• Users Online: 126
  • Print this page
  • Email this page

Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 4  |  Page : 211-217

Evaluation of the satisfaction and effectiveness of the learning in abdominal wall surgery in residents of the digestive system surgery at a tertiary public hospital in Brazil

1 Abdominal Wall Unit, Department of Surgery of Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil; Professor at Santa Casa de Misericórdia of São Paulo School of Medical Sciences, São Paulo, Brazil; Hernia Center, Gastrointestinal Surgery Service, Oswaldo Cruz German Hospital, São Paulo, SP, Brazil
2 Hernia Center, Gastrointestinal Surgery Service, Oswaldo Cruz German Hospital, São Paulo, SP, Brazil; Postgraduate at the Santa Casa de Misericórdia of São Paulo School of Medical Sciences, São Paulo, Brazil
3 Medical student at the Santa Casa de Misericórdia of São Paulo School of Medical Sciences, São Paulo, Brazil
4 Surgery resident of the Brotherhood of Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
5 Abdominal Wall Unit, Department of Surgery of Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil; Postgraduate at the Santa Casa de Misericórdia of São Paulo School of Medical Sciences, São Paulo, Brazil
6 Hernia Center, Gastrointestinal Surgery Service, Oswaldo Cruz German Hospital, São Paulo, SP, Brazil
7 Abdominal Wall Unit, Department of Surgery of Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
8 Abdominal Wall Unit, Department of Surgery of Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil; Professor at Santa Casa de Misericórdia of São Paulo School of Medical Sciences, São Paulo, Brazil

Date of Submission12-Sep-2021
Date of Decision22-Oct-2021
Date of Acceptance01-Nov-2021
Date of Web Publication31-Dec-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.
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_61_21

Rights and Permissions

AIM: To report the outcomes of questionnaire assessment about the teaching of the abdominal wall surgery and the incorporation of the techniques taught during the general surgery and digestive tract surgery residency into the individual practice. METHODS: The graduated surgeons and resident doctors from 2014 to 2019 were invited to answer a standardized questionnaire about the abdominal wall surgery teaching program, mastery of specific techniques, and medical practice of each. We performed a chi-square test to evaluate whether the degree of satisfaction correlates to the degree of personal confidence and whether it correlates to performing the procedure in this practice. RESULTS: When assessing the degree of self-confidence to perform specific procedures, all students were confident in performing the Lichtenstein procedure; 22% were confident in transabdominal pre-peritoneal hernioplasty (TAPP); 77% were confident in Rives-Stoppa and anterior separation technique; and 18% were confident in Transversus Abdominis Muscle Release (TAR) technique. The statistical analysis showed a correlation between teaching program satisfaction and the degree of self-confidence only for the TAR procedure (P = 0,06). The analysis also showed a correlation between the degree of self-confidence to perform a specific procedure and its usage on daily practice only for the Rives-Stoppa procedure (P = 0,00). CONCLUSION: These results show the importance of a structured Abdominal Wall Surgery Program, as well as the continuing education evaluation and quality improvement, as the instrument exposed, which to our knowledge, is the first questionnaire to assess the teaching of the abdominal wall and it may be considered a helpful tool.

Keywords: Abdominal wall surgery, questionnaire of conclusion, residency, surgery teaching

How to cite this article:
Roll S, Antonio Pivetta LG, Lima Konichi RY, Fujikawa VK, Lucarelli Antunes Pd, de Carvalho JP, Macret JZ, Maranhão Dia ER, Francis MY, Ribeiro HB, Freitas Amaral PH, Silva RA. Evaluation of the satisfaction and effectiveness of the learning in abdominal wall surgery in residents of the digestive system surgery at a tertiary public hospital in Brazil. Int J Abdom Wall Hernia Surg 2021;4:211-7

How to cite this URL:
Roll S, Antonio Pivetta LG, Lima Konichi RY, Fujikawa VK, Lucarelli Antunes Pd, de Carvalho JP, Macret JZ, Maranhão Dia ER, Francis MY, Ribeiro HB, Freitas Amaral PH, Silva RA. Evaluation of the satisfaction and effectiveness of the learning in abdominal wall surgery in residents of the digestive system surgery at a tertiary public hospital in Brazil. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Aug 8];4:211-7. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/211/334565

