has Post Grad Certifications in Management of Health Services (1998, Open University) and in Medical Informatics (2002, RCSEd)
He has been undertaking abdominal wall reconstructive surgery since 2004, when he was appointed as a consultant surgeon at York Hospital and an honorary senior lecturer at Hull York Medical School. He is now a director of cancer and support services. Within this role, he manages the departments of endoscopy, radiology, pathology, pharmacy, oncology and clinical haematology across both York and Scarborough Hospitals. He is interested in the triumvirate of service improvement, research and teaching of AWR. For further information on work at the YAWU and to share ideas, please email: [email protected]
Reference 1 These patient resources can be accessed at: https://www.yorkhospitals.nhs.uk/our-services/az-of-services/abdominal-wall-reconstruction/