Validation of newly developed physical laparoscopy simulator in transabdominal preperitoneal (TAPP) inguinal hernia repair

Iterative Design and Manufacturing of a 3D-Printed Pediatric Open and Laparoscopic Integrated Simulator for Hernia Repair (POLISHeR)

BACKGROUND

Inguinal hernia is a common childhood pathology, making inguinal hernia repair (IHR) a key pediatric surgical procedure. Surgical success relies heavily on knowledge of groin anatomy, and both open and laparoscopic approaches require considerable repetition to master. As surgical simulators have been shown to improve performance for other surgical procedures, we developed a combined open and laparoscopic pediatric IHR simulator-named POLISHeR-to train residents, fellows, and practicing surgeons in both types of repair.

METHODS

A CT scan of a 7-year-old was scaled down to create a virtual 3D model of a 2-year-old using our validated protocol for anatomical modelling. Physical replicas of the pelvis, abdominal wall, aorta, and inferior vena cava were 3D-printed to create a life-size unisex base for open and laparoscopic IHR, while a small mobile unisex base was 3D-printed for open IHR. We recruited six experienced surgeons and trainees to pilot the face validity of POLISHeR.

RESULTS

After multiple iterations, we successfully developed a modular 3D-printed simulator for open and laparoscopic IHR. Printing the life-size base cost $331.69 USD, whereas the small base cost $17.54. An open modular cartridge cost $9.92 for females and $14.21 for males, whereas replacement parts cost under $1.30. A laparoscopic modular cartridge cost $6.16 for females and $10.91 for males, whereas replacement parts cost $0.28. Pilot study participants provided encouraging feedback with respect to POLISHER's face validity.

CONCLUSIONS

Our low-cost simulator holds promise for enhancing training for pediatric IHR. Our next step is to conduct validation trials for trainees and practicing surgeons in both well-resourced and resource-limited settings.

LEVEL OF EVIDENCE

Not applicable.

Development and validation of a high-quality simulator with exchangeable peritoneum for transabdominal preperitoneal laparoscopic inguinal hernia repair

INTRODUCTION

Practical simulation training with proper haptic feedback and the fragility of the human body is required to overcome the long learning curve associated with laparoscopic inguinal hernia repair (LIHR). However, few hernia models accurately reflect the texture and fragility of the human body. Therefore, in this study, we developed a novel model for transabdominal preperitoneal (TAPP) LIHR training and evaluated its validity.

METHODS

We developed a high-quality mock peritoneum with a hydrated polyvinyl alcohol layer and a unique two-way crossing cellulose fiber layer. To complete the simulation, the peritoneum was adhered to a urethane foam inguinal base with surgical landmarks. Participants could perform all the procedures required for the TAPP LIHR. Twenty-four surgeons performed TAPP LIHR simulation using a novel simulator. Their opinions were rated on a 5-point Likert scale. Additionally, 6 surgical residents and 10 surgical experts performed the procedure. Their performance was evaluated using the TAPP checklist score and procedure time.

RESULTS

Most participants strongly agreed that the TAPP LIHR simulator with an exchangeable peritoneum model was useful. The participants agreed on the model fidelity for tactile sensation, forceps handling, and humanlike anatomy. In comparisons between surgical residents and experts, the experts had significantly higher scores (10.6 vs. 17.2, p < 0.05) and shorter procedure times (92.3 vs. 55.9 min; p < .05) than did surgical residents.

CONCLUSIONS

We developed a high-quality exchangeable peritoneal model that mimics the human peritoneum's texture and fragility. This model enhances laparoscopic simulation training, potentially shortening TAPP LIHR learning curves.

Hernia 3D training model: a new inguinal hernia 3D-printed simulator

OBJECTIVE

Barros et al. demonstrated a 3D printed model that exhibits anatomical representativeness, low cost, and scalability. The model was created based on subtraction data obtained from computed tomography scans. Images were modeled and reconstructed in 3D to display the male inguinal region, typically viewed using a laparoscopic approach. To evaluate the functionality and quality of the anatomical representation of the hernia 3D training model.

METHODS

A model was created based on subtraction data derived from computed tomography scans of the pelvic bones and lumbar spine using the Blender 3.2.2 software program. Images were modeled and reconstructed in 3D to display the male inguinal region, typically viewed using a laparoscopic approach. Polylactic acid plastic was used to print the model. Some structures were made using ethylene vinyl acetate to enable possible material replacement and model reutilization. Thirty surgeons with various training levels were invited to use the model. Transabdominal inguinal hernioplasty was performed by simulating the same steps as those of a laparoscopic surgery, and the surgeons answered a questionnaire regarding the simulation.