  Introduction Top

Medical Residency (MR) is a modality of postgraduate education for doctors that is characterized by “in-service training” offered by health institutions under the guidance of qualified medical professionals. In Brazil, it is also a form of a specialization course,[1] and the professional who wishes to enter the MR program must undergo a selection process consisting essentially of a written test and if the educational institution deems necessary, a practical assessment. There may also be an interview comprising up to 10% of the final grade.[2],[3] The MR program in general surgery currently has a three-year extension period for recognition as a specialist in General Surgery and allows graduates to apply to the areas of trauma and video laparoscopic surgery.[4] The Basic Surgery modality, composed of only two years, is a prerequisite for the other surgical subspecialties and does not provide the title of specialist. Among these subspecialties, there is digestive tract surgery, whose residence period is two years. The resident doctor goes through several training programs and, among them, the abdominal wall surgery program.

In Brazil, residents compose a large part of the medical staff in large hospitals, and their role is essential in health care. Meanwhile, they also have specific training needs, being necessary to the hospitals that offer highly qualified training programs to guarantee the quality of their service. Moreover, a medical doctor’s routine in a hospital is intense, and 40% of professionals suffer from emotional exhaustion.[5] This compromises not only patient care but also the expectations and learning process of the newly graduated professional. Thus, the assessment and improvement of the work environment for professionals contributes to the final results.

MR consists not only of the improvement of professional competencies developed throughout graduation but also of training in the specialty of choice, a gradual increase of responsibility for medical acts, the capacity of initiative, evaluation and judgment, and the development of critical spirit ethical values.[6],[7],[8] The development of all these skills represents an important transition in one’s professional life and shapes the future profile of the physician.[9],[10] In this light, the responsibility of the preceptors and teachers is enormous, so the discussion about the teaching–learning process in MR is pertinent.[5]

Undergraduate medical education is the subject of many studies, both nationally and internationally; several times, it addresses the need to combine scientific knowledge, clinical reasoning, the development of practical skills, and, at the same time, the formation of medical character and professionalism.[11],[12],[13],[14],[15],[16] However, this does not reproduce itself over the subject of MR.[10],[17],[18] There is still little to no academic material addressing the contents of the resident’s training, the training process itself, and of how and what they learn.[10],[19] This gap in scientific knowledge over the education in MR also stems from the lack of protocols that allow the evaluation of this course by trained residents. A study carried out by Favrod in 2006[20] in Switzerland demonstrated that the application of a questionnaire at the completion of residency is a viable, inexpensive, and effective method to obtain relevant information about teaching inside a hospital. When comparing the application of the questionnaires with the realization of an interview, it was observed that they facilitate the collection of data from a large group of individuals while guaranteeing their anonymity, thus contributing to the reliability of the information collected.[21-22] In doing so, conducting systematic surveys with questionnaires provides valuable information over the degree of satisfaction of the resident with the teaching program and work environment, enabling the identification of strengths and detecting aspects that must be improved.

Therefore, the main objective of this study is to evaluate, through a standardized questionnaire, the resident’s abdominal wall surgery learning during the Digestive Tract Surgery program and its impact on professional life.

  Materials and Methods Top

The data for this study were obtained from Central Hospital of the Irmandade da Santa Casa de Misericórdia de São Paulo; a tertiary, philanthropic hospital, belonging to the Irmandade da Santa Casa de Misericórdia de São Paulo. The institution provides services to the Sistema Universal de Saúde (SUS). It is considered one of the most important hospital reference centers in Brazil, located in the central region of the city of São Paulo (https://www.santacasasp.org.br/portal/site/quemsomos/historico).

The internship in Abdominal Wall Surgery in our service consists of a combined theoretical and practical three months’ immersion in a specialty, with periodic lectures and observational, supervised, and oriented surgeries. The graduates and residents who completed the internship were contacted by email or by phone and invited to answer a standardized questionnaire comprising 10 closed questions about the teaching program; five subjective questions that address the expertise on specific techniques (Lichtenstein, TAPP, Rives-Stoppa, incisional hernioplasty using the TAR, and anterior separation of components); and five questions about the medical practice of each of the said techniques [Table 1].
Table 1: Results and percentages

Click here to view

Inclusion criteria

  • Graduates of the digestive tract surgery program after 2013 (year of implementation of the abdominal wall discipline).

  • Residents who have already completed the abdominal wall surgery program.

  • Exclusion criteria

  • Nonagreement with the informed consent form.

  • Not having participated in the abdominal surgery program.

  • Graduates of the digestive tract surgery program before 2013.

