Improved laparoscopic skills in gynaecology trainees following a simulation-training program using take-home box trainers.

BACKGROUND: Lack of time and access to equipment are recognised barriers to simulation training. AIM: To investigate the effect of a take-home laparoscopic simulator training program on the laparoscopic skills of gynaecology trainees. METHOD: Participants (n = 17 in 2015, n = 16 in 2016) were supplied with a box trainer, associated equipment and instructions on self-directed training. A program was designed and implemented in 2015 comprising of ten weekly laparoscopic skills tasks and modified in 2016 to eight monthly tasks. Half of the participants were randomly allocated a supervisor. Participants performed baseline and post-training assessments of laparoscopic skills in a box trainer task (thread transfer) and virtual reality simulator tasks (laparoscopic tubal ligation and bilateral oophorectomy). RESULTS: Trainees in 2015 demonstrated an improvement in the median time to complete the laparoscopic tubal ligation task (baseline 124 s vs post-training 91 s, P = 0.041). There was no difference in the number of tubal ligation bleeding incidents, or in the time taken to complete the box trainer thread transfer task. In 2016 trainees demonstrated improvement in tubal ligation time (baseline 251 vs 71 post-training, P = 0.021) and bilateral oophorectomy time (baseline 891 s vs 504 post-training, P = 0.025). There was no significant difference in other outcome measures. There was no difference found in performance when groups were compared by supervisor allocation. CONCLUSION: A take-home box trainer simulation-training program was associated with improvement in laparoscopic skills. This type of program may improve trainee access to simulation training.

Simulation training for family planning procedures.

PURPOSE OF REVIEW: To review the current evidence for use of simulation in family planning procedural training. RECENT FINDINGS: A variety of simulation models exist for abortion, contraception, and sterilization procedures, ranging from low to high fidelity. Most models for abortion and contraception are low fidelity, inexpensive, and provide opportunities for acquisition and practice of procedural skills. Hysteroscopic and laparoscopic simulation models for sterilization procedures are generally higher fidelity, and their use has been shown to increase knowledge, skill performance, and procedural comfort. SUMMARY: Existing evaluation of family planning simulation education shows consistently positive results related to improved procedural knowledge and comfort. Although some studies have shown increased provision of family planning services following simulation-training interventions, further evaluation is needed to determine the impact on clinical outcomes.

Laparoscopic virtual reality simulator and box trainer in gynecology.

OBJECTIVE: To investigate whether a virtual reality simulator (LapSim) and traditional box trainer are effective tools for the acquisition of basic laparoscopic skills, and whether the LapSim is superior to the box trainer in surgical education. METHODS: In a study at Ege University School of Medicine, Izmir, Turkey, between September 2008 and March 2013, 40 first- and second-year residents were randomized to train via the LapSim or box trainer for 4 weeks, and 20 senior residents were allocated to a control group. All 3 groups performed laparoscopic bilateral tubal ligation. Video records of each operation were assessed via the general rating scale of the Objective Structured Assessment of Laparoscopic Salpingectomy and by operation time in seconds. RESULTS: Compared with the control group, the LapSim and box trainer groups performed significantly better in total score (P<0.01 and P<0.01, respectively) and time (P=0.03 and P=0.01, respectively). There were no differences between the LapSim and box trainer groups. CONCLUSION: Novice residents who trained on a LapSim or box trainer performed better live laparoscopies than residents who trained via standard clinical surgical education. Training with a virtual reality simulator or box trainer should be considered before actual laparoscopic procedures are carried out.

Learning curve of hysteroscopic placement of tubal sterilization microinserts in 15 gynecologists in the Netherlands.

OBJECTIVE: To evaluate the learning curve of hysteroscopic placement of tubal sterilization microinserts by gynecologists in the Netherlands. DESIGN: Prospective multicenter study (Canadian Task Force II-2). SETTING: Ten community (teaching) hospitals in the Netherlands. PATIENT(S): A total of 631 women who underwent permanent sterilization by tubal microinserts. INTERVENTION(S): Hysteroscopic placement of tubal sterilization microinserts performed by 15 gynecologists experienced in performing operative hysteroscopy, starting from their very first placement. MAIN OUTCOME MEASURE(S): Effect of increasing experience in time on procedure time, pain score, successful bilateral placement, and complications. RESULT(S): Bilateral successful placement with confirmation of adequate positioning at follow-up evaluation was achieved in 480 (76.1%) patients at first attempt and in 44 (7.0%) at second attempt. Median procedure time was 8.0 minutes (range: 3-40), and 31 (4.9%) patients were lost to follow-up evaluation. Gravidity showed to be a confounding factor and was consequently adjusted for. A learning curve was seen in a statistically significant decrease of procedure time with increasing experience. The decrease in procedure time extended to 11 to 15 cases and was followed by a plateau phase of the subsequent 60 cases. In contrast, pain scores, successful placement, and complication rate appeared not to improve with increasing experience. CONCLUSION(S): A learning curve for hysteroscopic tubal sterilization was seen for procedure time, but successful placement, pain score, and complication rate were not clearly influenced by increasing experience.

