In recent years Abdominal Wall Surgery (AWS) has seen exponential growth in terms of understanding the risk factors associated with the occurrence of a hernia,1–3 preoperative care (i.e., prehabilitation),4,5 intraoperative care (enhanced description and comprehension of surgical anatomy, incorporation of new surgical techniques, improvements in prosthetic materials, addition of robotic surgery)6–9 and postoperative care.10,11 In the previous context, there has been a parallel increase in surgeons' interest in understanding the practice and complexity of AWS.12 Recently, the European Union of Medical Specialists (UEMS) has recognized AWS as a specific working group by creating the "European Board of Abdominal Wall Surgery" (EBAWS)13. Moreover, the claim for the need to identify “AWS Units” is not new.14 In fact, the European Hernia Society (EHS) has formulated some accreditation and certification requirements for such "Units"15 which have contributed to specific pioneering proposals in some countries in our environment.16,17 Given the above and considering the wide spectrum of difficulty in AWS (from less complex to the most complex cases), the knowledge required to perform it (surgical anatomy, risk factors, surgical techniques, prosthetic materials, postoperative care) and the minimum facilities necessary for its practice, regulation from scientific societies first and from health policies second, is necessary regarding the "capabilities" of different centers to carry out this specific type of surgery, both in terms of human resources and infrastructure. A first step in this "regulation" is the establishment of criteria by scientific societies for the "accreditation" of these Abdominal Wall Surgery Units. From the Spanish Association of Surgeons (AEC), concern for meeting quality standards within a clinical, educational, and research framework has driven the development of the necessary criteria for the accreditation of units in different training areas of General and Digestive Surgery, including Abdominal Wall Surgery.18,19

The primary objective of this work is to present the accreditation model for Abdominal Wall Units in our country approved by the AEC. The secondary objective is to gather information through an online survey among members of the AEC's abdominal wall section on their potential involvement and healthcare activity in Abdominal Wall Units in Spain.

In the last 20 years, and probably more markedly in the last decade, general surgery has increasingly fragmented into subspecialties.25 Processes within the specialty of General and Digestive Surgery (GDS) that were previously treated indistinctly by "general surgeons" are now treated by "subspecialists" (i.e., highly specialized) and it is unlikely that this paradigm shift towards "subspecialization" within general surgery is reversible.25 Aware of this situation, the AEC considers it "essential to define and regulate the acquisition of high specialization competences within GDS, and proposes the Regulation for the accreditation of specialized surgical units".18,19 The objectives of the AEC are clear: to favor the consolidation and organization of the current reality of the GDS specialty in most hospitals in our country, to collaborate so that legislation on specific training areas within the specialty is well defined, and to lay the foundations for the training of specialists in the different areas of subspecialization.18 Ultimately, as previously published: "the objective of accreditation by the AEC is, therefore, to define specialized surgical units as those functional elements of the health system that meet the defined requirements regarding their provision, solvency, care specialization, teaching, and research".18

Abdominal wall surgery is also incorporated into the accreditation regulations for specialized units proposed by the AEC.19 From our point of view, this incorporation is not serendipitous and comes from a general surgical perspective related to our environment and from a local surgical perspective related to the analysis of a survey on abdominal wall units in our country.

Regarding our environment and to the best of our knowledge, it is the European continent that is the leading promoter of the recognition (globally) of abdominal wall surgery as its own entity. Principally driven by the EHS and the UEMS. The EHS promotes projects recognizing the growing need for specialized centers/units in abdominal wall surgery26 and to train specialists in abdominal wall surgery12; promoting the publication of clinical guidelines referring to different aspects of the treatment of abdominal wall pathology27–33 or participating in educational platforms about the abdominal wall,34 among other multiple activities. The UEMS has also played a definitive role in the specialization of abdominal wall surgery by forming a specific working group and creating the "European Board of Abdominal Wall Surgery" (EBAWS).13 Probably based on the previous framework, specific pioneering proposals have been made in some countries in our environment16,17 that attempt to define (each in its context) the requirements that different centers must have for a specialized practice of abdominal wall surgery. The AEC's proposal presented in this work adds to these few pioneering initiatives in Europe and defines the AEC as one of the first surgical societies worldwide to propose criteria for what can be considered a specialized unit in abdominal wall surgery. On the other hand, recently other parts of the world such as the USA (with clear influence on global surgical evolution) are beginning to become aware of the differences between centers in treatments for complex abdominal wall reconstructions35 and the need to redefine the knowledge of an emerging specialty such as specialization in abdominal wall surgery.36

