Gynecology resident laparoscopy training: present and future

The impact of laparoscopic gynecological surgery training on the technicity index of a developing country center

PURPOSE

To compare laparoscopic gynecological surgery training between a developed country's reference center (host center) and a public reference service in a developing country (home center), and use the technicity index (TI) to compare outcomes and to determine the impact of laparoscopic gynecological surgery fellowship training on the home center's TI.

METHODS

The impact of training on the home center was assessed by comparing surgical performance before and after training. TI was assessed in 2017 in the host center, and before and after training in the home center. Epidemiological and clinical data, and information on reason for surgery, preoperative images, estimated intraoperative bleeding, operative time, surgical specimen weight, hospital stay length, complication and reintervention rates were collected from both institutions. Home center pre-training data were retrospectively collected between 2010 and 2013, while post-training data were prospectively collected between 2015 and 2017. A two-tail Z-score was used for TI comparison.

RESULTS

The analysis included 366 hysterectomies performed at the host center in 2017, and 663 hysterectomies performed at the home center between 2015 and 2017. TI in the host center was 82.5%, while in the home center it was 6% before training and 22% after training. There were no statistical differences in length of hospital stay, preoperative uterine volume, surgical specimen weight and complication rate between centers. However, significantly shorter mean operative time and lower blood loss during surgery were observed in the host center.

CONCLUSIONS

High-quality laparoscopic training in a world-renowned specialized center allowed standardizing laparoscopic hysterectomy procedures and helped to significantly improve TI in the recipient's center with comparable surgical outcomes.

Ascertaining the Effects of Tissue Sealers on Minor Laparoscopic Procedures between Obstetrics and Gynecology Residents: A Prospective Cohort Study

Background and Objectives: The type of instrumentation used during laparoscopic surgery might impact on the learning curve of resident surgeons. The aim of this study was to investigate differences in operator satisfaction and surgical outcomes between tissue sealers and classic bipolar instruments during gynecological laparoscopies performed by residents. Materials and Methods: A prospective cohort study conducted at two tertiary university hospitals between March 2019 and March 2021, on consecutive procedures: salpingo-oophorectomies (Group 1) and salpingectomies (Group 2), subdivided according to the utilized device: radiofrequency tissue sealers (Groups A1 and A2) or bipolar forceps (Groups B1 and B2). Results: 80 procedures were included. Concerning salpingo-oophorectomies, better visibility (8.4 ± 0.8 vs. 7.3 ± 0.9; p = 0.03), reduced difficulty (5.4 ± 1.2 vs. 7.0 ± 1.4; p = 0.02), improved overall satisfaction (9.2 ± 0.4 vs. 7.6 ± 1.0; p = 0.02) and reduced procedure time (7.8 ± 3.4 vs. 12.6 ± 3.1; p = 0.01) were reported by residents using tissue sealers. Intraoperative blood loss (12.2 ± 4.7 mL vs. 33.2 ± 9.7 mL; p = 0.01) and 24 h postoperative pain (4.5 ± 1.1 vs. 5.7 ± 1.8; p = 0.03) were lower in group A1 than B1. For salpingectomies, a significant reduction in duration was found in A2 compared to B2 (7.2 ± 3.4 min vs. 13.8 ± 2.2 min; p = 0.02). Tissue sealers enhanced visibility (8.1 ± 1.1 vs. 6.7 ± 1.4; p = 0.01), difficulty (6.5 ± 1.1 vs. 7.5 ± 0.9; p = 0.04) and improved satisfaction (9.3 ± 0.5 vs. 7.5 ± 0.6; p = 0.01). Moreover, hemoglobin loss and postoperative pain were reduced in A2 relative to B2 [(8.1 ± 4.2 % vs. 4.5 ± 1.1%; p = 0.02) and (5.1 ± 0.9 vs. 4.1 ± 0.8; p = 0.03), respectively] Conclusions: The use of sealing devices by residents was related to reduced difficulty as well improved visibility and overall satisfaction, with improved surgical outcomes.

