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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 skills.


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 communicated.


Discussions: Residents’ laparoscopic simulation time was dismal at our program in this study. Dedicated mandatory simulation time may increase participation.

Topics: 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 sessions.  


Discussions: With a dedicated curriculum and proctored teaching, residents in obstetrics and gynecology can successfully pass the FLS certification exam with their initial test. 

Topics: 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 issues.


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 issues. 


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.

Topics: 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.


Background: Multiple 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 curriculum.


Methods: IRB 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 message.


Results: This 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 tasks.


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.

Topics: 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 residency program.


Background: The 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 operating room.


Methods: 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.


Results: The 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 courses. 

Topics: 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 suturing task.


Background: The 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.


Methods: OB-Gyn 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.

Topics: 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

Purpose: To 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 procedures.


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.

Topics: 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

Purpose: To 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 are done.


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.


Discussions: A 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 credits.


Topics: 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

Purpose: To 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 cystotomy repair.


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- and post-simulation.


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 3.1/5, p=0.09).

Discussions: Our bladder model is easily constructed and inexpensive. It performs well for open cystotomy repair but has been decreased in size to better perform laparoscopically.

Topics: 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

Topics: 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 platforms.


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

Topics: 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 performed.


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 scores.


Keywords: Colposcopy, resident education, innovative

Topics: 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 simulation.


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

Topics: CREOG & APGO Annual Meeting, 2016, Resident, Faculty, Residency Director, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Assessment, Simulation, Minimally Invasive Surgery,

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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 on needs.


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 procedures).


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 procedure performance.


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

Topics: CREOG & APGO Annual Meeting, 2016, Resident, Faculty, Residency Director, Residency Coordinator, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, Assessment, Simulation, Minimally Invasive Surgery,

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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 applicants.


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

Topics: 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

Topics: CREOG & APGO Annual Meeting, 2016, Resident, Faculty, Residency Director, Patient Care, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Simulation, Problem-Based Learning, Minimally Invasive Surgery,

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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 robotic platform.


Discussions: Robotic skills acquired through simulation appear to be easier to maintain than laparoscopic skills gained via simulation. 


Keywords: simulation, minimally invasive

Topics: 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 readmission rates. 


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

Topics: 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.

Topics: 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.

Topics: CREOG & APGO Annual Meeting, 2015, Resident, Residency Director, Patient Care, GME, Assessment, Simulation, Minimally Invasive Surgery,

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