Regarding the local surgical perspective derived from the analysis of a survey on abdominal wall surgery units in our country, it is interesting to observe how the majority (71%) of respondents belonged to university hospitals and the majority (80.4%) responded that they had an AWS unit in their service. However, more than half (54%) responded that it was not a unit with exclusive dedication to abdominal wall surgery but integrated into another unit, which was not clearly defined as the highest percentage of responses (36%) was that the abdominal wall unit was integrated into the option "other units". On the other hand, very important aspects in the proper management of patients with abdominal wall pathology that should align with current clinical practice guidelines offered contradictory responses, thus, 29% of respondents did not use prehabilitation measures or 46% did not perform bariatric surgery (if necessary) before abdominal wall surgery, which seems not to align with the current recommendations of the ASMBS (American Society for Metabolic and Bariatric Surgery) and the IFSO (International Federation for the Surgery of Obesity and Metabolic Disorders) recommending bariatric surgery in case of elective abdominal wall hernia surgery and severe obesity.37 Furthermore, 38% did not register their operated patients in their own database and 58% did not do so in EVEREG. Nevertheless, the majority responded that they perform minimally invasive surgery for inguinal and incisional hernias, advanced abdominal wall repair techniques such as component separation (anterior or posterior), or complex abdominal wall pathology such as paraestomal hernia. It is paradoxical to observe an environment of majority practice of advanced and complex repair techniques, in relation to a variable structural organization, with high percentages of potential poor management of patient prehabilitation measures and defective activity control/registration. It seems logical, therefore, that the AEC proposes an accreditation model for abdominal wall units to favor the consolidation and organization of the current reality of this part of the GDS, in the face of a national survey where an insufficient definition of abdominal wall units in terms of structural quality (i.e., specific or integrated units, organizational definition), process quality (i.e., prehabilitation, collaboration with other units, guidelines follow-up), or outcome quality (i.e., data registration, complications, morbidity and mortality) seems to be guessed.

Limitations in the present work can be considered the potential discrepancy in the definition of the accreditation structure where perhaps other characteristics could be considered. However, the joint work of the AEC scientific committee and the abdominal wall section has covered from minimum to specific criteria that encompass the care, teaching, and research areas, laying the foundations for the optimal care of patients and the training of specialists in the specific area of the abdominal wall.

The results of the survey should also be interpreted with some limitations. Firstly, the survey was self-administered and was not subjected to internal or external validation before its distribution. Although the survey instrument had not been validated, 2 experienced abdominal wall surgeons reviewed its content. Secondly, the response rate was 17% (204/1181). However, some studies have shown that bias induced by the response rate does not seem to pose a great threat to the validity of the questionnaires.38 Even so, it is possible that the responses do not accurately represent the practice patterns and attitudes of the surveyed surgeons.38 On the other hand, this is the largest and only survey to date among surgeons regarding AWS units in our country. Thirdly, the survey was distributed among members of the AEC's abdominal wall section, but surgeons who do not belong to this were not asked. There is likely to be a selection bias, as the section members have a declared interest in abdominal wall surgery. However, precisely the fact that the survey is made to surgeons with a special interest in the abdominal wall reinforces the veracity of the results and the need for an accreditation proposal.

In summary, the evolution of GDS leads to subspecialization in a process that does not seem reversible. The process of accreditation of abdominal wall surgery units in our country will contribute to an improvement in structural quality, process quality, and outcome quality of abdominal wall surgery.

This work has not been funded by any public or private funds.

The authors declare that artificial intelligence has not been used in the preparation of this work.

The authors declare that they have no conflicts of interest in relation to this work.