The Future in Standards of Care for Gynecologic Laparoscopic Surgery to Improve Training and Education

Standards of care offer doctors and patients the confidence that an established quality, evidence-based, care is provided, and represent a tool for optimal responding to the population’s needs. It is expected that they will increasingly express a multimodal relationship with gynecologic laparoscopy. Laparoscopy is, now, a standard procedure in operative gynecology, standards are embedded in many laparoscopic procedures, standardization of the skills/competency assessment has been progressively developed, and the proof of competency in laparoscopy may become a standard of care. A continuous development of surgical education includes standard equipment (that may bring value for future advance), standardized training, testing (and performance) assessment, educational process and outcome monitoring/evaluation, patients’ care, and protection, etc. Standards of care and training have a reciprocally sustaining relationship, as training is an essential component of standards of care while care is provided at higher standards after a structured training and as credentialing/certification reunites the two. It is envisaged that through development and implementation, the European wide standards of care in laparoscopic surgery (in close harmonization with personalized medicine) would lead to effective delivery of better clinical services and provide excellent training and education.

Development of a Low-Fidelity Laparoscopic Sacrocolpopexy Simulation Model and Evaluation of Curriculum

OBJECTIVES

Minimally invasive sacrocolpopexy (SCP) is a compelling surgical procedure that requires advanced laparoscopic suturing and dissection skills and knowledge of pelvic retroperitoneal anatomy. The aim of this study was to develop a low-cost laparoscopic SCP model and educational curriculum to improve dissection and suturing skills along with anatomic knowledge to avoid complications.

METHODS

The pelvic SCP model was developed with easily available material that was placed on the commercial pelvic bone model to construct a vagina, major vessels, ureter, peritoneum, and areolar tissue. A comprehensive curriculum encompassing didactic and technical skills components on the pelvic model was used to teach laparoscopic SCP. Participants completed precurriculum and postcurriculum multiple-choice questionnaires to evaluate the didactic component. A modified Objective Structured Assessment of Technical Skills (OSATS) tool was used to measure technical skills before and after technical skills curriculum.

RESULTS

Among the 10 senior residents, 6 (60%) were studying at their fourth postgraduate year, and 3 (30%) were studying at their third postgraduate year. Postcurriculum test scores (14.5 vs 10.6) for assessment of cognitive knowledge were significantly improved (P < 0.001). The median postcurriculum OSATS scores (26.5; range, 18-30) were significantly improved (P = 0.005). Laparoscopic SCP OSATS scores increased from median 21 to median 26.5 after cognitive and technical curriculum, showing a 21.4% improvement. The majority (70%) of residents believed that the SCP model would be useful to enhance skills acquisition before performing the skill in the operating room.

CONCLUSIONS

A low-fidelity laparoscopic SCP curriculum showed improvement in cognitive knowledge and technical skills.

Correcting the Fundamentals of Laparoscopic Surgery "Illusion of Validity" in Laparoscopic Vaginal Cuff Suturing

STUDY OBJECTIVE

The "illusion of validity" is a cognitive bias in which the ability to interpret and predict surgical performance accurately is overestimated. To address this bias, we assessed participants comparing fundamentals of laparoscopic surgery (FLS) and non-FLS tasks with cadaveric vaginal cuff suturing to determine the most representative simulation task for laparoscopic vaginal cuff suturing.

DESIGN

Validity (Messick framework) study comparing FLS and non-FLS tasks with cadaveric vaginal cuff suturing.

SETTING

Simulation center cadaver laboratory.

PARTICIPANTS

Obstetrics and gynecology residents (n = 21), minimally invasive gynecologic surgery fellows (n = 3), gynecologic surgical subspecialists (n = 4), general obstetrician/gynecologists (n = 10).

