Hernia U: challenges and opportunities of an online platform for surgical education

The internet has become an essential tool for education1. Nowadays, it is widely used by physicians for obtaining medical information. There was no website for surgical education before the year 2000. The pioneer website was WebSurg, from IRCAD, France2. There are different types of distant education: telesurgery (live or edited), live lectures, case discussions and so on2,3. These new learning methods are considered as distant education and can be integrated in the surgical curriculum2. There are many online tools used to share knowledge: websites, mobile programs for cell phones or even social media4,5. The aim of this study is to describe an online and free surgical education tool for students, residents and surgeons who want to update their knowledge in abdominal wall surgery.

T he internet has become an essential tool for education 1 . Nowadays, it is widely used by physicians for obtaining medical information. There was no website for surgical education before the year 2000. The pioneer website was WebSurg, from IRCAD, France 2 . There are different types of distant education: telesurgery (live or edited), live lectures, case discussions and so on 2,3 . These new learning methods are considered as distant education and can be integrated in the surgical curriculum 2 . There are many online tools used to share knowledge: websites, mobile programs for cell phones or even social media 4,5 . The aim of this study is to describe an online and free surgical education tool for students, residents and surgeons who want to update their knowledge in abdominal wall surgery.

Hernia U structure
Hernia U (www.herniau.com) was created with the objective to expand the abdominal wall surgery (AWS) educational landscape and make it available for surgeons all around the globe. It is an online platform where surgeons can register with no cost and subscribe for different activities: basic and deeper discussions regarding complex situations, live case reviews, a video library and podcast series.
In 2016, it was understood that it was time to expand the hernia educational landscape. Hernia specialists created the Hernia U platform to offer content to everyone who wanted to revisit their hernia education.
Hernia U offers the following activities: Obviously, when using a website platform with wellknown national and international surgeons supported by societies, this is not an issue. Even in platforms such as WebSurg, there is a concern with the quality of the published material, as demonstrated by Kartal et al.

Current challenges of Surgical Education online
It is important to highlight that only medical professionals can access the Hernia U platform. There Thinking about this issue, SAGES published a statement for clinical education and consultation when related to social media 13 . The society endorses the professional use of these social media groups for medical and surgical education and quality improvement.
Furthermore, it recognizes that the participants can acquire a superior education with access to international experts. This is the basis of Hernia U: access to hernia specialists to improve how you treat your patients with simple or complex abdominal wall defects. SAGES also endorses that the surgeon should determine the need to seek patient permission when posting clinical cases, and an optional consent template was proposed 13 .

Surgical education going live
Another popular tool to disseminate knowledge and rich discussions is the live surgery broadcast. This was possible with the development of minimally invasive surgery with high quality image and also faster internet connection around the globe 3 . It is well known that the learning curve of MIS and robotic surgery is longer than with other procedures 14,15 . Furthermore, this learning curve influences clinical and financial outcomes 16,17 .
That is the reason why a live broadcast is so important: to optimize outcomes during the learning curves for the ones who are not experienced and don´t have an available high level training opportunity. However, a broad adoption of telementoring and telesurgery is limited by legal and ethics concerns. In a live broadcast procedure, the patient is exposed to previously unseen risks such as technical failure of the robot or network and hacking 11 . Therefore, it is extremely important to have a specific informed consent aligned with the Institutional Review Board before performing this modality. A key point is surgeon´s selection. Experts used to perform this modality should carefully be selected and paired with an experienced moderator who plays a crucial role, filtering the chat and flow of questions, allowing the surgeon to safely navigate through the procedure. Furthermore, patients' safety must always come first, and Hernia U In times when students and physicians look for online material to improve their knowledge regarding different types of procedures, a free platform with known and certified hernia specialists brings a solid contribution to spread a valid knowledge to improve management of patients, and an updated surgical technique based on scientific evidence.