Procedure-specific simulation for vaginal surgery training: A randomized controlled trial.

INTRODUCTION: Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure-specific simulation skills, vs usual training, result in improved operative competence. MATERIAL AND METHODS: We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self-confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05). CLINICALTRIALS: gov: Registration no. NCT05887570. RESULTS: We randomized 83 residents to intervention or control and 55 completed the trial (2011-23). Baseline characteristics were similar, except for more fourth-year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2-16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8-22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self-confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups. CONCLUSIONS: Compared to usual training, procedure-specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters.

Establishing Validity for a Vaginal Hysterectomy Simulation Model for Surgical Skills Assessment.

OBJECTIVE: To use the Messick validity framework for a simulation-based assessment of vaginal hysterectomy skills. METHODS: Video recordings of physicians at different levels of training and experience performing vaginal hysterectomy on a high-fidelity vaginal surgery model were objectively assessed using a modified 10-item Vaginal Surgical Skills Index, a one-item global scale of overall performance, and a pass-fail criterion. Participants included obstetrics and gynecology trainees and faculty from five institutions. Video recordings were independently assessed by expert surgeons blinded to the identities of the study participants. RESULTS: Fifty surgeons (11 faculty, 39 trainees) were assessed. Experience level correlated strongly with both the modified Vaginal Surgical Skills Index and global scale score, with more experienced participants receiving higher scores (Pearson r=0.81, P<.001; Pearson r=0.74, P<.001). Likewise, surgical experience was also moderately correlated with the modified Vaginal Surgical Skills Index and global scale score (Pearson r=0.55, P<.001; Pearson r=0.58, P<.001). The internal consistency of the modified Vaginal Surgical Skills Index was excellent (Cronbach's alpha=0.97). Interrater reliability of the modified Vaginal Surgical Skills Index and global scale score, as measured by the intraclass correlation coefficient, was moderate to good (0.49-0.95; 0.50-0.87). Using the receiver operating characteristic curve and the pass-fail criterion, a modified Vaginal Surgical Skills Index cutoff score of 27 was found to most accurately (area under the curve 0.951, 95% CI 0.917-0.983) differentiate competent from noncompetent surgeons. CONCLUSION: We demonstrated validity evidence for using a high-fidelity vaginal surgery model with the modified Vaginal Surgical Skills Index or global scale score to assess vaginal hysterectomy skills.

Hysterectomy Route and Numbers Reported by Graduating Residents in Obstetrics and Gynecology Training Programs.

OBJECTIVE: To characterize trends in self-reported numbers and routes of hysterectomy for obstetrics and gynecology residents using the Accreditation Council for Graduate Medical Education (ACGME) case log database. METHODS: Hysterectomy case log data for obstetrics and gynecology residents completing training between 2002-2003 and 2017-2018 were abstracted from the ACGME database. Total numbers of hysterectomies and modes of approach (abdominal, laparoscopic, and vaginal) were compared using bivariate statistics, and trends over time were analyzed using simple linear regression. RESULTS: Hysterectomy data were collected from 18,982 obstetrics and gynecology residents in a median of 243 (interquartile range 241-246) ACGME-accredited programs. The number of graduating residents increased significantly over time (12.1/year, P<.001), whereas the number of residency programs decreased significantly (0.52 fewer programs per year, P<.001) over the 16-year period. For cases logged as "surgeon," the median number of abdominal hysterectomies decreased by 56.5% from 85 (interquartile range 69-102) to 37 (interquartile range 34-43) (P<.001). The median number of vaginal hysterectomies decreased by 35.5% from 31 (interquartile range 24-39) to 20 (interquartile range 17-25) (P=.002). The median total number of hysterectomies per resident decreased by 6.3% from 112 (interquartile range 97-132) to 105 (interquartile range 92-121) (P=.036). In contrast, the median number of laparoscopic hysterectomies increased by 115% from 20 (interquartile range 13-28) in 2008-2009 to 43 (interquartile range 32-56) in 2017-2018, despite the decrease in overall number of hysterectomies (P<.001). These trends were statistically significant. CONCLUSIONS: The total number of hysterectomies performed by obstetrics and gynecology residents in the United States is decreasing, and the routes are changing with decreases in abdominal and vaginal approaches, and an increase in use of laparoscopic hysterectomy.

Transvaginal Natural Orifice Transluminal Endoscopic (vNOTES) Hysterectomy Learning Curve: Feasibility in the Hands of Skilled Gynecologists.

