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Original Investigation
Pacific Coast Surgical Association
January 2017

Global Outreach Using a Systematic, Competency-Based Training Paradigm for Inguinal Hernioplasty

Author Affiliations
  • 1Hernia Repair for the Underserved, Omaha, Nebraska
  • 2Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles
  • 3Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
  • 4Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
  • 5Department of Surgery, Southern Illinois University School of Medicine, Springfield
  • 6Division of Pediatric Surgery, University of Nebraska College of Medicine, Omaha
  • 7Department of Surgical Science, University of Insubria, Instituto Clinico Sant’Ambrogio, Milano, Italy
  • 8Department of Surgery, University of Catania, Catania, Italy
  • 9Division of General Surgery, School of Medical Sciences of Santa Casa de São Paulo, São Paulo, Brazil
  • 10Department of Surgery, Wilhelmsburg Groß-Sand Hospital, Hamburg, Germany
  • 11Department of Surgery, L’Hôpital de l’Université d’État d’Haïti, Port-au-Prince, Haiti
  • 12Department of Surgery, University of North Carolina, Charlotte
JAMA Surg. 2017;152(1):66-73. doi:10.1001/jamasurg.2016.3323
Key Points

Question  Can a structured training paradigm address the inconsistency in inguinal hernia operations performed worldwide?

Findings  In this prospective, observational study, 81 surgeon trainees at 16 hospitals in 5 countries underwent systematic training in Lichtenstein hernioplasty, a subset of whom became certified regional trainers. During the training series, improvements in operative performance were statistically significant for all countries and sites.

Meaning  Regional competency-based training provides a standard method to address the global burden of surgical disease.


Importance  Sustainable, capacity-building educational collaborations are essential to address the global burden of surgical disease.

Objective  To assess an international, competency-based training paradigm for hernia surgery in underserved countries.

Design, Setting, and Participants  In this prospective, observational study performed from November 1, 2013, through October 31, 2015, at 16 hospitals in Brazil, Ecuador, Haiti, Paraguay, and the Dominican Republic, surgeons completed initial training programs in hernia repair, underwent interval proficiency assessments, and were appointed regional trainers. Competency-based evaluations of technical proficiency were performed using the Operative Performance Rating Scale (OPRS). Maintenance of proficiency was evaluated by video assessments 6 months after training. Certified trainees received incentives to document independent surgical outcomes after training.

Main Outcomes and Measures  An OPRS score of 3.0 (scale of 1 [poor] to 5 [excellent]) indicated proficiency. Secondary outcomes included initial vs final scores by country, scores among surgeons trained by the regional trainers (second-order trainees), interval scores 6 months after training, and postoperative complications.

Results  A total of 20 surgeon trainers, 81 local surgeons, and 364 patients (343 adult, 21 pediatric) participated in the study (mean [SD] age, 47.5 [16.3] years; age range, 16-83 years). All 81 surgeons successfully completed the program, and all 364 patients received successful operations. Mean (SD) OPRS scores improved from 4.06 (0.87) before the initial training program to 4.52 (0.57) after training (P < .001). No significant variation was found by country in final scores. On trainee certification, 20 became regional trainers. The mean (SD) OPRS score among 53 second-order trainees was 4.34 (0.68). After 6-month intervals, the mean (SD) OPRS score among participating surgeons was 4.34 (0.55). The overall operative complication rate during training series was 1.1%.

Conclusions and Relevance  Competency-based training helps address the global burden of surgical disease. The OPRS establishes an international standard of technical assessment. Additional studies of long-term surgeon trainer proficiency, community-specific quality initiatives, and expansion to other operations are warranted.