The Residency Buddy System\': A Better Way to Encourage Laparoscopy Simulation Training?
Purpose: To determine if a “buddy-system” compared to independent
training increases laparoscopic simulation time amongst residents.
Background: Based on prior research, laparoscopic box-trainers
improve proficiency on surgical skills, however voluntary simulation time by
residents is traditionally low. We propose that a buddy system approach to
simulation will increase laparoscopic training time, and further improve
Methods: Thirty-two residents at a single obstetric and
gynecology residency program were consented for the study. Each
buddy pair was composed of a junior and senior resident. During the first half
of the 20-week study, 12 residents were randomly assigned a buddy while 20
remained solo. During the second half, solo-trainers were assigned
buddies and conversely buddies were made solo. Residents recorded check-in and -out
times electronically. (Assignments were provided via email at the beginning and
mid-way points; no other contact was made.) At the conclusion of the study
period a survey link was distributed.
Results: Six of the 32 residents (18.8%) attended simulation in
the 20-weeks, with an average time of 2 hours 14 minutes. In the solo-trainer
group, 1 resident checked in 3 times and 2 residents once. In the buddy group,
1 pair checked in together and 1 person checked in alone. Fifteen
residents (46.9%) completed the survey. Thirteen (86.7%) agreed they
accurately reported times; 1 was neutral and 1 never attended. All communicated
with their buddy monthly or less frequently, while 10 of them never
Discussions: Residents’ laparoscopic simulation time was dismal at our
program in this study. Dedicated mandatory simulation time may increase
CREOG & APGO Annual Meeting, 2019, Faculty, Residency Director, Medical Knowledge, CME, Independent Study, Minimally Invasive Surgery,
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Successful Implementation of an OB/GYN Resident FLS Training Curriculum
Purpose: To describe the implementation of an ob/gyn resident
Fundamentals of Laparoscopic Surgery (FLS) training curriculum
Background: Beginning in May 2020, all ob/gyn graduating residents
will be required to successfully complete the FLS program as a prerequisite for
specialty board certification.
Methods: Between January 2017 – April 2018, 36 ob/gyn residents
participated in the BCM FLS curriculum. The curriculum consisted of six
3-hour faculty supervised gynecologic simulation sessions, 24/7 individual
access to the simulation lab, proctored voluntary one-on-one sessions, and a
final mock FLS session. Participants were followed with attendance
sign-in sheets to gauge number and time involved in all sessions.
Residents completed evaluation forms after each simulation session.
Descriptive statistics were utilized to determine the average/range of
the number and time involved in the practices sessions, between PGY levels and
FLS pass rates.
Results: All 36 ob/gyn residents successfully completed FLS
certification on the first attempt. In addition to the mandatory
sessions, residents required an average of 8.64 independent practice sessions
(range 3-22) lasting an average 72 minutes/session. Approximately 688
minutes (range 235 – 1357 minutes) of independent practice were required to
pass the FLS exam. Many residents felt that the curriculum gave them
adequate support to succeed on the exam and stated that one of the most
valuable components of the curriculum were proctored teaching
Discussions: With a dedicated curriculum and proctored teaching, residents
in obstetrics and gynecology can successfully pass the FLS certification exam
with their initial test.
CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Residency Coordinator, Medical Knowledge, GME, Simulation, Minimally Invasive Surgery,
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Management of Postoperative Issues in Gynecology and Gynecologic Oncology: A New Method for Teaching Residents
Purpose: This project sought to develop and assess a curriculum to
improve resident knowledge of and comfort in managing common post operative
Background: Junior obstetrics/gynecology residents enter training
with varied experience in post-operative management. They are often the first
contact for surgical patients with little formal education on post-operative
Methods: Eleven common post-operative issues were identified
based on literature review, resident experience and gynecology/gynecologic
oncology faculty input. Topic based curriculum included: example case,
pathophysiology, differential diagnosis, next steps, and useful resources. It
was presented at two educational sessions, involving lectures and small-group
simulations. Residents completed a pre and post-assessment questionnaire
assessing comfort level in managing (10-point Likert scale) and baseline
knowledge about (content-specific questions) the topics.
Results: Twenty-three residents participated.Seventeen
completed one or both pre-assessment surveys (nine junior residents). Ten
completed one or both post-assessment surveys (five junior residents). All
post-assessment respondents reported improved knowledge of issues covered.
