Original ReportsTraining and Assessment of Hysteroscopic Skills: A Systematic Review
Introduction
Hysteroscopy has become invaluable in gynecological practice by providing direct endoscopic visualization of the uterine cavity.1 Hysteroscopy can be used for diagnostic and therapeutic purposes; to investigate abnormal uterine bleeding, infertility, neoplastic areas; and to perform endometrial ablations and resections of intrauterine pathologies.2 Most hysteroscopic procedures are low risk and can be performed in an outpatient setting3, 4, 5; nonetheless, operative hysteroscopic experience is essential for the prevention of procedure-related complications.6, 7, 8, 9, 10
Both gynecologists and graduating residents acknowledge the importance of gynecologic endoscopy skills, including hysteroscopic skills.11 Similar to learning other surgical techniques, there is a need for thorough practice of hysteroscopy in the published literature, and several training curricula have been proposed.12, 13, 14, 15, 16, 17, 18, 19, 20
Performance of the hysteroscopic procedure is associated with certain technical challenges, including the fulcrum effect, loss of binocular vision, limited haptic feedback, and decreased mobility because of fixed access when performing hysteroscopy.21 Therefore, comprehensive training programs must be developed based on evidence with ongoing systematic feedback and assessment of competence.22, 23 Although challenging, hysteroscopic performance improves with training,24 and training also provides increased learning and retention.25, 26, 27 Assessment tools with sufficient validity evidence are necessary to provide feedback during training (i.e., formative assessment) and for certification (i.e., summative assessment).28, 29 Furthermore, assessment tools can be used to measure the effect of new training interventions, such as simulation-based training.30
The purpose of this review is to identify and systematically summarize existing evidence on hysteroscopic training and assessment.
The research question is: What is the current evidence on hysteroscopic training and assessment?
Section snippets
Material and Methods
The systematic review was carried out in accordance with the preferred reporting items for systematic reviews and meta-analyses statement.31
Study Selection
A total of 324 records were identified, of which 269 remained after removal of duplicates (Fig.). In addition, 4 records were retrieved from the authors’ own records24, 35, 36, 37 (2 conference papers from www.virtamed.com 24, 35 and 2 conference papers from Journal of Minimally Invasive Gynecology36, 37). The predefined inclusion and exclusion criteria and screening of titles and abstracts led to the exclusion of 231 records. Eligibility was assessed for 42 records, including 7 conference
Discussion
The current systematic review sums up the different hysteroscopic training and assessment tools, which have been described to date. Only 26 studies were identified.
The majority of the studies focused on VR simulators (Table 1). Nevertheless, only a limited number of VR training models were presented, and these focused on sterilization procedures. Furthermore, only 3 studies described comprehensive training curricula with both theoretical and technical components. The remaining studies used
Conclusions
Published studies on hysteroscopy training and assessment have demonstrated limited study samples with large variations in the study designs and contents. Overall, the studies have presented consistent findings that increased training is correlated with improved performance, but the training interventions considered were not uniform and the assessment tools used to assess trainee competence were not supported by sufficient validity evidence.
Acknowledgments
The authors would like to thank Henrik Hornemann, librarian at the Copenhagen University Library, Denmark, for his support with the search string development. No funding was provided for this support and no conflict of interest existed.
References (84)
- et al.
Complications of hysteroscopy: a prospective, multicenter study
Obstet Gynecol
(2000) - et al.
A multicenter survey of complications associated with 21,676 operative hysteroscopies
Eur J Obstet Gynecol Reprod Biol
(2002) Complications of hysteroscopy
Obstet Gynecol Clin North Am
(1999)- et al.
Intraoperative and early postoperative complications of operative hysteroscopy
Obstet Gynecol Clin North Am
(2000) Complications of hysteroscopic and uterine resectoscopic surgery
Obstet Gynecol Clin North Am
(2010)- et al.
Endoscopy teaching in Canada: a survey of obstetrics and gynecology program directors and graduating residents
J Minim Invasive Gynecol
(2006) - et al.
Hysteroscopic training guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic Laparoscopists
J Am Assoc Gynecol Laparosc
(2000) - et al.