Hysteroscopic sterilization using a virtual reality simulator: assessment of learning curve.

STUDY OBJECTIVE: To assess the learning curve using a virtual reality simulator for hysteroscopic sterilization with the Essure method. DESIGN: Prospective multicenter study (Canadian Task Force classification II-2). SETTING: University and teaching hospital in the Netherlands. PARTICIPANTS: Thirty novices (medical students) and five experts (gynecologists who had performed >150 Essure sterilization procedures). INTERVENTIONS: All participants performed nine repetitions of bilateral Essure placement on the simulator. Novices returned after 2 weeks and performed a second series of five repetitions to assess retention of skills. Structured observations on performance using the Global Rating Scale and parameters derived from the simulator provided measurements for analysis. MEASUREMENTS AND MAIN RESULTS: The learning curve is represented by improvement per procedure. Two-way repeated-measures analysis of variance was used to analyze learning curves. Effect size (ES) was calculated to express the practical significance of the results (ES ≥ 0.50 indicates a large learning effect). For all parameters, significant improvements were found in novice performance within nine repetitions. Large learning effects were established for six of eight parameters (p < .001; ES, 0.50-0.96). Novices approached expert level within 9 to 14 repetitions. CONCLUSION: The learning curve established in this study endorses future implementation of the simulator in curricula on hysteroscopic skill acquisition for clinicians who are interested in learning this sterilization technique.

Does residency training improve cognitive competence in obstetric and gynaecologic surgery?

OBJECTIVE: To develop an operative knowledge assessment tool to evaluate the cognitive competence of trainees in obstetric and gynaecologic surgery and to determine the rate of change in competence during a five-year residency program. METHODS: Twenty-eight participants in five training groups (PGY-1 to PGY-5) in McGill University's residency program in obstetrics and gynaecology underwent an evaluation based on surgical cognitive competence (SCC) assessment tools developed for three different obstetric and gynaecologic operations: open total abdominal hysterectomy (TAH), Caesarean section, and laparoscopic bilateral tubal sterilization (BTL). The tools were developed as checklists listing every step in each operation based on techniques described in current surgical texts. Using analysis of variance and linear regressions, statistical significance was established for procedure-specific scores and overall SCC scores. In addition, the rate of change of cognitive competence throughout the training years was calculated. Finally, using a t test, the overall SCC score was compared to a "critical steps score". RESULTS: Critical steps scores and overall SCC scores increased with training experience at an average yearly rate of 13.36% (P < 0.001). Procedure-specific scores increased yearly, by 15.73% for TAH (P < 0.001), 8.06% for Caesarean section (P < 0.001), and 16.31% for BTL (P < 0.001). The difference between overall scores and critical steps scores was not statistically significant for the study cohort (P = 0.94). CONCLUSION: Surgical cognitive competence among obstetrics and gynaecology residents can be reliably assessed with our evaluation tool, and it increases proportionally with residency education, reaching maximum scores during the final year of training. This type of information may be helpful in ascertaining how long a residency program should be.

Hysteroscopic placement of tubal sterilization implants: virtual reality simulator training.

STUDY OBJECTIVE: To assess face and construct validity of a new virtual reality (VR) training simulator for hysteroscopic placement of tubal sterilization implants. DESIGN: Nonrandomized, controlled trial comparing responses and performance of novices and experts on the simulator. DESIGN CLASSIFICATION: Canadian task force II-1. SETTING: Forty-six gynecologists were personally invited or recruited at the 33rd Conference of the French National College of Gynecologists and Obstetricians (CNGOF) from December 9 to 12, 2009, grouped as 20 experts and 26 novices. They all performed the defined sequence of virtual procedures on the simulator (case 1 for familiarization, case 4 for study assessment) and finally completed the study questionnaire. MEASUREMENTS AND MAIN RESULTS: Responses to realism, educational potential, and general opinion were excellent, proving face validity. Significant differences between novices and experts were assessed for 7 of the 15 metrics analyzed, proving construct validity. CONCLUSIONS: We established face and construct validity for EssureSim, an educational VR simulator for hysteroscopic tubal sterilization implant placement. The next steps are to investigate convergent and predictive validity to affirm the real capacity of transferring the skills learned on the training simulator to the patient in the operating room.