INTERVENTIONS

Tasks included a simulated vaginal cuff (ipsilateral port placement), needle passage through a metal eyelet loop (contralateral and ipsilateral), and intracorporeal knot tying (contralateral and ipsilateral). Simulation task times were compared with the placement of the first cadaveric vaginal cuff suture time, as well as the in-person and blinded Global Operative Assessment of Laparoscopic Skills (GOALS) score ("relations to other variables" validity evidence). Statistical analyses included Spearman's test of correlation (continuous and ordinal variables) or Wilcoxon rank sum test (categoric variables).

MEASUREMENTS AND MAIN RESULTS

There was a stronger association with cadaver cuff suturing time for simulated vaginal cuff suturing time (r = 0.73, p <.001) compared with FLS intracorporeal contralateral suturing time (r = 0.54, p <.001). Additional measures associated with cadaveric performance included subspecialty training (median: 82 vs 185 seconds, p = .002), number of total laparoscopic hysterectomies (r = -0.53, p <.001), number of laparoscopic cuff closures (r = -0.61, p <.001), number of simulated laparoscopic suturing experiences (r = -0.51, p <.001), and eyelet contralateral time (r = 0.52, p <.001). Strong agreement between the in-person and blinded GOALS (intraclass correlation coefficient = 0.80) supports response process evidence. Correlations of cadaver cuff time with in-person (Spearman's r = -0.84, p <.001) and blinded GOALS (r = -0.76, p <.001) supports relations to other variables evidence CONCLUSION: The weaker correlation between FLS suturing and cadaver cuff suturing compared with a simulated vaginal cuff model may lead to an "illusion of validity" for assessment in gynecology. Since gynecology specific validity evidence has not been well established for FLS, we recommend prioritizing the use of a simulated vaginal cuff suturing assessment in addition to FLS.

Gynecology-obstetric resident surgery training: a national evaluation

OBJECTIVES

The main objective of this study was to evaluate surgery training and evaluation of French gynecology-obstetrics residents. The second objective was to evaluate using simulation during residency.

STUDY DESIGN

This national descriptive study, utilized a questionnaire to survey all interns in French gynecology and obstetrics. At the end of a study, 129 responses of residents were analyzed.

RESULTS

The participation rate was 12%. The majority of residents were women (84%) and the highest response rate was from the Ile-de-France region (36%). The lowest rate was from the Southern region. The majority of residents were in the eighth semester (20%). Residents reported surgical and obstetric orientations in 53% (n = 68) and 44% (n = 57) of cases, respectively. Registration for cancer oncology was reported by 22% (n = 28) of respondents. Evaluation of oncologic surgery training was mostly considered "good" by the surgical group and "passable" by the obstetrics group. Access to simulators was usually restricted and most often utilized the pelvitrainer. Sessions were typically not mandatory and numbered between zero and five per semester. Three types of simulators were accessible in the Ile-de-France, North-West, West and Rhône-Alpes. The North-East did not have access to animal models, and the South-West did not have access to corpses. Surgical classes were more common in the Rhône-Alpes, North-East, Ile-de-France and North-West regions. To improve their training in oncological surgery, 64% (n = 18) of residents planned to do an inter-university exchange and 54% had completed additional specialized training. Measures that were most expected to improve training were increased training in surgery (96% of respondents, n = 27) and more intensive coaching (96%, n = 27).

CONCLUSIONS

Companionship is a pillar of residents training, but its effectiveness is variable. One solution could be to implement better use of simulation methods.

Effectiveness of a one-day laparoscopic suture course

We aimed to determine the effectiveness of a one-day course on laparoscopic suturing skills development by performing a prospective study with obstetrics and gynaecology specialists. The course consisted of a theoretical portion describing the suturing technique basics and a practical portion consisting of box trainer suturing. Before and after the course, each trainee was given 10 min to introduce the suture material into the abdomen, properly position the needle using a needle holder, pass the suture through premarked points on the silicone pads and tie an intracorporeal knot. The procedures were video recorded and evaluated after the course. The results showed that there were statistically significant reductions in the needle holding, suture passing and knot tying times after completing the course. Overall, the one-day course was an effective training programme for improving a surgeon's laparoscopic suturing skills. IMPACT STATEMENT What is already known on this subject? Currently, many countries have centres that provide laparoscopic training as part of the medical residency education. However, a standardised training programme has not been implemented worldwide. What do the results of this study add? In this study, we pointed out the effectiveness of a one-day laparoscopic suturing course. A one-day suturing course is easy to implement, cheap and effective. What are the implications of these findings for clinical practice and/or further research? A one-day suturing course should be implemented worldwide, especially in those countries lacking sufficient financial resources to provide laparoscopic training as part of the medical residency programme.