Average self-rated comfort level increased for ten of eleven topics amongst
junior residents (average increase 1.6 points (range 0.5 – 3.2; p = 0.02)).
Largest increase in score was for hypoxia and low urine output. Average scores
maintained or improved for 80% of the content questions (not significant).
Residents had no preference for lecture versus small group format.
Discussions: As a result of directed teaching, resident knowledge of
post-operative issues showed measurable improvement. Resident comfort level in
management increased significantly for 90% of topics covered, most noticeably
amongst junior residents. A systematic, resident-led curriculum on
post-operative management can improve resident knowledge and patient care.
CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Patient Care, Medical Knowledge, GME, Simulation, Lecture, Problem-Based Learning, Team-Based Learning, Gynecologic Oncology, Minimally Invasive Surgery, Female Pelvic Medicine & Reconstructive Surgery, General Ob-Gyn,
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Implementation of Laparoscopic Simulation Curriculum in Obstetrics and Gynecology Residency: A Pilot Study
Purpose: A pilot study to
implement a laparoscopic curriculum for our residency program.
studies have shown the effectiveness of laparoscopic simulators in training
residents technical skills needed to gain proficiency in the operating room.
Unfortunately, many programs struggle to incorporate this routinely in their
approval was obtained. A survey was sent to different residency programs to
assess other implemented laparoscopic curriculums. UF OB/GYN residents were
enrolled in the curriculum (N=11), which included a pre/post-curriculum survey
and baseline FLS scores. A cost-effective, portable laparoscopic trainer was
designed and given to each resident. They were required to record 10-minute
videos weekly for evaluation and individual feedback were given through text
showed that on average, there was a slight improvement in perceived proficiency
by the residents after implementation of the curriculum. There is improvement
in average time to completion of all three tasks, but it was not statistically
significant. Initially, 3 out of 11 residents could perform intracorporeal
knot-tying; all 11 residents could complete this task after the curriculum
(p=0.0019). Secondary outcomes showed that individual practice outside of
the mandatory practice is positively correlated with improvement in 2 out of 3
Discussions: This is a good stepping
stone to help our program develop a laparoscopic curriculum especially with the
new ABOG requirement of passing the FLS exam prior to taking the written board
exam. Mandatory deliberate practice ensured that residents practiced
laparoscopic skills weekly. This was made even more accessible by giving
residents a home laparoscopic trainer.
CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Residency Director, Practice-Based Learning & Improvement, GME, Simulation, Minimally Invasive Surgery,
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Fundamentals of Gynecologic & Minimally Invasive Surgery for the Fourth Year Medical Student
Purpose: Development of a
four-week elective rotation in minimally invasive gynecology designed for
fourth year medical students to meet the gynecology knowledge and skill
milestone objectives for students entering an obstetrics and gynecology
curriculum is modeled on the milestone-based approach implemented by the
Council on Resident Education in Obstetrics and Gynecology. Proficient
psychomotor skills are developed, allowing a more prepared learner in the
students follow a four-week structured curriculum. The time is divided equally
between clinical observation, skills training, and independent study.
Proficient knowledge of pelvic anatomy, surgical instrumentation, surgical
energy, and dissection are obtained. The student completes a skills training
program with two hours of dedicated practice time per day, gaining proficiency
in laparoscopic tissue manipulation and laparoscopic suturing. Clinical
activities include observation in the operating room and outpatient gynecology
clinics. Weekly written and oral testing and mentor feedback of surgical skill
progression is emphasized.
course has been well received at the two institutions it was implemented at
over the last four years. Learners have felt prepared to assist and participate
in laparoscopic surgeries upon entering their residency program.
Discussions: Implementation of
skills curriculum is paramount given the new American Board of Obstetrics and
Gynecology requirement of Fundamentals of Laparoscopic Surgery certification.
