Mastery Learning Inguinal Hernia Repair
Condition: Inguinal Hernia
MeSH terms: Hernia; Hernia, Inguinal
Study type: Interventional

Summary: 
      Abstract: Minimally invasive techniques are now ubiquitous in the management of surgical
      disease. Competence in laparoscopy requires specialized training and practice. With the
      decrease of resident work hours, training programs need to explore and adopt efficient
      strategies to teach and evaluate laparoscopic skills. For economic, ethical, and legal
      considerations, the operating room may no longer be the ideal environment for teaching these
      basic technical skills. There appears to be a role for simulation in response to this need.
      The transfer of laparoscopic skills learned in a simulated environment to the operating room
      has showed mixed results. Overall, it seems that surgical skills training outside the
      operating room is beneficial, but the best method(s) of designing, implementing and
      evaluating such skills curriculums have yet to be identified.

      The laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is an example of a
      procedure that is associated with a steep learning curve and requires mastery of basic
      laparoscopic skills. In addition, an increased recurrence and complication rates in the early
      learning curve of this procedure, underscores the importance of adequate training. The
      current practice of teaching the TEP repair in the operating room under an
      apprenticeship-based model is associated with increased operative time and costs. We propose
      that the training of surgical trainees outside the operating room with a structured, mastery
      oriented simulation-based curriculum will help reduce the learning curve of the TEP repair,
      improve operative performance, and decrease operative time and costs.
    

Detailed description: 
      Specific Aims:

      Inguinal hernias are a common ailment of the general population. Their surgical management
      through a laparoscopic totally extraperitoneal (TEP) approach has been shown to lead to less
      discomfort and faster recovery than do classic open repairs with equal effectiveness.
      Nonetheless, the TEP repair has not been adopted widely because of concerns regarding a
      substantial learning curve. In addition, the current practice of teaching the TEP procedure
      in the operating room under an apprenticeship-based model is associated with increased
      operative time and cost. The training of surgeons in laparoscopic skills outside the
      operating room with simulation-based strategies has emerged as an attractive alternative.
      Many studies have demonstrated that trainees who practice laparoscopic skills in a simulated
      environment show improvement of those skills when tested in that same environment. Few
      studies however, have been able to demonstrate a direct correlation between such simulation
      training and improved performance in the operating room. It appears from these studies that
      surgical skills training outside the operating room is beneficial, but the best methods have
      yet to be identified.

      Our long-term research goal is to explore and adopt efficient simulation-based strategies to
      teach and evaluate surgical skills to surgical trainees. Our objective for this study is to
      design and evaluate a simulation-based curriculum based upon the concepts of mastery learning
      theory (achievement of pre-specified expert-derived benchmarks without time constraints) and
      to develop an objective mean of assessing operative performance that will both aid in
      shortening the learning curve of the TEP inguinal hernia repair for surgical trainees. Our
      central hypothesis is that the training of surgery residents outside the operative room with
      simulation-based strategies, such as the TEP mastery learning curriculum will improve
      operative performance and reduce operative time during the TEP repair. The rationale for this
      study is that the identification of effective strategies to shorten the learning curve of the
      TEP repair that translate into decreased operative time will not only increase the adoption
      of the TEP repair with its inherent benefits to more candidate patients, but will also lead
      to substantial cost-savings and perhaps improved patient outcomes. We are especially well
      prepared to complete this study as we are a part of an academic referral center that treats a
      myriad of inguinal hernias patients and educates hundreds of surgical residents on a
      continuous basis.

      Specific Aim 1: To compare the TEP mastery learning curriculum with the apprenticeship-based
      model of learning the TEP repair in the operative room on operative time and operative
      performance of TEP inguinal hernia repairs performed by surgical trainees.

      Hypothesis 1a: Surgical trainees who undergo the TEP mastery learning curriculum will achieve
      lesser mean operative times while performing a TEP inguinal hernia repair when compared to
      those who followed the apprenticeship-based model.

      Hypothesis 1b: Surgical trainees who undergo the TEP mastery learning curriculum will achieve
      greater mean operative performance scores while performing a TEP inguinal hernia repair when
      compared to those who followed the apprenticeship-based model.

      Secondary Aim:

      Compare the rate of TEP inguinal hernia repair post-operative complications, specifically
      urinary retention for patients operated on by surgical residents who underwent the mastery
      learning curriculum versus those who underwent the apprenticeship-based model.

      This research is innovative because it will challenge the current paradigm of teaching basic
      laparoscopic skills in the operative room and will strive to link surgical education methods
      to objective patient level outcomes such as operative time and cost. At the completion of
      this project, it is our expectation that we will be better prepared to continue our efforts
      of translating new educational modalities/technologies to improve the delivery of healthcare.
      Our anticipated findings will have a relevant impact in how we educate the surgeons of
      tomorrow.
    

Intervention name(s): Mastery Learning TEP Curriculum; Current Practice
Intervention type(s): Behavioral; Procedure
Intervention description(s): A simulation-based educational curriculum; The current practice of learning how to perform the TEP repair in the operating room is under direct supervision of the staff surgeon without any simulation pre-training.
Other intervention name(s): TEP Curriculum
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Keywords: laparoscopic; totally extraperitoneal inguinal hernia repair