Simulation-based Mastery Learning Improves Patient Outcomes in Laparoscopic Inguinal Hernia Repair: A Randomized Controlled Trial

Ann Surg. 2011 Sep;254(3):502-9; discussion 509-11. doi: 10.1097/SLA.0b013e31822c6994.


Objective: To evaluate a mastery learning, simulation-based curriculum for laparoscopic, totally extraperitoneal (TEP) inguinal hernia repair.

Background: Clinically relevant benefits from improvements in operative performance, time, and errors after simulation-based training are not clearly established.

Methods: After performing a baseline TEP in the OR, general surgery residents randomized to mastery learning (ML) or standard practice (SP) were reassessed during subsequent TEPs. The ML curriculum involved Web-based modules followed by training on a TEP simulator until expert performance was achieved. Operative time, performance, and patient outcomes adjusted for staff, resident participation, difficulty of repair, PGY-level, and patient comorbidities were compared between groups with mixed effects-ANOVA and generalized linear models.

Results: Fifty residents (PGY1-5) performed 219 TEP repairs on 146 patients. Baseline operative time, performance, and demographics were similar between groups. To achieve mastery, ML-residents (n = 26) required a median of 16 (range 7-27) simulated repairs. After training, TEPs performed by ML-residents were faster than those by SP-residents, with time corrected for participation (mean ± SD, 34 ± 8 minutes vs. 48 ± 14 minutes; difference -13; 95%CI, -18 to -8; P < 0.001). Operative performance scores (GOALS, scale 6-30) were better for ML residents (21.9 ± 2.8 vs. 18.3 ± 3.8; P = 0.001). Intraoperative complications (peritoneal tear, procedure conversion), postoperative complications (urinary retention, seroma), and need for overnight stay were less likely in the ML group (adjusted odds ratios 0.14, 0.04, and 0, respectively; all P < 0.05).

Conclusions: A simulation-based ML curriculum decreased operative time, improved trainee performance, and decreased intra- and postoperative complications and overnight stays after laparoscopic TEP inguinal hernia repair. Identifier: NCT01085500.

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Aged
  • Analysis of Variance
  • Computer Simulation*
  • Computer-Assisted Instruction*
  • Female
  • General Surgery
  • Hernia, Inguinal / surgery*
  • Hospitals, University
  • Humans
  • Internship and Residency*
  • Laparoscopy*
  • Length of Stay
  • Linear Models
  • Male
  • Middle Aged
  • Patient Satisfaction
  • Single-Blind Method
  • Time Factors
  • Treatment Outcome
  • User-Computer Interface

Associated data