Gynecologic endoscopy skills training and assessment: review

The role of simulation and warm-up in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

The purpose of the review is to update the reader on the current literature and recent studies evaluating the role of simulation and warm-up as part of surgical education and training, and maintenance of surgical skills.

RECENT FINDINGS

Laparoscopic and hysteroscopic simulation may improve psychomotor skills, particularly for early-stage learners. However, data are mixed as to whether simulation education is directly transferable to surgical skill. Data are insufficient to determine if simulation can improve clinical outcomes. Similarly, performance of surgical warm-up exercises can improve performance of novice and expert surgeons in a simulated environment, but the extent to which this is transferable to intraoperative performance is unknown. Surgical coaching, however, can facilitate improvements in performance that are directly reflected in operative outcomes.

SUMMARY

Simulation-based curricula may be a useful adjunct to residency training, whereas warm-up and surgical coaching may allow for maintenance of skill throughout a surgeon's career. These experiences may represent a strategy for maintaining quality and value in a lower volume surgical setting.

Standardizing hysteroscopy teaching: development of a curriculum using the Delphi method

BACKGROUND

Hysteroscopy is performed often and in many indications but is challenging to learn. Hands-on training in live patients faces ethical, legal, and economic obstacles. Virtual reality simulation may hold promise as a hysteroscopy training tool. No validated curriculum specific in hysteroscopy exists. The aim of this study was to develop a hysteroscopy curriculum, using the Delphi method to identify skill requirements.

METHODS

Based on a literature review using the key words "curriculum," "simulation," and "hysteroscopy," we identified five technical and non-technical areas in which skills were required. Twenty hysteroscopy experts from different French hospital departments participated in Delphi rounds to select items in these five areas. The rounds were to be continued until 80-100% agreement was obtained for at least 60% of items. A curriculum was built based on the selected items and was evaluated in residents.

RESULTS

From November 2014 to April 2015, 18 of 20 invited experts participated in three Delphi rounds. Of the 51 items selected during the first round, only 25 (49%) had 80-100% agreement during the second round, and a third round was therefore conducted. During this last round, 80-100% agreement was achieved for 31 (61%) items, which were used to create the curriculum. All 14 residents tested felt that a simulator training session was acceptable and helped them to improve their skills.

CONCLUSIONS

We describe a simulation-based hysteroscopy curriculum focusing on skill requirements identified by a Delphi procedure. Its development allows standardization of training programs offered to residents.

Training and Assessment of Hysteroscopic Skills: A Systematic Review

OBJECTIVE

The aim of this systematic review was to identify studies on hysteroscopic training and assessment.

DESIGN

PubMed, Excerpta Medica, the Cochrane Library, and Web of Science were searched in January 2015. Manual screening of references and citation tracking were also performed. Studies on hysteroscopic educational interventions were selected without restrictions on study design, populations, language, or publication year. A qualitative data synthesis including the setting, study participants, training model, training characteristics, hysteroscopic skills, assessment parameters, and study outcomes was performed by 2 authors working independently. Effect sizes were calculated when possible. Overall, 2 raters independently evaluated sources of validity evidence supporting the outcomes of the hysteroscopy assessment tools.

RESULTS

A total of 25 studies on hysteroscopy training were identified, of which 23 were performed in simulated settings. Overall, 10 studies used virtual-reality simulators and reported effect sizes for technical skills ranging from 0.31 to 2.65; 12 used inanimate models and reported effect sizes for technical skills ranging from 0.35 to 3.19. One study involved live animal models; 2 studies were performed in clinical settings. The validity evidence supporting the assessment tools used was low. Consensus between the 2 raters on the reported validity evidence was high (94%).

CONCLUSIONS

This systematic review demonstrated large variations in the effect of different tools for hysteroscopy training. The validity evidence supporting the assessment of hysteroscopic skills was limited.

Assessment of Developmental Progress Using an Objective Structured Clinical Examination-Simulation Hybrid Examination for Obstetrics and Gynecology Residents

OBJECTIVE

The Test of Integrated Professional Skills (TIPS) is an objective structured clinical examination-simulation hybrid examination that assesses resident integration of technical, cognitive, and affective skills in Obstetrics and Gynecology (OBGYN) residents. The aim of this study was to analyze performance patterns and reactions of residents to the test to understand how it may fit within a comprehensive assessment program.

DESIGN

A retrospective, mixed methods review of the design and implementation of the examination, patterns of performance of trainees at different levels of training, focus group data, and description of use of TIPS results for resident remediation and curriculum development.

SETTING

OBGYN residents at New York University Langone Medical Center, a tertiary-care, urban academic health center.

PARTICIPANTS

OBGYN residents in all years of training, postgraduate year-1 through postgraduate year, all residents completing the TIPS examination and consenting to participate in focus groups were included.

RESULTS

In all, 24 residents completed the TIPS examination. Performance on the examination varied widely among individuals at each stage of training, and did not follow developmental trends, except for technical skills. Cronbach α for both standardized patient and faculty ratings ranged from 0.69 to 0.84, suggesting internal consistency. Focus group results indicated that residents respond to the TIPS examination in complex ways, ranging from anxiety about performance to mixed feelings about how to use the data for their learning.

CONCLUSION

TIPS assesses a range of attributes, and can support both formative and summative evaluation. Lack of clear developmental differences and wide variation in performance by learners at the same level of training support the argument for individualized learning plans and competency-based education.

Cerebrospinal fluid reconstitution via a perfusion-based cadaveric model: feasibility study demonstrating surgical simulation of neuroendoscopic procedures

Cadaveric surgical simulation carries the advantage of realistic anatomy and haptic feedback but has been historically difficult to model for intraventricular approaches given the need for active flow of CSF. This feasibility study was designed to simulate intraventricular neuroendoscopic approaches and techniques by reconstituting natural CSF flow in a cadaveric model. In 10 fresh human cadavers, a simple cervical laminectomy and dural opening were made, and a 12-gauge arterial catheter was introduced. Saline was continuously perfused at physiological CSF pressures to reconstitute the subarachnoid space and ventricles. A neuroendoscope was subsequently inserted via a standard right frontal bur hole. In 8 of the 10 cadavers, adequate reconstitution and endoscopic access of the lateral and third ventricles were achieved. In 2 cadavers, ventricular access was not feasible, perhaps because of a small ventricle size and/or deteriorated tissue quality. In all 8 cadavers with successful CSF flow reconstitution and endoscopic access, identifying the foramen of Monro was possible, as was performing septum pellucidotomy and endoscopic third ventriculostomy. Furthermore, navigation of the cerebral aqueduct, fourth ventricle, prepontine cistern, and suprasellar cistern via the lamina terminalis was possible, providing a complementary educational paradigm for resident education that cannot typically be performed in live surgery. Surgical simulation plays a critical and increasingly prominent role in surgical education, particularly for techniques with steep learning curves including intraventricular neuroendoscopic procedures. This novel model provides feasible and realistic surgical simulation of neuroendoscopic intraventricular procedures and approaches.