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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 117-121

Evaluation of long-term impact of education program Hernia Help—Hernia Repair for the Underserved (HRFU) in Brazil

1 Santa Casa de Misericórdia of São Paulo School of Medical Sciences, São Paulo, SP, Brazil; Hernia Center, Gastrointestinal Surgery Service, Oswaldo Cruz German Hospital, São Paulo, SP, Brazil
2 Santa Casa de Misericórdia of São Paulo School of Medical Sciences, São Paulo, SP, Brazil
3 Santa Casa de Misericórdia of São Paulo School of Medical Sciences, São Paulo, SP, Brazil; Abdominal Wall Unit, Brotherhood of Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
4 Hernia Center, Gastrointestinal Surgery Service, Oswaldo Cruz German Hospital, São Paulo, SP, Brazil
5 Abdominal Wall Unit, Brotherhood of Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
6 Santa Casa de Misericórdia of São Paulo School of Medical Sciences, São Paulo, SP, Brazil; Hernia Center, Gastrointestinal Surgery Service, Oswaldo Cruz German Hospital, São Paulo, SP, Brazil; Abdominal Wall Unit, Brotherhood of Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil

Date of Submission23-Jun-2021
Date of Decision15-Jul-2021
Date of Acceptance07-Aug-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Mr. Luca Giovanni Antonio Pivetta
Rua treze de maio, 1815—Centro de Especialidades do Hospital Alemão Oswaldo Cruz—bloco A. CEP 01323-903, São Paulo.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_40_21

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AIM: Hernia HelpHernia Repair for the Underserved (HRFU) is a non-governmental organization (NGO) that has the following objectives: (1) to provide free hernia surgery to underserved populations, (2) to train local surgeons in a competency-based training program, and (3) to assist local authorities in creating self-sustaining hernia repair teams that can provide further care to the community. We aim to report a quality research of the training program of Hernia Help. Materials and Methods: Fifty-five surgeons who took the courses promoted by Hernia Help were contacted by email or telephone and invited to participate in the study. Those who accepted by signing their own and individual terms will answer a standardized questionnaire (10 closed questions) that evaluates the training course, as well as the incorporation of the technique taught in the participant’s daily practice. Results: Hernia HelpHRFU trained 55 surgeons in Brazil, of which 33 responded to the contact and agreed to participate in the study; 16 did not return the contact; 2 refused to participate in the study; and 4 could not be reached for lack of means of contact. Of this group, all see Hernia Help as a good experience to them, and it has fulfilled the scope of teaching the modified Lichtenstein technique (MLT), and 88% adopted the technique in their daily practice. Of the group that adopted the MLT (29 participants), 6 (20.6%) admitted that they do not follow every step as it was taught. Additionally, 9 (31%) also reported that they have altered, to some degree, the technique when performing it in their daily practice. In addition, 4 (13.7%) admitted that they need another course. In contrast, 26 (89.6%) feel confident to teach the MLT, and 22 (75,8%) manifest the intent to participate as instructors in other occasions. Conclusion: Those results may indicate the need to develop new forms to help these students become proficient and perform the MTL following the steps. Besides, the study shows that Hernia HelpHRFU is a valuable initiative to educate surgeons—in developing countries—to build a sustainable inguinal hernia program in their communities.

Keywords: Abdominal wall surgery, continuous medical education, surgery, surgery teaching

How to cite this article:
Pivetta LA, Lima Konichi RY, Fujikawa VK, Venancio de Carvalho JP, Macret JZ, Maranhão Dia ER, Francis MY, Ribeiro HB, Amaral Pd, Silva RA, Roll S. Evaluation of long-term impact of education program Hernia Help—Hernia Repair for the Underserved (HRFU) in Brazil. Int J Abdom Wall Hernia Surg 2021;4:117-21

How to cite this URL:
Pivetta LA, Lima Konichi RY, Fujikawa VK, Venancio de Carvalho JP, Macret JZ, Maranhão Dia ER, Francis MY, Ribeiro HB, Amaral Pd, Silva RA, Roll S. Evaluation of long-term impact of education program Hernia Help—Hernia Repair for the Underserved (HRFU) in Brazil. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Dec 6];4:117-21. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/3/81/327066