This course allows the learner to enter residency proficient in laparoscopic
psychomotor skills and having a fundamental base of knowledge for gynecology
and minimally invasive procedures. Future collection of subjective and
objective evaluation data could validate the further development of similar
CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Patient Care, Medical Knowledge, Professionalism, GME, Assessment, Simulation, Problem-Based Learning, Minimally Invasive Surgery,
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A Short Laparoscopic Drill That Improves Vaginal Cuff Closure at Different Institutions
Purpose: Evaluate whether a
laparoscopic simulation drill improves performance on a validated vaginal cuff
number of laparoscopic training materials available to teach gynecologic
procedures is increasing; however, there is a lack of evidence showing that
these methods result in improved surgical skills among obstetrics and
gynecology (OB-Gyn) trainees.
trainees at two academic institutions participated in laparoscopic
teaching (15 minutes per trainee) using the \"eyelet\"
simulation drill with a defined proficiency metric developed and
conducted by a fellowship trained minimally invasive gynecologic surgeon.
Pre- and post-teaching suturing tasks were recorded and scored blindly by the
same physician using a validated vaginal cuff model and the Global
Operative Assessment of Laparoscopic Skills (GOALS). Pre- and post-teaching
surveys were administered to assess laparoscopic experience, Fundamentals
of Laparoscopic Surgery (FLS) exposure, and opinions about the teaching.
Results: Among 25
participants, vaginal cuff suturing scores increased from a baseline median
score of 5 (interquartile range [IQR] 2-5) to 7 (IQR 5-8) after teaching
(p<0.001) with 92% of participants agreeing or strongly agreeing the
simulation teaching was helpful for learning laparoscopic skills. The majority
preferred the eyelet drill to FLS and felt the eyelet drill, rather than FLS,
should be used for training and assessment.
Discussions: Simulation teaching was
associated with improved vaginal cuff suturing performance. Short standardized
drills, like the eyelet drill, should be evaluated in a larger sample with the
ultimate goal of standardizing the Ob-Gyn laparoscopic training curriculum.
CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Practice-Based Learning & Improvement, GME, CME, Simulation, Minimally Invasive Surgery,
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Video Curriculum for Gynecologic Surgery
evaluate the efficacy of a surgical video curriculum versus standard learning
throughout the rotation.
Background: With decreasing surgical volume, training time restrictions, and more
routes to approach individual cases, efficient and effective tools for surgical
learning are essential. We developed
several videos teaching pelvic anatomy and steps of common gynecologic
Methods: The video curriculum was presented to alternating groups of students
completing their OBGYN clinical rotation compared with standard rotation
exposure. Participants knowledge of relevant anatomy and surgical steps was
assessed at baseline, the rotation end, and immediately after exposure in the
video group. Mean score assessment scores, overall impressions, and learning
preferences were evaluated.
Results: All 42 participants had similar training, case exposure, and baseline
scores. At the end of the rotation, the
mean rotation-end scores were 34% and 46% for control and video groups
(p=0.005), and the difference remained significant when corrected for baseline
score (p=0.012). The mean post-test score rose to 49% compared to a baseline
mean of 25% (p<0.001). Seventy-four percent of participants preferred video
over text, 86% reported the series was a useful educational tool, 90% would use
the videos for case preparation, and 55% felt more engaged during surgery.
Discussions: The video
series improved students’ performance on assessment of anatomy and surgical
steps. Overall impressions of the video series were positive and most students
reported they preferred video to text format.
Moving forward, videos like these can be used and examined as adjunctive
tools for acquisition of specific surgical knowledge and skills.
CREOG & APGO Annual Meeting, 2018, Student, Resident, Faculty, Clerkship Director, Medical Knowledge, GME, UME, Independent Study, Minimally Invasive Surgery,
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There Is an APP for That: Vaginal Hysterectomy
create an instructional app which includes medical knowledge, procedural steps
and assessments based on the ACOG curriculum for vaginal hysterectomy.
Background: Vaginal hysterectomy is the evidence based medicine route of choice when
feasible. Significant challenges exist
in teaching this procedure due to lack of simulation training, proper
assessment of specific techniques and timely instruction prior to performing
the procedure. There is also
considerable variation in how cases are tracked and assessments of technique
Methods: Key features/contents of the application include: 1) ACOG curriculum for vaginal hysterectomy,
2) a complete step by step live and simulated surgical video tutorial, 3) a
procedural step by step assessment (10 steps-- 0-10 score), 4) a global
surgical rating scale (7 metrics), and 5) a knowledge based assessment (4
metrics, 0-4 scale).
