Simulation-Based Training Improves Operative Performance of Totally Extraperitoneal (TEP) Laparoscopic Inguinal Hernia Repair – A Randomized Controlled Trial

Yo Kurashima, MD, PhD, Liane S Feldman, MD, Pepa A Kaneva, MSc, Gerald M Fried, MD, Simon Bergman, MD, Sebastian V Demyttenaere, MD, Melina C Vassiliou, MD, MEd

McGill University

Laparoscopic inguinal hernia repair (LIHR) is associated with reduced post-operative pain and earlier return to normal activities compared to open repair, however, the procedure is difficult to learn. The purpose of this randomized controlled trial was to measure the impact of a novel LIHR curriculum incorporating the McGill Laparoscopic Inguinal Hernia Simulator (MLIHS) by comparing operative performance of residents trained with this new curriculum to those with traditional training.

17 surgical residents (PGY 2-5) participated in a half-day didactic LIHR course, and were then randomized to the simulation-based proficiency curriculum (Training, T) or standard residency training (Control, C). We used MLIHS for the LIHR simulation training. The simulator and its metrics were previously validated for assessment. Simulator and operative performances were evaluated in both groups at baseline and after the study period during totally extraperitoneal (TEP) repair, using the validated Global Operative Assessment of Laparoscopic Skills–Groin Hernia (GOALS-GH, maximum score=25). Simulator practice was partly proctored and additional assistance was available upon request. Training was complete when an expert-level GOALS-GH score of 24 was reached in the simulator. OR evaluators were blinded to the training status of participants. GOALS-GH scores were compared between T and C groups using t-test. Results reported as mean (95% CI) or median [IQR]. P <0.05 was considered significant.

Of the 17 participants who were randomized, 14 completed their final evaluations (5 T: PGY 3 and 9 C: PGY 2-5). There were no differences in LIHR numbers as primary operator between T group 1 [0;3] and C group 1 [1;5] (P = 0.84) or baseline GOALS-GH scores (T 14.8 (12.8-16.8) and C 13.6 (12.3-14.8), P = 0.20). The mean number of training sessions to achieve proficiency was 4.8 (95% CI 4.4-5.2) and mean time of total training was 109min (95% CI 61.9-149.1). T group participants reported high educational efficiency and value of TEP simulation-based proficiency curriculum (mean 4.4 on scale of 1-5). After training, OR performance improved in the T group by +3.4 (2.0 – 4.8) points (P = 0.002), whereas no significant change was seen in the C group by +1.2 (-1.1 – 3.6), (P = 0.27). Final GOALS-GH scores were higher in the T group compared to the C group (18.2 (14.9 – 21.5) vs. 14.8 (12.4 – 17.1), P = 0.06).

This study demonstrates the transfer of skills acquired using a low-cost procedure-specific simulator to the OR. Residents who trained to proficiency on the MLIHS performed better in the operating room compared to those who had not. These results provide evidence to support the use of simulation to teach LIHR.

Session: Podium Presentation

Program Number: S110

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