Mastery Learning Inguinal Hernia Repair

Specific Aims:

Inguinal hernias are a common ailment of the general population1. 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.

SPECIFIC AIM 2: Develop and validate a TEP-specific operative performance measurement tool
and compare it against existing tools such as the Global Assessment of Laparoscopic Skills
(GOALS) and the version of the Objective Structured Assessment of Technical Skills (OSATS)
modified for laparoscopic surgery.

Hypothesis 2: A TEP-specific operative performance measurement tool will have a higher
degree of validity and reliability than the GOALS or OSATS tools when assessing laparoscopic
skills of surgical residents performing a TEP hernia repair.

Secondary Aims:

1. Compare the cost of the teaching the TEP repair in the operating room under an
apprenticeship-based model versus the costs associated with the TEP Mastery Learning
Curriculum.

2. 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.