BACKGROUND: During Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) the surgeon operates exclusively through a single vaginal entry point, leaving no external scarring. OBJECTIVES: To evaluate the learning curve of vNOTES hysterectomy by experienced gynecologists based on surgical times and short-term outcomes. METHODS: A retrospective study was conducted of the first 25 vNOTES hysterectomy surgeries performed from July to December 2018 at Rambam Health Care Campus by a single surgeon. The primary outcome was hysterectomy time. Secondary outcomes included intra-operative bleeding, length of hospitalization, postoperative pain, and need for analgesia. Socio-demographic and clinical data were retrieved from patient electronic medical charts. RESULTS: Median age was 64.5 years (range 40-79). Median hysterectomy time was 38 minutes (range 30-49) from the first cut until completion. Comparisons between median hysterectomy time in the first 10 hysterectomies and in the 15 subsequent procedures demonstrated a significant decrease in median total time: 45 minutes (range 41-49) vs. 32 minutes (range 30-38), respectively (P = 0.024). The median estimated intraoperative blood loss decreased from 100 ml (range 70-200) in the first 10 hysterectomies to 40 ml (range 20-100) in the subsequent procedures (P = 0.011). CONCLUSIONS: vNOTES hysterectomy is feasible by an experienced gynecologist, with an exponential improvement in surgical performance in a short period as expressed by the improvement in hysterectomy time, low complication rates, negligible blood loss, minimal post-surgical pain, fast recovery, and short hospitalization. vNOTES allows easier and safer access to adnexal removal compared to conventional vaginal surgery.

Vaginal Hysterectomy Suturing Skills Training Model and Curriculum.

BACKGROUND: Declining vaginal hysterectomy numbers in obstetrics and gynecology training programs highlights the need for innovative methods to teach vaginal surgical skills. We describe our experience with a vaginal hysterectomy skills simulation curriculum. INSTRUMENT: A low-fidelity bench model was constructed to simulate four vaginal hysterectomy suturing tasks. A polyvinyl chloride downspout adapter and low-cost materials simulate the Heaney pedicle stitch, simple pedicle stitch, double ligature, and continuous running stitch. EXPERIENCE: Faculty expert vaginal surgeons established proficiency levels for each task. Resident (N=30) pass rates for tasks 1, 2, and 3 were 1 of 30 (3.3%), 7 of 30 (23.3%), and 4 of 30 (13.3%), respectively, for the left side, and 3 of 30 (10%), 9 of 30 (30%), and 10 of 30 (33.3%), respectively, for the right side. For task 4, the pass rate was 14 of 30 (46.7%). The majority of residents felt that the model simulates the technical skills required for vaginal hysterectomy and agreed that vaginal skills laboratory training would improve their ability to perform procedures in the operating room. Ninety-two percent of residents felt that a vaginal surgery skills curriculum would be a useful addition to their simulation education. CONCLUSION: A proficiency-based vaginal hysterectomy skills simulation curriculum using a low-fidelity model may be an important training and evaluation tool for vaginal surgical skills training.

Teaching Vaginal Hysterectomy via Simulation: Creation and Validation of the Objective Skills Assessment Tool for Simulated Vaginal Hysterectomy on a Task Trainer and Performance Among Different Levels of Trainees.

OBJECTIVES: The use of simulation-based education to train surgeons is widely accepted. Although many authors describe the use of an Objective Skills Assessment Test (OSAT) to assess performance of various surgical procedures, there is a paucity of research on use of this modality to evaluate vaginal surgery skills. We created a vaginal hysterectomy procedure-specific checklist (PSC) to complete the OSAT (which is composed of a PSC and a global rating scale [GRS]). The primary objective of this study is to evaluate the performance of a novel evaluation strategy for vaginal hysterectomy using an OSAT combining PSC and GRS. METHODS: This is a descriptive prospective study from a single institution. After orientation to the model, participants were filmed performing vaginal hysterectomy. A blinded grader scored each subject using the PSC and GRS. RESULTS: Medical students, residents, fellows, and attendings performed vaginal hysterectomy on a simulated model. Mean PSC and GRS scores increased significantly with surgeon level of experience (P < 0.001). Procedure-specific checklist scores significantly correlated with GRS scores (P < 0.001). CONCLUSIONS: The vaginal hysterectomy model and PSC have been studied across different surgeon levels using OSATs. Training programs should consider using this low-cost task trainer as a teaching tool.

