A Novel Hiatal Hernia and Fundoplication Simulator Results in Significant Trainee Skills Improvement

Tomokazu Kishiki, Brittany Lapin, JoAnn Carbray, Michael B Ujiki. NorthShore University HealthSystem Grainger Center for Simulation and Innovation

Background: Simulation training in laparoscopic surgery has been shown to improve surgical performance; however, advanced laparoscopic surgery training has not been yet established. The purpose of this study was to develop a new system of laparoscopic surgery training for hiatal hernia and fundoplication.

Method: A laparoscopic training box model for hiatal hernia repair and fundoplication was developed. Nine general surgery residents participated in a 4-week dedicated skills curriculum covering five advanced laparoscopic procedures: (1) Equipment, Positioning and Trocar Placement, (2) Ability to Close Hiatus, (3) Fundoplication Set up, (4) Fundoplication Suture Placement and (5) Ability to Manipulate Instruments. The training system was composed of a pre-test, mentored instruction, practice, and post-test. Residents completed a confidence survey pre- and post-test, and each task was scored by the resident and an evaluator. Paired t-test assessed differences pre- and post, and intraclass correlation coefficient (ICC) was used to evaluate reliability.

Result: Evaluators rated residents as improving significantly pre- to post-training on all five tasks (p<0.01 for all). Residents self-evaluated themselves as improving significantly on (1) equipment, positioning and trocar placement (p<0.01), (2) ability to close hiatus (p=0.02), and (5) ability to manipulate instruments (p<0.01). They improved on the other two tasks but the difference did not reach statistical significance ((3) set up of fundoplication (p=0.10) and (4) fundoplication suture placement (p=0.051)). The pre-training test showed moderate to strong reliability between residents and evaluators with agreement on all five tasks (ICC >0.6 for all but (3) set up of fundoplication (ICC=0.49, p=0.07)). The post-training test showed moderate to strong agreement between residents and evaluators for (1) equipment, positioning and trocar placement (ICC=0.67), (2) ability to close hiatus (ICC=0.86), and (3) set up fundoplication (ICC=0.77), however (4) fundoplication suture placement and (5) ability to manipulate instruments showed poor agreement (ICC=0.06 and 0.23, respectively). The residents improved their confidence in performing hiatal hernia and fundoplication on all 12 questions, with 10 of the 12 confidence questions showing significant improvement. In resident evaluation, all residents found the system very helpful. 33% of residents rated the system as difficult, with all residents indicating they would be comfortable doing the procedure independently.

Conclusion: Our simulation system is effective and useful for training residents in hiatal hernia and fundoplication.