Proficiency for Advanced Laparoscopic Procedures in Gynecologic Residency Program: Do all Residents Need to be Trained?

OBJECTIVES: To assess the current state of laparoscopic gynecologic surgery in the Dutch residency program, the level of competence among graduated residents, and whether they still perform these procedures. Furthermore, their current attitudes toward the implementation of minimally invasive surgery into residency training were assessed. DESIGN: An online survey (Canadian Task Force Classification III) regarding the level of competence, performance, training, and interest for gynecologic laparoscopic procedures. PARTICIPANTS/SETTING: Gynecologists who finished residency training between 2008 and 2013 in the Netherlands. RESULTS: Response rate was 73% (171/235). The scores for all basic and intermediate laparoscopic procedures performed immediately after residency showed the highest competence level (median 5, of scale 1-5). The competence level for advanced laparoscopic procedures was less at 3, indicating that the graduated residents are not able to perform these procedures without supervision. Overall, 56% of the gynecologists no longer perform any level 3 advanced procedures, and 86% do not perform level 4 advanced procedures. Gynecologists who still perform the inquired laparoscopic procedures scored a significantly higher competence level immediately after residency training for most of procedures compared with the gynecologists who do not perform these procedures. CONCLUSION: Residents are sufficiently trained for basic and intermediate laparoscopic procedures during residency training. However, they are not sufficiently equipped to perform advanced laparoscopic procedures without supervision. We should consider training advanced procedures especially to a selected group of residents because most gynecologists do not perform these procedures after residency. The learning curve for advanced procedures continues to rise after finishing residency for those who keep on performing these procedures, therefore an additional fellowship is recommended for this group.

Training of hysteroscopic skills in residency program: the Dutch experience.

STUDY OBJECTIVE: To evaluate whether hysteroscopy training in the Dutch gynecological residency program is judged as sufficient in daily practice, by assessment of the opinion on hysteroscopy training and current performance of hysteroscopic procedures. In addition, the extent of progress in comparison with that of the residency program of a decade ago is reviewed. DESIGN: Survey (Canadian Task Force Classification III). PARTICIPANTS: Postgraduate years 5 and 6 residents in obstetrics and gynecology and gynecologists who finished residency within 2008 to 2013 in the Netherlands. INTERVENTION: Subjects received an online survey regarding performance and training of hysteroscopy, self-perceived competence, and hysteroscopic skills acquirement. RESULTS: Response rate was 65% of the residents and 73% of the gynecologists. Most residents felt adequately prepared for basic hysteroscopic procedures (86.7%), but significantly less share this opinion for advanced procedures (64.5%) (p < 0.01). In comparison with their peers in 2003, the current residents demonstrated a 10% higher appreciation of the training curriculum. However, their self-perceived competence did not increase, except for diagnostic hysteroscopy. Regarding daily practice, not only do more gynecologists perform advanced procedures nowadays but also their competence level received higher scores in comparison with gynecologists in 2003. Lack of simulation training was indicated to be the most important factor during residency that could be enhanced for optimal acquirement of hysteroscopic skills. CONCLUSION: Implementation of hysteroscopic procedures taught during residency training in the Netherlands has improved since 2003 and is judged as sufficient for basic procedures. The skills of surgical educators have progressed toward a level in which gynecologists feel competent to teach and supervise advanced hysteroscopic procedures. Even though the residency preparation for hysteroscopy is more highly appreciated than a decade ago, this study indicated that simulation training might serve as an additional method to improve hysteroscopic skills acquisition. Future research is needed to determine the value of simulation training in hysteroscopy.

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.

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.

An "intermediate curriculum" for advanced laparoscopic skills training with virtual reality simulation.

STUDY OBJECTIVE: To estimate face and construct validity for a novel curriculum designed for intermediately skilled laparoscopic surgeons on a virtual reality simulator. It consists of 5 exercises that focus on training precision and coordination between both hands. DESIGN: Prospective study (Canadian Task Force II-2). SETTING: Three university hospitals and 4 teaching hospitals in the Netherlands. SUBJECTS: Residents, consultants, and laparoscopic experts (n = 69) in the fields of general surgery, gynecology, and urology participated. Participants were divided into 4 groups on the basis of their level of laparoscopic experience: resident, years 1-3 (n = 15); resident, years 4-6 (n = 17); consultant (n = 19); and laparoscopic experts (n = 18). INTERVENTIONS: Participants completed 3 runs of 5 exercises. The first run was an introduction, and the second and third runs were used for analysis. The parameters time, path length, collisions, and displacement were compared between groups. Afterward the participants completed a questionnaire to evaluate their laparoscopic experience and identify issues concerning the simulator and exercises. MEASUREMENTS AND MAIN RESULTS: The expert group was significantly faster (p <.05) than other groups in 4 of 5 exercises. The parameter displacement demonstrated a significant difference between the expert group and other groups in 2 of the 4 exercises in which this parameter was relevant (p <.05). In the questionnaire (n = 68), training capacity of the curriculum was scored with a median of 4 points on a 5-point Likert scale. Of all participants, 92.6% indicated that this curriculum is suitable as an addition to a basic skills module within their residency program. CONCLUSION: Face and construct validity were estimated for an advanced virtual reality curriculum for intermediately skilled laparoscopic surgeons. The results indicate that the curriculum is suitable for training of residents and consultants and to assess and maintain their laparoscopic skills.

Ovarian metastasis in a transposed ovary 10 years after primary cervical cancer: the importance of histologic examination and review of literature.

Cases of cervical carcinoma metastasing to the transposed ovary are rarely reported in the literature. In this report, the authors present the case of a 53-year-old woman with a persisting, unsuspected cyst in the right transposed ovary, 10 years after treatment for adenosquamous carcinoma of the cervix. It is the first report describing a secondary ovarian malignancy originating from a cervical adenosquamous carcinoma in a transposed ovary. In addition, this is the first account of an ovarian metastasis 10 years after primary treatment for cervical cancer. Furthermore, pathologic examination with immunohistochemistry and human papillomavirus genotyping played a key role in the diagnostic process, as the case did not raise suspicion by ultrasound findings neither by cytological examination after cytological aspiration or by appearance during surgery.