RESULTS

Twenty-eight surgeons responded, seven of whom were experts in the treatment of abdominal wall hernias. The model was deemed easy to use, realistic, and anatomically precise, establishing it as a valuable supplement to minimally invasive surgery training.

CONCLUSION

The evaluation of this 3D model was favorable, as it accurately depicted the inguinal region anatomically, while also proving to be cost-effective for training purposes. The model could be a good option, particularly beneficial for training surgeons at the beginning of their careers.

EHS guidelines for inguinal hernia repair. The reality of the current situation in Spain. A proposal to standardize its implementation during surgical training

Laparoscopic inguinal hernia repairs are underused in our country and do not fulfil to the recommendations of the European Hernia Society (EHS) guidelines. Thus, it is essential to establish measures that increase its use. We propose that the Spanish Association of Surgeons (AEC) promote these actions and that they should be incorporated into the specialty program. The proposed measures include Standardization of learning; reinforce anatomical knowledge; regulated practices with simulators; promote the use of the open posterior approach; rotations through centers of excellence; accreditation of specialized units and use a registry of activity as quality control.

Implementation and Validation of a Novel and Inexpensive Training Model for Laparoscopic Inguinal Hernia Repair

Purpose: The aim of this study was to develop and validate a reproducible low-cost model useful for the development and acquisition of skills and competencies required for endoscopic hernia repairs. Methods: Ten general surgery residents (PGY3) were instructed to construct the model and perform the maneuvers necessary for the simulation of laparoscopic inguinal hernioplasty by the trans-abdominal pre-peritoneal (TAPP) technique. They practiced for 4 weeks in the model, and the time required to perform simulated hernioplasty by the laparoscopic TAPP technique in the initial session was compared to the time required after 4 weeks of training. Results: The time required to perform the exercise was significantly lower than in the initial session (p < 0.01). The time required by residents to complete the exercise in the initial session was significantly longer than that used by expert surgeons in the same task (p < 0.01), and although a significant difference persisted, this difference was substantially reduced to 3.60 min after the residents completed 4-week training in the model (p < 0.01). An independent expert, blinded to the level of training of the person who performed the exercise, could recognize all residents as novices and all experienced surgeons as experts in the initial session of the exercise with the model, but after 4 weeks of training, they did not recognize 4 of the 10 residents as novices (p < 0.05). Conclusion: The routine implementation of training in this model could be very useful in the laparoscopic inguinal hernioplasty teaching-learning process.

Characteristics of laparoscopic and open hernia repair simulation models: a systematic review

Purpose

Barriers to education in open and laparoscopic hernia repair technique include a steep learning curve and reduced theatre time for junior surgical trainees. This is particularly evident during the current COVID-19 pandemic. Simulation models may provide further opportunities for training in hernia repair outside of the traditional surgical apprenticeship model.

Methods

A systematic review was carried out following PRISMA guidelines to identify and evaluate simulation models in hernia repair. Of the 866 records screened, 27 were included in the analysis. These were assessed for face, content and construct validity, as well as their attempt to measure educational impact.

Results

Simulation models were identified comprising of animal tissues, synthetic materials and virtual reality (VR) technology. Models were designed for instruction in repair of inguinal, umbilical, incisional and diaphragmatic hernias. Twenty-one laparoscopic hernia repair models were described. Many models demonstrated validity across several domains, and three showed transferability of skills from simulation to the operating room. Of the six open hernia repair simulation models, none were found to have demonstrated an educational impact in addition to assessing validity.

Conclusion

Few models individually were able to demonstrate validity and educational impact. Several novel assessment tools have been developed for assessment of progress when performing simulated and real laparoscopic inguinal hernia repair. More study is required, particularly for open hernia repair, including randomized controlled trials with large sample sizes to assess the transferability of skills.

Simulation in Hernia Surgery: Where Do We Stand?

Simulation seems to be the best method of improving medical attitude, technical skills, and operating times. A literature review of the available data in simulation for hernia surgery was performed. Surgical simulation has been included as a main requirement in residency programs and endorsed by several surgical societies. However, evaluating how simulation affects patient's outcomes is challenging. In addition, simulation training represents an institutional economic burden that could undermine its implementation and development. Published data support that simulation-based training is a highly efficient tool, thus, its implementation should be strongly encouraged.

A structured program for teaching pancreatojejunostomy to surgical residents and fellows outside the operating room: a pilot study

Background

Pancreatojejunostomy (PJ) is one of the most difficult and challenging abdominal surgical procedures. There are no appropriate training systems available outside the operating room (OR). We developed a structured program for teaching PJ outside the OR. We describe its development and results of a pilot study.

