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

C T Zipper; U Friedrich; J Backhaus; S König; S Mavroveli; A Wiegering; S Olbrecht; F Puppe; S A Günster; U A Dietz

doi:10.1007/s10029-019-02094-5

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. 2020 Dec;24(6):1307-1315. doi: 10.1007/s10029-019-02094-5. Epub 2019 Dec 2.

Authors

C T Zipper¹, U Friedrich¹, J Backhaus², S König², S Mavroveli³, A Wiegering^{1

4}, S Olbrecht⁵, F Puppe⁵, S A Günster⁶, U A Dietz^{7

8}

Affiliations

¹ Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Strasse 6, 97080, Wuerzburg, Germany.
² Institute of Medical Teaching and Medical Education Research, University of Wuerzburg, Josef-Schneider Strasse 2, 97080, Wuerzburg, Germany.
³ London General Surgical Skills Programme, Imperial College London, South Wharf Road, Paddington, London, W2 1BL, UK.
⁴ Department of Biochemistry and Molecular Biology, University of Wuerzburg, Am Hubland, 97074, Wuerzburg, Germany.
⁵ Institute for Artificial Intelligence and Applied Informatics (VI), University of Wuerzburg, Am Hubland, 97074, Wuerzburg, Germany.
⁶ Institut für Allgemeinmedizin, Friedrich-Alexander-Universitaet Erlangen-Nuernberg, Universitaetsstrasse 29, 91054, Erlangen, Germany.
⁷ Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Strasse 6, 97080, Wuerzburg, Germany. ulrich.dietz@spital.so.ch.
⁸ Department of General, Visceral, Vascular and Thoracic Surgery, Kantonsspital Olten (soH), Baselstrasse 150, 4600, Olten, Switzerland. ulrich.dietz@spital.so.ch.

PMID: 31792801
DOI: 10.1007/s10029-019-02094-5

Abstract

Background: 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".

Results: 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" (M_beg. = 2.33, M_exp. = 3.94, p < 0.001), "tissue handling" (M_beg. = 2.11, M_exp. = 3.72, p < 0.001), "near misses and errors" (M_beg. = 2.67, M_exp. = 3.67, p < 0.001), and "end-product quality" (M_beg. = 2.78, M_exp. = 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.

Conclusions: 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.

Keywords: Fatty triangle; Incisional hernia repair; Retromuscular mesh repair; Simulation; Surgical model; Validation.

MeSH terms

Adult
Female
Herniorrhaphy / methods*
Humans
Incisional Hernia / surgery*
Male
Silicones / metabolism*
Surgical Mesh / standards*

Substances

Silicones