Results: The data captured on the app can be accessed via IPAD and iPhone mobile
devices and is verified by Apple. The
evaluations can be directly emailed to any database.
comprehensive instructional surgery app coupled with real time assessment will
provide greater learning efficiency and will more effectively improve surgical
skills. This app has the potential to
standardize surgical evaluation in the operating room and provide a more
efficient method to track surgeon competency using ACOG guidelines. The assessment is currently employed by the
ACOG Simulation Consortium Working group during vaginal hysterectomy simulation
and is part of a surgical simulation course which certified by the ABOG for MOC
CREOG & APGO Annual Meeting, 2018, Resident, Faculty, Clerkship Director, Osteopathic Faculty, Residency Director, Residency Coordinator, Medical Knowledge, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Assessment, Simulation, Lecture, Minimally Invasive Surgery,
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Teaching Cystotomy Repair: Low Fidelity Model Provides Effective Simulation at Minimal Cost
develop an inexpensive bladder model that can be used to teach Ob-Gyn Residents
open and laparoscopic cystotomy repair.
Background: Recognition of cystotomy and repair is a requirement of Ob-Gyn surgical
milestones. Simulation products currently exist for cystoscopy but not for
Methods: Pilot study of a novel low fidelity bladder model that can be used for
simulation of both open and laparoscopic cystotomy repair. A cystotomy model
was created using the following materials: small whoopee cushion “bladder
mucosa”, shelf liner “bladder muscularis” and Press\'n Seal® for “serosa”. Markings were placed inside the cushion to
represent the trigone with ureteral orifices. Residents were asked to identify
the model’s anatomic landmarks and rate their confidence in identifying
cystotomy and performing both and open and laparoscopic cystotomy repair, pre-
Results: 16 bladder models were constructed for approximately $1.50 per model. The
model is reusable and manipulated well with surgical instruments and suture
both open and laparoscopically; the model was a bit large for the laparoscopic
trainer and lighting became a challenge for suturing. All participating
residents correctly identified the anatomic structures post-simulation compared
to 12/13 pre-simulation. Change in mean resident
confidence was statistically significant for identifying cystotomy (pre M=3.1/5
vs post M=4.2/5, p=0.009) and performing open cystotomy repair (pre M=2.4/5 vs
post M=4/5, p= 0.03) but not for laparoscopic repair (pre M=1.6/5 vs post M
bladder model is easily constructed and inexpensive. It performs well for open
cystotomy repair but has been decreased in size to better perform
CREOG & APGO Annual Meeting, 2018, Resident, Faculty, Residency Director, Medical Knowledge, Practice-Based Learning & Improvement, GME, Simulation, Minimally Invasive Surgery, General Ob-Gyn,
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Effect of Instituting a Laparoscopic Curriculum on Laparoscopic Knowledge for OBGYN Residents
Background: Numerous obstacles exist for learning the principles
and technical skills necessary for minimally invasive operations. This
challenges the traditional teaching model solely in the operating room. Also,
well preparing the residents prior to entering the operating room should
improve surgical time, skills, and patient safety.
Methods: A prospective interventional study, performed at an
academic affiliated community hospital. We administered a pre-intervention test
to 20 OBGYN residents (10 junior and 10 senior). The questions pertained to
fundamental principles of laparoscopy including patient positioning and related
nerve injuries, electrosurgery, laparoscopic equipment, physiological
considerations, and laparoscopic complications. After the course of the
academic year, all the residents were administered a post-intervention exam.
Test scores were compared, averages calculated, and t-test applied.
Results: In the first stage, the average pretest score for
junior residents was 35%, and for seniors was 42.14%. Nonetheless, the average
posttest score for junior residents was 75.71%, and for seniors was 48,70%.
This means the junior residents group improved 40,71%, while the senior
residents improved 6,42%. T-test was applied, and showed statiscally
significant difference (t-value=5.20; p=0.00003).
Discussions: Introducing a laparoscopic curriculum to a residency
program has a significant impact on improving resident knowledge of the
fundamental principles of laparoscopy, more so than the traditional method.
Future studies are underway to evaluate the effect of a structured simulation
course on resident operating room performance.