Optimizing resident operative self-confidence through competency-based surgical education modules: are we there yet?

INTRODUCTION AND HYPOTHESIS: Self-confidence is the belief in one's ability to perform and can be enhanced by training. Surgical education should aim to optimize trainee confidence. We designed three procedure-specific competency-based modules to teach vaginal hysterectomy (VH), anterior (AR) and posterior repair (PR) to novice gynecology residents. We hypothesized each module would improve self-confidence and satisfaction during index procedure performance in the operating room. METHODS: This was an ancillary analysis of a larger randomized-controlled trial of gynecologic educational interventions. Residents at three Canadian universities were included if they had previously performed fewer than five index procedures independently. Intervention residents received educational modules; controls engaged in self-directed learning. All residents performed one or more of the three surgeries and filled out a validated Self-Confidence Scale and a Satisfaction Scale. Scores were compared between groups. Correlations were sought between self-confidence and various variables. RESULTS: Forty-six residents at three Canadian universities were randomized (21 intervention, 25 control). Most residents had never performed the index procedure. Overall, self-confidence was significantly higher (p = 0.021) in the intervention group for VH, but not for AR and PR (p = 0.94 and p = 0.12, respectively). Compared with controls, self-confidence was also significantly higher in intervention residents who had never performed VH (p = 0.026) or PR (p = 0.027) and in first and second year intervention residents. There was a positive correlation between self-confidence and satisfaction. CONCLUSIONS: Surgical modules improved self-confidence preferentially in the most junior residents and for more complicated procedures. The wide self-confidence ranges observed suggest that optimization should be an important goal for surgical educators.

Validation of an educational simulation model for vaginal hysterectomy training: a pilot study.

INTRODUCTION AND HYPOTHESIS: The Miya Model ™ (Miyazaki Enterprises, Winston-Salem, NC, USA) was designed as a realistic vaginal surgery simulation model. Our aim was to describe this model and present pilot data on validity and reliability of the model as an assessment tool of vaginal hysterectomy skills. METHODS: We video recorded ten obstetrics and gynecology residents (novice group) and ten practicing gynecologists (expert group) performing vaginal hysterectomy using the Miya model. Blood loss and time taken to complete the procedure were documented. Participants evaluated the model using a postsimulation survey. In addition, two experienced gynecologic surgeons independently evaluated video recordings of each participant's performance using two previously validated global rating scales: Reznick's Objective Structured Assessment of Technical Skill (OSATS) and Vaginal Surgical Skills Index (VSSI). RESULTS: Most participants (80% of novice and 100% of expert group) rated the model as effective or highly effective for vaginal hysterectomy training and assessment. Median time to procedure completion was significantly higher in the novice group, whereas median estimated blood loss was no different between groups. No significant differences were observed in the composite median OSATS or VSSI scores between groups. The interrater reliability indices for subscales and composite scores of the OSATS and VSSI were high and ranged from 0.79 to 0.90 and 0.77 to 0.93, respectively. CONCLUSIONS: With further study, the Miya Model may be a useful tool for teaching and assessing vaginal surgical skills.

Effect of Surgical Trainee Presence on Vaginal Hysterectomy Outcomes.

STUDY OBJECTIVE: Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications. DESIGN: Retrospective, multicenter, cohort study (Canadian Task Force classification II-2). SETTING: Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites. PATIENTS: Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012. INTERVENTION: ACS-NSQIP database. MEASUREMENTS AND MAIN RESULTS: Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality. CONCLUSION: Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.

Validation of the Simulated Vaginal Hysterectomy Trainer.

STUDY OBJECTIVE: To establish construct validity of the simulated vaginal hysterectomy trainer (SimVaHT). DESIGN: A cross-sectional validation study (Canadian Task Force classification II-2). SETTING: A single academic medical center in the United States. SUBJECTS: Fourteen residents in obstetrics and gynecology (4 postgraduate year [PGY] 1, 4 PGY-2, 3 PGY-3 and 3 PGY-4). PGY-1 and PGY-2 residents were grouped to form the "junior level" cohort, whereas PGY-3 and PGY-4 residents comprised the "senior level" cohort. INTERVENTIONS: Each participant underwent surgical skill simulation by performing a simulated vaginal hysterectomy on a practical, inexpensive vaginal hysterectomy trainer. MEASUREMENTS AND MAIN RESULTS: The primary outcome was resident surgical skill as assessed by the Objective Structured Assessment of Technical Skills Global Rating Scale (GRS). All obstetrics and gynecology residents were videotaped performing a simulated vaginal hysterectomy on the SimVaHT. The tapes were reviewed independently by 2 blinded urogynecology experts, each of whom provided a GRS score. The primary outcome was overall GRS scores. The secondary outcome was time to complete the exercise. GRS scores were compared between junior- and senior-level residents. Senior-level residents scored significantly higher on the GRS overall compared with junior-level residents (p = .008). CONCLUSION: Construct validity was demonstrated for the SimVaHT. The SimVaHT is a practical and inexpensive tool that may improve resident vaginal surgical skills before their first case in the operating room.

