Long-term evaluation of the Hernia Compact course of the German Hernia School.

INTRODUCTION: Since 2011, the German Hernia Society has developed the German Hernia School (GHS) as a standardized hernia surgery training program for younger surgeons, consisting of the Hernia Compact basic module. It is a standardized three day training program (cadaver workshop, ultrasound simulation training, and hands-on training). After 12 years of experience, a survey was conducted to evaluate the long term effect of this training. METHOD: Using an anonymous online-questionnaire, we contacted from September 2023 to October 2023 the Hernia Compact course participants via the congress organizer "Weitmeer" and the German Hernia Society. This online questionnaire contains 18 multiple choice questions regarding participants' age, gender, professional experience, participation in other modules of the German Hernia School, the effect of the course on their daily practice and their specific interest in hernia and abdominal wall surgery. RESULTS: A total of 146 participants responded to the anonymous online questionnaire. A majority of 132 of 146 participants (90.42%) responded that this course improved the quality of surgical and hernia training (n = 146, no missing data). 141 of 146 individuals (96.58%) recommended the course to surgical colleagues (n = 146, no missing data). There were 89.73% of participants, (n = 146, no missing data) that developed a specific interest in hernia and abdominal wall surgery after the course. For 78.08% (n = 146, no missing data) of participants hernia and abdominal wall surgery was one of the most important activities in their daily surgical practice. CONCLUSION: The standardized Hernia Compact basic course of the German Hernia School appears to have a huge impact on the quality of hernia surgery training in Germany and Austria. It might also help generate a specific interest in hernia surgery among participants.

Assessing knowledge and confidence of surgical residents in inguinal hernia repair using a low-cost synthetic model.

PURPOSE: Open repair of groin hernia is an essential skill for the general surgeon. This study aimed to develop a low-cost hernia model based on a validated high-fidelity model and assess its effectiveness in teaching inguinal hernia repair to surgical trainees from many institutions throughout Africa. METHODS: Using inexpensive, locally available materials, a low-cost hernia model was created. Six models were constructed, and a workshop was conducted for surgical residents. Pre- and post-workshop surveys were administered to assess knowledge, confidence, and understanding. Statistical analyses were performed using paired t tests and the Wilcoxon signed-rank test. RESULTS: The low-cost hernia model consisted of various readily available materials and cost an average of $5.07. Sixty-eight trainees participated in the workshop, and 59 completed the post-workshop survey. Participants reported a significant increase in confidence for both mesh and non-mesh repairs and an improved understanding of hernia anatomy after the workshop. Trainees scored an average of 5.6 (SD 1.9) out of 10 questions on the pre-workshop quiz and 7.9 (SD 1.4) out of 10 on the post-workshop quiz (p < 0.001), indicating improved knowledge. All trainees supported the use of the model for education. CONCLUSION: The low-cost hernia model demonstrated its effectiveness in enhancing trainees' understanding of hernia anatomy and increasing their confidence in hernia repair. Integrating low-cost hernia models into training programs can help improve trainees' knowledge and confidence in a safe and affordable environment.

Kinematic data profile and clinical outcomes in robotic inguinal hernia repairs: a pilot study.

BACKGROUND: Surgical training requires clinical knowledge and technical skills to operate safely and optimize clinical outcomes. Technical skills are hard to measure. The Intuitive Data Recorder (IDR), (Sunnyvale, CA) allows for the measurement of technical skills using objective performance indicators (OPIs) from kinematic event data. Our goal was to determine whether OPIs improve with surgeon experience and whether they are correlated with clinical outcomes for robotic inguinal hernia repair (RIHR). METHODS: The IDR was used to record RIHRs from six surgeons. Data were obtained from 98 inguinal hernia repairs from February 2022 to February 2023. Patients were called on postoperative days 5-10 and asked to take the Carolina Comfort Scale (CCS) survey to evaluate acute clinical outcomes. A Pearson test was run to determine correlations between OPIs from the IDR with a surgeon's yearly RIHR experience and with CCS scores. Linear regression was then run for correlated OPIs. RESULTS: Multiple OPIs were correlated with surgeon experience. Specifically, for the task of peritoneal flap exploration, we found that 23 OPIs were significantly correlated with surgeons' 1-year RIHR case number. Total angular motion distance of the left arm instrument had a correlation of - 0.238 (95% CI - 0.417, - 0.042) for RIHR yearly case number. Total angular motion distance of right arm instrument was also negatively correlated with RIHR in 1 year with a correlation of - 0.242 (95% CI - 0.420, - 0.046). For clinical outcomes, wrist articulation of the surgeon's console positively correlated with acute sensation scores from the CCS with a correlation of 0.453 (95% CI 0.013, 0.746). CONCLUSIONS: This study defines multiple OPIs that correlate with surgeon experience and with outcomes. Using this knowledge, surgical simulation platforms can be designed to teach patterns to surgical trainees that are associated with increased surgical experience and with improved postoperative outcomes.

