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Capstone project venrtal incisional hernia repair


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Capstone project venrtal incisional hernia repair

  1. 1. Subject area Capstone Project Learners MOSTAFA HEGAZY Educational project title Ventral Incisional Hernia Sublay Mesh Repair Type of educational project (new course, curriculum, teaching session, intervention, innovation, or other) New Course Educational project brief description A ventral incisional herniaisone of the mostcommon complicationsin general surgery. Long term incidence of 10%-20%(1), primary suture repair about 31%-58%(2), with a shift to tension-free mesh repair incidences of recurrence lessthan10%(3). For open incisional hernia repair, the technique of a retro rectus prosthetic mesh sublayaugmentationdescribedbyStoppaandRivesfromFrance in1973, has become the standardprocedure in many countries (5). Sublaymeshrepairprovedlessrecurrence rate,lesspost-operative complications,andearlyhospital discharge, cost-effective technique. So we design a course to teach open sub lay mesh repair of ventral incisional hernia repair in Sohag Teaching Hospital with the guidance of review literature, and clinical trials all over the world. We plannedourcourse as a teachingcourse forthe Fellowesin the general surgery department in our hospital whoare the major learnersinourteachinghospital.Ingeneral,thistechnique is very simple can be easily done and learned, so the learners will benefit from adjoining this course as new surgical experience, innovative technique, and future surgical career. Design; the plan shows that the first step is to evaluate our learners (Fellowes) before starting the course. On the firstday of thiscourse a reviewof literature theoretical discussion sessions each session about 2hours, on the first session we intended to review the anatomy of the abdominal wall, pathophysiology of ventral incisional hernia,howtopreventitsoccurrences,typesof openmeshrepair,different types of mesh materials. In the secondsession,we willdiscussbesttechniquesforopenventral incisional hernia repair, immediate and remote postoperative complications, and in the long run. Lastly, we will discuss in detail the steps of sublay mesh repair. Clinical Session:abedside examof eachpatientbefore gettingto the theatre, we will review using a (5-minute procedure) bedside exam the history and the investigation are discussed with the Fellowes, fitness, general condition, and lastly patient written consent. On the second day, we will move to the operating room, In the operating room after the introduction of anesthesia, we planned to operate upon one patient using sublaymeshrepair, we have preparedtooperate onat least5 patientsof a ventral incisional hernia during this course.At the same time, we will directly transmit a video conference from the operating room to the lecture room where the other staff members, residents, and the other fellows, follow direct video transmission. Discussion of the operative details technique and steps of this with our assistants(Fellowes), and other attendants through direct video conference. Goals of the project Improve,medical knowledge,surgical skillsand bettersurgeonattitude. Achievingbetterpatientsatisfaction,fewercomplications To achieve cost-effectiveness for ventral incisional repair with little burden on hospital financial resources, and local society.
