AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION Ventral Repair

Benefits and Risks of Your Operation Patient Education B e n e fi t s — An operation is the only This educational information is way to repair a hernia. You can return to help you be better informed to your normal activities and, in most about your operation and cases, will not have further discomfort. empower you with the skills and Risks of not having an operation— knowledge needed to actively The size of your hernia and the pain it participate in your care. causes can increase. If your intestine becomes trapped in the hernia pouch, you will have sudden pain and vomiting Keeping You Common Sites for Ventral Hernia and require an immediate operation. Informed If you decide to have the operation, Information that will help you possible risks include return of the further understand your operation The Condition hernia; infection; injury to the bladder, and your role in healing. A ventral hernia is a bulge through blood vessels, or intestines; and an opening in the muscles on the continued pain at the hernia site. Education is provided on: abdomen. The hernia can occur at a Overview ...... 1 past incision site (incisional), above the navel (epigastric), or other weak Condition, Symptoms, Tests ...... 2 Expectations muscle sites (primary abdominal). Treatment Options…...... 3 Before your operation—Evaluation may include blood work, urinalysis, Risks and Common Symptoms Possible Complications ...... 4 ultrasound, or a CT scan. Your surgeon ● Visible bulge on the abdomen, and provider will review Preparation especially with coughing or straining your health history, home medications, and Expectations ...... 5 ● Pain or pressure at the hernia site and pain control options. Your Recovery and Discharge ...... 6 The day of your operation—You will Pain Control...... 7 Treatment Options not eat or drink for 6 hours before the Glossary/References ...... 8 operation. Most often, you will take your Surgical Procedure home medication with a sip of water. You will need someone to drive you home. Open hernia repair—An incision is made near the site, and the hernia Your recovery—You may go home within is repaired with mesh or by suturing 24 hours for small hernia procedures (sewing) the muscle closed. but may need to stay in the hospital longer for more complex repairs. The Laparoscopic hernia repair—The average length of stay for patients with hernia is repaired by mesh or sutures a complex hernia repair is 1.5 days.1 inserted through instruments placed into small incisions in the abdomen. Call your surgeon if you have severe pain, cramping, chills with a Nonsurgical Procedure high fever (higher than 101°F), odor or Watchful waiting is an option for increased drainage from your incision, adults with that are reducible or no bowel movement for 3 days. and not uncomfortable.1-3

This first page is an overview. For more detailed information, review the entire document.

AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation The Condition, Symptoms, Ventral Hernia Repair and Diagnostic Tests SAMPLE

Keeping You Abdominal muscle Informed Abdominal (lining of abdomen) Wall Hernias

They are also called Large hernia with ventral hernias. loop of intestine They can occur: • At birth (congenital) Small hernia with • Over time due to intestine bulge muscle weakness • At a past incision site Fat Incisional Hernias2-4 Incisional hernias can develop at the laparoscopic port site in 5 of 1,000 patients and in up to 150 of 1,000 patients who have had a prior open abdominal incision. Most appear in Symptoms the first 5 years after an The most common symptoms of a hernia are: operation. Risk factors The Condition ●●Visible bulge in the abdominal wall, that can contribute The Hernia especially with coughing or straining to formation include: A ventral hernia is a bulge through an opening in ●●Hernia site pain or pressure the muscles on the abdomen. If the hernia reduces • Obesity, which Sharp abdominal pain and vomiting in size when a person is lying flat or in response creates tension may mean that the intestine has slipped to manual pressure, it is reducible. If it cannot and pressure on through the hernia sac and is strangulated. be reduced, it is irreducible or incarcerated, abdominal muscles This is a surgical emergency and and a portion of the intestine may be bulging immediate treatment is needed. • Large abdominal through the hernia sac. A hernia is strangulated incisions if the intestine is trapped in the hernia pouch • Postoperative and the blood supply to the intestine is Common Tests infection (note that decreased. This is a surgical emergency.2 smoking is related to History and Physical A primary abdominal hernia occurs higher infection rates) spontaneously at an area of natural The site is checked for a bulge. • Weakness of the weakness of the abdominal muscle. connective tissue Additional Tests (see Glossary) An incisional hernia bulges through a past (the material between Other tests may include: the cells of the body incision site. This issue can be the result of that gives it strength, scar tissue or weak muscles around the site. ●●Ultrasound sometimes called An epigastric hernia bulges ●●Computerized tomography (CT) scan the cellular glue) midline above the umbilicus. ●●Blood tests • Diabetes mellitus ●●Urinalysis • Pulmonary disease ●●Electrocardiogram (ECG)—for patients over 45 or if high risk of heart problems