Keywords: laparoscopy, residency, curriculum
CREOG & APGO Annual Meeting, 2016, Resident, Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Practice-Based Learning & Improvement, GME, CME, Quality & Safety, Problem-Based Learning, Faculty Development, Minimally Invasive Surgery, General Ob-Gyn,
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Laparoscopic and Robotic Skills Are Transferable in a Simulation Setting: a Randomized Controlled Trial
Background: Residents are increasingly being trained on robotic
techniques instead of traditional laparoscopy. Although simulation training
does provide an effective supplement for traditional surgical training, less is
known if skills are transferable between the laparoscopic and robotic
Methods: In a randomized single-blinded controlled trial of 40
simulation-skill-naïve medical students, participants completed a baseline
evaluation on a robotic pegboard-transfer task (Mimic dV-Trainer) and
laparoscopic peg-transfer task (Fundamentals of Laparoscopic Surgery). Skills
were evaluated using validated objective and subjective global rating scales
(GRS) by two blinded expert surgeons. Participants were randomized to practice
on either the robotic (N=20) or laparoscopic (N=20) task. After practice,
participants were reevaluated performing both tasks.
Results: At baseline, there were no significant differences in
objective measures (time to task completion, motion metrics) or composite GRS
scores on both tasks between the groups. Participants performed their
respective tasks faster (p < .001, p < .003), more efficiently (p <
.001) and with a higher percent improvement in composite GRS scores (p <
.001). The laparoscopic group improved their robotic performance with an
increase in mean composite GRS scores of 15 to 20 but this change did not reach
statistical significance (p=0.091). Participants who practiced robotically significantly
improved their laparoscopic performance with an increase in mean composite GRS
scores of 15 to 19 (p < 0.02).
Discussions: Skills learned on either the robotic or laparoscopic
platform appear to be transferable; however, robotic skills appear to be more
transferable to the laparoscopic platform, than vice versa.
Keywords: Surgical Simulation
CREOG & APGO Annual Meeting, 2016, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Residency Director, Residency Coordinator, Practice-Based Learning & Improvement, Simulation, Minimally Invasive Surgery,
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Does Visual Feedback and Interactive Learning Modules Improve Resident Learning of Colposcopy?
Background: There is no current literature available assessing the
different teaching modalities available for colposcopy. Given the movement
towards active learning in medical education, learning modules were designed to
capitalize on these methodologies and comparison to standard teaching methods
Methods: 1) Retrospective chart review of colposcopic
examinations performed by UTHSCSA residents. Colposcopic impression,
referral cytology and final histopathology were assessed. The level of
agreement between histology and colposcopic impression was reviewed, results
stratified by training level. 2) Baseline survey on resident confidence levels,
perceived level of knowledge and satisfaction with training conducted as well
as administration of the ASCCP Resident Assessment of Competency in Colposcopy
Examination(RACCE) was performed. The educational intervention (5 online
modules designed around adult learning pedagogy) was administered and the
survey and RACCE exam repeated after 6 months.
Results: Resident confidence levels, perceived level of
knowledge and satisfaction with trainingall improved following the educational
intervention. Scores on the objectiveonline examination demonstrated
improvement for each PGY level following theintervention, with the highest
increases in score seen at the PGY 1 and 2levels. Statistically significant
improvements were seen in medical knowledgeand management sections of the exam.
Discussions: Colposcopic teaching and learning is most influential
in early stages (PGY1) of residency. Visual feedback and novel interactive
teaching modalities improve resident confidence levels, knowledge and exam
Keywords: Colposcopy, resident education, innovative
Minimally Invasive Surgery, Assessment, GME, Medical Knowledge, Patient Care, Residency Director, Faculty, Resident, 2016, CREOG & APGO Annual Meeting,
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Do Skills Acquired with the Laparoscopic Box Trainer Translate to the Video Simulator?
Background: As the popularity of laparoscopic surgery increases in
gynecology, programs strive to effectively train residents to be proficient
laparoscopic surgeons. Few studies have assessed the effect box training vs VR
Methods: First and second year residents were scheduled to
undergo 8 box trainer sessions from July 2014 - June 2015 at Strong Memorial
Hospital. In July 2015, they were tested on the box trainer and VR simulator to
assess for changes in time to completion and proficiency of 4 FLS tasks: 1) Peg
transfer 2) Precision cutting 3) Intracorporeal knot tying and 4)
Extracorporeal knot tying (only for box trainer) as well as transferability of
skills between simulators.