[How do young surgeons understand and grasp the new concepts, new techniques, and recent progress of hernia and abdominal wall surgery?]

With the development of modern surgery, the field of hernia and abdominal wall surgery is undergoing a transformative change, and new techniques, new concepts, and recent progress are being updated, which have motivated the high-quality development of the discipline. In the past two decades, the development of hernia and abdominal wall surgery in China has been recognized by international peers. Many young surgeons have gradually become the main force in the treatment of hernia and leaders in surgical technique. The innovation and development of discipline will never terminate; young surgeons as the main force should seriously think about how to improve their professional qualities. Young surgeons are interested in the innovation of surgical techniques and need to push for a traditional operation on the one hand and an innovative operation on the other. Updates to concepts and acquisition of new materials are more important, which can provide a solid foundation for technological innovation. Young surgeons should start with the basics and classics. Understanding the history and development of new techniques, new concepts and recent progress, and grasping indications of clinical application, is the important part of growing up for young surgeons, which can make surgical treatment more standardized, benefit patients, and promote the progress of Chinese specialized medical education.

Performance assessment using sensor technology.

Over the past 30 years, there have been numerous, noteworthy successes in the development, validation, and implementation of clinical skills assessments. Despite this progress, the medical profession has barely scratched the surface towards developing assessments that capture the true complexity of hands-on skills in procedural medicine. This paper highlights the development implementation and new discoveries in performance metrics when using sensor technology to assess cognitive and technical aspects of hands-on skills.

The Effect of an Interval Training on Skill Retention of High-Complex Low-Volume Minimal Invasive Pediatric Surgery Skills: A Pilot Study.

Background: Current training programs for complex pediatric minimal invasive surgery (MIS) are usually bulk training, consisting of 1- or 2-day courses. The aim of this study was to examine the effects of bulk training versus interval training on the preservation of high-complex, low-volume MIS skills. Materials and Methods: Medical students, without prior surgical experience, were randomly assigned to either a bulk or interval training program for complex MIS (congenital diaphragmatic hernia [CDH] and esophageal atresia [EA] repair). Both groups trained for 5 hours; the bulk group twice within 3 days and the interval groups five times in 3 weeks. Skills retention was assessed at 2 weeks, 6 weeks, and 6 months posttraining, using a composite score (0%-100%) based on the objective parameters tracked by SurgTrac. Results: Seventeen students completed the training sessions (bulk n = 9, interval n = 8) and were assessed accordingly. Retention of the skills for EA repair was significantly better for the interval training group than for the bulk group at 6 weeks (P = .004). However, at 6 months, both groups scored significantly worse than after the training sessions for EA repair (bulk 60 versus 67, P = .176; interval 63 versus 74, P = .028) and CDH repair (bulk 32 versus 67, P = .018; interval 47 versus 62, P = .176). Conclusion: This pilot study suggests superior retention of complex pediatric MIS skills after interval training, during a longer period of time, than bulk training. However, after 6 months, both groups scored significantly worse than after their training, indicating the need for continuous training.

At-home hands-on surgical training during COVID19: proof of concept using a virtual telementoring platform.

INTRODUCTION: Surgeons in practice have limited opportunities to learn new techniques and procedures. Traditionally, in-person hands-on courses have been the most common means for surgeons to gain exposure to new techniques and procedures. The COVID19 pandemic caused a cessation in these courses and left surgeons with limited opportunities to continue their professional development. Thus, SAGES elected to create an innovative hands-on course that could be completed at home in order to provide surgeons with opportunities to learn new procedures during the pandemic. METHODS: This course was initially planned to be taught as an in-person hands-on course utilizing the Acquisition of Data for Outcomes and Procedure Transfer(ADOPT) method 1. We identified a virtual telementoring platform, Proximie Ltd(London, UK), and a company that could create a model of an abdominal wall in order to perform a Transversus Abdominis Release, KindHeart™(Chapel Hill, NC, USA). The course consisted of pre-course lectures and videos to be reviewed by participants, a pre-course call to set learning goals, the hands-on telementoring session from home, and monthly webinars for a year. RESULTS: The ADOPT hands-on hernia course at home was successfully completed on October 23rd of 2020. All participants and faculty were successfully able to set up their model and utilize the telementoring platform, but 15% required assistance. Post course-surveys showed that participants felt that the course was successful in meeting their educational goals and felt similar to prior in-person courses. CONCLUSIONS: SAGES was successfully able to transition and in-person hands-on course to a virtual at-home format. This innovative approach to continuing professional development will be necessary during the times of the COVID19 pandemic, but may be a helpful option for rural surgeons and others with travel restrictions in the future to continue their professional development without the need to travel away from their practice.