  Introduction Top

The inguinal hernia is one of the most frequent surgical conditions in the world, with approximately 20 million such surgeries being performed every year for correcting this condition.[1] The frequency of inguinal hernias in the general population is 13 cases per 10,000, being more prevalent in males, and it is estimated that around 27.2% of men will have inguinal hernia during their lifetime.[2] Given the scope of this disease, one can observe an important socioeconomic impact, both individually and in the society as a whole, having an effect on the social coexistence as well as daily and economic activities of the patients. In Brazil, the main means of assistance to the population, especially to those in lower social classes, is the public health system that, according to the Federal Medicine Council data from 2017, has a waiting list with more than 95,000 patients, implying a long delay period for the surgery.[3]

Based on this, in 2012, the Hernia Help—Hernia Repair for Undeserved, a non-governmental organization that is active in eight countries, was found. The main goals of this organization are: to provide hernia surgeries for the needy population; to train and assist local surgeons to become multipliers; and to assist hospitals and local authorities in order to create self-sustaining programs for hernia surgery for the benefit of the local population.[4],[5]

In Brazil, the Hernia Help is performed with the assistance of the abdominal wall surgery group of the Santa Casa de Misericordia, and during this time period three training workshops were given with the support of the Santa Casa de São Paulo Medical Sciences College (FCMSCSP), the respective Municipal Health Secretaries, and private enterprise, in seven cities during the years 2014, 2015 and 2018, in which 235 patients were operated and 55 surgeons received training.[6],[7]

The surgery performed during these missions is the inguinal hernioplasty using the modified Lichtenstein technique (MLT),[7],[8],[9],[10],[11],[12] a procedure with a good cost–benefit relation and with a low learning curve. Such techniques contribute to the success of the Hernia Help—HRFU campaigns allowing for performing the low-cost surgeries and with a high potential of procedure replication. Moreover, it can be done with local anesthesia associated with sedation, without the need of the patient being admitted for long periods of time.

The MLT training has a theoretical portion and a practical portion composed of five surgeries. First, through standardized and systematic teaching, volunteer surgeons underwent an expository class on inguinal hernioplasty using the Lichtenstein technique, in which they received a detailed explanation of technical aspects, intraoperative difficulties, tactics to avoid complications, and critical analysis of postoperative complications, being able to interactively discuss, criticize, and clarify doubts. Surgeons who have already participated as students can become volunteer instructors in the next task force.

After the class, the surgeons are summoned to the Surgical Center for a detailed discussion of the cases to be operated on, individually, with their respective tutor. To measure skills, abilities, and attitudes, the surgeon in training actively participates in five surgeries. In the first, the student helps the instructor and then performs the other four surgeries assisted by the professor, in which he must demonstrate his knowledge, skill, and ability to reproduce the technique. After each procedure performed by the student, the teacher assesses him through the Qualification Form, in which the items are scored and graded from 1 to 5 to assess whether the student fulfills the skills necessary to use the technique.

Lazzarini-Mendes et al.,[9] in 2016, published a study evaluating the MLT learning curve using the “See one, do one, teach one” method, used by Hernia Help, based on the analysis of the “Qualification Form” applied by the program, questionnaires over the practical changes after training and its validity (confidence level and training value). The study showed a significant and relevant difference in the assessment of outcomes during the making of the four herniorrhaphies that, unequivocally, demonstrated a character of continuous medical education when students from the previous task force, who became instructors, were able to apply and transfer the skills and attitudes toward the new students. Analysis on the performance curves of the skills outcomes (direction, incision, dissection, cut, mesh fixation, flow, and performance), concluded that the skills, competences, and attitudes were fully achieved with this type of teaching, thus completing the conditions for the reproducibility of this method of continuing education.[9]

The instructors are surgeons previously trained and certified during other missions. The students are physicians who have already finished their residency in general surgery in an institution accredited by the Ministry of Education (MEC) and are certified general surgeons who already perform inguinal hernia surgery in their communities. The patients are selected by their positions in the waiting line of the Health System of the Municipality Health Secretary and by participant institutions.