Visuospatial ability correlates with performance in simulated gynecological laparoscopy.

OBJECTIVE: To analyze the relationship between visuospatial ability and simulated laparoscopy performed by consultants in obstetrics and gynecology (OBGYN). STUDY DESIGN: This was a prospective cohort study carried out at two community hospitals in Sweden. Thirteen consultants in obstetrics and gynecology were included. They had previously independently performed 10-100 advanced laparoscopies. Participants were tested for visuospatial ability by the Mental Rotations Test version A (MRT-A). After a familiarization session and standardized instruction, all participants subsequently conducted three consecutive virtual tubal occlusions followed by three virtual salpingectomies. Performance in the simulator was measured by Total Time, Score and Ovarian Diathermy Damage. Linear regression was used to analyze the relationship between visuospatial ability and simulated laparoscopic performance. The learning curves in the simulator were assessed in order to interpret the relationship with the visuospatial ability. RESULTS: Visuospatial ability correlated with Total Time (r=-0.62; p=0.03) and Score (r=0.57; p=0.05) in the medium level of the virtual tubal occlusion. In the technically more advanced virtual salpingectomy the visuospatial ability correlated with Total Time (r=-0.64; p=0.02), Ovarian Diathermy Damage (r=-0.65; p=0.02) and with overall Score (r=0.64; p=0.02). CONCLUSIONS: Visuospatial ability appears to be related to the performance of gynecological laparoscopic procedures in a simulator. Testing visuospatial ability might be helpful when designing individual training programs.

[State of the art about teaching hysteroscopy to gynaecologist surgeons in France and in Europe. CONFORM investigation into the training of the hysteroscopic placement of microinserts]. / Etat des lieux de la formation des chirurgiens gynécologues à l'hystéroscopie en France et en Europe. Enquête CONFORM sur la formation à la mise en place des implants de stérilisation tubaire par voie transcervicale.

OBJECTIVE: Since 2002, Conceptus company markets in France and Europe the Essure microinsert as permanent hysteroscopic intratubal sterilization, and organizes a meeting, a training and an assistance on a few cases. The data from this interview and the results of the first cases done with assistance of Conceptus instructors were collected prospectively between January 2004 to December 2006. The purpose is to make a state of the art about teaching hysteroscopy to gynaecologist surgeons in France and in Europe. PATIENTS AND METHODS: According to their statements about their knowledge of hysteroscopy practice, surgeons were classified in four groups. Group 1 included those who had a bad knowledge and a sporadic practice, group 2 those who had no formation and an empirical practice, group 3 those who had a regular practice and an incomplete formation or whose formation was in progress and group 4 those with fully-formed surgeons with a regular practice. RESULTS: One thousand one hundred and fourty-four women underwent hysteroscopic sterilisation with a global success rate of 92.13%. Were included 536 surgeons and 498 were evaluated. There were 80 (16.06%) surgeons in group 1, 149 (29.92%) in group 2, 121 (24.30%) in group 3 and 148 (29.72%) in group 4. Failure rates for each group were respectively 16.25%, 10.07%, 9.10% and 4.73% (p < or = 0.01). The presence of an instructor was associated with a fast improvement judging from the classification in a higher level group in 47.83%, 28.21% and 25% respectively for the groups 1 to 3 after the second visit and in 75%, 58.33% and 20% after the third visit. DISCUSSION AND CONCLUSION: It seems important to establish a modern and low-cost teaching program to improve surgeon's theoretical and practical formation in hysteroscopy in order to increase success rates and reduce possible complications. Theoretical formation has to include a good knowledge of the material and its use: diameter and form of the operative channel, obliquity of the scope, liquid of distension and kind of current used. Practical formation could be done at once with virtual models to get used with the manipulation of the scope and thanks to the use of different currents with the assistance of a trained surgeon.

Training of residents in laparoscopic tubal sterilization: long-term failure rates.

