What Is the Influence of Simulation-Based Training Courses, the Learning Curve, Supervision, and Surgeon Volume on the Outcome in Hernia Repair?-A Systematic Review

Teaching Airway Management Using Virtual Reality: A Scoping Review

Airway management, a defined procedural and cognitive skillset embracing routine tracheal intubation and emergency airway rescue, is most often acquired through an apprenticeship model of opportunistic learning during anesthesia or acute care residency training. This training engages a host of modalities to teach and embed skill sets but is generally time- and location-constrained. Virtual reality (VR)-based simulation training offers the potential for reproducible and asynchronous skill acquisition and maintenance, an advantage that may be important with restricted trainee work hours and low frequency but high-risk events. In the absence of a formal curriculum from training bodies-or expert guidance from medical professional societies-local initiatives have filled the VR training void in an unstructured fashion. We undertook a scoping review to explore current VR-based airway management training programs to assess their approach, outcomes, and technologies to discover programming gaps. English-language publications addressing any aspect of VR simulation training for airway management were identified across PubMed, Embase, and Scopus. Relevant articles were used to craft a scoping review conforming to the Scale for quality Assessment of Narrative Review Articles (SANRA) best-practice guidance. Fifteen studies described VR simulation programs to teach airway management skills, including flexible fibreoptic bronchoscopic intubation (n = 10), direct laryngoscopy (n = 2), and emergency cricothyroidotomy (n = 1). All studies were single institution initiatives and all reported different protocols and end points using bespoke applications of commercial technology or homegrown technologic solutions. VR-based simulation for airway management currently occurs outside of a formal curriculum structure, only for specific skill sets, and without a training pathway for educators. Medical educators with simulation training and medical professional societies with content expertise have the opportunity to develop consensus guidelines that inform training curricula as well as specialty technology use.

RAWS4all project: validation of a new silicone model for robotic TAPP inguinal hernia repair

BACKGROUND

Trans-abdominal pre-peritoneal (TAPP) hernia repair is a complex procedure that presents several challenges. Even though, due to the high prevalence of inguinal hernia, TAPP technique is increasing in frequency and robotic Abdominal Wall Surgery (rAWS) is emerging as a valuable tool in this regard. Although inguinal TAPP procedure principles have been published and simulation is needed, the availability of validated models remains scarce.

METHODS

A new low-cost model was developed to simulate inguinal rTAPP repair. For validity assessment, a new TAPP-specific fidelity questionnaire and assessment scale were developed to compare the performance of novices and experts in the simulated procedure. The models used were assessed at 60 min for execution and quality score.

RESULTS

Twenty-five residents and specialists from all over the country participated in this study. Execution, quality, and global performance was higher in the seniors group compared to juniors (8.91 vs 6.36, p = 0.02; 8.09 vs 5.14, p < .001; and 17 vs. 11,5, p < .001, respectively). Overall fidelity was assessed as being very high [4.41 (3.5-5.0), α = .918] as well as face [4.31 (3.0-5.0), α = .867] and content validity [4.44 (3.2-5.0), α = .803]. Participants strongly agreed that the model is adequate to be used with the DaVinci® Robot [4.52 (3.5-5.0), α = .758].

CONCLUSION

This study shows face, content, and construct validity of the model for inguinal TAPP simulation, including for robotic surgery. Therefore, the model can be a valuable tool for learning, understanding, practicing, and mastering the TAPP technique prior to participating in the operating room.

Separating the components of an abdominal wall fellowship

Complex abdominal wall reconstruction is an emerging subspecialty yet, despite the abundance of abdominal wall hernias requiring treatment and the increasing complexity of this type of surgery, there are few opportunities for surgeons to gain subspecialist training in this field. In this paper we discuss the need for focused training in complex abdominal wall reconstruction, outline some of the problems that may be hindering the availability of such opportunities and propose potential solutions to these issues.

The Lichtenstein technique is being used adequately in inguinal hernia repair: national analysis and review of the surgical technique

INTRODUCTION

it is estimated that approximately 20 million people undergo inguinal hernia surgery annually in the world, with the Lichtenstein technique being the most performed surgical procedure. The objective of this study is to analyze the knowledge of the technical principles used in the Lichtenstein technique.

METHOD

Survey-type intersectional study approved by the research ethics committee of São Camilo University Center (CAAE: 70036523.1.0000.0062). During the research period, 11,622 e-mails were sent to members of the main national surgical societies with research on the technical principles of Lichtenstein surgery. The survey was carried out using an electronic form with 10 multiple-choice questions. The form was answered anonymously on the SurveyMonkey and Google Forms platforms.

RESULT

744 responses were received to the electronic form. Based on this number of respondents, our survey has a confidence level of 95% with a margin of error of 3.5%. It was observed that there is no standardization of the technique among the majority of responders (53.4%). Many surgeons still perform digital dissection of the spermatic cord (47%). A small number of interviewees (15.2%) performed sutures with absorbable thread in the region of the internal oblique aponeurosis, while more than half (55.2%) continued to perform sutures with non-absorbable thread. Most surgeons use a small overlap or fix the mesh juxtaposed to the pubic symphysis (51%).

