A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction.

INTRODUCTION: Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes. METHODS: We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital. RESULTS: We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway. CONCLUSION: In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.

Cardiobacterium hominis endocarditis presenting as acute embolic stroke: a case report and review of the literature.

We report on a case of endocarditis attributable to Cardiobacterium hominis in a 31-year-old man who presented with acute-onset, left-sided hemiparesthesia. Magnetic resonance imaging of the brain showed acute infarctions in 2 areas of the right cerebral cortex, and a transesophageal echocardiogram revealed vegetation in a previously unrecognized bicuspid aortic valve. The patient completed a 6-week course of ceftriaxone and aspirin, with resolution of the vegetation and neurological complications. Our literature review of C. hominis endocarditis suggests that aortic-valve involvement is associated with high stroke and valve-surgery rates. Favorable outcomes and treatment success are evident with either penicillin or ceftriaxone, in combination with (if indicated) valve surgery in patients with neurological complications.