Results: The average time taken to complete the various tasks
at the last training session compared to the first training sessions were -22%
(Task 1), -30% (Task 2), -19% (Task 3) and -6% (Task 4) and at the final
evaluation on the box trainer were -8% (Task 1), -11% (Task 2) +12% (Task 3)
and +42% (Task 4). The time difference between the box trainer and VR
simulator were -4% (Task 1), +2% (Task 2), and +53% (Task 4).
Discussions: No suturing tasks are translatable between the box
trainer and the VR simulator. With Box trainer, although the gain in
proficiency was maintained for 2 months with tasks 1 and 2, there is some loss
of this gain with tasks 3 and 4.
Keywords: Simulation training, Laparoscopy
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Do Faculty and Residents Agree on Obstetrics and Gynecology Surgical Training Needs?
Background: Surgical education is an essential, complex, component
of residency training. Resident and faculty needs are important in guiding the
educational agenda; studies demonstrate that these groups do not always agree
Methods: A 50-item needs assessment tool was administered during
scheduled meetings at our single academic center to capture resident and
faculty perceptions of the adequacy of our program’s surgical training; all
items were ranked on a 5-point agreement scale. Content domains included
feedback, surgical preparation, intra-operative performance, simulation, and
the Ob-Gyn Milestones procedures (we assessed satisfaction with training and
the perceived helpfulness of simulation to improve performance of those
Results: 12 surgical faculty (80%) and 13 residents (87%)
completed the needs assessment; t-tests compared resident/faculty group
differences. Both groups agreed on the adequacy of surgical content domains,
however, faculty consistently self-reported delivering feedback at a
significantly higher level than residents’ perceived receiving it (p <
0.05). Both groups were least satisfied with training in cystotomy
repair, breech vaginal delivery, and 3rd/4th-degree laceration repair. Both
rated simulation in breech vaginal delivery and vaginal hysterectomy as most
useful for improving performance. For all procedures, faculty consistently
rated at significantly higher levels, simulation’s usefulness to improve
Discussions: Although residents and faculty agree on areas needing
most improvement, differences exist in perception of feedback and usefulness of
simulation to improve performance.
Keywords: needs assessment, surgical training
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Comparing Performance on the Virtual Laparoscopic and Robotic Simulators Among Medical Students Pursuing Surgical versus Non-surgical Residencies
Background: Acceptance of medical school graduates into surgical
training programs is currently not based on tangible indicators of technical
skills, as these skills are not evaluated either before or during the selection
process.In this study, we sought to compare the learning curves on the virtual
laparoscopic and robotic trainers between medical students pursuing surgical
versus non-surgical residency specialties to determine if the technical skill
levels of surgical residency applicants exceeds those of non-surgical residency
Methods: The study enrolled 56 medical students with no prior
laparoscopic or robotic experience. The study population included 51.8%
male participants and 48.2% female participants ranging in age from 23-32.
Approximately 30% desired to pursue a surgical residency. All
participants performed five repetitions of two comparable tasks on each of the
trainers: a camera targeting task and a coordination task. Performance was
measured by time to complete each task.
Results: A paired t-test was used to confirm significant improvement
across the five trials on all four tasks on the laparoscopic and robotic
trainers in both the surgical and non-surgical groups. An independent
t-test revealed no significant difference in the improvement in performance
from trial 1 to trial 5 on the laparoscopic or robotic trainer between the
surgical and non-surgical groups.
Discussions: This study demonstrated that significant improvement
was observed over the five repetitions on all four tasks on the laparoscopic
and robotic trainers. There was no significant difference in improvement in
performance from trial 1 to trial 5 on either trainer between the two groups.
This data suggests that there is no self-selection of applicants for surgical
residency based on actual surgical skills. Furthermore, using technical skills
as selection criteria for surgical training may not better discriminate those
applicants with an aptitude for a surgical specialty.
Keywords: Simulators, Laparoscopy, Robotics
CREOG & APGO Annual Meeting, 2016, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Patient Care, Practice-Based Learning & Improvement, GME, CME, Simulation, Minimally Invasive Surgery,
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Skills Acquisition and Logistical Challenges Faced by Junior Year Obstetrics and Gynecology Residents Using the Box Trainer
Background: Box training has been shown to be an effective form of
laparoscopic skills training that is hands-on and cost-effective.