  2. 2. Objective of the project By endof thiscourse (2 successive dayscourse),general surgeryfellowship will be able to 1)Discussdifferenttechniquesof openventral incisional herniarepair. 2)Differentiate betweentypesof meshesused inherniarepair. 3)Describe the complicationsof openmeshrepair. 4)Describe indetail the stepsof Sublaymeshrepair. 5) operate uponand assistforat leastone patientapplyingthistype of Sublaymesh repair during the course Background On mylongexperienceinthe fieldof general surgery,we found that the routine use of synthetic mesh in open ventral incisionalherniarepair,recurrence rate have beendropped,butmostsurgeonsusedwhatis called Inlay meshrepairwhere the meshisanchoredtothe edgesof the wound but it was complicated by mesh migration, intestinal fistula formation, and poor postoperative compliances Afterthat surgeonsshiftedtowardwhatiscalledOnlaymeshrepair,where the mesh was implanted in front of the newly formed linea alba, the postoperative complications in the form of seroma formation, chronic pain, stiff abdominal wall, and recurrence of incisional hernia, all these led to shift away from Onlay mesh repair. With a review of literature, we found that Sublay mesh repair which was first introduced by the French surgeons (Rives &Stoppa 1970) a great shift toward this type of repair has happened. In this type of repair the meshisimplantedinfrontof closedposteriorsheathandperitoneum, behindthe rectusmuscle,thennewlinea alba is fashioned in front of the mesh and rectus muscle, this type of repair has had less postoperative complications, no or little seroma , less chronic pain, less recurrence rate,and short hospital stay with better patients compliance. In our hospital(SohagTeachingHospital) surgeons still use Onlay mesh repair, with many problems happened, due postoperative complications, long hospital stay, more financial problem as this problem affect our communityinthe formof delay return works, affect the hospital resources, because of long hospital stay with the current techniques used in hernia repair, it affects also the general surgeons as little numbers of senior consultants practice this technique which leads at the end that most of the new generation of surgeons have known little about this type of open ventral incisional hernia mesh repair. So our curriculum for learning general surgery fellows the Sublay retro rectus mesh repair will improve the learning objective and long-life learning of surgical skills. This course will provide our hospital with more trained surgeons, also it will help to reduce the burden of incisional herniadisease inthe longrun.The introductionof retrorectus,sublaytechnique using polypropylene meshes had significantly decreased the recurrence rates after open incisional hernia repair. This technique is very simple that can be easily done and easily learned. A needassessmentprotocol hasbeenperformed,informal discussion and interviews with learners(Fellowes), residents and our staff members in the general surgery department, direct observation of targeted learners duringtheirfellowshipschedules,smallgroupdiscussionswiththe majorityof the participantshave been done. This need assessment showed that the majority of our staff members agree for the implementation of this course as it will elevate the levelof fellowsinthe generalsurgerydepartment,addmore surgical skills,andget a perfect surgeon attitude. It alsoshowedthatthe existingcurriculuminmanagingventral incisional herniarepair has some drawbacks and mustbe changedbyintroducingthisnewcurriculum(sublaymeshrepair),alsomore trainingprograms in which we intended to repeat regularly our training course. The trainers (fellows) have already good experience in managing ventral incisional hernia but by onlay mesh repair technique, after completing the course, a shift to sublay mesh repair technique can be achieved by regular training, cooperation with the staff members of the general surgery department, and the hospital administration system. Implementationcanbe achievedbythe guidance of the chief manager,the cooperationof ourgeneral surgeon's chiff, our colleagues, etc. the wellness of our learners, availability of financial resources, and technology demands.___________________________________________________________________________________