2 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Surgical and Ventral Hernia Repair Nonsurgical Treatment

Open Repair

Double Mesh Repair

Laparoscopic Repair Single Sutured Muscle Repair Mesh Mesh Repair Repair

Laparoscopic Hernia Repair Surgical Treatment Keeping You The surgeon will make several small The type of operation depends on the hernia punctures or incisions in the abdomen. Informed size, location, and if it is a repeat hernia. Your Ports or trocars (hollow tubes) are inserted health, age, anesthesia risk, and the surgeon’s into the openings. Surgical tools are placed Open versus Laparoscopic expertise are also important. An operation into the ports. The abdomen is infl ated Incisional Repair is the only treatment for a hernia repair. with carbon dioxide gas to make it easier There is no one type of repair for the surgeon to see the hernia. Mesh is Open Hernia Repair that is good for all ventral sutured, stapled, or clipped to the muscle hernias. Laparoscopic repairs are The surgeon makes an incision near the around the hernia site. The hernia site associated with lower infection hernia site. The bulging tissue is gently can also be sewn directly together. pushed back into the abdomen. Sutures, rates and shorter hospital mesh, or a tissue fl ap is used to close the stays. There is no diff erence in muscle. With complex or large hernias, small Nonsurgical Treatment recurrence rates, long-term pain, drains may be placed going from inside to or quality of life. For patients the outside of the abdomen. The site is closed Watchful waiting is an option for a hernia with strangulated intestines using sutures, staples, or surgical glue. without symptoms. All patients should and infections, the laparoscopic get treatment if they have sudden sharp approach may not be an option.1,6,7 Open Mesh Repair abdominal pain and vomiting. These Will My Hernia Come Back? The hernia sac is removed. Mesh is symptoms can indicate an incarcerated placed over the hernia site. The mesh hernia and . Mesh reduces the risk that the hernia will return again.8 Mesh can is attached using sutures sewn into the Trusses or belts made to apply pressure on be tacked, stapled, or sutured. stronger tissue surrounding the hernia a hernia require correct fi tting. When used site. Mesh is often used for large hernia correctly, part or complete control of the Obesity and wound complications repairs and may reduce the risk that the hernia was achieved in 31% of patients, and increase the risk of recurrence.9 hernia will come back. The site is closed 64% found the truss to be uncomfortable.5 You may be placed on a weight using sutures, staples, or surgical glue. loss, smoking cessation, or a diabetes control program before an elective repair to support the best outcome.

3 Ventral Hernia Repair Risk of this Procedure SAMPLE

Risks from Outcomes Reported Percentage Keeping You Informed in the Last 10 Years of Literature

Urinary retention: Inability to urinate 21% General anesthesia, older age, prostate problems, and diabetes after the urinary catheter is removed may be associated with urinary retention. A temporary catheter or medication may be used to treat retention.

Seroma: A collection of 12% A seroma usually goes away on its own within 4 to 6 weeks. serous (clear/yellow) fluid Rarely, the fluid is removed with a sterile needle.10

Recurrence: A hernia can recur Open 12% Recurrence rates are higher for complex or infected hernia repair up to several years after repair Laparoscopic 10% or for repairs done without mesh. In a 5-year follow-up, 6% to 20% 11 of patients with mesh repair experienced serious complications, Non-Mesh17% including bowel obstruction, fistulas, or tunneling wounds.12

Intestines/bowel injury Open Less than 1% Injury will be repaired at the time of operation. If there is bowel Laparoscopic 4.3% 13 leakage into the abdominal cavity, the hernia repair will be done after the bowel heals. A nasogastric (NG) tube will be placed to keep the stomach empty until fluid is moving through the bowel.