  • The data on the response from surgical residents were analyzed to separately study the three domains covered in the questionnaire (satisfaction, security, and practice) and to analyze the existence of correlations between them. Only the satisfaction variable is treated as categorical and numerical, being: Favorable = 4; Partially favorable = 3; Partially unfavorable = 2; and Unfavorable = 1. The others are treated only as categorical variables. The degree of satisfaction was also studied, that is, the average of the responses of the items. Finally, the analysis was performed using the statistical software R18.

      Results Top

    All graduated residents of digestive tract surgery[24] who completed the internship in abdominal wall surgery were contacted; among them, 95.8%[23] agreed to participate in this study, among whom 87% were men and 13% were women, whose average age was found to be 35 years (29–38 years).

    When the questions about the teaching program were analyzed, 100% agreed, at some level, that the round contributed to the learning of abdominal wall surgery. In addition, 100% of them strongly agreed that this period was important to improve the quality of the treatment that was offered to their patients.

    When asked whether this internship brought them a differential in relation to other surgeons’ education, 95.65% were favorable, and 4.35% were partially favorable. In addition, 95.65% of respondents reported that they had contact with new technologies during the program.

    Each question of the satisfaction analysis was carried out separately; its percentages and distribution of responses are shown in [Table 1]. In addition, a numerical value was assigned to the answers with the intention of determining whether the average of responses in this domain of the questionnaire could determine the overall satisfaction of respondents. We observed that the average of the responses in the Satisfaction domain is 3.7 (close to the maximum value, four), which leads us to conclude that the average satisfaction of the internship is high. It is also worth noting that only 25% of the sample has an average below 3.5 [Figure 1].
    Figure 1: Histogram of the average variable in the satisfaction questions

    Click here to view

    When evaluating the residents’ confidence to perform specific procedures [Table 1], they all reported being confident to perform inguinal hernioplasty using the Lichtenstein technique. Regarding laparoscopic inguinal hernioplasty using the TAPP technique, only 30.4% said they were confident; however, regarding the Rives-Stoppa technique, 78.3% said they were confident, and 13% said they were partially confident. Regarding TAR, 56.5% considered themselves partially confident and 21.7% partially insecure. Finally, regarding the previous separation of components: 72.9% said they were confident, whereas 21.7% considered themselves partially confident.

    Finally, whether or not the residents use the aforementioned techniques in their daily practice was evaluated, and the following positive results were found: Lichtenstein 95.65%, TAPP 78.3%, Rives-Stoppa 82.6%, TAR 39.1, and technique of anterior separation of components 52.2% [Table 1].

    Subsequently, an inferential analysis was performed using the Fischer Test,[19] with the aim of verifying whether there was a correlation between the responses in the dimensions of satisfaction and confidence in the performance of a procedure; between satisfaction and execution in daily practice; and between confidence in the performance and execution in daily practice.

    The inferential analysis between satisfaction/practice and satisfaction/confidence was performed using a numerical score versus satisfaction or practice. The average satisfaction test (Saphiro–Wilk test[20]) was applied to the score obtained and, since the averages in the satisfaction domain were very high, there was no statistical significance in the relationship between satisfaction and practice or confidence.

    Regarding the inferential analysis between safety and the practice of a given procedure, no correlation was obtained about Lichtenstein [Table 2] and TAPP [Table 3]. We obtained correlations in the following techniques: Rives-Stoppa (P = 0.038) [Table 4]; TAR (P = 0.022) [Table 5]; and anterior separation of the components (P = 0.005) [Table 6].
    Table 2: Lichtenstein: security × practice

    Click here to view
    Table 3: TAPP: security × practice (P = 0.134)

    Click here to view
    Table 4: Rives-Stoppa: security × practice (P = 0.038

    Click here to view
    Table 5: TAR: security × practice (P = 0.022)

    Click here to view
    Table 6: Anterior separation: security × practice (P = 0.005)

    Click here to view

      Discussion Top

    The domain analysis of questions involving satisfaction showed that residents and graduates are satisfied with the abdominal wall surgery teaching program at the institution, both when individually analyzing each question and in the mean obtained from the answers.

    The lack of safety in the use of the TAPP technique may be associated with the need for material from a donation to perform this procedure in a public tertiary hospital—since the necessary materials are not covered by SUS—a fact that limits the number of surgeries that can be performed by each student, which may justify the lower degree of confidence to perform this procedure at the end of the internship.