  3. 3. Design and development Our curriculumplancan be summarizedasa 2 consecutive dayscourse thatincludestheoretical knowledge thenclinical andoperative skill training. FirstDay -Introductionandaimof work (8 AM -8.15 AM)(15 minutes)) -overview of the course ingeneral. (8.15 AM - 8.30 AM)(15 minutes) Anatomyof the abdominal wall (8.30 AM - 9.30 AM)(60 minutes)) Pathophysiologyof incisionalhernia 9.30 AM - 10.30 AM)(60 minutes)) Etiologyof ventral incisional hernia (10-30 AM- 11.30 AM)(60 minutes) Breakout(from11-30 AM - 12. AM)(30 minutes) Clinical Presentation (12 PM- 1 PM)(60 minutes) Typesof meshesusedinherniarepair 1 PM - 1.30 PM)(30 minutes)) Techniquesof ventral incisional herniarepair 1.30 PM - 3 PM)(90 minutes)) Breakout3 PM- 3.30 PM)(30 minutes) Shiftto Bedside ClinicalOrientation Case Presentation: Ventral Incisional Hernia (3.30 PM - 5PM)(90 minutes) :SecondDay (Fridayfrom8 AM – 8 PM) The firstcase of Sublay openmeshrepairof ventral incisionalhernia(8AM- 10 AM) Discussion(From10 AM - 12 PM) Secondoperative case Discussion(12PM - 12.30 PM) Breakout(1PM - 3 PM) Thirdoperative case Discussion(3PM- 5 PM) Fourthoperative case Discussion(5PM - 7 PM) 5Th. operative case Discussion(7PM - 8 PM) EndingSession Certificate of attendance A planto designanddevelopthe course foropensublaymeshventral incisional herniarepair with regard to our learningobjectives, this plan starting from the time that we decided to put curriculum for the training course, these include theoretical lecturessessionstocoveraliterature review uponthe previously documented data in the literature that talking about ventral incisional hernia, the anatomy of the abdominal wall, factors that incorporatedinthe occurrence of hernia,pathophysiological conditions ,incidence , recurrence, complications, methodsof repair,typesof meshesusedinmeshrepair,sublaytechnique ,how topreventincisional hernia and lastly how to prevent recurrences. On the other hand, clinical and operative sessions where the our learner can be trained on how to present a case of ventral incisionalhernia,andinthe theaterhow tobecome a good assistant in operation like this, lastly howthe learneroperatesbyhisown,withmyassistance ( hand on training)and how to master such technique. Theoretical lecture: this will be in the shape PowerPoint presentation, active discussion, video review. Clinical session: bedside 10-minute exam. Operating room: Supervised clinical experiences Demonstration for sublay mesh repair The flippedclassroom, Pre-session homework in the form of a short video about ventral incisional hernia (7-9 minute), this video will be delivered on the network website of our teaching hospital, to be a pre -work assignment. On class interactive session with a short group session, not more than 5 learners in the flip class. Video review at the end of theoretical sessions. Post-session homework, with some interleaving questions. Realybecause of the missionisnotonlyself-dependencywe are inneedof otherteacherstoshare on regulation , the advancement of some theoretical sessions and clinical case presentation, or as an advisor in the flip
  4. 4. classroom, assistance in the operating room, and operator for some cases in the theater. Before the course startswe have to do an assessmentof ourcooperatingteachers,thentrainingthemin special sessiononthe technique of sublaymeshrepair,advisingsome videoreview,anddiscusswiththe importance of our course, and they can help the forward progress ___________________________________________________________________________________________. Implementation Hughescitedthat to a achieve curriculumpotential,animplementationmust be addressed and the curriculum developer must ensure that sufficient resources, political and financial support, (6) Identification of the resources resources Implementation of our new course Sublay mesh repair of ventral incisional hernia, considered as a part of continuing medical educational curriculum, in Sohag Teaching Hospital, one of the leading hospitals in upper Egypt, serving a great number of population among Sohag government. So,we puta planforthe implementationof ourproject,aswe define ourhospital resources,greatattentionhas been paid for the personnel: the first faculty, we have already prepared a plan so that all general surge ons in SohagTeachingHospital shouldhave the opportunitytoshare theirexperienceduringthe course, concentrated prework PowerPoint, lectures, videos available for training purposes. Audiovisual,computing,informationtechnology,secretarialandothersupportstaff, we have already prepared to deliverpreliminarytrainingcoursesforco-team members, as they have a great task considering our project. Patients: there is a good follow of patients that visit the outpatient general surgery clinic complaining of postoperative ventral incisional hernia, and we decided to operate upon some selected cases. Time: considering the time the curriculum director, faculty, support staff, and learners, the schedule of the project can be applied on 2 successive days, no extreme overload burden on staff members or their regular hospital duties. Facilities: space, clinical sites, clinical equipment, educational equipment, virtual space (servers, content managementsoftware),ourhospital alreadyhave manyworkshops,conferences,and