Surgical Anatomy of Vaginal Hysterectomy-Impact of a Resident-Constructed Simulation Model.

OBJECTIVES: Obstetrics and gynecology residents are less prepared to perform vaginal hysterectomy (VH), despite its advantages over other hysterectomy routes. The American Congress of Obstetricians and Gynecologists and Council on Resident Education in Obstetrics and Gynecology have prioritized simulation training in VH. Our objective was to improve residents' understanding of surgical anatomy of VH using a resident-constructed, low-cost, low-fidelity model. METHODS: A single simulation session was held in November 2016. Residents constructed a pelvic model, guided by 2 surgeons. A pretest and a posttest were administered. Experienced-based responses were tabulated for frequencies and contents. Improvement on knowledge-based questions was assessed using McNemar's test. RESULTS: Of 20 residents, 16 completed the pretest and 14 (70%) completed pretests and posttests. One hundred percent of postgraduate year (PGY)-4 had performed greater than 10 VH (11-21) and 75% of PGY-3 had performed 5 to 12 VH. Although 75% of PGY-3 and 100% of PGY-4 felt comfortable performing VH, baseline knowledge of essential surgical anatomy of VH was low (65.8%). The PGY-3 and -4 group (n=8) experienced a mean improvement of 24.4% (mean pretest score 65.8% vs mean posttest score 90%; 95% confidence interval, +14.1% to +33.3%, P=0.0005). The PGY-1 and -2 groups (n=6) experienced a mean improvement of 43.3% (mean pretest score, 41.7% vs mean posttest score, 85%; 95% confidence interval, +26.7% to +59.2%, P=0.001). After the session, all residents reported improved understanding surgical anatomy of VH and "more hands-on sessions" was the most frequently requested teaching aid. CONCLUSIONS: Residents desire additional model-based simulation training in VH, and such structured, model-based simulations can identify and address gaps in resident knowledge of surgical anatomy of this important operation.

Multiparous Ewe as a Model for Teaching Vaginal Hysterectomy Techniques.

BACKGROUND: Despite being linked to improving patient outcomes and limiting costs, the use of vaginal hysterectomy is on the wane. Although a combination of reasons might explain this trend, one cause is a lack of practical training. An appropriate teaching model must therefore be devised. Currently, only low-fidelity simulators exist. Ewes provide an appropriate model for pelvic anatomy and are well-suited for testing vaginal mesh properties. This article sets out a vaginal hysterectomy procedure for use as an education and training model. METHOD: A multiparous ewe was the model. Surgery was performed under general anesthesia. The ewe was in a lithotomy position resembling that assumed by women on the operating table. EXPERIENCE: Two vaginal hysterectomies were performed on two ewes, following every step precisely as if the model were human. Each surgical step of vaginal hysterectomy performed on the ewe and on a woman were compared side by side. We identified that all surgical steps were particularly similar. The main limitations of this model are costs ($500/procedure), logistic problems (housing large animals), and public opposition to animal training models. CONCLUSION: The ewe appears to be an appropriate model for teaching and training of vaginal hysterectomy.

Feasibility of Vaginal Hysterectomy for Female-to-Male Transgender Men.