    Regarding TAR, the low degree of safety suggests that because it is a complex procedure that requires a longer learning curve, most graduates do not feel safe to perform the technique, a fact that, in turn, is in accordance with the study conducted by Köckerling et al.,[25] which deals with the growing need for surgeons specialized in the abdominal wall due to the evolution of the complexity of the techniques and, consequently, an increase in their learning curve.

    Regarding the Modified Lichtenstein Technique (TLM), the absence of variation in responses made it impossible to carry out deeper statistical analyses. However, it is worth noting that all residents reported feeling safe in performing the technique, which can be correlated with its low cost and ease of replication, with a lower learning curve when compared with the other techniques.[26],[27] During the internship in abdominal wall surgery at the Irmandade da Santa Casa de Misericórdia de São Paulo, joint efforts were made to teach this technique in partnership with the NGO Hernia Help–Hernia repair for the underserved, where training workshops were held to teach the technique to 55 surgeons, in seven Brazilian cities, forming an international collaborative working group to promote medical education and access to health.[27-29] These joint efforts can also explain the high degree of confidence in the reported performance.

    When we critically assessed the lack of statistical correlation between the domains of satisfaction/safety and safety/practice, the small sample size and the small variation in the distribution of responses in the satisfaction domain made the analysis of these correlations impractical. However, we believe that when applied to a larger sample, the questionnaire can contribute to such an assessment.

    In relation to TLM, the inferential analysis on the relationship between safety and practice did not result in relevant statistical data since 100% of the residents said they were confident about the realization of this technique. Regarding TAPP, the fact that laparoscopic surgery is becoming more and more frequent for the correction of hernias may justify the variation in the responses obtained by the candidates. This fact, associated with the small number of interviewees, made it impossible to obtain a statistically significant result (P = 0.134).

    Finally, when the techniques with the highest degree of complexity (Rives-Stoppa, TAR, and anterior separation of components) were evaluated, the analysis showed that security in their performance is correlated with the willingness of the residents to perform them in their individual practice. This result corroborates the need for well-structured teaching of these essential techniques in the training of surgeons, demonstrating the effectiveness of the program.

    This study has limitations in terms of statistical analysis due to the relatively small number of participants and all respondents having reported being satisfied with the abdominal wall stage, a fact that made it impossible to define statistically relevant correlations between the domains of satisfaction, safety, and practice. Our perspective with this study is to apply it multicenter, comparing personal perspectives of different residency programs, improving the teaching of Abdominal Wall Surgery in Brazil.

      Conclusions Top

    The study demonstrated the importance of a well-structured abdominal wall surgery program during the residency of digestive tract surgery, not only due to contact with the techniques mentioned in this study but also to make the surgeons trained by the institution proficient in each one.

    To our knowledge, this is the first questionnaire to assess the teaching of abdominal wall surgery and may prove to be a useful tool for its constant improvement.

    Declaration of patient consent

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

    Ethical policy and institutional review board statement

    The protocol was approved by the ethics committee of Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil (register: 34760020.7.0000.5479).

    Financial support and sponsorship


    Conflicts of interest

    Sergio Roll has received personal fees for consulting from B. Braun, Medtronic, Ethicon and Bard that are not related to the present submission. Maurice Youssef Francis has received personal fees for consulting from B. Braun. Dr. Sergio Roll is an Associate Editor 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 Associate Editor and their research groups.

    Luca Giovanni Antonio Pivetta, Renata Yumi Lima Konichi, Victor Enzo Fujikawa, Pedro de Souza Lucareli Antunes, João Paulo Venancio de Carvalho, Eduardo Rullo Maranhão Dias, Jessica Zilberman Macret, Pedro Henrique de Freitas Amaral, and Rodrigo Altenfelder Silva declare that they have no conflict of interest.