The role of laparoscopy in the propaedeutics of gynecological diagnosis1

Purpose

To evaluate agreement between pre- and post-laparoscopy gynecological diagnosis in order to demonstrate the rationality of this minimally invasive technique use in gynecological propaedeutics.

Methods

Retrospective chart review study conducted between March 2010 and October 2016 based on a convenience sample. 315 patients undergoing surgical laparoscopy at the Center of Gynecologic Endoscopy and Family Planning of Botucatu Medical School/UNESP. Pre- and postoperative diagnoses were compared by the diagnosis agreement test considering the proportions of events.

Results

Laparoscopy contributed to diagnosis in 59.6% of infertility cases (P>0.05), in 93.7% of chronic pelvic pain of undetermined origin (P<0.01) and conclusively elucidated the diagnosis of acute abdomen and the ruling out of tubo-ovarian abcess (P<0.05). Laparoscopy also increased the diagnosis of pelvic-abdominal adhesions in 76.7% (P>0.05).

Conclusion

The use of laparoscopy considerably contributed to diagnostic elucidation, especially in cases of undetermined chronic pelvic pain.

Implementation and validation of a retroperitoneal dissection curriculum

BACKGROUND

Competency-based education requires educators to use simulation training for the purposes of education and assessment of resident trainees. Research demonstrates that improvement in surgical skills acquired in a simulated environment is transferrable to the operative environment. Laparoscopic retroperitoneal dissection, opening the retroperitoneal space and identifying the ureter, is a fundamental skill for gynecologists. Integrating simulation models into a formal and comprehensive curriculum for teaching ureterolysis could translate to increased surgical competency.

OBJECTIVE

Our goal was to validate a comprehensive curriculum for laparoscopic retroperitoneal dissection for the purpose of identification of the ureter by evaluating intraoperative performance.

STUDY DESIGN

A comprehensive curriculum, encompassing didactic and technical skills components and using a previously developed pelvic model, was designed to teach laparoscopic ureterolysis. Novice surgeons (postgraduate years 3-5) were recruited. Participants completed precurriculum and postcurriculum multiple-choice questionnaires to evaluate a didactic component. Preperformance and postperformance on the model was video-recorded. As part of the technical component, participants received constructive feedback from expert surgeons on how to perform laparoscopic retroperitoneal dissection using the simulation model. Participants were then video-recorded performing laparoscopic retroperitoneal dissection in the operating room within 3 months of the curriculum. All videos were blindly assessed by an expert using the Objective Structured Assessment of Technical Skills tool. At the conclusion of the study, participants completed a course evaluation.

RESULTS

Thirty novice gynecologic surgeons were recruited. High baseline knowledge of ureteric anatomy and injury (multiple-choice question score median and interquartile range) still significantly increased from 7 (5-7.25) precurriculum to 8 (7-9) postcurriculum (P < .001). The median (interquartile range) technical Objective Structured Assessment of Technical Skills score increased significantly from 24.5 (23-28.25) precurriculum to 30 (29.75-32) postcurriculum (P < .001). Video-recordings were completed for 23 participants performing laparoscopic retroperitoneal dissection in the operating room. Intraoperative Objective Structured Assessment of Technical Skills scores (median of 29 [interquartile range 27-32]) correlated with postcurriculum Objective Structured Assessment of Technical Skills scores on the model (r = 0.53, P = .01). The ureter was identified intraoperatively by 91% (n = 21/23) of participants. The majority of residents (81%, n = 21/26) were more comfortable completing a supervised retroperitoneal dissection as a result of participating in the curriculum. Residents believed that this model would be useful to enhance skills acquisition prior to performing the skill in the operating room (65%, n = 17/26).