CONCLUSION

Our research identified that a small percentage of respondents adequately know the technical principles of Lichtenstein surgery. The result brings us new insights into the need to review Lichtenstein technique.

Efficacy of extended view totally extra peritoneal approach versus laparoscopic intraperitoneal on lay mesh plus for abdominal wall hernias: a single center preliminary retrospective study

BACKGROUND

Laparoscopic minimally invasive surgery has become the primary treatment for ventral hernias. The laparoscopic intraperitoneal on lay mesh (IPOM) plus approach for abdominal wall hernias is the most used procedure, while extended view totally extraperitoneal (e‑TEP) repair is a newer option. This study aimed to compare the effectiveness and complications of the 2 procedures for abdominal wall hernias repair.

METHODS

This was a retrospective and comparative single-center study done at The Second Clinical Medical College, Jinan University Hospital (Shenzhen People's Hospital), Shenzhen, China. The study included patients with a 2 to 6 cm abdominal wall defect who underwent hernia repair from January 2022 to December 2022. Patients' baseline characteristics, hernia features, operative time, blood loss, postoperative pain level, and total hospitalization expenses were extracted from the medical records and compared between patients who underwent the IPOM plus and e-TEP repair.

RESULTS

A total of 53 patients were included: 22 in the e-TEP group and 31 in IPOM plus group. Patient demographic characteristics were similar between the 2 groups. The operation time of the e-TEP groups was significantly longer than the IPOM plus (98.5 ± 10.7 min vs. 65.9 ± 7.3 min, P < 0.01). Postoperative pain levels (VAS; visual analog scale) (4.2 ± 0.9 vs. 6.7 ± 0.9, P < 0.01), analgesic requirements (Tramadol) (25.0 ± 37.0 mg vs. 72.6 ± 40.5 mg, P < 0.01), length of hospital stay (1.2 ± 0.5days vs. 2.2 ± 0.6days, P < 0.01), and total hospitalization expenses (19695.9 ± 1221.7CNY vs. 35286.2 ± 1196.6CNY, P < 0.01) were significantly lower in the e-TEP group. The mean intraoperative blood loss was similar between the 2 groups. No postoperative complications were observed in either group.

CONCLUSION

The e-TEP approach for abdominal wall hernias appears to be better than IPOM plus with respect to postoperative pain levels(VAS: 4.2 ± 0.9 vs. 6.7 ± 0.9, P < 0.01), analgesic requirements(25.0 ± 37.0 mg vs. 72.6 ± 40.5 mg, P < 0.01), length of hospital stay(1.2 ± 0.5days vs. 2.2 ± 0.6days, P < 0.01), and hospitalization costs (19695.9 ± 1221.7CNY vs. 35286.2 ± 1196.6CNY, P < 0.01).

Influence of the learning curve on the immediate postoperative pain intensity after laparoscopic inguinal hernioplasty

Introduction

Inguinal hernia repairs represent one of the most commonly performed surgical operations worldwide. As more experience has been gained over the past decades with laparoscopic techniques, they are now widely used also for the repair of primary and unilateral inguinal hernias, representing a safe and effective alternative. One of the major concerns of patients undergoing inguinal hernia repair is postoperative pain and socio-professional reintegration.

Aim of study

This study started from the hypothesis that the learning curve could influence postoperative pain intensity after laparoscopic inguinal hernioplasty.

Methods

A retrospective - comparative study was performed, including a general surgeon's first consecutive cases (n=87) of TAPP (transabdominal preperitoneal procedure) hernioplasty procedures with implantation of self-gripping surgical prosthesis were investigated.

Results

The evaluation of clinical and surgical aspects resulted in similar values in case of the studied groups. A reduction in surgical time was observed in case of patients operated after completing the learning curve (p = 0.0005) On the first postoperative day patients complained mostly about persistent and severe type of pain. Average Pain Index calculated with help of Simple Numeric Pain Scale resulted in similar values. Length of analgesic treatment showed no significant differences. Although higher intensity pain was mostly caracteristic in case of patients operated during the learning process, no significant relationship between learning curve and postoperative pain intensity were highlited.

Conclusion

TAPP can be a safe technique for young surgeons as well, with the right study program the procedure can be mastered safely.

Learning curve for adoption of robot-assisted minimally invasive esophagectomy: a systematic review of oncological, clinical, and efficiency outcomes

BACKGROUND

Robot-assisted minimally invasive esophagectomy (RAMIE) is gaining increasing popularity as an operative approach. Learning curves to achieve surgical competency in robotic-assisted techniques have shown significant variation in learning curve lengths and outcomes. This study aimed to summarize the current literature on learning curves for RAMIE.

METHODS

A systematic review was conducted in line with PRISMA guidelines. Electronic databases PubMed, MEDLINE, and Cochrane Library were searched, and articles reporting on learning curves in RAMIE were identified and scrutinized. Studies were eligible if they reported changes in operative outcomes over time, or learning curves, for surgeons newly adopting RAMIE.

