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

Zendejas, Benjamin MD, MSc*,†; Cook, David A. MD, MHPE†,‡,§; Bingener, Juliane MD*; Huebner, Marianne PhD; Dunn, William F. MD†,§; Sarr, Michael G. MD*; Farley, David R. MD*,†

doi: 10.1097/SLA.0b013e31822c6994
Papers of the 131st ASA Annual Meeting

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

Supplemental Digital Content is Available in the Text.General Surgery residents randomized to a mastery learning, simulation-based training TEP curriculum outperformed residents involved in standard clinical practice by demonstrating decreased operative time, improved operative performance, as well as improvements in patient outcomes - fewer intra- and postoperative complications, and a decreased need for overnight stays.

*Department of Surgery

Mayo Clinic Multidisciplinary Simulation Center

Department of Medicine

§Office of Education Research

Department of Health Sciences Research, Mayo Clinic, Rochester, MN.

Reprints: David R. Farley, MD, Department of Surgery, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905. E-mail:

Disclosure: Supported by the grant from the National Center for Research Resources (NCRR), Grant Number 1 UL1 RR024150, a component of the National Institutes of Health (NIH), and the NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH.

Supplementary digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Presented at the 131st Annual Meeting of the Americal Surgical Association, April 14–16, 2011, Boca Raton, FL.

© 2011 Lippincott Williams & Wilkins, Inc.