Improving operative performance using a laparoscopic hernia simulator Elizabeth C. Hamilton, M.D., Daniel J. Scott, M.D., Ajay Kapoor, M.D., Fiemu Nwariaku, M.D., Patricia C. Bergen, M.D., Robert V. Rege, M.D., Seifu T. Tesfay, R.N., Daniel B. Jones, M.D.* Southwestern Center for Minimally Invasive Surgery, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9092, USA Manuscript received July 31, 2001; revised manuscript September 2, 2001 Presented at the 53rd Annual Meeting of the Southwestern Surgical Congress, Cancun, Mexico, April 29 –May 2, 2001. Abstract Background: Traditionally, the acquisition of surgical skill has occurred entirely in the operating room. To meet the expanding challenges of cost containment and patient safety, novel methods of surgical training utilizing ex-vivo workstations are being developed. The purpose of our study was to evaluate the impact of a laparoscopic training curriculum on surgical residents’ operative performance. Methods: Twenty-one surgery residents completed baseline laparoscopic total extraperitoneal (TEP) hernia repairs. Operative performance was evaluated using a validated global assessment tool. Each resident was then randomized to a control group or a trained group. A CD ROM, video, and simulator were used for training. At the end of the study, each resident’s operative performance was again evaluated. Results: Improvement was significantly greater in the trained group in five of the eight individual global assessment areas as well as the composite score (P 0.05). Questionnaire data suggested that training resulted in improved understanding of the TEP hernia repair (P = 0.01) and an increased willingness to offer the operation to patients with nonrecurrent unilateral hernias (P = 0.02). Conclusions: A multimodality laparoscopic TEP hernia curriculum improves residents’ knowledge of the TEP hernia repair and comfort in performing the procedure, and may also improve actual operative performance. © 2002 Excerpta Medica, Inc. All rights reserved. Keywords: Laparoscopic total extraperitoneal hernia repair; Skills training; Global assessment; Surgical education; Simulation Although minimally invasive approaches to hernia repair were first introduced in the early 1980s, they did not gain significant recognition in the United States until the mid 1990s after laparoscopic cholecystectomy was well ac- cepted [1]. Currently, two popular techniques for the lapa- roscopic repair of inguinal hernias include the transabdom- inal preperitoneal (TAPP) and the totally extraperitoneal (TEP) approaches [2]. The TEP approach avoids violation of the peritoneal cavity. However, owing to its confusing anatomy, TEP hernia repair can be difficult to learn and may have a steep learning curve. Training surgeons outside of the operating room to per- form minimally invasive surgery may decrease operative complications [3], enhance efficiency [4], and reduce long- term cost. Previous efforts to train surgery residents in the skills laboratory [5–7] have been devoid of didactic sessions to improve cognitive knowledge. Recently, we reported improvement in operative performance on a laparoscopic cholecystectomy from formal training on either a video- trainer or a MIST VR [8,9]. However, by all accounts, surgical success is multifactorial requiring not only good technical skill, but also sound judgment and knowledge [10]. Both didactic and hands-on skills training are integral parts of any curriculum used to establish a link between performance on an ex-vivo surgical training system and performance in the operating room. The purpose of this study was to evaluate the impact of a laparoscopic hernia curriculum on resident surgeons’ op- erative performance and confidence with a laparoscopic TEP hernia repair. Methods Twenty-one third- and fourth-year surgery residents were enrolled in the study between January 2000 and March * Corresponding author. Tel.: +1-214-648-9000; fax: +1-214-648- 9448. E-mail address: www.utsouthwestern.edu/cmis. The American Journal of Surgery 182 (2001) 725–728 0002-9610/01/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S0002-9610(01)00800-5