Risks Based on the ACS Risk Percentage Keeping You Informed Calculator in June 2017*

Wound infection: Infection at the Open 3.9% Antibiotics and drainage of the wound may be needed. Smoking area of the incision or near the Laparoscopic Less than 1% can increase the risk of infection. where was performed

Return to surgery: The need to go Open 2.5% Significant pain and bleeding may cause a return to surgery. back to the operating room due to Laparoscopic Less than 1% Your surgical and anesthesia team is prepared to reduce all a problem after the prior surgery risks of return to surgery.

Pneumonia: Infection in the lungs Open: 1.2% Stopping smoking, movement and deep breathing after your Laparoscopic Less than 1% operation can help prevent respiratory infections.

Urinary tract infection: Infection Open 1.2% Drinking fluids and catheter care decrease the risk of of the bladder or kidneys Laparoscopic Less than 1% bladder infection.

Blood clot: A clot in the legs Open 1.1% Longer surgery and bed rest increase the risk. Getting up, walking that can travel to the lung Laparoscopic Less than 1% 5 to 6 times per day, and wearing support stockings reduce the risk.

Heart complication: Includes heart Less than 1% Problems with your heart or lungs can be aggravated by general attack or sudden stopping of the heart anesthesia. Your anesthesia provider will take your history and suggest the best option for you.

Renal (kidney) failure: Kidneys no Less than 1% Preexisting renal conditions; fluid imbalance, Type 1 diabetes; over longer function in making urine and/or age 65; antibiotics; and other medications may increase the risk. cleaning the blood of toxins

Death Less than 1%

Any complication, including: Surgical Open 9.7% Complications related to general anesthesia and surgery may be infections, breathing difficulties, blood Laparoscopic 2.9% higher in smokers, elderly and obese patients, and those with high clots, renal (kidney) complications, blood pressure and breathing problems. Wound healing may also cardiac complications, and return to the be decreased in smokers and those with diabetes and immune operating room system disorders. *The ACS Surgical Risk Calculator estimates the risk of an unfavorable outcome. Data is from a large number of patients who had a surgical procedure similar to this one. If you are healthy with no health problems, your risks may be below average. If you smoke, are obese, or have other health conditions, then your risk may be higher. This information is not intended to replace the advice of a doctor or health care provider. To check your risks, go to the ACS Risk Calculator at http://riskcalculator.facs.org.

4 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Expectations: Preparing Ventral Hernia Repair for Your Operation

What You Can Expect The Day of Your Questions Home Medication Operation to Ask Bring a list of all of the medications, vitamins, and ●●You should not eat or drink for at any over-the-counter medicines that you are taking. least 6 hours before the operation. About my Your medications may have to be adjusted before operation: ●●You should bathe or shower and your operation. Some medications can affect your clean your abdomen with a mild • What are the side recovery and response to anesthesia. Most often you antibacterial soap. effects and risks will take your morning medication with a sip of water. of anesthesia? ●●You should brush your teeth and Anesthesia rinse your mouth with mouthwash. • What technique Let your anesthesia provider know if you have ●●Do not shave the surgical site; the surgical will be used to allergies, neurologic disease (epilepsy, stroke), heart team will clip the hair near the incision site. repair the hernia disease, stomach problems, lung disease (asthma, (laparoscopic or emphysema), endocrine disease (diabetes, thyroid ●●Let the surgical team know if you are not open; mesh or conditions), or loose teeth; use alcohol or drugs; feeling well or if there have been any with sutures)? take any herbs or vitamins; or if you have a history of changes in your health since last seeing and vomiting with anesthesia. your surgeon. • What are the risks of this procedure If you smoke, you should let your surgical team know, What to Bring for me? and you should plan to quit. Quitting before your ●●Insurance card and identification surgery can decrease your rate of respiratory and • Will you be wound complications and increase your chances of ●●Advance directives (see glossary) performing the staying smoke-free for life. Resources to help you quit ●●List of medicines entire operation may be found at www.facs.org/patienteducation or yourself? www.lungusa.org/stop-smoking. ●●Loose-fitting, comfortable clothes • What level of pain ●●Slip-on shoes that don’t require Length of Stay should I expect that you bend over If you have local anesthesia, you will usually go and how will it home the same day. You may stay overnight After Your Operation be managed? if you have a repair of a large or incarcerated You will be moved to a recovery room where • How long will it hernia. A laparoscopic repair may result in a your heart rate, breathing rate, oxygen be before I can longer anesthesia time. Complications such as saturation, blood pressure, and urine output return to my normal severe nausea and vomiting or an inability to will be closely watched. Be sure that all activities (work, pass urine may also result in a longer stay. visitors wash their hands. driving, lifting)? Safety Checks Preventing Pneumonia • May I have my An identification (ID) bracelet and allergy bracelet and Blood Clots hernia repaired with your name and hospital/clinic number will Movement and deep breathing after your during a gastric be placed on your wrist. These should be checked operation can help prevent postoperative bypass surgery? by all health team members before they perform complications such as blood clots, fluid any procedures or give you medication. Your in your lungs, and pneumonia. Every surgeon will mark and initial the operation site. hour, take 5 to 10 deep breaths and Fluids and Anesthesia hold each breath for 3 to 5 seconds. An intravenous line (IV) will be started to give you When you have an operation, you are at fluids and medication. For general anesthesia, you risk of getting blood clots because of not will be asleep and pain free during the operation. A moving during anesthesia. The longer and tube may be placed down your throat to help you more complicated your surgery, the greater breathe during the operation. For spinal anesthesia, the risk. This risk is decreased by getting up a small needle with medication will be placed in and walking 5 to 6 times per day, wearing your back alongside your spinal column. You will special support stockings or compression be awake during the operation but pain-free. boots on your legs, and for high-risk patients, taking a medication that thins your blood. 5 Ventral Hernia Repair Your Recovery and Discharge SAMPLE