Methods

We have created this structured program to help surgical residents and fellows acquire both didactic knowledge and technical skills to perform PJ. A manual was created to provide general knowledge about PJ and the specific PJ procedure used in our institution. Based on questionnaires completed by trainers and trainees, the procedure for PJ was divided into twelve steps and described in detail. After creating the manual, we developed organ models, needles and a frame box for simulation training. Three residents (PGY3-5) and three fellows (PGY6 or above) participated in a pilot study. Objective and subjective evaluations were performed.

Results

Trainees learn about PJ by reading the procedure manual, acquiring both general and specific knowledge. We conducted simulation training outside the OR using the training materials created for this system. They simulate the procedure with surgical instruments as both primary and assistant surgeon. In this pilot study, as objective assessments, the fellow-group took less time to complete one anastomosis (36 min vs 48 min) and had higher scores in the objective structured assessment of technical skill (average score: 4.1 vs 2.0) compared to the resident-group. As a subjective assessment, the confidence to perform a PJ anastomosis increased after simulation training (from 1.6 to 2.6). Participants considered that this structured teaching program is useful.

Conclusion

We developed a structured program for teaching PJ. By implementing this program, learning opportunities for surgical residents and fellows can be increased as a complement to training in the OR.

Radiological Society of North America (RSNA) 3D Printing Special Interest Group (SIG) clinical situations for which 3D printing is considered an appropriate representation or extension of data contained in a medical imaging examination: abdominal, hepatobiliary, and gastrointestinal conditions

Background

Medical 3D printing has demonstrated value in anatomic models for abdominal, hepatobiliary, and gastrointestinal conditions. A writing group composed of the Radiological Society of North America (RSNA) Special Interest Group on 3D Printing (SIG) provides appropriateness criteria for abdominal, hepatobiliary, and gastrointestinal 3D printing indications.

Methods

A literature search was conducted to identify all relevant articles using 3D printing technology associated with a number of abdominal pathologic processes. Each included study was graded according to published guidelines.

Results

Evidence-based appropriateness guidelines are provided for the following areas: intra-hepatic masses, hilar cholangiocarcinoma, biliary stenosis, biliary stones, gallbladder pathology, pancreatic cancer, pancreatitis, splenic disease, gastric pathology, small bowel pathology, colorectal cancer, perianal fistula, visceral trauma, hernia, abdominal sarcoma, abdominal wall masses, and intra-abdominal fluid collections.

Conclusion

This document provides initial appropriate use criteria for medical 3D printing in abdominal, hepatobiliary, and gastrointestinal conditions.

Senior General Surgery Resident Confidence in Performing Abdominal Wall Hernia Repairs

BACKGROUND

It is expected that graduating general surgery residents be confident in performing common abdominal wall hernia repairs. The objective of our study was to assess the confidence of senior surgical residents in these procedures and to identify factors that correlate with confidence.

METHODS

We performed a cross-sectional survey of PGY-4 and PGY-5 general surgery residents at ACGME-accredited programs in the United States in the spring of 2019. Respondents rated their confidence level in 12 hernia procedures on a Likert scale from 1 (not confident) to 5 (extremely confident). Respondents were classified as "Not Confident" (Not Confident, Minimally Confident, Neutral responses) or "Confident" (Confident, Extremely Confident responses). Resident characteristics, program characteristics, and operative experience were collected, and we calculated the area under the curve to screen which factors discriminated between those confident versus not. Multivariable Poisson regression was used to estimate prevalence ratios (PR) and 95% confidence intervals (CI) to identify which factors were most predictive.

RESULTS

A total of 93 surveys were completed. Respondents reported low confidence rates (25%-60%) in the following hernia repairs: minimally invasive (MIS) inguinal, femoral, tissue (nonmesh) inguinal, pediatric inguinal, and abdominal wall reconstruction. High confidence rates (>80%) were reported for open umbilical, open ventral, and MIS ventral hernia repairs. For MIS inguinal hernia repair, PGY-5 level was associated with a twofold increase in confidence (PR = 2.01; 95% CI = 1.34-3.30), and dedicated research years were associated with low confidence (PR = 0.67; 95% CI = 0.43-1.04). In general, higher operative volumes of a specific repair were associated with increased confidence in that procedure.

CONCLUSIONS

Senior surgical residents reported low confidence in performing a variety of essential hernia repairs (particularly MIS inguinal, femoral, and tissue inguinal). Addressing factors associated with low confidence may help increase resident confidence.