RESULTS

Fifteen studies reporting on 1767 patients were included. Nine studies reported on surgeons with prior experience of robot-assisted surgery prior to adopting RAMIE, with only four studies outlining a specified RAMIE adoption pathway. Learning curves were most commonly analyzed using cumulative sum control chart (CUSUM) and were typically reported for lymph node yields and operative times, with significant variation in learning curve lengths (18-73 cases and 20-80 cases, respectively). Most studies reported adoption without significant impact on clinical outcomes such as anastomotic leak; significant learning curves were more likely in studies, which did not report a formal learning or adoption pathway.

CONCLUSION

Reported RAMIE adoption phases are variable, with some authors suggesting significant impact to patients. With robust training through formal programmes or proctorship, however, others report RAMIE adoption without impact on clinical outcomes. A formalized adoption curriculum appears critical to prevent adverse effects on operative efficiency and patient care.

Risk of Reoperation for Recurrence After Elective Primary Groin and Ventral Hernia Repair by Supervised Residents

Importance

Surgical training involves letting residents operate under supervision. Since hernia repair is a common procedure worldwide, it is a frequent part of the surgical curriculum.

Objective

To assess the risk of reoperation for recurrence after elective primary groin and ventral hernia repair performed by supervised residents compared with that by specialists.

Design, Setting, and Participants

This nationwide register-based cohort study included data from January 2016 to September 2021. Patients were followed up until reoperation, emigration, death, or the end of the study period. The study used data from the Danish Inguinal and Ventral Hernia Databases linked with data from the Danish Patient Safety Authority's Online Register via surgeons' unique authorization ID. The cohort included patients aged 18 years or older who underwent primary elective hernia repairs performed by supervised residents or specialists for inguinal, femoral, epigastric, or umbilical hernias. Hernia repairs were divided into the following 4 groups: Lichtenstein groin, laparoscopic transabdominal preperitoneal (TAPP) groin, open ventral, and laparoscopic ventral.

Exposures

Hernia repairs performed by supervised residents vs specialists.

Main Outcomes and Measures

Reoperation for recurrence, analyzed separately for all 4 groups.

Results

A total of 868 specialists and residents who performed 31 683 primary groin and 7777 primary ventral hernia repairs were included in this study. The median age of patients who underwent hernia repair was 60 years (IQR, 48-70 years), and 33 424 patients (84.7%) were male. There was no significant difference in the adjusted risk of reoperation after Lichtenstein groin hernia repair (hazard ratio [HR], 1.26; 95% CI, 0.99-1.59), laparoscopic groin hernia repair (HR, 1.01; 95% CI, 0.73-1.40), open ventral hernia repair (HR, 0.89; 95% CI, 0.61-1.29), and laparoscopic ventral hernia repair (HR, 2.96; 95% CI, 0.99-8.84) performed by supervised residents compared with those by specialists. There was, however, a slightly increased unadjusted, cumulative reoperation rate after Lichtenstein repairs performed by supervised residents compared with those by specialists (4.8% vs 4.2%; P = .048).

Conclusions and Relevance

The findings of this study suggest that neither open nor laparoscopic repair of groin and ventral hernias performed by supervised residents appeared to be associated with a higher risk of reoperation for recurrence compared with the operations performed by specialists. This indicates that residents may safely perform elective hernia repair when supervised as part of their training curriculum.

Educational Scoring System in Laparoscopic Cholecystectomy: Is It the Right Time to Standardize?

Background and Objectives: Laparoscopic cholecystectomy (LC) is one of the most performed surgeries worldwide. Procedure difficulty and patient outcomes depend on several factors which are not considered in the current literature, including the learning curve, generating confusing and subjective results. This study aims to create a scoring system to calculate the learning curve of LC based on hepatobiliopancreatic (HPB) experts’ opinions during an educational course. Materials and Methods: A questionnaire was submitted to the panel of experts attending the HPB course at Research Institute against Digestive Cancer-IRCAD (Strasbourg, France) from 27–29 October 2022. Experts scored the proposed variables according to their degree of importance in the learning curve using a Likert scale from 1 (not useful) to 5 (very useful). Variables were included in the composite scoring system only if more than 75% of experts ranked its relevance in the learning curve assessment ≥4. A positive or negative value was assigned to each variable based on its effect on the learning curve. Results: Fifteen experts from six different countries attended the IRCAD HPB course and filled out the questionnaire. Ten variables were finally included in the learning curve scoring system (i.e., patient body weight/BMI, patient previous open surgery, emergency setting, increased inflammatory levels, presence of anatomical bile duct variation(s), and appropriate critical view of safety (CVS) identification), which were all assigned positive values. Minor or major intraoperative injuries to the biliary tract, development of postoperative complications related to biliary injuries, and mortality were assigned negative values. Conclusions: This is the first scoring system on the learning curve of LC based on variables selected through the experts’ opinions. Although the score needs to be validated through future studies, it could be a useful tool to assess its efficacy within educational programs and surgical courses.