Instructional methods of attendings as exhibited during intraoperative takeovers: A pilot study.

BACKGROUND: This pilot study examined intraoperative instructional techniques during "takeovers," defined as the act of an attending taking control of a case from a resident. This work describes what happens during takeovers and identifies possible reasons for takeovers. METHODS: Intraoperative audio-video recordings during 25 laparoscopic inguinal hernia repair procedures were collected. Participants included 2 postgraduate year-5 residents and 5 attendings. Postoperative evaluation forms were completed by attendings. Coding schemes for takeovers during hernia reduction and mesh placement steps were developed using conventional and directed content analysis in an iterative process by study team members, including individuals with expertise in education, surgery, and surgical education. RESULTS: Takeovers occurred in 72% of cases. Frequency of takeovers was not related to case difficulty or differences in resident technical skill levels, nor did they decrease over the duration of the 2-month rotation. Takeovers most commonly occurred when a resident struggled to progress the case. They also occurred when anatomy was unclear or when the attending wanted to teach a specific skill. Differences were identified among attendings regarding frequency of takeovers. The majority of takeover behaviors were directed at instructing residents; however, attendings' teaching techniques did not vary by resident. CONCLUSION: Attending teaching habits appear to be independent of resident skills and depend on the attending's teaching style rather than residents' learning needs. Findings highlight the need for faculty development to help surgical educators learn how to tailor instruction to individual trainees. Additionally, future research is needed to establish the effectiveness of instruction through takeovers in the operating room.

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.

Global versus task-specific postoperative feedback in surgical procedure learning.

BACKGROUND: Task-specific checklists and global rating scales are both recommended assessment tools to provide constructive feedback on surgical performance. This study evaluated the most effective feedback tool by comparing the effects of the Observational Clinical Human Reliability Analysis (OCHRA) and the Objective Structured Assessment of Technical Skills (OSATS) on surgical performance in relation to the visual-spatial ability of the learners. METHODS: In a randomized controlled trial, medical students were allocated to either the OCHRA (n = 25) or OSATS (n = 25) feedback group. Visual-spatial ability was measured by a Mental Rotation Test. Participants performed an open inguinal hernia repair procedure on a simulation model twice. Feedback was provided after the first procedure. Improvement in performance was evaluated blindly using a global rating scale (performance score) and hand-motion analysis (time and path length). RESULTS: Mean improvement in performance score was not significantly different between the OCHRA and OSATS feedback groups (P = .100). However, mean improvement in time (371.0 ± 223.4 vs 274.6 ± 341.6; P = .027) and path length (53.5 ± 42.4 vs 34.7 ± 39.0; P = .046) was significantly greater in the OCHRA feedback group. When stratified by mental rotation test scores, the greater improvement in time (P = .032) and path length (P = .053) was observed only among individuals with low visual-spatial abilities. CONCLUSION: A task-specific (OCHRA) feedback is more effective in improving surgical skills in terms of time and path length in novices compared to a global rating scale (OSATS). The effects of a task-specific feedback are present mostly in individuals with lower visual-spatial abilities.

Improving surgical education in East Africa with a standardized hernia training program.