Given the goals that Hernia Help—HRFU plans to reach, it is necessary to evaluate the proposed training and its long-term impacts in the medical practice of the trained surgeons, with this research being approved by the Ethical Committee associated to itCAE 33466020.7.0000.5479.

  Materials and Methods Top

The surgeons trained during the Hernia Help—HRFU missions in Brazil were contacted by telephone or e-mail and were invited to take part in the study. Those who accepted, using contract of adhesion and by signing the Clear and Free Consent Term, were given a questionnaire with 10 dichotomous and subjective questions. This questionnaire tries to evaluate the training provided during the Hernia Help—HRFU missions, as well as the training impacts in their respective medical practices.

The data of the analysis were tabulated and evaluated by one of the team members, unknowing the participant’s identity, therefore ensuring the confidentiality of the answers and preventing any direct contact between the researcher and the participant.

  • Inclusion criteria: In the research, surgeons were included who made themselves available by adhering to the Clear and Free Consent Term and answering the proposed questionnaire.

  • Exclusion criteria: From the research, surgeons who did not respond to the team’s attempts to contact, those who refused to participate in the research, or those who the team had no means to contact were excluded.

  • After tabulating the data, Pearson’s chi-square parametric test (χ2) was applied with the purpose of checking whether the need of new training on the technique had any connection or not, with the fact that the interviewee is following the technique as it was taught or even if the participant had made changes in the MLT.

      Results Top

    In the Hernia Help—HRFU missions, there was the participation of 55 surgeons, of which 33 answered to the contact made and accepted to join the study; 16 did not respond to the attempted contact; 2 refused to participate; and 4 could not be reached by lack of means of contacting them.

    The participants’ distribution for the years the training workshops were done and their participation in the research are shown in [Table 1].
    Table 1: Accounting of those contacted according to the year they participated in the missions

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    The distribution of the answers for the research participants, as well as their distribution during the years, is represented in [Table 2].
    Table 2: Questionnaire results

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      Discussion Top

    The results point toward a wide acceptance of the Hernia Help training, which includes 100% of those interviewed, that is, even those who did not incorporate the MLT in their professional practice.

    As for the general impression about the training provided, all the participants who answered the questionnaire evaluated the experience in the project as enriching for their professional lives, and they considered that the project’s goals were reached.

    Of the 33 who were interviewed, 88% (29) adopted the technique after the conclusion of the project, which corroborates both the reproducibility and the capability of the course student to become capable to perform the MLT through a limited number of procedures.

    Of those 29, 93% (27) do not feel any difficulty in using the technique and 89% (29) feel that they are ready to teach and/or lead the procedure. Such data suggest not only the wide acceptance of the MLT, but also its mastering, as we see that the majority of the interviewees feel ready to teach it. Such interpretation is corroborated by the low number of participants that feel the need of new training, 13% (4).

    Seeking to find the reason for the need of new training, which was brought up by four participants, we used Pearson’s χ2 test, trying to correlate that data with whether the interviewee performs or not the Lichtenstein technique as it was taught, or even if they have made any changes to the technique per se. Having the result that the need of a new course has no relation to the student following the technique (P = 0.89), as well as it does not depend on the changes (P = 0.78), we did not find a direct relation with the Hernia Help teaching; however, we believe that it can be attributed to each student’s learning curve, as well as to the individual’s characteristics, which would need a more detailed analysis.

    The personal changes of the technique can also be interpreted as a difficulty in learning it, or even due to a cultural factor still present in the specialty; in significant part, the surgical techniques used were not based on scientific evidence. Even if it once used to be expected, nowadays, the changes in the standardization must be based on scientific evidence, such as the change proposed and taught in the Hernia Help.[13]

      Conclusion Top

    Our data point us to the conclusion about the efficiency of the Hernia Help as a continuous education project, with high levels of acceptance of the MLT by the participants. The technique, per se, is of easy understanding, teaching, and practice, as it is seen the low need of a second training, as evaluated by self-perception of the student. It is important to highlight that the majority of the participants not only feel comfortable in teaching the technique, but also volunteer in taking part of the project as teachers, which favors the perpetuation of the project and its growth.