A Decade Later-Progress and Next Steps for Pediatric Simulation Research

SUMMARY STATEMENT

A decade ago, at the time of formation of the International Network for Pediatric Simulation-based Innovation, Research, and Education, the group embarked on a consensus building exercise. The goal was to forecast the facilitators and barriers to growth and maturity of science in the field of pediatric simulation-based research. This exercise produced 6 domains critical to progress in the field: (1) prioritization, (2) research methodology and outcomes, (3) academic collaboration, (4) integration/implementation/sustainability, (5) technology, and (6) resources/support/advocacy. This article reflects on and summarizes a decade of progress in the field of pediatric simulation research and suggests next steps in each domain as we look forward, including lessons learned by our collaborative grass roots network that can be used to accelerate research efforts in other domains within healthcare simulation science.

Implementation of robot-assisted groin hernia repair diminishes the prospects of young surgeons' training: a nationwide register-based cohort study

PURPOSE

Robot-assisted groin hernia repair is becoming more popular in recent years but may remove operations from surgical trainees. We aimed to investigate the educational level of the surgeons who performed robot-assisted groin hernia repair and the rate of supervision and compare this to open and laparoscopic groin hernia repair.

METHODS

This register-based study was reported according to the RECORD statement and used linked data from the Danish Hernia Database and the Danish Patient Safety Authority's Online Register. We included surgeons that performed robot-assisted, laparoscopic, and/or open groin hernia repairs performed between January 1, 2015, and June 15, 2021 in Denmark.

RESULTS

A total of 916 surgeons performing 43,856 groin hernia repairs were included in this study. Surgical specialists performed 98% of the robot-assisted groin hernia repairs, 89% of the laparoscopic repairs (p < 0.0001), and 54% of the Lichtenstein repairs (p < 0.0001). Only 5% of the robot-assisted groin hernia repairs were supervised compared with 11% of the laparoscopic repairs (p < 0.0001) and 28% of the open repairs (p < 0.0001).

CONCLUSION

Almost all groin hernia repairs performed with the robot-assisted technique were performed by surgeons specialized in general surgery. The proportions of surgeons specialized in surgery were higher for robot-assisted operations compared with laparoscopic or open groin hernia surgery. Thus, our data suggest a lack of involvement of surgeons in training, and this diminishes the educational potential in the pool of groin hernia operations by the use of robot-assisted repairs.

Robot-assisted groin hernia repair is primarily performed by specialized surgeons: a scoping review

Surgical residents routinely participate in open and laparoscopic groin hernia repairs. The increasing popularity of robot-assisted groin hernia repair could lead to an educational loss for residents. We aimed to explore the involvement of surgical specialists and surgical residents, i.e., non-specialists, in robot-assisted groin hernia repair. The scoping review was reported according to PRISMA-ScR guideline. A protocol was uploaded at Open Science Framework, and a systematic search was conducted in four databases: PubMed, EMBASE, Cochrane CENTRAL, and Web of Science. Included studies had to report on robot-assisted groin hernia repairs. Data charting was conducted in duplicate. Of the 67 included studies, 85% of the studies described that the robot-assisted groin hernia repair was performed by a surgical specialist. The rest of the studies had no description of the primary operating surgeon. Only 13% of the included studies reported that a resident attended the robot-assisted groin hernia repair. Thus, robot-assisted groin hernia repair was mainly performed by surgical specialists, and robot-assisted groin hernia repair therefore seems to be underutilized to educate surgical residents.

Learning curve analysis using the cumulative summation method for totally extraperitoneal repair of the inguinal hernia

PURPOSE

The totally extraperitoneal repair (TEP) technique has been widely performed, and compared with open surgery, TEP results in less postoperative pain and similar surgical outcomes in the treatment of inguinal hernias. However, TEP has a longer learning curve than does conventional surgery.

METHODS

The data for patients who underwent TEP for inguinal hernias by a single surgeon between April 2017 and July 2019 were analyzed retrospectively. The cumulative summation (CUSUM) method and the following two variables were used to analyze the learning curve: (1) the operation event (OE), including intraoperative complications and conversion to open surgery; and (2) the operation score (OS), as calculated by the operation time, patient body mass index, and disease characteristics.

RESULTS

The CUSUM chart showed three phases for both the OE and OS. The former reached a first inflection point after the 85th case and decreased after the 200th case, and the latter reached a plateau after the 101st case and decreased after the 203rd case. The operation time was longer in phases 1 and 2 than in phase 3 (64.2 min versus 47.9 min versus 31.1 min; p < 0.001), and the OS was lower in phase 3 than in the other phases (71.9 points versus 106.4 points versus 142.7 points; p < 0.001). Ten cases of intraoperative complications were observed, all in the first and second phases (p = 0.011).

CONCLUSION

At least approximately 100 cases are required for the initial learning period, and an additional 103 cases are required for the accumulation of additional experience. Surgical competency can be gained after 203 TEPs are performed.