INTRODUCTION: Inguinal hernias are among the most common surgical diseases in Africa. The current International HerniaSurge Guidelines recommend mesh-based surgical techniques in Low Resource Settings (LRS). This recommendation is currently unachievable in large parts of Africa due to the unaffordability of mesh and lack of appropriate training of the few available surgeons. There is, therefore, a need for formal training in mesh surgery. There is an experience in Hernia Repair for the Underserved in Central and South America, however, inadequate evidence of structured training in Africa. MATERIAL AND METHODS: Since 2016, the aid Organizations, Surgeons for Africa and Operation Hernia have developed and employed a structured hernia surgical training program for postgraduate surgical trainees and medical doctors in Rwanda. This course consists of lectures on relevant aspects of hernia surgery and hands-on training in operating theatres. The lectures emphasize anatomy and surgical technique. All parts of the training were evaluated. Formal pre-course evaluation was conducted to assess the personal surgical experience of the trainees. RESULTS: Over a 3-year period, a structured hernia training programme was employed to train a total of 36 surgical trainees in both mesh and also non mesh hernia surgery. The key principle in this course is the continuous competence assessment and feedback. Evidence is provided to demonstrate improvement in surgical skills as well as knowledge of surgical anatomy which is essential to acquiring surgical competency. With self-assessment, expressed on a Likert scale, the participants could improve the theoretical knowledge about hernias from median 4.4 (on a scale of 1-10) before training to 8.4 after the training. The specific knowledge about anatomy could be improved in the same assessment from 4.8 before training to 8.1. after the training. After training course 12 of the 36 participants (33.33%) were able to carry out both suture- and mesh-based operations of simple inguinal hernias completely and independently. 20 of the 36 participants (55.55%) required only minimal supervision and only four participants (11.11%) required surgical supervision even after the completion of the course. CONCLUSION: We have demonstrated that, medical personnel in Africa can be trained in mesh and non-mesh hernia surgery using a structured training programme.

Impact of Trainee Participation on Inguinal Hernia Repair Outcome: A Study Based on the Swedish Hernia Register.

OBJECTIVE: The aim of this study was to investigate whether differences in postoperative outcome exist between open inguinal hernia repairs performed by surgical trainees and those performed by specialist surgeons. SUMMARY OF BACKGROUND DATA: Inguinal hernia repair is the prototype educational surgical procedure. The impact of trainee participation on postoperative outcome is still controversial and despite earlier studies no reliable hernia-specific data exist. METHODS: The study cohort was based on the Swedish Hernia Register and consisted of 61,161 cases of male patients aged 18 years and older with open anterior mesh repair of a primary inguinal hernia between January 1, 2002, and December 31, 2014. The study cohort was selected to represent the typical trainee procedure in Sweden. Primary outcome measures were reoperation due to hernia recurrence and postoperative 30-day complications. RESULTS: Procedures with longer operating times were at a higher risk for reoperation when performed by supervised trainees [57 to 72 minutes: hazard ratio (HR) 1.55, 99% confidence interval (99% CI) 1.05-2.27] or unsupervised trainees (57 to 72 minutes: HR 1.60, 99% CI 1.18-2.17; >72 minutes: HR 1.72, 99% CI 1.25-2.37). The same was true for specialist and trainee-assisted specialists with operating times <43 minutes (HR 1.63, 99% CI 1.25-2.13; HR 1.58, 99% CI 1.09-2.28). Postoperative 30-day complications were generally associated with longer operating times and occurred at all levels of experience. CONCLUSION: Trainee participation in open inguinal repair in combination with longer operating time is a risk factor associated with higher reoperation rates. This calls for a more structured supervision of trainees in an assumedly basic procedure.

Is Youtube a potential training source for total extraperitoneal laparoscopic inguinal hernia repair?

BACKGROUND: The aim of this study is to evaluate the quality of the most commonly viewed total extraperitoneal laparoscopic inguinal hernia repair (TEP) videos on Youtube, which is the largest social and medical media broadcasting service, concerning educational purposes. METHOD: A search with the keyword "total extraperitoneal laparoscopic inguinal hernia repair" was performed on Youtube. The first 120 videos among the search results were downloaded and 55 of them were included in the study. A scoring system developed by the authors according to the recent literature was utilized for evaluation of the videos. Video demographics were evaluated for the quality and upload source. RESULTS: Among the enrolled videos, video quality was rated as good in 13 (23.6%), as moderate in 22 (40%), and as poor in 20 (36.4%). Video length, presence of narration, number of likes, and comments were significantly higher in the good group. Upload source was an academic center in 14 (25.5%), a community hospital in 22 (40.0%), and a physician in 19 (34.5%). The mean video score of the academic center group (8 ± 4.095) and community hospital group (8.64 ± 3.259) was significantly higher than the physician group (5.47 ± 2.632) (p = 0.010). Video quality was not correlated with total views or views per day. CONCLUSION: Total extraperitoneal laparoscopic inguinal hernia repair procedure videos uploaded to Youtube demonstrate considerable heterogeneity in terms of educational quality and the number of good quality videos is significantly low. This heterogeneity is attributed to the lack of peer review process for the evaluation of educational quality of the videos. Therefore, a physician intending to learn and practice a surgical procedure properly (TEP repair in this situation) should not consider a broadcasting service without a peer review process as a reliable training source.