courses which have been held,sono problems concerning, lectures room, room for bedside exam and the operating room, as there are more than three well-equippedtheatres,withwell-trained nursing staff, infection control team, technical staff for overcoming accidentally discovered problems in electric supply O2 supply, instruments sterilization, and disinfection, etc. Funding/costs: direct financial costs, hidden or opportunity costs, faculty compensation, costs of scholarship: our teachinghospital hasagreat budgetforscientificresearchesplansalreadyavailable,itwill coveragreatpart of course costs,a minimumpartof financial resources can be achieved by sharing of working companies which deal with the hospital, as drugs, equipment, and disposable tools supply companies. To obtainsupportforour project,we have starteda planto convince mostof the stakeholders,learners, as well as the administrative authority Having the support of learners when implementing our project can achieve their to acquire the knowledge, skills, and attitudes necessary to be a successful surgeon, accreditation for a future career, their opinions can also affect those with administrative power. Trainers, we convinced them to devote great amounts of their time, enthusiasm, and energy to the course as gaining broad faculty support is very important also the course is important, effective, and positively affects them and our institution. The administrative authority ( hospital administrators, department chairman) can allocate the funds,space,facultytime,curriculartime,andpolitical supportthatare critical to the course, therefore,helpful toencourage inputfromstakeholdersasthe curriculumisbeingplanned,aswell astoprovide stakeholders with the appropriate rationale and evaluation data to address their concerns about our project. To developadministrative mechanismstosupportourcourse curriculum, the projectdesignwasasfollow: Administrative structure;todelineateresponsibilitiesanddecisionmaking,ateamof our seniorsurgical residents,fellows,andotheremployeesundermydirectguidance me,thisteamisresponsible for,
  5. 5. communicationwiththe hospitalauthority, todelineategoalsandobjectives;informationaboutthe intended course.Thisteamalso hasthe taskto communicate withthe learnersandfaculty,preparingfacilitiesand equipment,scheduling;evaluationresults,andfeedbackconcerningourproject.Thisaimcan be achieved through,websitesforthe project,social medialinks,andmeetingsnegotiations.The teamalsohelpstodeliver syllabusmaterials,site visits,reports,andanychange inthe curriculumdesign,throughpreparationand distributionof schedulesandcurricularmaterials;collection,collation,anddistributionof evaluationdata; curricularrevisionsandreportanychanges. We planned for presenting and publishing a feed about the curriculum of our project in national and international journals of surgery. The administrative teamof the course anticipatesdifferentbarriers,addressesthese barriers,andhowto overcome them.The mostrelevantbarrierisfinancialresources,we made adeal withthe hospital funding resourcesauthoritytosupportthe project,andto supplyfinancial supportforanyhiddencostappearingduring projectimplementation. Consideringthe peoplesharinginthe projectmaybe few barriers,butwe convincedthemtodotheirbestas we will rewardthemtoo. Full implementation is our aim as it is a short (2days) course, but we consider the course as a piloting course, and there is a plan for project curriculum enhancement and maintenance in the long run. _________________________________________________________________________________ Assessment Some say:assessment drives learning, so we try to create a strong relationship between assessment and the goals of the course concerning what learners (Fellowes) should be learning, what we actually teach in this course. When the goals of our project closely match the content of the courses and the nature of course assessment we can feel certain that our efforts have been successful. So our plan to assess the project successfulness summarized as follow: Formative evaluationof anindividual learner(fellow) and the senior surgeons (faculty)who deliver the course that is used to help the individual improves performance: identification of areas for improvement Summative Evaluationof anindividual learner and the senior surgeons (faculty)that are used for judgments or decisions about the individual motivation to maintain or improve performance as well as certification of performance. Program Evaluation Formative evaluation of the program to improve course performance with identification of areas for improvement. Summative: evaluation of the course for decisions about the program or program developers judgments regardingsuccess,efficacy;decisionsregardingthe allocationof