Risk Factors for Conversion in Laparoscopic Totally Extraperitoneal Inguinal Hernioplasty

BACKGROUND

Conversion is a surgical concern because the surgical technique can change during surgery. Surprisingly, there is no study in the literature on the causes and risk factors leading to conversion in laparoscopic total extraperitoneal inguinal repair (TEP). There is also no consensus on the prevention and causes of this condition in TEP. The aim of this study was to evaluate the risk factors underlying the development of conversion during TEP.

MATERIALS AND METHODS

We recruited 962 consecutive patients who underwent TEP between May 2016 and May 2021. All data were collected retrospectively. The outcomes of patients who converted to open surgery were compared with those without conversion. Multivariate analysis identified independent risk factors for conversion.

RESULTS

The overall incidence of conversion was 4.05% (n=39). The median age was 42 years (18 to 83) and body mass index was 25.2 kg/m2 (15.67 to 32.9). Significant clinical factors associated with conversion included old age, American Society of Anesthesiologists (ASA) score, large peritoneal tear (PT), Charlson comorbidity index, previous surgery, large hernial defects, presence of scrotal hernia, and the defect size of inguinal hernia. Multivariate analysis identified independent risk factors for conversion: large hernial defect, large PT, previous lower abdominal surgery, previous hernia surgery, and scrotal hernia.

CONCLUSION

Conversion is a minor complication seen during TEP and its incidence varies depending on many factors. Previous lower abdominal surgery and a large PT carries a 6-fold increased risk for conversion from laparoscopic to open surgery during TEP.

Assessing Operative Skill in the Competency-based Education Era: Lessons From the UK and Ireland

INTRODUCTION

Decisions regarding the operative competence of surgical residents in the United Kingdom and Ireland are informed by operative workplace-based assessments (WBAs) and operative number targets for index procedures. This review seeks to outline the validity evidence of these assessment methods.

METHODS

A review of the MEDLINE (Pubmed), EMBASE and Cochrane Library databases was undertaken in accordance with the Joanna Briggs Institute Protocol for Scoping Reviews (2020). Articles were included if they provided evidence of the validity of procedure-based assessments, direct observation of procedural skills, or indicative operative number targets. The educational impact of each article was evaluated using a modified Kirkpatrick model.

RESULTS

Twenty-eight articles outlining validity evidence of WBAs and operative number targets were synthesised by narrative review. Five studies documented users' views on current assessment methods (Kirkpatrick level 1). Two articles recorded changes in attitudes towards current operative assessments (level 2a). Ten studies documented the ability of current assessments to record improvements in operative competence (level 2b). Ten studies measured a change in behaviour as a result of the introduction of these assessments (level 3). One article studied the ability of operative assessments to predict clinical outcomes (level 4b).

CONCLUSIONS

Operative WBAs are reliable. Scores achieved correlate with both time spent in training and recorded operative experience. Trainers and residents have concerns regarding the subjectivity of these assessments and the opportunistic nature in which they are used. Operative number targets are not criterion-referenced, lack validity evidence, and may be set too low to ensure operative competence.

Latest Trends on the Attenuation of Systemic Foreign Body Response and Infectious Complications of Synthetic Hernia Meshes

Throughout the past few years, hernia incidence has remained at a high level worldwide, with more than 20 million people requiring hernia surgery each year. Synthetic hernia meshes play an important role, providing a microenvironment that attracts and harbors host cells and acting as a permanent roadmap for intact abdominal wall reconstruction. Nevertheless, it is still inevitable to cause not-so-trivial complications, especially chronic pain and adhesion. In long-term studies, it was found that the complications are mainly caused by excessive fibrosis from the foreign body reaction (FBR) and infection resulting from bacterial colonization. For a thorough understanding of their complex mechanism and providing a richer background for mesh development, herein, we discuss different clinical mesh products and explore the interactions between their structure and complications. We further explored progress in reducing mesh complications to provide varied strategies that are informative and instructive for mesh modification in different research directions. We hope that this work will spur hernia mesh designers to step up their efforts to develop more practical and accessible meshes by improving the physical structure and chemical properties of meshes to combat the increasing risk of adhesions, infections, and inflammatory reactions. We conclude that further work is needed to solve this pressing problem, especially in the analysis and functionalization of mesh materials, provided of course that the initial performance of the mesh is guaranteed.

[Pain and quality of life after laparoscopic transabdominal preperitoneal hernioplasty with different ways of fixing the peritoneum. Results of early completion randomized clinical trial]

OBJECTIVE

To compare and statistically evaluate the severity of pain syndrome and quality of life depending on the method of fixation of the parietal peritoneum during laparoscopic hernia repair (suture fixation or the use of tack fixation).

METHODS

A randomized clinical trial was conducted from May to June 2021 at the Lomonosov Moscow State University Medical Center. It was planned to observe patients for a year. In the first group, the fixation of the parietal peritoneum was performed using suture fixation, in the second group, the peritoneal flap was fixed using a fixation device. In the course of statistical data processing, it was planned to study the dependence of the duration of the operation, the severity of the pain syndrome in the early postoperative period, the frequency of complications, the quality of life of patients in the postoperative period on the chosen method of the fixation of the parietal peritoneum.

