Incisional hernia repair requires detailed anatomic knowledge. Regarding median subxiphoidal hernias, the proper preparation of the fatty triangle is challenging. To foster proficiency-based training, a cost-efficient model for open median retromuscular mesh repair resembling the human body was developed, including the main anatomical structures related to the procedure. The aim is to create and validate a high-fidelity model on open retromuscular mesh repair suitable for "training before doing".
Materials and methods
Different types of fabrics for imitation of connective tissue and 2-component silicones were used to construct the incisional hernia model. Sample size for validation of the model was determined by a triangular testing approach. Operations from six beginners and six experts were assessed by three blinded-raters. Reliability and construct-validity were evaluated on a behaviorally anchored rating scale (highest score: 4) for the criteria: “instrument use”, “tissue handling”, “near misses and errors”, and “end-product quality”.
The model authentically mimicked an open median retromuscular mesh repair. Participants considered the procedure realistic. Reliability was excellent, ranging from 0.811 to 0.974 for “end-product quality”, and “tissue handling“ respectively. Construct-validity was confirmed with experts significantly outperforming beginners in the “use of instruments” (Mbeg. = 2.33, Mexp. = 3.94, p < 0.001), “tissue handling” (Mbeg. = 2.11, Mexp. = 3.72, p < 0.001), “near misses and errors” (Mbeg. = 2.67, Mexp. = 3.67, p < 0.001), and “end-product quality” (Mbeg. = 2.78, Mexp. = 3.72, p < 0.001). Criterion-validity revealed a paradox effect: beginners performed significantly better than experts (p < 0.05) when preparing the fatty triangle.
The model covers all relevant aspects involved in median-open retromuscular incisional hernia mesh repair. Performance differences between beginners and experts confirm construct-validity and thereby realism of the model. It enables to efficiently improve and practice technical skills of the demanding surgery.
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Israelsson LA, Jonsson T (1997) Overweight and healing of midline incisions: the importance of suture technique. Eur J Surg 163:175–180
Mudge M, Hughes L (1985) Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 72:70–71
Dietz UA, Wiegering A, Germer CT (2014) Eingriffsspezifische Komplikationen der Hernienchirurgie. Chirurg 85:97–104
Rives J, Pire J, Flament J, Palot J, Body C (1985) Treatment of large eventrations. New therapeutic indications apropos of 322 cases. Chirurgie 111:215–225
Winkler M, Gerharz E, Dietz U (2008) Overview and evolving strategies of ventral hernia repair. Urologe 47:740–747
Dietz UA, Menzel S, Lock J, Wiegering A (2018) The treatment of incisional hernia. Dtsch Arztebl Int 115:31–37
Conze J, Prescher A, Kisielinski K, Klinge U, Schumpelick V (2005) Technical consideration for subxiphoidal incisional hernia repair. Hernia 9:84–87
Conze J, Prescher A, Klinge U, Saklak M, Schumpelick V (2004) Pitfalls in retromuscular mesh repair for incisional hernia: the importance of the “fatty triangle”. Hernia 8:255–259
Rogmark P, Smedberg S, Montgomery A (2018) Long-term follow-up of retromuscular incisional hernia repairs: recurrence and quality of life. World J Surg 42:974–980
Ziv A, Wolpe PR, Small SD, Glick S (2003) Simulation-based medical education: an ethical imperative. Acad Med 78:783–788
Aggarwal R, Darzi A (2006) Technical-skills training in the 21st century. NEJM 355:2695–2696
Reznick RK, MacRae HJ (2006) Teaching surgical skills—changes in the wind. NEJM 355:2664–2669
Brydges R, Hatala R, Zendejas B, Erwin PJ, Cook DA (2015) Linking simulation-based educational assessments and patient-related outcomes: a systematic review and meta-analysis. Acad Med 90:246–256
Friedrich U, Backhaus J, Zipper C, König S, Mavroveli S, Wiegering A, Olbrecht S, Puppe F, Dietz UA (2019) Validation and educational impact study of the NANEP high-fidelity simulation model for open preperitoneal mesh repair of umbilical hernia. Hernia. https://doi.org/10.1007/s10029-019-02004-9(Epub ahead of print)
Maithel S, Sierra R, Korndorffer J, Neumann P, Dawson S, Callery M, Jones D, Scott D (2006) Construct and face validity of MIST-VR, endotower, and CELTS. Surg Endosc 20:104–112
Henriksen NA, Deerenberg EB, Venclauskas L, Fortelny RH, Miserez M, Muysoms FE (2018) Meta-analysis on materials and techniques for laparotomy closure: the MATCH review. World J Surg 42:1666–1678
Dietz UA, Kuhfuß I, Debus ES, Thiede A (2006) Mario Donati and the vertical mattress suture of the skin. World J Surg 30:141–148
Miskovic D (2012) Proficiency gain and competency assessment in laparoscopic colorectal surgery. PhD Thesis, Imperial College London, Department of Surgery and Cancer. pp 230
Kogan JR, Holmboe ES, Hauer KE (2009) Tools for direct observation and assessment of clinical skills of medical trainees: a systematic review. JAMA 302:1316–1326