Proposal of a formal gynecologic endoscopy curriculum
J Minim Invasive Gynecol
(2009) Safety and training
Baillieres Clin Obstet Gynaecol
(1995)Optimal acquisition and assessment of proficiency on simulators in surgery
Surg Clin North Am
(2010)
Effectiveness of simulation training in improving the operative performance of the Essure procedure
J Minim Invasive Gynecol
Proficiency maintenance: impact of ongoing simulator training on laparoscopic skill retention
J Am Coll Surg
Development of an objective structured assessment of technical skills for obstetric and gynecology residents
Obstet Gynecol
Efficacy of a simulation lab on training residents for the essure procedure
J Minim Invasive Gynecol
Training of hysteroscopic skills in residency program: the Dutch experience
J Surg Educ
Virtual reality hysteroscopy
J Am Assoc Gynecol Laparosc
Teaching surgical hysteroscopy with a computer
J Am Assoc Gynecol Laparosc
The HysteroTrainer, a simulator for diagnostic and operative hysteroscopy
J Am Assoc Gynecol Laparosc
Use of an objective structured assessment of technical skills (OSATS) tool during a hysteroscopy workshop for resident evaluation and education
J Minim Invasive Gynecol
Building a hysteroscopy curriculum in a community-based residency program
J Minim Invasive Gynecol
Schreuder HWR. Hysteroscopic sterilization using a virtual reality simulator: assessment of learning curve
J Minim Invasive Gynecol
A new curriculum for hysteroscopy training as demonstrated by an objective structured assessment of technical skills (OSATS)
Am J Obstet Gynecol
Efficacy of a novel educational curriculum using a simulation laboratory on resident performance of hysteroscopic sterilization
Fertil Steril
Objective structured assessment of technical skills (OSATS) evaluation of hysteroscopy training: a prospective study
Eur J Obstet Gynecol Reprod Biol
Hysteroscopic training: the butternut pumpkin model
J Am Assoc Gynecol Laparosc
Surgical simulation: where have we come from? Where are we now? Where are we going?
J Minim Invasive Gynecol
Gynecologic endoscopy skills training and assessment: review
J Minim Invasive Gynecol
Hysteroscopy. ACOG technical bulletin number 191-April
Int J Gynaecol Obstet
Manual of Hysteroscopy—Diagnostic, Operative and Office Hysteroscopy
Complications in hysteroscopy: prevention, treatment and legal risk
Curr Opin Obstet Gynecol
Comparison of complications rates in endoscopic surgery performed by a clinical assistant vs. an experienced endoscopic surgeon
J Gynecol Endosc Surg
Survey of training in minimal access surgery in the West Midlands region of the UK
Gynecol Endosc
Resident training and endoscopic hospital privileging
Curr Opin Obstet Gynecol
Recommendations by the Gynecologic Endoscopy Working Group of the German Society of Obstetrics and Gynecology for the advancement of training and education in minimal-access surgery
Arch Gynecol Obstet
ESHRE guidelines for training, accreditation and monitoring in gynaecological endoscopy. European society for human reproduction and embryology. Committee of special interest group on reproductive surgery
Hum Reprod
Training, certification, and credentialing in gynecologic operative endoscopy
Clin Obstet Gynecol
Effect of practice on standardised learning outcomes in simulation-based medical education
Med Educ
Deliberate practice improves obstetrics and gynecology residents’ hysteroscopy skills
J Grad Med Educ
Development and transferability of a cost-effective laparoscopic camera navigation simulator
Surg Endosc
Optimal training design for procedural motor skills: a review and application to laparoscopic surgery
Psychol Res
The learning curve for a colonoscopy simulator in the absence of any feedback: no feedback, no learning
Surg Endosc
The formula for a successful laparoscopic skills curriculum
Arch Surg
Cited by (20)
Essentials in Minimally Invasive Gynecology Manual Skills Pilot Validation Trial: EMIG Manual Skills Pilot Study
2020, Journal of Minimally Invasive GynecologyCitation Excerpt :Although hysteroscopy is an extremely important aspect of MIGS, there is no such component in the FLS system. Although first published in the mid-1990s [9–11], there are still relatively few hysteroscopic simulation studies available in the literature, with a limited number evaluating construct validity [12–14] with variable quality and none to date demonstrating predictive validity [15,16]. The EMIG Hysteroscopy Simulation System may provide an opportunity to expand this critically important aspect of simulation science for the gynecologic community.
Serious games, simulations, and virtual patients
2020, Digital Innovations in Healthcare Education and TrainingVirtual patients and serious games
2019, Clinical Simulation: Education, Operations and EngineeringHow I do… a low-cost hysteroscopy model
2018, Gynecologie Obstetrique Fertilite et SenologieHysteroscopic resection on virtual reality simulator: What do we measure?
2018, Journal of Gynecology Obstetrics and Human ReproductionCitation Excerpt :This score included time, cumulative path length and camera alignment is probably the best criteria to discriminate surgeon level. New methods for training residents in the increasing number of required endoscopic surgery skills are needed, and among them VR simulators hold considerable promise [30–32]. VR simulators automatically provide feedback about how well the trainee performed, by scoring a variety of parameters, some of which cannot be obtained in the OR, such as path length traveled by the endoscope or visualization tie [24].
Operative and diagnostic hysteroscopy: A novel learning model combining new animal models and virtual reality simulation
2017, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :Also, a learning curve is necessary in simulation depending on the surgical procedure. Different models have been explored for hysteroscopy training, ranging from butternut pumpkin resection [12], to animal models [13] such as pig bladder and cattle uterus [14]. Virtual simulators, like the Hystim™ simulator have also been used for teaching purposes [15].