resources, motivation/recruitment of learners and faculty, promotion, dissemination: presentations, publications. The most importantstepinour planto the evaluationof ourproject is to identify the users of the evaluation. Course participants are interested in the assessment of their own performance and the performance of the project.The evaluationcanalsoprovide feedback and motivation for continued improvement for the learners (Fellowes), and the teachers (senior surgeons). Otherstakeholderswhohave administrativeresponsibility for, allocate resources to, or are otherwise affected by the curriculum will also be interested in evaluation results. These might include the hospital administrators, the general surgery department chair, general surgery residents,specialists and consultants, other individuals who help in political support, and other organizations that have contributed funds or other resources to our project. To some extent evaluation of our project may of interest to educators from other institutions and serve as a basisfor publications/presentations.Asasociety(Sohaggovernment) isconsideredasthe mainindividuals who benefit from a medical care project, society members (the patients) are also considered as stakeholders. Formative Evaluationof anindividual learner(fellow) andthe seniorsurgeons(faculty)whodeliverthe course that isusedto helpthe individual improvesperformance: - identificationof areasforimprovement,
  6. 6. To determine whether the curriculum is achieving its goals - To measure students‘ progress toward these goals - To determine students‘ readiness to move on to the next stage of training - Summative Evaluationof anindividual learnerandthe seniorsurgeons(faculty)that are used for judgments or decisions about the individual: - the motivation of an individual to maintain or improve performance Program Evaluation Formative evaluation of the program to improve course performance: - identification of areas for improvement Summative: evaluation of the course for decisions about the program or program developers judgments regardingsuccess,efficacy.Tocreate a teaching&learningsysteminwhichstudentslearnhow tobecome great physicians A randomized controlled pre-course and a post-course test (true experimental) is our plan to be used in the assessment of the learners through multi-measure methods including and individual interviews, direct observation,multiple-choice questions(MCQ‘s), objective standardized clinical exams (OSCE‘s), and computer interactive tests.Tools forprogramevaluationinthe formof;questionnaires(networksurveys),groupmeetings. ----------------------------------------------------------------------------------------------------------------------------- ---------- Challenges Fundingproblems;isanexampleof challengeswhichwe anticipate duringthe implementationof ourcourse,in spite thatSohag TeachingHospital,hasa budgetforcontinuingeducational medical program, the hiddencostof the course can appear,we have plannedtoovercome suchchallengesbymakingadeal withone or more of the national drugcompaniestosupportour project. Also,teachingmembersforthe course have littleavailabletime,sowe convincedthemtodotheirbest,we promise themwithrewards,whichaddmore tohiddencost. Computingandtechnologyskills,networking,datacollection,andsocial mediachallenges,forthese challenges we plannedcondensedtrainingcoursesforthe ITteam. Time factor inthe operatingroomisproblematicassome operation may take longer time than expected so we prepare more than2 theatresto overcome suchchallenge,inaddition, surgeons may be confronted with some challenges in the operating room as electric supply cut off, shortage in O2 supply, nursing staff problems, technicians, co-workers, anesthesia team shortage, etc., so we have a well-trained team controlling any challenges anticipated during 2nd.operative day. ----------------------------------------------------------------------------------------------------------------- References (1)SchumpelickV,Klinge U, Rosch R, et al. (2006): Light weight meshes in incisional hernia repair, J.Min Access Surg 2(3):117-123 (2)ClarkC.J.,FisherM.,WalkerG. et al.(2006): Rives-Stopparetromuscularrepairforincisional hernia. Surg Res 130 (2):245-246. (3)Millikan KW. (2003): Incisional hernia repair. SurgClin North Am; 83: 1223–1234 (4)PetersenS,Henke G,ZimmermannL,etal. (2004): Ventral rectus fascia closure on top of mesh hernia repair in sublay technique. Plas & Rec Surg 114(7): 1754-1760. (5)Schumpelick V, Stumpf M. and Conze J. (2009): Incisional Hernia Repair.In: Kirby IB, et al. (Eds.) General Surgery; Principles and International Practice.2nd. Ed. Springer-Verlag London Limited.pp: 1266-1273 (6) ThomasPA,KernDE, HughesMT, ChenBY. CurriculumDevelopmentforMedical Education,3rd Edition. Baltimore:JohnsHopkinsUniversityPress;2016.