Larson JL, Williams RG, Ketchum J, Boehler ML, Dunnington GL (2005) Feasibility, reliability and validity of an operative performance rating system for evaluating surgery residents. Surgery 138:640–649
Williams RG, Sanfey H, Dunnington GL (2012) A controlled study to determine measurement conditions necessary for a reliable and valid operative performance assessment: a controlled prospective observational study. Ann Surg 256:177–187
Gebhardt A (2014) Design of Experiments Using R. In: Wales WB (ed) Topics in statistical simulation. Springer, Heidelberg, pp 217–228
Rasch D, Guiard V (2004) The robustness of parametric statistical methods. Psychol Sci 46:175–208
Stallard N, Todd S (2000) Exact sequential tests for single samples of discrete responses using spending functions. Stat Med 19:3051–3064
Whitehead J, Stratton I (1983) Group sequential clinical trials with triangular continuation regions. Biometrics 39:227–236
Nunnally JC, Bernstein IH (1967) Psychometric theory, vol 226. McGraw-Hill, New York
Harrysson I, Hull L, Sevdalis N, Darzi A, Aggarwal R (2014) Development of a knowledge, skills, and attitudes framework for training in laparoscopic cholecystectomy. Am J Surg 207:790–796
Meredith W, Tisak J (1990) Latent curve analysis. Psychometrika 55:107–122
Krautter M, Weyrich P, Schultz JH, Buss SJ, Maatouk I, Jünger J, Nikendei C (2011) Effects of Peyton's four-step approach on objective performance measures in technical skills training: a controlled trial. Teach Learn Med 23:244–250
Backhaus J, Jeske D, Poinstingl H, Koenig S (2017) Assessing efficiency of prompts based on learner characteristics. Computers 6:7. https://doi.org/10.3390/computers6010007
Heitzmann N, Fischer F, Kühne-Eversmann L, Fischer MR (2015) Enhancing diagnostic competence with self-explanation prompts and adaptable feedback. Med Educ 49:993–1003
Glaser R, Bassok MJ (1989) Learning theory and the study of instruction. Ann Rev Psychol 40:631–666
Roberts KE, Bell RL, Duffy AJ (2006) Evolution of surgical skills training. World J Gastroenterol 12:3219–3224
Botden SM, Buzink SN, Schijven MP, Jakimowicz JJ (2007) Augmented versus virtual reality laparoscopic simulation: What is the difference? World J Surg 31:764–772
Dopson S, Locock L, Gabbay J, Ferlie E, Fitzgerald L (2003) Evidence-based medicine and the implementation gap. Health 7:311–330
Kruger J, Dunning D (1999) Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. J Pers Soc Psychol 77:1121–1134
Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG (2003) Causes and prevention of laparoscopic bile duct injuries. Analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 237:460–469
Jakobson MJ, Levin JA, Kapur M (2019) Education is a complex system: conceptual and methodological implications. Educ Res. https://doi.org/10.3102/0013189X19826958
Dietz UA, Fleischhacker A, Menzel S, Klinge U, Jurowich C, Haas K, Heuschmann P, Germer CT, Wiegering A (2017) Risk-adjusted procedure tailoring leads to uniformly low complication rates in ventral and incisional hernia repair: a propensity score analysis and internal validation of classification criteria. Hernia 21:569–582
Gockal F, Morrisson S, Kudsi OY (2019) Robotic retromuscular ventral hernia repair and transversus abdominis release: short-term outcomes and risk factors associated with perioperative complications. Hernia 23:371–385
Muysoms F, Van Cleven S, Pletinckx P, Ballacer C, Ramaswamy A (2018) Robotic transabdominal retromuscular umbilical prosthetic hernia repair (TARUP): observational study on the operative time during the learning curve. Hernia 22:1101–1111
Conflict of interest
The authors disclose that there was no conflict of interest. The study was funded by the Medical Faculty Wuerzburg, Germany (Grant no. 620–2015) and third-party funds of working group of the Division of Hernia Repair and Abdominal Wall Reconstruction of the University Hospital Wuerzburg.
The review and ethics board of the Medical Faculty of the University of Wuerzburg was consulted and it did not consider an approval necessary, since the study protocol was not deemed to represent biomedical or epidemiological research (Protocol No. 20161013 02).
Human and animal rights
Sensible identificatory data were treated according to the data protection policy of the University of Wuerzburg.
Consent to video-recording of the procedure without personal identificatory captures was obtained at the beginning of the study from each participant.
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Zipper, C.T., Friedrich, U., Backhaus, J. et al. Incisional hernia repair in a high-fidelity silicone model for open retro-muscular mesh implantation with preparation of the fatty triangle: validation and educational impact study. Hernia 24, 1307–1315 (2020). https://doi.org/10.1007/s10029-019-02094-5
- Incisional hernia repair
- Retromuscular mesh repair
- Fatty triangle
- Surgical model