Learning Curve of Robotic Rives-Stoppa Ventral Hernia Repair: A Cumulative Sum Analysis.

Background: Robotic Rives-Stoppa ventral hernia repair (rRS-VHR) is a minimally invasive technique that incorporates extraperitoneal mesh placement, using either transabdominal or totally extraperitoneal access. An understanding of its learning curve and technical challenges may guide and encourage its adoption. We aim at evaluating the rRS-VHR learning curve based on operative times while accounting for adverse outcomes. Materials and Methods: We conducted a retrospective analysis of patients undergoing rRS repair for centrally located ventral and incisional hernias. A single surgeon operative time-based cumulative sum (CUSUM) analysis learning curve was created, and a composite outcome was used for risk-adjusted CUSUM (RA-CUSUM). Results: Eighty-one patients undergoing rRS-VHR were included. A learning curve was created by using skin-to-skin times. Accordingly, patients were grouped into three phases. The mean skin-to-skin time was 72.2 minutes, and there was a significant decrease in skin-to-skin times throughout the learning curve (Phase-I: 86.4 minutes versus Phase-III: 63.8 minutes; P = .001), with a gradual decrease after 29 cases. Eleven patients experienced adverse composite outcomes, which were used to create a RA-CUSUM graph. Results showed the highest adverse outcome rates in Phase-II, with a gradual decrease in risk-adjusted operative times after 51 cases. Conclusions: Consistently decreasing operative times and adverse outcome rates in rRS-VHR was observed after the completion of 29 and 51 cases, respectively. Future studies that provide group learning curves for this procedure can deliver more generalizable results in terms of its performance rates.

Impact of Robotic Surgery on Residency Training for Herniorrhaphy and Cholecystectomy.

Robotic surgery has increased for common general surgery procedures. This study evaluates how robotic use affects the case distributions of herniorrhaphy and cholecystectomy for general surgery residents according to postgraduate year (PGY). We reviewed Accreditation Council for Graduate Medical Education (ACGME) biliary or hernia cases logged by surgical residents in the academic year 2017-2018. Operative reports were reviewed to compare approaches (robotic, laparoscopic, and open) by resident role and PGY level. Open cholecystectomies were excluded. Overall, 470 hernia and 657 cholecystectomy cases were logged. Hernia repairs were performed robotically in 15.9%, laparoscopically in 9.5%, and open in 74.7%. Cholecystectomies were performed robotically in 16.4% and laparoscopically in 83.6%. Residents were teaching assistants in 1.8% of hernia repairs and 1.5% of cholecystectomies. Distribution of cases by technique and PGY level was significantly different for both procedures, with chief residents performing the majority of robotic cholecystectomies (52.6%, P < .0001) and hernia repairs (59.7%, P < .0001). Migration of robotic cases to senior resident level and low percentage of teaching assistant roles held by residents suggest exposure to common operations may be delayed during general surgery residency training. Introduction of new technology in surgical training should be carefully reviewed and may benefit from a structured curriculum.

Accuracy and usefulness in assessing proficiency of the observational clinical human reliability assessment checklist of the open inguinal hernia repair procedure: A cross-sectional study.

BACKGROUND: The Observational Clinical Human Reliability Assessment (OCHRA) can be used to score errors during surgical procedures. To construct an OCHRA-checklist, steps, substeps, and hazards of a surgical procedure need to be defined. A step-by-step framework was developed to segment surgical procedures into steps, substeps, and hazards. The first aim of this study was to investigate if the step-by-step framework could be used to construct an accurate Lichtenstein open inguinal hernia repair (LOIHR) stepwise description. The second aim was to investigate if the OCHRA-checklist based on this stepwise description was accurate and useful for surgical training and assessment. MATERIALS AND METHODS: Ten expert surgeons rated statements regarding the accuracy of the LOIHR stepwise description, the accuracy, and the usefulness of the LOIHR OCHRA-checklist (eight, seven, and six statements, respectively) using a 5-point Likert scale. One-sample Wilcoxon signed-rank test was used to compare the outcomes to the neutral value of 3. RESULTS: The accuracy of the stepwise description and the accuracy and usefulness of the OCHRA-checklist were rated statistically significantly higher than the neutral value of 3 (median 4.75 [5.00-4.00] with p = .009, median 5.00 [5.00-4.00] with p = .012, median 4.00 [5.00-4.00] with p = .047, respectively). The experts rated the OCHRA-checklist to be useful for the training (5.00 [5.00-4.00], p = .009), and assessment (4.50 [5.00-4.00], p = .010) of surgical residents. CONCLUSION: This preliminary study showed that the stepwise LOIHR description constructed using the step-by-step framework was found to be accurate. The LOIHR OCHRA-checklist developed using the stepwise description was also accurate, and particularly useful for the training and assessment of proficiency of surgical residents.