OBJECTIVE: To describe the hysterectomy data among a cohort of transgender men and nontransgender (ie, cisgender) women with a particular goal to evaluate the feasibility of vaginal hysterectomy among transgender men. METHODS: This cohort study includes all hysterectomies performed for benign indications on transgender men and cisgender women at a single academic county hospital from 2000 to 2012. Hysterectomy cases and patient gender were identified by billing records and confirmed by review of medical records. Primary study outcome was the hysterectomy route among transgender men compared with cisgender women. We also examined risk factors and operative outcomes. Student two-sided t tests, χ analysis, and descriptive statistics are presented; sensitivity analyses using regression techniques were performed. RESULTS: Hysterectomies for benign gynecologic procedures were performed in 883 people: 33 on transgender men and 850 on cisgender women. Transgender men were younger, had fewer pregnancies and deliveries, and smaller uteri. The leading indication for hysterectomy differed significantly: pain (85%) was most common among transgender men (compared with 22% in cisgender women; P<.001), whereas leiomyomas (64%) was most common for cisgender women (compared with 21% in transgender men; P<.001). Vaginal hysterectomies were performed in 24% transgender men and 42% of cisgender women. Estimated blood loss was less among transgender men (P=.002), but when uterine size and route of hysterectomy were considered, the difference between gender groups was no longer significant. There was no difference in patients experiencing complications between the groups. CONCLUSION: Transgender men and cisgender women have different preoperative characteristics and surgical indications. Vaginal hysterectomies have been successfully completed among transgender men. Because vaginal hysterectomy is a viable procedure for this population, it should be considered in surgical planning for transgender men.

Impact of robotic technology on hysterectomy route and associated implications for resident education.

OBJECTIVE: We sought to compare the proportion of benign hysterectomies performed vaginally and the mean number of hysterectomies with resident involvement by route before and after robot implementation. STUDY DESIGN: This multicenter, retrospective cohort study using nonsynchronous controls was conducted through the Society of Gynecologic Surgeons Fellows' Pelvic Research Network. The route of hysterectomy for benign disease was compared for 1-year periods before (prerobot) and after (postrobot) robotic introduction at 4 academic institutions. We reviewed medical records and recorded patient demographics, hysterectomy approach, preoperative and postoperative diagnosis, and resident involvement. RESULTS: In all, 1440 hysterectomies were included: 732 in the prerobot group and 708 in the postrobot group. Median age was 46 years and mean body mass index was 29.5 (standard deviation, 6.9). The proportion of hysterectomies performed via the vaginal route decreased from 42.5% prerobot to 30.5% postrobot (P < .0001) and via the abdominal route from 22.1% prerobot to 16.5% postrobot (P = .001). The proportion of hysterectomies performed laparoscopically increased from 1.6% prerobot to 11.9% postrobot (P < .0001). At a mean of 2.3 years after introduction of the robot into an institution, hysterectomies performed using robotic assistance accounted for 23.3% of hysterectomies for benign disease. Mean uterine weight was similar in the prerobot and postrobot groups. Resident involvement in all hysterectomies done via all routes other than robotic increased from 81.0% prerobot to 88.6% postrobot; however, residents were involved in only 58.9% of robotic hysterectomies. CONCLUSION: The proportion of hysterectomies performed vaginally has significantly decreased since the adoption of robotic technology at institutions included in this study. The proportion of hysterectomies with resident involvement is lower with a robotic approach than any other route.

Considerations to improve the evidence-based use of vaginal hysterectomy in benign gynecology.

Vaginal hysterectomy fulfills the evidence-based requirements as the preferred route of hysterectomy for benign gynecologic disease. Despite proven safety and effectiveness, the vaginal approach for hysterectomy has been and remains underused in surgical practice. Factors associated with underuse of vaginal hysterectomy include challenges during residency training, decreasing case numbers among practicing gynecologists, and lack of awareness of evidence supporting vaginal hysterectomy. Strategies to improve resident training and promote collaboration and referral among practicing physicians and increasing awareness of evidence supporting vaginal hysterectomy can improve the primary use of this hysterectomy approach.

The fellowship effect: how the establishment of a fellowship in female pelvic medicine and reconstructive surgery affected resident vaginal hysterectomy training.

OBJECTIVE: We report on trends in resident-performed vaginal hysterectomies before and after the establishment of a female pelvic medicine and reconstructive surgery fellowship at Vanderbilt University Medical Center. STUDY DESIGN: We examined medical records and resident self-reports concerning all hysterectomies at our institution in an 8-year period: 4 years before fellowship and 4 years after. Route of hysterectomy, resident and fellow involvement, and division of attending surgeon were recorded from the electronic medical record. Resident Accreditation Council for Graduate Medical Education (ACGME) case log data were used to estimate the number of hysterectomies where residents reported themselves as the primary surgeon. RESULTS: During the 8-year period of this study, 3317 hysterectomies were performed at our institution, 41% (1371) before and 59% (1946) after fellowship. Prior to fellowship, 29% (393) were vaginal, 56% (766) were abdominal, and 15% (212) were laparoscopic/robotic. After addition of fellowship, 23% (449) were vaginal, 31% (597) were abdominal, and 46% (900) were laparoscopic/robotic. Of the total vaginal hysterectomies (TVH), there was resident involvement in 98.0% (385) cases before fellowship and 98.2% (441) cases after fellowship. From the ACGME case log data, the resident identified himself/herself as the primary surgeon in 388 cases before and 393 cases after fellowship. During this time period, medical records indicate a fellow was involved in 42% (189) of TVH, with resident involvement in all but 5 of these procedures. CONCLUSION: Frequency of resident involvement in TVH cases, either as primary surgeon or team member, remained constant after the addition of the female pelvic medicine and reconstructive surgery fellowship.