CONCLUSION

A comprehensive retroperitoneal dissection curriculum showed improvement in cognitive knowledge and technical skills, which also translated to competent performance in the operating room. In addition to the objective measures, residents believed that their skills acquisition was improved following course completion.

Determining the Effect of External Stressors on Laparoscopic Skills and Performance Between Obstetrics and Gynecology Residents

STUDY OBJECTIVE

To evaluate the effect of stress on laparoscopic skills between obstetrics and gynecology residents.

DESIGN

Observational prospective cohort study.

DESIGN CLASSIFICATION

Prospective cohort.

SETTING

Urban teaching university hospital.

PARTICIPANTS (PATIENTS)

Thirty-one obstetrics and gynecology residents, postgraduate years 1 to 4.

INTERVENTION

We assessed 4 basic laparoscopic skills at 2 sessions. The first session was the baseline; 6 months later the same skills were assessed under audiovisual stressors. We compared the effect of stress on accuracy and efficiency between the 2 sessions.

MEASUREMENTS AND MAIN RESULTS

A linear model was used to analyze time. Under stress, residents were more efficient in 3 of the 4 modules. Ring transfer (hand-eye coordination and bimanual dexterity), p = 0.0304. Ring of fire (bimanual dexterity and measure of depth perception), p = 0.0024 and dissection glove (respect of delicate tissue planes), p = 0.0002. Poisson regression was used to analyze the total number of penalties. Residents were more likely to acquire penalties under stress. Ring transfer, p = 0.0184 and cobra (hand-to-hand coordination), p = 0.0487 yielded a statistically significant increase in penalties in the presence of stressors. Dissection glove p = 0.0605 yielded a nonsignificant increase in penalties.

CONCLUSION

Our work confirmed that while under stress residents were more efficient, this translated into their ability to complete tasks faster in all the tested skills. Efficiency, however, came at the expense of accuracy.

Assessment of laparoscopic skills of Gynecology and Obstetrics residents after a training program

Objective

To evaluate laparoscopic skills of third-year Gynecology and Obstetrics residents after training at a training and surgical experimentation center.

Methods

Use of a prospective questionnaire analyzing demographic data, medical residency, skills, competences, and training in a box trainer and in pigs.

Results

After the training, there was significant improvement in laparoscopic skills according to the residents (before 1.3/after 2.7; p=0.000) and preceptors (before 2.1/after 4.8; p=0.000). There was also significant improvement in the feeling of competence in surgeries with level 1 and 2 of difficulty. All residents approved the training.

Conclusion

The training was distributed into 12 hours in the box trainer and 20 hours in animals, and led to better laparoscopic skills and a feeling of more surgical competence in laparoscopic surgery levels 1 and 2.

Navigation forces during wrist arthroscopy: assessment of expert levels

PURPOSE

To facilitate effective and efficient training in skills laboratory, objective metrics can be used. Forces exerted on the tissues can be a measure of safe tissue manipulation. To provide feedback during training, expert threshold levels need to be determined. The purpose of this study was to define the magnitude and the direction of navigation forces used during arthroscopic inspection of the wrist.

METHODS

We developed a set-up to mount a cadaver wrist to a 3D force platform that allowed measurement of the forces exerted on the wrist. Six experts in wrist arthroscopy performed two tasks: (1) Introduction of the camera and visualization of the hook. (2) Navigation through the wrist with visualization of five anatomic structures. The magnitude (Fabs) and direction of force were recorded, with the direction defined as α being the angle in the vertical plane and β being the angle in the horizontal plane. The 10th-90th percentile of the data were used to set threshold levels for training.

RESULTS

The results show distinct force patterns for each of the anatomic landmarks. Median Fabs of the navigation task is 3.8 N (1.8-7.3), α is 3.60 (-54-44) and β is 260 (0-72).