Learning inguinal hernia repair? A survey of current practice and of preferred methods of surgical residents.

PURPOSE: During surgical residency, many learning methods are available to learn an inguinal hernia repair (IHR). This study aimed to investigate which learning methods are most commonly used and which are perceived as most important by surgical residents for open and endoscopic IHR. METHODS: European general surgery residents were invited to participate in a 9-item web-based survey that inquired which of the learning methods were used (checking one or more of 13 options) and what their perceived importance was on a 5-point Likert scale (1 = completely not important to 5 = very important). RESULTS: In total, 323 residents participated. The five most commonly used learning methods for open and endoscopic IHR were apprenticeship style learning in the operation room (OR) (98% and 96%, respectively), textbooks (67% and 49%, respectively), lectures (50% and 44%, respectively), video-demonstrations (53% and 66%, respectively) and journal articles (54% and 54%, respectively). The three most important learning methods for the open and endoscopic IHR were participation in the OR [5.00 (5.00-5.00) and 5.00 (5.00-5.00), respectively], video-demonstrations [4.00 (4.00-5.00) and 4.00 (4.00-5.00), respectively], and hands-on hernia courses [4.00 (4.00-5.00) and 4.00 (4.00-5.00), respectively]. CONCLUSION: This study demonstrated a discrepancy between learning methods that are currently used by surgical residents to learn the open and endoscopic IHR and preferred learning methods. There is a need for more emphasis on practising before entering the OR. This would support surgical residents' training by first observing, then practising and finally performing the surgery in the OR.

The State of Surgical Task Sharing for Inguinal Hernia Repair in Limited-Resource Countries.

BACKGROUND: In limited-resource countries, the morbidity and mortality related to inguinal hernias is unacceptably high. This review addresses the issue by identifying capacity-building education of non-surgeons performing inguinal hernia repairs in developing countries and analyzing the outcomes. METHODS: PubMed was searched and included are studies that reported on task sharing and surgical outcomes for inguinal hernia surgery. Educational methods with quantitative and qualitative effects of the capacity-building methods have been recorded. Excluded were papers without records of outcome data. RESULTS: Seven studies from African countries reported 14,108 elective inguinal hernia repairs performed by 230 non-surgeons with a mortality rate of 0.36%. Complications were reported in 4 of the 7 studies with a morbidity rate of 14.2%. Two studies reported on follow-up: one with no recurrences in 408 patients at 7.4 months and the other one with 0.9% recurrences in 119 patients at 12 months. Direct comparison of outcomes from trained non-surgeons to surgeons or surgically trained medical doctors is limited but suggests no difference in outcomes. Quantitative capacity-building effects include increase in surgical workforce, case volume, elective procedures, mesh utilization, and decreased referrals to higher level of care institutions. Qualitative capacity-building effects include feasibility of prospective research in limited-resource settings, improved access to surgical care, and change in practice pattern of local physicians after training for mesh repair. CONCLUSION: Systematic training of non-surgeons in inguinal hernia repair is potentially a high-impact capacity-building strategy. High-risk patients should be referred to a fully trained surgeon whenever possible. Randomized study designs and long-term outcomes beyond 1 year are needed.

Evaluating how residents talk and what it means for surgical performance in the simulation lab.

BACKGROUND: This paper explores a method for assessing intraoperative performance by modeling how surgeons integrate skills and knowledge through discourse. METHODS: Senior residents (N = 11) were recorded while performing a simulated laparoscopic ventral hernia (LVH) repair. Audio transcripts were coded for five discourse elements related to knowledge, skills, and operative independence. Epistemic network analysis was used to model the ordered integration of the five discourse elements. RESULTS: Participants with poorer hernia repair outcomes had stronger connections between the discourse elements operative planning and asking for information or advice (Operative planning), while participants with better hernia repair outcomes had stronger connections between the discourse elements giving assistant instructions and identifying errors (Operative management): (p = .006; Cohen's d = 2.79). CONCLUSION: Participants with better hernia repair outcomes engaged in more operative management communication during the simulated procedure. This ability to integrate multiple operative steps and verbally communicate them significantly correlated with better operative outcomes.