Your Recovery Keeping You and Discharge Informed Thinking Clearly High-Fiber Foods If general anesthesia is given or if you need Foods high in fi ber include beans, to take narcotics for pain, it may cause you to Handwashing Steri-Strips® feel diff erent for 2 or 3 days, have diffi culty bran cereals and whole-grain Wound Care breads, peas, dried fruit (fi gs, with memory, or feel more fatigued. You apricots, and dates), raspberries, should not drive, drink alcohol, or make any ● Always wash your hands before and after blackberries, strawberries, big decisions for at least 2 days. touching near your incision site. sweet corn, broccoli, baked Nutrition ● Do not soak in a bathtub until your stitches, potatoes with skin, plums, pears, Steri-Strips®, or staples are removed. apples, greens, and nuts. ● When you wake up from the anesthesia, You may take a shower after the second you will be able to drink small amounts postoperative day unless you are told not to. of liquid. If you do not feel sick, you can begin eating regular foods. ● Follow your surgeon’s instructions on when to change your bandages. ● Continue to drink about 8 to 10 glasses of water each day. ● A small amount of drainage from the incision is normal. If the dressing is ● Eat a high-fi ber diet so you don’t strain soaked with blood, call your surgeon. while having a bowel movement. ● If you have Steri-Strips in place, Activity they will fall off in 7 to 10 days. ● Slowly increase your activity. Be sure ● If you have a glue-like covering over the to get up and walk every hour or so incision, let the glue to fl ake off on its own. to prevent blood clot formation. ● Avoid wearing tight or rough clothing. ● You may go home the same day for a It may rub your incisions and make simple repair. If you have other health it harder for them to heal. conditions or complications such as nausea, vomiting, bleeding, or infection ● Protect the new skin, especially after surgery, you may stay longer. from the sun. The sun can burn and cause darker scarring. ● Do not lift items heavier than 10 pounds or participate in strenuous ● Your scar will heal in about 4 to 6 activity for at least 6 weeks. weeks and will become softer and continue to fade over the next year. Work and Return to School Bowel Movements ● After recovery, you can usually return to work or school within 2 to 3 days. Avoid straining with bowel movements by increasing the fi ber in your diet with high- ● You will not be able to lift anything fi ber foods or over-the-counter medicines (like over 10 pounds, climb, or do strenuous Metamucil® and FiberCon®). Be sure you are Do not lift anything activity for 4 to 6 weeks following drinking 8 to 10 glasses of water each day. over 10 pounds. surgical repair of a ventral hernia. A gallon of milk Pain ● Lifting limitation may last for 6 months weighs 9 pounds. for complex or recurrent repairs.2 The amount of pain is diff erent for each person. The new medicine you will need after your operation is for pain control, and your doctor will advise how much you should take. You can use throat lozenges if you have sore throat pain from the tube placed in your throat during your anesthesia.