      References Top

    Brazil, Presidency of the Republic. Decree No. 80,281 of September 5, 1977. Regulates Medical Residence, Creates the National Commission for Medical Residence and Makes Other Provisions. Brasilia; 1977.  Back to cited text no. 1
    Ministry of Education. National Medical Residency Commission. CNRM Resolution No. 02 of August 27, 2015. Brazil.  Back to cited text no. 2
    Article 22 of Law 12,871, of October 22, 2013, regarding public selection process of candidates for Medical Residency Programs, Federal Official Gazette. Brasília, 28 Aug. 2015; section 1, p. 3.  Back to cited text no. 3
    Brazil. Resolution nº 48, of 21 June 2018, MEC Secretariat of Higher Education.  Back to cited text no. 4
    Biaggi P, Peter S, Ulich E. Stressors, emotional exhaustion and aversion to patients in residents and chief residents––what can be done? Swiss Med Wkly 2003;133:339-46.  Back to cited text no. 5
    Chaves MM, Rosa AR (Org.) Federação Pan-Americana de Faculdades e Escolas de Medicina. Educação médica nas Américas: o desafio dos anos 90. São Paulo: Cortez; 1999.  Back to cited text no. 6
    Martins LAN. Residência médica: Estresse e crescimento. São Paulo: Casa do Psicólogo; 2005.  Back to cited text no. 7
    Ministério da Educação. Secretaria de Ensino Superior. Residência médica. Available from: http://portal.mec.gov.br/index.php?option=com_content&view=article&id=12263&Itemid=506. [Last accessed on 2019 Feb 3].  Back to cited text no. 8
    Botti S, Rego S. Processo ensino-aprendizagem na residência médica. Revista Brasileira de Educação Médica 2010;4: 132-40.  Back to cited text no. 9
    Feuerwerker LCM. Mudanças na educação médica e residência médica no Brasil. Interface Comun Saúde Educ 1998;2:51-71.  Back to cited text no. 10
    Branch WT Jr, Kern D, Haidet P, Weissmann P, Gracey CF, Mitchell G, et al. The patient-physician relationship. Teaching the human dimensions of care in clinical settings. JAMA 2001;286:1067-74.  Back to cited text no. 11
    Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the flexner report. N Engl J Med 2006;355:1339-44.  Back to cited text no. 12
    Mufson MA. Professionalism in medicine: The department chair’s perspective on medical students and residents. Am J Med 1997;103:253-5.  Back to cited text no. 13
    Stephenson AE, Adshead LE, Higgs RH. The teaching of professional attitudes within UK medical schools: Reported difficulties and good practice. Med Educ 2006;40:1072-80.  Back to cited text no. 14
    Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA 1999;282:830-2.  Back to cited text no. 15
    Ministério da Saúde. Secretaria de Políticas de Saúde. Uma nova escola médica para um novo sistema de saúde. Saúde e Educação lançam programa para mudar o currículo de medicina. Rev Saúde Pública 2002;36:375-8.  Back to cited text no. 16
    Calil LC. Proposta de um modelo pedagógico para programas de residência médica. Rev Bras Med 2000;57:751-6.  Back to cited text no. 17
    Teunissen PW, Boor K, Scherpbier AJ, van der Vleuten CP, van Diemen-Steenvoorde JA, van Luijk SJ, et al. Attending doctors’ perspectives on how residents learn. Med Educ 2007;41:1050-8.  Back to cited text no. 18
    Feuerwerker LCM. Avaliação da residência médica em São Paulo. Cad Fundap 1996;19:153-69.  Back to cited text no. 19
    Favrod C, Koch N, Deriaz S, Wasserfallen J. Usefulness of a systematic exit survey for assessing residents’ satisfaction with postgraduate training: A pilot study. MedEdPublish2016;5:56.  Back to cited text no. 20
    Giacalone RA, Knouse SB, Montagliani A. Motivation for and prevention of honest responding in exit interviews and surveys. J Psychol 1997;131:438-48.  Back to cited text no. 21
    R Core Team. R: A Language and Environment for Statistical Computing. Vienna: R Foundation for Statistical Computing; 2018.  Back to cited text no. 22
    Conover WJ. Practical nonparametric statistics. New York; Chichester: John Wiley; 1971.  Back to cited text no. 23
    Samuel Sanford S, Martin BW. An analysis of variance test for normality (complete samples). Biometrika 1965;52:591-611.  Back to cited text no. 24
    Köckerling F, Sheen AJ, Berrevoet F, Campanelli G, Cuccurullo D, Fortelny R, et al. The reality of general surgery training and increased complexity of abdominal wall hernia surgery. Hernia 2019;23:1081-91.  Back to cited text no. 25
    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.  Back to cited text no. 26
    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. 27
    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.  Back to cited text no. 28
    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. 29


      [Figure 1]

      [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


        Similar in PUBMED
       Search Pubmed for
       Search in Google Scholar for
     Related articles
        Access Statistics
        Email Alert *
        Add to My List *
    * Registration required (free)  

      In this article
       Materials and Me...
       Article Figures
       Article Tables

     Article Access Statistics
        PDF Downloaded204    
        Comments [Add]    

    Recommend this journal