    Therefore, the project shows that it fulfills its stipulated goals and shows great potential as an agent for improvement in the field of hernia correction, in a way to benefit the population served by the Brazilian national health system.

    Ethics approval

    The protocol was approved by the Ethics Committee of Brotherhood of Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil (register: 33466020.7.0000.5479).

    Informed consent

    Informed consent was obtained from all individual participants included in the study.

    Financial support and sponsorship

    This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.

    Conflicts of interest

    SR has received personal fees for consulting from B. Braun, Medtronic, Ethicon, and Bard that are not related to the present submission. MYF has received personal fees for consulting from B. Braun. LGAP, RYLK, VEF, JPVC, ERMD, JZM, PHFA, RAS declare that they have no conflicts of interest. Dr. Sergio Roll is an Editorial Board member of International Journal of Abdominal Wall and Hernia Surgery. The article was subject to the journal’s standard procedures, with peer review handled independently of this Editorial Board member and their research groups.

      References Top

    Kingsnorth A, LeBlanc K. Hernias: Inguinal and incisional. Lancet 2003;362:1561-71.  Back to cited text no. 1
    Primatesta P, Goldacre MJ. Inguinal hernia repair: Incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996;25:835-9.  Back to cited text no. 2
    Conselho Federal de Medicina. Available from: <www.portal.cfm.org.br>. Accessed on October 21, 2019.  Back to cited text no. 3
    Hernia Repair for the Underserved. Available from: <www.herniahelp.org>. Accessed on September 15, 2019.  Back to cited text no. 4
    Schroeder AD, Campanelli G, Cavalli M, Cusick R, Fitzgibbons R, Gilbert A, et al. Humanitarianism in surgery. Hernia 2017;21:963-71.  Back to cited text no. 5
    Fujikawa VK, Konichi RL, Barros PHF, Silva RA, Chen D, Roll S. Hernia Repair for the Underserved: Fostering surgical education and assisting underserved populations in Brazil. In: 2019 AHS Annual Meeting, 2019, Las Vegas. Paris: Springer; 2019. v. 23. p. S76.  Back to cited text no. 6
    Moore AM, Datta N, Wagner JP, Schroeder AD, Reinpold W, Franciss MY, et al. Centralized, capacity-building training of Lichtenstein hernioplasty in Brazil. Am J Surg 2017;213: 277-81.  Back to cited text no. 7
    Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension-free hernioplasty. Am J Surg 1989;157:188-93.  Back to cited text no. 8
    Lazzarini-Mendes CJ, Pacheco AM, Destro BB, Tamaro C, Nogueira FA, Chen D, et al. Systematic training model for teaching, development and training of instructors in inguinal hernia treatment using the Lichtenstein technique. Hernia Campaign 2014 & 2015. Rev Col Bras Cir 2016;43: 382-91.  Back to cited text no. 9
    Moore AM, Carter NH, Wagner JP, Filipi CJ, Chen DC. Web-based video assessments of operative performance for remote telementoring. Surg Technol Int 2017;30:25-30. PMID: 28695970.  Back to cited text no. 10
    Wagner JP, Schroeder AD, Espinoza JC, Hiatt JR, Mellinger JD, Cusick RA, et al. Global outreach using a systematic, competency-based training paradigm for inguinal hernioplasty. JAMA Surg 2017;152:66-73. doi: 10.1001/jamasurg.2016.3323. PMID: 27706482.  Back to cited text no. 11
    Datta N, MacQueen IT, Schroeder AD, Wilson JJ, Espinoza JC, Wagner JP, et al. Wearable technology for global surgical teleproctoring. J Surg Educ 2015;72:1290-5.  Back to cited text no. 12
    Amid PK. Lichtenstein tension-free hernioplasty: Its inception, evolution, and principles. Hernia 2004;8:1-7.  Back to cited text no. 13


      [Table 1], [Table 2]


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