Impact of Endoscopic Surgical Skill Qualification System on Surgical Technique and Training in Japan: Insights from an Eight-Year Survey.

Background: The Endoscopic Surgical Skill Qualification System (ESSQS), established by the Japanese Society for Endoscopic Surgery, provides a centralized video-based framework for certifying advanced laparoscopic surgeons. Its impact on surgical practice and education in inguinal hernia repair has not been fully clarified.

Methods: Between 2016 and 2023, a nationwide questionnaire combining multiple-choice and open-ended items was distributed to all surgeons certified in endoscopic hernia repair under ESSQS. Of 120 eligible surgeons, 103 (85.8%) responded. Data included surgical techniques, dissection methods, mesh selection, fixation practices, and video submissions required for certification. Trends were analyzed across early (2016-2019) and late (2020-2023) cohorts.

Results: The surgical techniques used in the certification examination were transabdominal preperitoneal inguinal hernia repair (TAPP) (n = 99) and totally extraperitoneal inguinal hernia repair (n = 4). Gauze-assisted dissection became standard (>80% adoption). Use of L-sized mesh increased significantly in the late cohort compared with the early cohort (56.0% vs 85.7%; P = .00175), reflecting progressive standardization. Median video duration was 63 minutes, and the median number of cases before certification was approximately 100. Mesh fixation methods remained stable, with a median of 5-6 tacks per case.

Conclusions: The ESSQS has contributed to the standardization of surgical education and practice in Japan, particularly in TAPP hernia repair, and this framework-rarely seen in Western qualification systems-underscores the importance of structured evaluation in advancing both technical proficiency and educational quality. This study was approved by our Institutional Review Board (Approval No. 4763) and the Medical Ethics Committee of Kurashiki Central Hospital.