Methods: First and second year residents were enrolled in a laparoscopic
training curriculum consisting of a goal of 8 training sessions per resident
conducted between July 2014-June 2015. Each session was approximately 45
minutes long and focused on training to proficiency in 4 Fundamentals of
Laparoscopic Surgery (FLS) tasks: 1) Peg transfer 2) Precision cutting 3)
Extracorporeal knot tying and 4) Intracorporeal knot tying. Total number of
sessions completed and time to completion of all tasks were recorded throughout
the year for each resident.
Results: 100% of residents completed 4 sessions, 87.5%
completed 6 and 37.5% completed 8 sessions. Preliminary data shows that with a
minimum of 4 training sessions, there was an average 14% reduction in time for
Task 1, 27% for Task 2, 37% for Task 3 and 45% seconds per training for Task 4.
Discussions: Only 37.5% of residents were able to achieve the goal
of 8 sessions. The reasons for this low completion rate included difficulty in
identifying appropriate training times and urgent clinical duties. Increased
session completion was correlated with higher likelihood of attaining
proficiency with tasks 3 and 4, compared to 1 and 2.
Keywords: Simulation, laparoscopy, teaching
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Retention of Laparoscopic and Robotic Skills Twelve Weeks After Simulation Training
Background: Although minimally invasive simulation modeling
provides a supplement for traditional surgical training, there is less
objective data on longer-term skills retention.
Methods: We present the second stage of a randomized
single-blinded controlled trial in which 40 simulation-naïve medical students
were randomly assigned to practice pegboard transfer tasks on either
laparoscopic (N=20, Fundamentals of Laparoscopic Surgery, VT Medical Inc.,
Waltham, MA) or robotic (N=20, dV -Trainer, Mimic, Seattle, WA) platforms. In
the first stage, two expert surgeons evaluated participants on both tasks
immediately after training using previously validated global rating scales of
laparoscopic operative performance. In the second stage, participants were
evaluated on both tasks 12 weeks after training.
Results: Of the 40 participants who participated in the initial
training phase, 23 (11 laparoscopic and 12 robotic) underwent repeat
evaluation. Twelve weeks after training, there were no significant differences
between groups in objective measures or global rating scale composite scores
for the laparoscopic task. However, the robotic practice group demonstrated
significantly higher global rating scale composite scores on the robotic
simulation task (11.8 vs. 9.4, p=.04). Robotic training was associated with
improved economy of motion (p=.017) and fewer ring drops (p=.018) on the
Discussions: Robotic skills acquired through simulation appear to
be easier to maintain than laparoscopic skills gained via simulation.
Keywords: simulation, minimally invasive
CREOG & APGO Annual Meeting, 2016, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Medical Knowledge, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, UME, Simulation, Minimally Invasive Surgery,
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Outcomes of Robotic Hysterectomies Performed by Primary Resident Surgeons
Background: Although a number of reports delineate outcomes of
robotic-assisted gynecological surgery in both academic and non-academic
practices, none have delineated outcomes of robotic-assisted laparoscopic hysterectomy
(RALH) performed by resident surgeons in training.
Methods: All RALH performed at the University of Missouri
during the first two years of resident participation (2008-2010) following
introduction of the da Vinci robotic platform were reviewed. Surgical outcomes
were compared between primary resident and attending surgeons; between
residents at different post-graduate year levels; and between residents with
different amounts of experience as prior primary or assistant surgeon.
Patient characteristics of age, body mass index (BMI), and uterine size were
considered in comparisons.
Results: Of 252 RALH performed over a 25-month period, 159 had
available intraoperative data. Of these, 146 without concurrent planned
procedures were included in the analysis. Ninety-four (64%) of these cases were
performed by 13 resident primary surgeons supervised by attending surgeons, and
the remainder were performed by primary attending surgeons. The number of
cases that each resident performed as primary surgeon ranged from 2-13, with a
median of 7 cases. Using general linear models to control for patient
characteristics, we determined that higher post-graduate year level was not
associated with estimated blood loss, time under anesthesia or procedure time.
Post-graduate year level was not related to the occurrence of intraoperative
complications, postoperative complications or patient readmission. In
models controlling for patient characteristics, resident cases had lower
estimated blood loss (median 75 mL vs. 100 mL) than attending cases, possibly
reflecting less complex cases performed by resident surgeons. There was
no difference between resident and attending primary surgeons for time under
anesthesia or procedure time. Primary resident surgeon cases experienced more
intraoperative complications, but equal postoperative complication or
Discussions: RALH can be performed safely by supervised primary
resident surgeons, with blood loss and long-term complication rates comparable
to those reported elsewhere for independent credentialed surgeons. However,
resident primary surgeons experienced more intraoperative visceral injuries,
which were repaired at the time of the procedure.
Keywords: competence robotic surgery
Minimally Invasive Surgery, Faculty Development, Quality & Safety, GME, Systems-Based Practice & Improvement, Patient Care, Residency Director, Osteopathic Faculty, Faculty, Resident, 2016, CREOG & APGO Annual Meeting,
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Laparoscopic Vascular Injury Simulation for Gynecology Residents
Objective: To improve resident competence in managing laparoscopic vascular injuries via simulation.
Methods: Residents participated in a simulated laparoscopic procedure. A mannequin containing basic vascular anatomy allowed for bleeding to occur. Residents participated in the simulation, underwent a debriefing, attended a lecture on the management of vascular injury, and then repeated the simulation. Residents took a pre-test, an immediate post-test, and a late post-test two weeks later. The tests contained survey questions, knowledge-based questions, and a free-text portion to simulate dictation.
Results: Twelve residents participated. Two (17%) had ever been involved in a vascular injury. Two (17%) had ever received prior instruction on management of vascular injury. The paired t-test was used to analyze the data. Knowledge scores improved from 48% on the pre-test to 88% on the early post-test (p<0.001) and 74% on the late post-test (p=0.002). Qualitative dictation scores improved from 11% on the pretest to 43% on the early post-test (p=0.005) and 30% on the late post-test (p=0.009). Resident confidence improved from 4% on the pre-test to 42% on the early post-test (p<0.001) and 56% on the late post-test (p<0.001). 100% felt the simulation was either quite helpful or extremely helpful. 100% wanted it repeated annually.
Conclusion: Our residents rarely see laparoscopic vascular injuries or learn about their management. This simulation showed a meaningful, statistically significant, and durable improvement in resident knowledge, confidence, and dictation quality. It was widely accepted by the residents and unanimously chosen to be part of the annual curriculum.
CREOG & APGO Annual Meeting, 2015, Resident, Patient Care, GME, Simulation, Minimally Invasive Surgery,
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Development and Validation of a Laparoscopic Simulation Model for Suturing the Vaginal Cuff
Study Objective: Create a novel, cost efficient surgical simulation model for training laparoscopic suturing of the vaginal cuff and present evidence regarding its validity as a training and assessment tool.
Methods: Construct validity was determined by comparing the scores on the Global Operative Laparoscopic Assessment of Laparoscopic Skills (GOALS) scale between ‘expert’ and ‘trainee’ groups as graded by two masked expert viewers. Our analysis includes the previously validated 5-question GOALS score and an 8-question score including the GOALS scale plus three additional metrics. The Wilcoxon rank-sum test was used to compare differences in scale scores and operating times between the groups. The Contrasting Groups method was used to determine the minimum passing score.
Results: Over 90% of the participants ‘agreed’ or ‘strongly agreed’ that the model closely resembled live surgery. Advanced Novices (PGY5-PGY7) performed comparably to the Experts, with similar GOALS score (Advanced Novice 22 vs. Experts 22.5, p=0.562) and total score (36 vs. 37.5, p=0.424). In contrast, the Early Novices (PGY2-PGY4) had significantly lower GOALS score (Early Novices: 16 vs. Experts: 22.5, p<.001) and total score (27 vs. 37.5, p<.001). The passing 8-question total score was 32 (see Figure). 9 of 10 Expert attempts (90%) achieved the passing total score, equal to the success rate for Advanced Novice attempts (9/10=90%), versus only 7 of 30 Early Novice attempts (23.3%).
Conclusion: This novel surgical simulation model allows novice surgeons to practice techniques of laparoscopic suturing to achieve competence prior to performing live surgery.
CREOG & APGO Annual Meeting, 2015, Resident, Residency Director, Patient Care, GME, Assessment, Simulation, Minimally Invasive Surgery,
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