Trends in reported resident surgical experience in hysterectomy.

STUDY OBJECTIVE: To compare differences in trends in reported surgical experience of residents in obstetrics and gynecology in the United States insofar as abdominal, vaginal, and laparoscopic hysterectomy. DESIGN: Retrospective analysis of the national case log reports from the Accreditation Council for Graduate Medical Education (ACGME) for obstetrics and gynecology cases logged as "surgeon" from 2002 to 2012 (Canadian Task Force classification III). SETTING: AGCME-accredited residency programs in obstetrics and gynecology. PARTICIPANTS: Eleven thousand five hundred and eight graduating residents in obstetrics and gynecology (n = 11 508). MEASUREMENTS AND MAIN RESULTS: Since 2008, when the ACGME began reporting the 4-year cumulative hysterectomy case load statistics for graduating residents in obstetrics and gynecology, there has been no significant change in the mean (SD) number of hysterectomies performed by residents from 118.1 (38.0) cases in 2008-2009 to 116.1 (31.0) cases in 2011-2012 (p = .16; 95% confidence interval [CI], -0.78 to 4.78). During the past decade, however, the total number of reported abdominal hysterectomies consistently decreased from 89.1 (34.2) cases in 2002-2003 to 59.1 (21.0) cases in 2011-2012 (28% decrease; p <.001; 95% CI, 27.7-32.3). The number of vaginal hysterectomies also trended down from 34.9 (19.2) cases to 19.4 (9.0) cases (40% decrease; p <.001; 95% CI, 14.3-16.7). The ACGME did not report the number of laparoscopic hysterectomies performed by residents until 2008-2009, when residents reported performing 23.4 (17.0) cases. From 2008 to 2012, this number increased to 38.5 (20.0) cases (72% increase; p <.001; 95% CI, 13.6-16.6). The proportion of reported laparoscopic hysterectomies performed with robotic assistance was not separately reported. CONCLUSIONS: Although the overall number of hysterectomies reported by residents has remained stable since 2008, the predominant modes of hysterectomy during the past decade have changed substantially, with laparoscopic hysterectomy comprising an increasingly large proportion of resident experience. As laparoscopic hysterectomy has become more common, reported cases of abdominal and vaginal hysterectomies have decreased. Additional statistics on the percentage of laparoscopic hysterectomies performed using robotic assistance would be valuable to additionally analyze the effect of this new technology on resident training.

Development and validation of simulation training for vaginal hysterectomy.

STUDY OBJECTIVE: To develop and validate an educational intervention based on vaginal hysterectomy (VH) simulation. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: Surgical skills simulation center. PATIENTS: Thirty residents in Obstetrics and Gynecology (11 PGY-2, 11 PGY-3, and 8 PGY-4). INTERVENTION: VH educational intervention that included a lecture, a video, and surgical skill simulation using a new inexpensive model. MEASUREMENTS AND MAIN RESULTS: The primary outcome was written test scores before and after the educational intervention, and the secondary outcome was self-rated confidence in performing VH. Baseline written scores were similar for all 3 training levels; however, baseline confidence scores were higher for PGY-3 and PGY-4 residents than for PGY-2 residents (p < .01). After the workshop, written test scores improved significantly for all trainees (median [range] improvement, 4 [3.5-5.0] points; p < .01). Mean (SD) improvement in confidence scores for PGY-4, PGY-3, and PGY-2 residents was 0 (0.5), 0.5 (0.8), and 1 (1.3), respectively, with improvement in confidence scores reaching significance only for PGY-2 residents (p < .02). All trainees expressed high satisfaction with the workshop. CONCLUSION: An educational intervention based on VH simulation is feasible and improves knowledge and confidence in junior residents with limited exposure to VH.