6 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Ventral Hernia Repair

Narcotic (Opioid) Pain Medication When to Contact Narcotics or opioids are used for severe Keeping You Your Surgeon pain. Possible side effects of narcotics are Informed Contact your surgeon if you have: sleepiness, lowered blood pressure, heart rate, and breathing rate; skin rash and Pain after Ventral ●●Pain that will not go away itching; ; nausea; and difficulty Hernia Repair ●●Pain that gets worse urinating. Some examples of narcotics include morphine, oxycodone (Percocet®/Percodan®), There was no difference in ●●A fever of more than 101°F (38.3°C) and hydromorphone (Dilaudid®). Medications long-term pain or quality of ●●Repeated vomiting can be given to control many of the side life scores when comparing effects of narcotics. laparoscopic with open ●●Swelling, redness, bleeding, or foul- procedures. Pain that continued smelling drainage from your wound site Pain Control without Medication for more than 6 months is ●●Strong or continuous abdominal Distraction helps you focus on other activities reported as 30 of 1,000 patients pain or swelling of your abdomen instead of your pain. Listening to music, having laparoscopic procedures playing games, or other engaging activities and 20 of 1,000 for open ●●No bowel movement by can help you cope with mild pain and anxiety. procedures. The cause of long- 3 days after the operation term pain will be assessed by Splinting your stomach by placing your surgeon and is sometimes a pillow over your abdomen with treated with local analgesia firm pressure before coughing or Pain Control injections.8 movement can help reduce the pain. Everyone reacts to pain in a different way. A scale from 0 to 10 is used to measure pain. Guided imagery helps you direct and At a “0,” you do not feel any pain. A “10” is control your emotions. Close your eyes the worst pain you have ever felt. Following and gently inhale and exhale. Picture a laparoscopic procedure, pain is sometimes yourself in the center of somewhere felt in the shoulder. This is due to the gas beautiful. Feel the beauty surrounding inserted into your abdomen during the you and your emotions coming back to procedure. Moving and walking help to your control. You should feel calmer. decrease the gas and the shoulder pain. Extreme pain puts extra stress on your body at a time when your body needs to focus OTHER INSTRUCTIONS: on healing. Do not wait until your pain has Guided imagery reached a “10” or is unbearable before telling your provider. It is much easier to control pain before it becomes severe. Non-Narcotic Pain Medication Most non-opioid analgesics are classified FOLLOW-UP APPOINTMENTS as non-steroidal anti-inflammatory drugs (NSAIDs). They are used to treat mild pain and WHO: inflammation or combined with narcotics to treat severe pain. Possible side effects of NSAIDs are stomach upset, bleeding in the DATE: digestive tract, and fluid retention. These side effects usually are not seen with short- term use. Let your doctor know if you have PHONE: heart, kidney, or problems. Examples of NSAIDs include ibuprofen, Motrin®, Aleve®, and Toradol® (given as a shot).