RESULTS

At the initial stage of the study, 8 patients with inguinal hernias were selected in the first group during randomization, and 6 patients were selected in the second group. Each patient of the second group in the early postoperative period had a more pronounced local pain, protective muscle tension in the projection of fixation of the parietal peritoneum with tacks, which was accompanied by negative psychoemotional reactions, an increase in the dose of analgesic drugs. Due to the revealed features of the early postoperative period in patients of second group, it was considered unethical and inappropriate to continue the study within the protocol.

CONCLUSION

The results obtained do not allow us to draw statistically supported conclusions. The solution of the problem of the peritoneal flap fixation method is possible in two ways: abandoning stapler fixation in favor of suture or conducting additional clinical studies with an analysis of the impact of the choice of peritoneal fixation technique not only on acute and chronic postoperative pain, but on quality of life in the early and delayed postoperative periods.

Achieving physical examination competence through optimizing hands-on practice cycles: a prospective cohort comparative study of medical students

Background

Deliberate practice (DP) was proposed for effective clinical skill training, which highlights focused, repetitive practice and feedback as the key points for practice. Although previous studies have investigated the effect of feedback in DP, little is known about the proper repetitive cycles of clinical skills training especially in physical examination (PE) training.

Methods

We drew learning curves and designed a comparative study to find out the optimal number of hands-on practice cycles, an important aspect of DP, in abdominal PE training for medical students. A comparative study was conducted to validate the optimal number of hands-on practice by dividing students into two cohorts including Cohort A (high-frequency hand-on training) and B (low-frequency hand-on training).

Results

The learning curve study of 16 students exhibited a threshold of four repetitive practices when 81.25% students reached the competence score. A total of 74 students’ final exam scores were collected for analysis. Students in Cohort A (4–5 PEs) scored significantly higher than those in Cohort B (≤3 PEs) (84.41 ± 11.78 vs 76.83 ± 17.51] in the final exam (P = 0.030)).

Conclusion

High-frequency practice can improve students’ competence of abdominal PE skill. We recommend four cycles of hands-on practice for each student in a training course like PE training.

Assessment of the Educational Quality, Accuracy, and Transparency of WebSurg Videos on Minimally Invasive Video-Assisted Parathyroidectomy

Background

The internet has changed the way both physicians and patients search for health information. WebSurg® is a valuable source of information that informs surgeons about new technologies and techniques and aims to promote quality, safety, and patient-centered care. In this study, our aim is to evaluate the popularity, quality, transparency, and accuracy of videos about minimally invasive video-assisted parathyroidectomy (MIVAP).

Materials and methods

A total of 31 videos related to MIVAP returned by the WebSurg® search engine in response to the keywords “MIVAP”, “video assisted parathyroidectomy’’, and “minimally invasive parathyroidectomy’’ were included in this study. Videos were evaluated in terms of time since upload, run time, country, academic degree, and the number of views and likes. The popularity of videos was determined by the video power index (VPI) formula. The DISCERN questionnaire score (DISCERNqs), global quality score (GQSc), and Journal of American Medical Association benchmark criteria (JAMABC) scoring systems were used to analyze WebSurg® videos for reliability and quality.

Results

The academic degree of the members was MD in 90.32% of uploaded videos. Forty-eight point thirty-eight percent (48.38%) of the videos were uploaded by members from France. There was no significant difference between the DISCERNqs, JAMABC, GQSc, and MIVAP scoring system (MIVAP-SS) scores in terms of academic degree and country. A statistically significant negative correlation was found between the time since upload and the VPI score (r=-0.683, p<0.001). The run time was positively correlated with the DISCERNqs, JAMABC, GQSc, and MIVAP-SS scores (p=0.003, p=0.002, p=0.003, p<0.001, respectively). For the MIVAP-SS score, the Spearman correlation analysis demonstrated a statistically significant positive correlation with VPI, DISCERNqs, JAMABC, and GQSc (p<0.05).

Conclusion

Videos about MIVAP are helpful for surgeons to learn the procedure step-by-step before the surgery they will be performing but still below the expected quality. It is recommended to use MIVAP-SS points, which is a novel scoring system, to ensure standardization and improve quality.

Proctored preceptorship model for learning eTEP repair for inguinal hernia for general surgery residents

BACKGROUND

Enhanced-view total extra-peritoneal (eTEP) inguinal hernia repair is a technically demanding procedure with a steep learning curve.

AIM

Examine the feasibility and effectiveness of an instructor approach to teaching residents how to perform laparoscopic eTEP independently following a dedicated course of individual teaching.

METHODS

Prospective analysis of eTEP procedures performed by residents between March 2018 and September 2020. Six residents dispersed into three groups-Group A: two junior residents, Group B: two mid-level residents and Group C: two senior residents. All residents performed a unilateral IHR comprised of five core steps. Data reviewed for each procedure included the time of each step, total time and autonomy degree as assessment for every step: 1st degree-dependent (physical assistance), 2nd degree-partially dependent (vocal assistance) and 3rd degree-independent. Early and late procedures were divided at 50% of cases.

RESULTS

Participants performed 44 procedures (220 steps). Late procedures presented with a significant improvement in all degrees of autonomy (1st degree p = 0.002, 2nd degree p = 0.007 and 3rd degree p < 0.0001) and in every step (Step 1 p = 0.015, Step 2 p = 0.006, Step 3 p < 0.0001, Step 4 p < 0.0001, Step 5 p = 0.002). There was no significant difference in surgery duration between early and late procedures (p = 0.32). At early procedures, junior residents needed significantly higher rates of physical intervention (1st degree) compared to the senior residents (p = 0.004). Conversely, there was no significant difference in 2nd degree of autonomy (p = 0.46), 3rd degree (p = 0.06) and surgery duration (p = 0.16). The last three procedures performed by all participants had no significant difference between the seniority groups in autonomy (1st degree p = 0.1, 2nd degree p = 0.18 and 3rd degree p = 0.1).

CONCLUSION

Dedicated course with an individual instructor's approach is effective in achieving competence, autonomy and confidence in performing eTEP in a short time.

Prophylactic Onlay Mesh Repair (POMR) Versus Primary Suture Repair (PSR) for Prevention of Incisional Hernia (IH) After Abdominal Wall Surgery: A Systematic Review and Meta-analysis

BACKGROUND

With many different operative techniques in use to reduce the incidence of incisional hernias (IH) following a midline laparotomy, there is no consensus among the clinicians on the efficacy and safety of any particular repair technique. This meta-analysis compares the prophylactic onlay mesh repair (POMR) and primary suture repair (PSR) for the incidence of IH.

METHODS

A meta-analysis and systematic review of MEDLINE, PubMed Central (via PubMed), Embase (via Ovid), SCOPUS, ScienceDirect, Google Scholar, SCI and Cochrane Library databases were undertaken. Seven randomized controlled trials assessing the outcomes of PSR and POMR were analyzed in accordance with the PRISMA statement. The risk of bias was assessed using the Rob2 tool.

RESULTS

According to the pooled analysis, POMR significantly reduced the incidence of IH compared to the PSR (OR 5.82 [95% CI 2.69, 12.58] P < 0.01) with a significantly higher seroma formation rate post-surgery (OR 0.35 [95% CI 0.18, 0.67] P < 0.01). Furthermore, the length of hospital stay (WMD -0.78 [95% CI -1.58, 0.02] P = 0.05) was significantly shorter for PSR compared to POMR group. Comparable effects were noted for reintervention, postoperative ileus, postoperative hematoma, postoperative mortality, long-term intervention and long-term deaths between the two groups.

CONCLUSIONS

POMR significantly reduces the risk of IH when compared to the PSR, with an increased risk of postoperative seroma formation and longer hospital stay. However, more RCTs with standardized protocols are needed for meaningful comparisons of the two interventions, along with longer duration of follow-up to assess the impact on the occurrence of IH.

Long-Term Trends and Predictors of Medical Resource Utilization and Medical Outcomes in Inguinal Hernia Repair: A Nationwide Cohort Study

BACKGROUND

Few studies have comprehensively and systematically analyzed nationwide samples. This study purposed to explore temporal trends and predictors of medical resource utilization and medical outcomes in these patients to obtain data that can be used to improve healthcare policies and to support clinical and administrative decision-making.

METHODS

This study used nationwide population data contained in the Longitudinal Health Insurance Database of Taiwan. The 14,970 inguinal hernia repair patients were enrolled in this study (age range, 18-100 years) from 1997 to 2013 in Taiwan. After temporal trends analysis of demographic characteristics, clinical characteristics, and institutional characteristics, predictors of postoperative medical resource utilization and medical outcomes were evaluated through multiple linear regression analysis and Cox regression analysis.

RESULTS

The prevalence of inguinal hernia repair per 100,000 population significantly decreased from 195.38 in 1997 to 39.66 in 2013 (p < 0.05). Demographic characteristics, clinical characteristics, and institutional characteristics were significantly associated with postoperative medical resource utilization and medical outcomes (p < 0.05). Of these characteristics, both surgeon volume and hospital volume had the strongest association.

CONCLUSIONS

The inguinal hernia repair prevalence rate gradually decreased during the study period. Demographic characteristics, clinical characteristics, and institutional characteristics had strong associations with postoperative medical resource utilization and medical outcomes. Furthermore, hospital volume and surgeon volume had the strongest associations with postoperative medical resource utilization and medical outcomes. Additionally, providing the education needed to make the most advantageous medical decisions would be a great service not only to patients and their families, but also to the general population.

Simulation in Hernia Surgery: Where Do We Stand?

Simulation seems to be the best method of improving medical attitude, technical skills, and operating times. A literature review of the available data in simulation for hernia surgery was performed. Surgical simulation has been included as a main requirement in residency programs and endorsed by several surgical societies. However, evaluating how simulation affects patient's outcomes is challenging. In addition, simulation training represents an institutional economic burden that could undermine its implementation and development. Published data support that simulation-based training is a highly efficient tool, thus, its implementation should be strongly encouraged.

Learning Curve for Minimally Invasive Surgery and How to Minimize It

In this article the authors discuss their experience of performing minimally invasive surgery, with emphasis on technique and how to avoid pitfalls. They also discuss the educational literature for learning new techniques and how to shorten the "learning curve."

[Learning curves in acquisition of experience for new technologies]

OBJECTIVE

Analysis of national and foreign trials investigating accumulation of experience in innovative technologies using the learning curves.

MATERIAL AND METHODS. S

Earching for Russian-language manuscripts was carried out within the references of the articles and in the ELIBRARY database. Foreign trials were selected from the PubMed database according to the keywords «learning curves in surgical practice». The discovered publications were studied for accordance with the objectives of this study.

RESULTS

Accumulation of experience in new technologies by using of learning curves is valuable to improve the training, determine duration of development of new technology and the factors affecting its characteristics.

CONCLUSION

The method is high-quality for comprehensive analysis of experience accumulation in new surgical technologies.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery

INTRODUCTION

The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature.

METHODS

A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated.

RESULTS

All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures.

CONCLUSION

A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

Development and evaluation of a novel simulation model for transabdominal preperitoneal (TAPP) inguinal hernia repair

BACKGROUND

Transabdominal preperitoneal (TAPP) inguinal hernia repair requires the surgeon to have good manual skills in laparoscopic surgery, as well as an understanding of the laparoscopic features of the groin anatomy. This is why TAPP is considered a more difficult surgical procedure compared to open techniques. Realistic training model for TAPP inguinal hernia repair would enhance surgeons' skills before they enter in the operation room. Our aim was to create a realistic, inexpensive, and easily reproducible model for laparoscopic TAPP inguinal hernia repair and to assess its effectiveness.

METHODS

The applied TAPP inguinal hernia repair training simulator consists of a laparoscopic box and an inguinal region model placed in it. The model of the groin area is made of the porcine stomach and assembling materials. Uniaxial tensile and T-peel tests were performed to compare the mechanical properties of the porcine stomach and the human cadaver peritoneum. Thirty eight surgeons performed TAPP inguinal hernia repair using this model. Their opinions were scored on a five-point Likert scale.

RESULTS

Close elastic modules of the porcine and human tissues (13.5 ± 4.2 kPa vs. 15.8 ± 6.7 kPa, p = 0.531) gave to trainees a realistic tissue feel and instrument usage. All participants strongly agreed that model was highly useful for TAPP inguinal hernia repair training. They also put the following points: the model as a whole 5 (3-5), simulation of anatomy 5 (3-5), simulation of dissection and mobilization 5 (3-5), and simulation of intracorporeal suture 5 (4-5).

CONCLUSIONS

We successfully created a model for TAPP inguinal hernia repair training. The model is made of inexpensive synthetic and biological materials similar to the human tissue. The model is easy to reproduce and can be used in the training programs of surgical residents.

TEP for elective primary unilateral inguinal hernia repair in men: what do we know?

INTRODUCTION

Based on the new international guidelines for groin hernia management, there is no one surgical technique that is suited to all patient characteristics and diagnostic findings. Therefore, a tailored approach should be used. Here, a distinction must be made between primary unilateral inguinal hernia in men and in women, bilateral inguinal hernia, scrotal inguinal hernia, inguinal hernia following pelvic and lower abdominal procedures, patients with severe cardiopulmonary complications, recurrent inguinal hernias and incarcerated inguinal and femoral hernias. This paper now explores the relevant studies on TEP for elective primary unilateral inguinal hernia in men, which constitutes the most common indication for repair.

MATERIAL

A systematic search of the available literature was performed in February 2019 using Medline, PubMed, Scopus, Embase, Springer Link and the Cochrane Library. Only meta-analyses, systematic reviews, RCTs and comparative registry studies were considered. 117 publications were identified as relevant.

RESULTS

RCTs and comparative registry analyses demonstrated the advantages of TEP with regard to postoperative complications, complication-related reoperations, and postoperative and chronic pain compared with Lichtenstein repair for elective primary unilateral inguinal hernia repair in men. No relevant differences were found compared with TAPP. Mesh fixation is not needed in TEP, but heavyweight meshes result in a lower recurrence rate. Extraperitoneal bupivacaine analgesia vs placebo does not demonstrate any advantages, but drainage is advantageous for seroma prophylaxis. The risk of chronic pain is negatively influenced by small defects, younger patient age, preoperative pain, higher BMI, postoperative complications, higher ASA score and risk factors.

CONCLUSION

For the subgroup of elective primary unilateral inguinal hernia in men, accounting for a proportion of less than 50% of the total collective, advantages were identified for TEP compared with open Lichtenstein repair but not versus TAPP.