Page 98 - International guidelines for groin hernia management

Hernia

anatomy on simulators does not necessarily lead to profi- translated and measured. While some believe that intensive
ciency. 34 Video assessment 35 reliably reveals the profi- mentor presence and teaching of pitfalls is pivotal, 40 other
5
ciency level for open IH repair. One study noted that the research disputes this. 47, 48 Residents do seem to be less
mental workload for experts in open IH repair is lower than frustrated with the low tech simulation. 49 There are not
for novices, supporting the need for cognitive learning enough data to prescribe the exact training modality in
prior to technical performance. which the knowledge should be transferred. The available
Teaching: Laparoscopic Hernia Repair studies suggest that cognitive and technical components are
A survey of more than 800 North American general sur- essential for meaningful outcomes.
geons and surgery residents found 59% felt they lacked the
requisite training for laparoscopic hernia repair and 26% Discussion, consensus and grading clarification
were interested in learning the technique. They were most The listed literature describes the current review of evidence-
likely to seek education in a course followed by expert based knowledge to the best of our abilities. Several large
proctoring. 36 The learning curve for the laparoscopic registry-basedstudiesandatleastonelargeRCThaverecently
techniques may be significant enough to prevent some provided updated information on the learning curves for open
surgeons from offering the technique to their patients. This and laparoscopic hernia repair. While none of our sources
underscores the need for effective training methods to represent perfect data, many have similar results which led us
ensure that patients will benefit. 36, 37 to provide strong statements and recommendations for ante-
The Cochrane Collaboration published a systematic rior mesh repair and laparoscopic TEP repairs.
review on laparoscopic surgical box model training for We did not find enough published evidence on open
surgical trainees with limited prior laparoscopic experi- tissue repair or an open posterior approach to reach firm
ence. The review included a variety of procedures, statements or recommendations. It is known that in the
including laparoscopic hernia repair. 38 It found that Shouldice Hospital surgeons are supervised in their first
laparoscopic box training improved patient outcome (e.g. 300 repairs, supporting our assumptions on learning curves
length of stay), operative time and performance. to achieve expert performance.
The review included a 2011 trial which demonstrated In our review we postulated several benchmarks to
that by achieving a proficiency level in the simulation delineate the progress of training to expert proficiency:
environment, residents performed better in the operating
• Reaching minimum safety standards
room than peers undergoing standard training and that their •
patients had fewer overnight admissions. The mastery Reaching physician-reported outcomes similar to tra-
ditionally available procedures
training included cognitive learning (anatomy review and
3
procedure steps learning) and technical skills training. The • Reaching an institutional performance level at which
the above standards and outcomes are met and patient-
trainees required on average 69 min (range 13–193 min)
reported outcomes exceed those of traditionally avail-
and 16 attempts (range 7–27) to be able to perform the
hernia repair in the low tech model 39 in mastery time able procedures
(2 min). When this was translated to the operating room, Many surgeons have graciously described their experi-
the operative time was statistically significantly improved ence with learning new procedures, especially the laparo-
by 6 min for operations with residents who underwent endoscopic TEP approach. In evaluating these reports in
training compared to operations with those who did not. the literature, several considerations apply:
The NSQIP data suggest that surgeons unaccompanied by
• Given the overall small number of expected complica-
residents perform laparoscopic hernia repair on average
tions for hernia repair, large numbers of procedures are
20 min faster. In this RCT, undergoing purposeful profi-
needed to identify a statistically significant change in an
ciency training shortened the in-OR learning curve. Others
outcome (e.g., complication, recurrence rate). When a
have proposed similar simulators, checklists and curric-
ula 4, 40–46 with the same goal. In laparoscopic training in statistically significant increase in complication occurs
in small patient cohorts (e.g., n = 20), that may signal a
general, high tech or low tech environments may be less
large effect size in complication rates.
important than the fact that knowledge and skills are

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