Preoperative skill evaluation in transabdominal preperitoneal (TAPP) inguinal hernia repair using a three-dimensional printed TAPP repair simulator

BACKGROUND

Although transabdominal preperitoneal laparoscopic inguinal hernia repair (TAPP LIHR) is becoming increasingly more critical in the management of hernias, it has a long learning curve. The learning curve is often measured by a shortened operative time without mention of the quality of the procedure. This study was performed to evaluate the efficacy of a three-dimensional printed TAPP LIHR simulator to evaluate the surgeon's preoperative skill before entering the operative theater.

METHODS

Fifteen surgeons in our institution were enrolled in this study. They performed simulation TAPP LIHR while being video recorded. The TAPP LIHR simulator allows for the performance of all procedures required in TAPP LIHR. All participants were classified according to several background factors: postgraduate years (PGYs) (1-5, 6-10, or > 10), number of TAPP LIHR procedures performed (< 10, 11-49, or > 50), and number of laparoscopic surgeries performed (≤ 100 or > 100). The correlation among PGYs, the number of TAPP repairs performed, and the checklist score was evaluated.

RESULTS

The mean total score and time required to perform TAPP LIHR were significantly different among the three TAPP LIHR experience groups (< 10, 11-49, and > 50 procedures; P < 0.05). The checklist score and time required to perform TAPP LIHR were strongly correlated with the number of TAPP LIHR procedures performed (r = 0.74 and r = 0.69, respectively). However, the checklist score showed a weak correlation with PGY (r = 0.52).

CONCLUSIONS

Preoperative skill evaluation using a TAPP LIHR simulator and TAPP repair checklist supports the distinction between novices and experts. Both education systems are a valuable and affordable tool for evaluation and training of TAPP LIHR.

Development and evaluation of a novel simulation model for transabdominal preperitoneal (TAPP) inguinal hernia repair

BACKGROUND

Transabdominal preperitoneal (TAPP) inguinal hernia repair requires the surgeon to have good manual skills in laparoscopic surgery, as well as an understanding of the laparoscopic features of the groin anatomy. This is why TAPP is considered a more difficult surgical procedure compared to open techniques. Realistic training model for TAPP inguinal hernia repair would enhance surgeons' skills before they enter in the operation room. Our aim was to create a realistic, inexpensive, and easily reproducible model for laparoscopic TAPP inguinal hernia repair and to assess its effectiveness.

METHODS

The applied TAPP inguinal hernia repair training simulator consists of a laparoscopic box and an inguinal region model placed in it. The model of the groin area is made of the porcine stomach and assembling materials. Uniaxial tensile and T-peel tests were performed to compare the mechanical properties of the porcine stomach and the human cadaver peritoneum. Thirty eight surgeons performed TAPP inguinal hernia repair using this model. Their opinions were scored on a five-point Likert scale.

RESULTS

Close elastic modules of the porcine and human tissues (13.5 ± 4.2 kPa vs. 15.8 ± 6.7 kPa, p = 0.531) gave to trainees a realistic tissue feel and instrument usage. All participants strongly agreed that model was highly useful for TAPP inguinal hernia repair training. They also put the following points: the model as a whole 5 (3-5), simulation of anatomy 5 (3-5), simulation of dissection and mobilization 5 (3-5), and simulation of intracorporeal suture 5 (4-5).

CONCLUSIONS

We successfully created a model for TAPP inguinal hernia repair training. The model is made of inexpensive synthetic and biological materials similar to the human tissue. The model is easy to reproduce and can be used in the training programs of surgical residents.

Educational system based on the TAPP checklist improves the performance of novices: a multicenter randomized trial

BACKGROUND

Despite recent developments in surgical education, obstacles including inadequate budget, limited human resources, and a scarcity of time have limited its widespread adoption. To provide systematic training for laparoscopic inguinal hernia repair, we had previously developed and validated a checklist to evaluate the recorded performance of transabdominal preperitoneal (TAPP) repair. We had also developed an educational system that included didactic materials based on the TAPP checklist and incorporated remote evaluation and feedback system. The aim of this study was to evaluate the educational impact of the TAPP education system on novice surgeons.

METHODS

Residents and surgeons from participating hospitals, who had performed 0 or 1 TAPP procedure, were randomly assigned to the intervention group (IG), who trained using this new educational tool, and the control group (CG), who trained using the conventional system. Their surgical videos were rated by blinded raters. All participants performed their first case prior to randomization. The primary outcome was improvement of TAPP checklist score from the first to the third case.

RESULTS

Eighteen participants from 9 institutes were recruited for this study. Seven participants in the IG and 5 participants in the CG were included in the final analysis. The participants in the IG demonstrated significant improvement in their TAPP performance (p = 0.044) from their first case to their third case, whereas their counterparts in the CG failed to make any significant progress during the same period (p = 0.581).

CONCLUSION

The new TAPP educational system was effective in improving the TAPP performance of novice surgeons.