Splinting Your Stomach

7 Ventral Hernia Repair More Information SAMPLE

For more information, please go to the American College of Surgeons Patient Education website at facs.org/patienteducation. For a complete review of hernia repair, consult Selected Readings in , “Hernia” 2015 Vol. 41 No. 7 at facs.org/SRGS. GLOSSARY REFERENCES Advance directives: Documents Hematoma: A localized collection The information provided in this report is chosen from signed by a competent person of blood in the tissue or organ. recent articles based on relevant clinical research or giving direction to health care trends. The research below does not represent all that providers about treatment choices. Local anesthesia: The loss of is available for your surgery. Ask your doctor if he or she sensation only in the area of recommends that you read any additional research. Blood tests: Tests usually include a the body where an anesthetic Chem-6 profile (sodium, potassium, drug is applied or injected. 1. Kurian A, Gallagher S, Cheeyandira A, et al. Predictors of in- chloride, carbon dioxide, blood hospital length of stay after laparoscopic ventral hernia repair: urea nitrogen, and creatinine) and Nasogastric tube: A soft plastic Results of multivariate logistic regression analysis. Surg Endosc. 2010 complete blood count (red blood tube inserted in the nose and Nov;24(11):2789-2792. doi: 10.1007/s00464-010-1048-4. cell and white blood cell count). down to the stomach; used to Epub 2010 Apr 24. empty the stomach of contents Computerized tomography and gases to rest the bowel. 2. Malangoni MA, Rosen MD, Hernias. In CM Townsend, RD Beauchamp (CT) scan: A diagnostic test using et al. Textbook of Surgery. Philadelphia, PA: Saunders, 2008. X ray and a computer to create Seroma: A collection of serous (clear/yellow) fluid. 3. Helgstrand F, Rosenberg J, Bisgaard T. Trocar site hernia after a detailed, three-dimensional laparoscopic surgery: A qualitative systematic review. Hernia. picture of your abdomen. Tunneling wounds: Wounds 2011;15:113-121. that have channels or tracts that Electrocardiogram (ECG): 4. Yahchouchy-Chouillard E, Aura T, Picone O et al. Incisional hernia extend from a wound into deeper Measures the rate and regularity related risk factors. Digestive Surgery. 2003;20:3-9. of heartbeats, the size of the layers of skin, muscle or fat. 5. Cheek CM, Williams MH, Farndon JR. Trusses in the management of heart chambers, and any Ultrasound: Sound waves are used hernia today. British Journal of Surgery. 1995;82:1611-1613. damage to the heart. to determine the location of deep structures in the body. A hand 6. Forbes SS, Eskicioglu C, McLeod RS et al. Meta-analysis of Fistula: An abnormal connection randomized controlled trials comparing open and laparoscopic between two hollow spaces, roller is placed on top of clear gel and rolled across the abdomen. ventral and incisional hernia repair with mesh. British Journal of such as blood vessels, intestines, Surgery. 2009;96:851-858. or other hollow organs. Urinalysis: A visual and chemical 7. Hwang CS, Wichterman KA, Alfrey EJ. Laparoscopic ventral hernia General anesthesia: A treatment examination of the urine, most often used to screen for urinary repair is safer than open repair: Analysis of the NSQIP data. with certain medicines that puts Journal of Surgical Research. 2009;156:213-216. you into a deep sleep so you do tract infections and kidney disease. not feel pain during surgery. 8. Brill JB, Turner PL. Long-term outcomes with transfascial sutures versus tacks in laparoscopic ventral hernia repair: A review. The American Surgeon. 2011;77:458-465. 9. Sauerland S, Korenkov M, Kleinen T, et al. Obesity is a risk factor for DISCLAIMER recurrence after incisional hernia repair. Hernia. 2004 Feb;8(1):42-46. Epub 2003 Sep 6. The American College of Surgeons (ACS) is a scientific and educational association of surgeons that was founded in 1913 to improve the quality 10. Turner PL, Park AE. Laparoscopic repair of ventral incisional hernias: of care for the surgical patient by setting high standards for surgical Pros and cons. Surgical Clinical of North America. 2008;88:85-100. education and practice. The ACS endeavors to provide procedure 11. Kokotovic D, Bisgaard T, Helgstrand F. Long-term Recurrence and education for prospective patients and those who educate them. It is not Complications Associated With Elective Incisional Hernia Repair. intended to take the place of a discussion with a qualified surgeon who JAMA. 2016 Oct 18;316(15):1575-1582. doi: 10.1001/jama.2016.15217. is familiar with your situation. The ACS makes every effort to provide 12. Burger JW, Luijendijk RW, Hop WC, et al. Long-term follow-up of a information that is accurate and timely, but makes no guarantee in this randomized controlled trial of suture versus mesh repair of incisional regard. hernia. Ann Surg. 2004 Oct;240(4):578-83. 13. Zhang Y , Zhou H, Chai Y, et al. Laparoscopic versus Open Incisional and Ventral Hernia Repair: A Systematic Review and Meta-analysis. World J Surg. 2014 Sep;38(9):2233-2240. doi: 10.1007/s00268-014- Originally reviewed January 2012 by: Revised May 2014 and July 2017 by: 2578-z. David Feliciano, MD, FACS David Feliciano, MD, FACS Mary T. Hawn, MD, FACS Mary T. Hawn, MD, MPH, FACS Kathleen Heneghan, PhD, RN Nancy Strand, MPH, RN

8 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation