Elsevier

Journal of Surgical Education

Volume 74, Issue 1, January–February 2017, Pages 84-90
Journal of Surgical Education

Original Reports
Integration and Validation of Hysteroscopy Simulation in the Surgical Training Curriculum

https://doi.org/10.1016/j.jsurg.2016.06.007Get rights and content

Objective

The primary objective of our study was to test the construct validity of the HystSim hysteroscopic simulator to determine whether simulation training can improve the acquisition of hysteroscopic skills regardless of the previous levels of experience of the participants. The secondary objective was to analyze the performance of a selected task, using specially designed scoring charts to help reduce the learning curve for both novices and experienced surgeons.

Design

The teaching of hysteroscopic intervention has received only scant attention, focusing mainly on the development of physical models and box simulators. This encouraged our working group to search for a suitable hysteroscopic simulator module and to test its validation. We decided to use the HystSim hysteroscopic simulator, which is one of the few such simulators that has already completed a validation process, with high ratings for both realism and training capacity. As a testing tool for our study, we selected the myoma resection task. We analyzed the results using the multimetric score system suggested by HystSim, allowing a more precise interpretation of the results.

Setting

Between June 2014 and May 2015, our group collected data on 57 participants of minimally invasive surgical training courses at the Kiel School of Gynecological Endoscopy, Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel.

Participants

The novice group consisted of 42 medical students and residents with no prior experience in hysteroscopy, whereas the expert group consisted of 15 participants with more than 2 years of experience of advanced hysteroscopy operations.

Results

The overall results demonstrated that all participants attained significant improvements between their pretest and posttests, independent of their previous levels of experience (p < 0.002). Those in the expert group demonstrated statistically significant, superior scores in the pretest and posttests (p = 0.001, p = 0.006). Regarding visualization and ergonomics, the novices showed a better pretest value than the experts; however, the experts were able to improve significantly during the posttest. These precise findings demonstrated that the multimetric scoring system achieved several important objectives, including clinical relevance, critical relevance, and training motivation.

Conclusion

All participants demonstrated improvements in their hysteroscopic skills, proving an adequate construct validation of the HystSim. Using the multimetric scoring system enabled a more accurate analysis of the performance of the participants independent of their levels of experience which could be an important key for streamlining the learning curve. Future studies testing the predictive validation of the simulator and frequency of the training intervals are necessary before the introduction of the simulator into the standard surgical training curriculum.

Introduction

Hysteroscopy is a minimally invasive technique for the assessment and treatment of intrauterine pathologies.1, 2 The development of new instruments and the introduction of fellowship programs for the training of residents in minimally invasive gynecological surgery have encouraged the usage and implementation of diagnostic and operative hysteroscopy in routine clinical practice.3, 4

In comparison with laparoscopy, hysteroscopic skills are often assumed to be less difficult to obtain.5 The teaching of hysteroscopic interventions has received little attention thus far, focusing mainly on the development of physical models and box simulators,6 while the demand for well-structured hysteroscopy training is expanding rapidly.7

Existing training models range from cow uteri and bladders to virtual reality; however, a Dutch survey revealed that lack of simulation training during residency was the leading factor that could be enhanced for optimal acquisition of hysteroscopic skills.7 This encouraged our working group to search for a suitable hysteroscopic simulator module and to test its validation.

With a widely accepted validation procedure yet to be established, we decided to follow the process suggested by researchers from the University of Switzerland in the evaluation of virtual reality simulators.8 The validation process is divided into the following 3 steps: face validation, defined as the extent to which the simulation resembles real-life simulation; construct validity, a set of evaluation procedures based on quality, ability, and traits it was designed to measure; and predictive validity, the extent to which the scores are predictive of actual performance.9

The primary objective of our study was to test the construct validity of the HystSim to determine whether simulation training improves the acquisition of hysteroscopic skills of the candidate independent of the previous level of experience by the use of a selected training scenario, applicable to contemporary practice. The secondary objective was to analyze the performance of a selected task using the scoring charts to reduce the learning curve for both novices and experienced surgeons.

Section snippets

Subjects

Between June 2014 and May 2015, our group collected data on 57 participants of minimally invasive surgical training programs at the Kiel School of Gynecological Surgery, Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Germany. The participants were divided into the following 2 groups: a novice group consisting of 42 medical students and junior residents with less than 2 years of gynecological experience and no prior experience in hysteroscopy, and

Results

All participants showed significant improvements in the posttest relative to the pretest (p < 0.002), independent of their previous level of experience. Regarding the overall result, the expert group exhibited superior performances in the posttest with a mean score of 206.60 (97.21) and a significant difference between the pretest and posttests with a mean of 154.20 (148.34) points. Following the Rosenthal test, a good comparative quantitative effect between the 2 groups was demonstrated

Discussion

The aim of our study is to evaluate the construct validity of the hysteroscopic simulator HystSim to integrate hysteroscopy simulation into the training curriculum, and secondly to analyze the learning curves of novice and expert groups to accelerate the acquisition of operative skills.

We decided to use the HystSim as it is one of the few hysteroscopic simulators that has already passed through a face and construct validation process for a diagnostic exercise, establishing high ratings for both

Conclusion

Before future implementation of the HystSim simulator into the surgical training curriculum, we recommend an interval study at 6 months after training to evaluate whether the benefit of simulation training degrades over this time and whether simulation training may need to be repeated at more frequent intervals. Such investigations are required to confirm the marginal value of simulation training in daily practice and its predictive validity.

References (11)

  • J.A. Janse et al.

    Training of hysteroscopic skills in residency program: the Dutch experience

    J Surg Educ

    (2015)
  • J. Bosteels et al.

    Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

    Cochrane Database Syst Rev

    (2013)
  • L. Mettler et al.

    Complications of uterine fibroids and their management, surgical management of fibroids, laparoscopy and hysteroscopy versus hysterectomy, haemorrhage, adhesions, and complications

    Obstet Gynecol Int

    (2012)
  • P. Capmas et al.

    Surgical techniques and outcome in the management of submucous fibroids

    Curr Opin Obstet Gynecol

    (2013)
  • J.I. Einarsson et al.

    Perceived proficiency in minimally invasive surgery among senior OB/GYN residents

    JSLS

    (2009)
There are more references available in the full text version of this article.

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