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Subject area Capstone Project Learners MOSTAFA HEGAZY
Ventral Incisional Hernia
Sublay Mesh Repair
Type of educational
(new course, curriculum,
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
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.
To achieve cost-effectiveness for ventral incisional repair with little burden on
hospital financial resources, and local society.
Objective of the project
By endof thiscourse (2 successive dayscourse),general surgeryfellowship will be
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
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
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
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
Design and development
Our curriculumplancan be summarizedasa 2 consecutive dayscourse thatincludestheoretical knowledge
thenclinical andoperative skill training.
(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))
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
(12 PM- 1 PM)(60 minutes)
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)
(Fridayfrom8 AM – 8 PM)
The firstcase of Sublay openmeshrepairof
ventral incisionalhernia(8AM- 10 AM)
Discussion(From10 AM - 12 PM)
Discussion(12PM - 12.30 PM)
Breakout(1PM - 3 PM)
Discussion(3PM- 5 PM)
Discussion(5PM - 7 PM)
5Th. operative case
Discussion(7PM - 8 PM)
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
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
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
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
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
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
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,
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;
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
Consideringthe peoplesharinginthe projectmaybe few barriers,butwe convincedthemtodotheirbestas we
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.
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
Formative evaluation of the program to improve course performance with identification of areas for
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,
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
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
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.
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.
(1)SchumpelickV,Klinge U, Rosch R, et al. (2006): Light weight meshes in incisional hernia repair, J.Min Access
(2)ClarkC.J.,FisherM.,WalkerG. et al.(2006): Rives-Stopparetromuscularrepairforincisional hernia. Surg Res
(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.