CONCLUSION

Unique expert data on navigation forces during wrist arthroscopy were determined. The defined maximum allowable navigation force of 7.3 N (90th percentile) can be used in providing feedback on performance during skills training. The clinical value is that this study contributes to objective assessment of skills levels.

Validating a standardized laparoscopy curriculum for gynecology residents: a randomized controlled trial

BACKGROUND

Residency programs struggle with integrating simulation training into curricula, despite evidence that simulation leads to improved operating room performance and patient outcomes. Currently, there is no standardized laparoscopic training program available for gynecology residents.

OBJECTIVE

The purpose of this study was to develop and validate a comprehensive ex vivo training curriculum for gynecologic laparoscopy.

STUDY DESIGN

In a prospective, single-blinded randomized controlled trial (Canadian Task Force Classification I) postgraduate year 1 and 2 gynecology residents were allocated randomly to receive either conventional residency training or an evidence-based laparoscopy curriculum. The 7-week curriculum consisted of cognitive didactic and interactive sessions, low-fidelity box trainer and high-fidelity virtual reality simulator technical skills, and high-fidelity team simulation. The primary outcome measure was the technical procedure score at laparoscopic salpingectomy with the use of the objective structured assessment of laparoscopic salpingectomy tool. Secondary outcome measures related to performance in multiple-choice questions and technical performance at box trainer and virtual reality simulator tasks. A sample size of 10 residents per group was planned (n = 20). Results are reported as medians (interquartile ranges), and data were compared between groups with the Mann-Whitney U, chi-square, and Fisher's exact tests (P ≤ .05).

RESULTS

In July 2013, 27 residents were assigned randomly (14 curriculum, 13 conventional). Both groups were similar at baseline. Twenty-one residents (10 curriculum, 11 conventional) completed the surgical procedure-based assessment in the operating room (September to December 2013). Our primary outcome indicated that curriculum-trained residents displayed superior performance at laparoscopic salpingectomy (P = .043). Secondary outcomes demonstrated that curriculum-trained residents had higher performance scores on the cognitive multiple-choice questions (P < .001), the nontechnical skills multiple-choice questions (P = .016), box trainer task time (P < .001), and all virtual reality simulator parameters.

CONCLUSION

Participation in a comprehensive simulation-based training curriculum for gynecologic laparoscopy leads to a superior improvement in knowledge and technical performance in the operating room compared with conventional residency training.

Designing a Standardized Laparoscopy Curriculum for Gynecology Residents: A Delphi Approach

BACKGROUND

Evidence suggests that simulation leads to improved operative skill, shorter operating room time, and better patient outcomes. Currently, no standardized laparoscopy curriculum exists for gynecology residents.

OBJECTIVE

To design a structured laparoscopy curriculum for gynecology residents using Delphi consensus methodology.

METHODS

This study began with Delphi methodology to determine expert consensus on the components of a gynecology laparoscopic skills curriculum. We generated a list of cognitive content, technical skills, and nontechnical skills for training in laparoscopic surgery, and asked 39 experts in gynecologic education to rate the items on a Likert scale (1-5) for inclusion in the curriculum. Consensus was predefined as Cronbach α of ≥0.80. We then conducted another Delphi survey with 9 experienced users of laparoscopic virtual reality simulators to delineate relevant curricular tasks. Finally, a cross-sectional design defined benchmark scores for all identified tasks, with 10 experienced gynecologic surgeons performing the identified tasks at basic, intermediate, and advanced levels.

RESULTS

Consensus (Cronbach α=0.85) was achieved in the first round of the curriculum Delphi, and after 2 rounds (Cronbach α=0.80) in the virtual reality curriculum Delphi. Consensus was reached for cognitive, technical, and nontechnical skills as well as for 6 virtual reality tasks. Median time and economy of movement scores defined benchmarks for all tasks.

CONCLUSIONS

This study used Delphi consensus to develop a comprehensive curriculum for teaching gynecologic laparoscopy. The curriculum conforms to current educational standards of proficiency-based training, and is suggested as a standard in residency programs.