OBJECTIVES: Laparoscopic tubal sterilization with bipolar coagulation is a common and effective method of contraception, and a procedure much used to teach laparoscopic surgical skills to Obstetrics and Gynaecology residents (trainees); but it has an inherent risk of failure. This study investigated the long-term failure rate of this procedure when performed by Obstetrics and Gynaecology residents on women treated in their teaching clinics. METHODS: From 1991 to 1994, Obstetrics and Gynaecology residents carried out 386 laparoscopic tubal sterilizations with bipolar coagulation at Yale-New Haven Hospital. Six to nine years after the procedure, the women concerned were contacted by telephone and data were collected about sterilization failure. RESULTS: Two failures of laparoscopic tubal sterilization with bipolar coagulation were identified: an ectopic pregnancy and a spontaneous abortion. For this time period, the long-term sterilization failure rate was 1.9% (0-4.4%). CONCLUSIONS: The long-term sterilization failure rate for laparoscopic tubal sterilization with bipolar coagulation performed by residents is comparable to the results of prior studies. These findings can be used to properly counsel women at a teaching clinic about the risks of sterilization failure with this procedure, and attest to the adequacy of residents' training and supervision.

The effect of special training for quinacrine sterilization (QS) in Faisalabad, Pakistan: a report on an 1833-women subset of 11,000 cases.

OBJECTIVE: To determine the impact of retrained clinicians on the efficacy of transcervical quinacrine sterilization. METHOD: Retraining of clinicians in the accepted insertion technique was conducted in 1996. From 1 January 1997 through 2001, they performed 1089 quinacrine sterilizations in 11 MCH clinics of the Mother & Child Welfare Association at Faisalabad, Pakistan. Of these, 885 women had a recorded follow-up visit (81.4%) by 31 December 2001. RESULT: Reported pregnancy failures declined after retraining from 5.4% (SE 2.3) for one year of use to 1.1% (SE 0.4) for 5 years of use. The rates at 4 years of use showed the expected increase in failures for women 30 years old or younger of 1.5% (SE 0.7) compared to 0.9% (SE 0.4) for those over 30; a lower rate of 0.8% (SE 0.4) for breastfeeding subjects and 2.2% (SE 1.1) for mothers not breastfeeding; but rates were similar for uterine length and post insertion traumatic bleeding. CONCLUSION: Quinacrine sterilization appears safe with acceptable efficacy.

Improving Falope-Ring application in laparoscopy training.

Laparoscopic Falope-Ring sterilization was performed by residents on 71 women. Immediately following application of the ring, methylene blue was injected through the cervix to assess tubal patency. Unilateral spillage of the dye was demonstrated in four patients (5.6%). In these instances a new ring was applied, or the tube was tied surgically. The high rate of tubal patency was attributed to the surgeons' inexperience. The findings suggest that the use of a patency test as an adjunct to sterilization with the Falope-Ring in training programs is likely to decrease the rate of surgical failures.

PIP: Gynecologist residents in training performed 71 laparoscopic Falope-Ring sterilizations under supervision, and effectiveness of the ligation was tested by dye passage. The operations were done with the KLI one-puncture laparoscope under general anesthesia, and methylene blue dye was introduced transcervically via the Rubin cannula used to stabilize the uterus. Patients ranged from 23-49 years, mean 29.8, parity 1-8, mean 23.7. Dye spilled out on one side in 4 cases, all with a ring verified as placed on the fallopian tube. Two instances of slow dye passage occurred with the ring 1.5-2.0 cm from the uterotubal junction. In one case the ring encircled only the serosa of an edematous tube, and in the other the ring was too distant. The only other complications were loss of 2 rings in the peritoneal cavity, application of a ring on the round ligament, later corrected and a cervical laceration requiring suturing. Since others have also reported higher failure rates of band laparoscopic sterilization early in physicians' experience, it is recommended that doctors in training use the dye patency test.

Regional training program of laparoscopy: impact on regional care.

In response to large numbers of requests for laparoscopic sterilization, the University of North Carolina began a training program to provide this service on a regional basis throughout the state. This report reviews the final distribution of centers providing these services: one within 50 miles of every person in the state. The clinical experience of 30 private physicians (excluding experience of residency training programs) was reviewed and found to parallel the national experience in provision of services, in complications, and in pregnancies. The brief but intense training program (2 days at the University of North Carolina and one morning at the physician's hospital) was found to result in rates of complications and failures similar to national levels of performance. Should the demand for laparoscopic sterilization increase in the coming years, the region has sufficient numbers of safely trained physicians to respond.