Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology.

OBJECTIVE: To provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates. TARGET POPULATION: Providers working to improve health care for Canadian women and their families; patients and their families. OUTCOMES: Simulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition. BENEFITS, HARMS, AND COSTS: This modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time. EVIDENCE: Articles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords "simulation" and "simulator." The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: All health care professionals working to improve Canadian women's health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.

Perceptions of safety culture and recording in the operating room: understanding barriers to video data capture.

OBJECTIVE: Recording in the operating room is an important tool to help surgical teams improve their performance. This is becoming more feasible using the Operating Room Black Box, a comprehensive data capture platform. Operating room (OR) staff, however, may voice reasonable concerns as recording initiatives are implemented. The objective of this study was to assess pre-implementation attitudes of OR staff toward operative recording and explore the relationship of these attitudes to the themes of (1) safety culture, (2) impostor syndrome, and (3) privacy concerns. METHODS: This cross-sectional survey study measured staff members' beliefs and opinions of operative recording and used three previously validated tools (safety attitudes questionnaire, clance impostor phenomenon scale, and dispositional privacy concern) to assess personal and professional factors. Concepts were correlated using Pearson's correlation coefficient. RESULTS: Forty-three staff members participated in this study, with a response rate of 45% (n = 43/96, 20/22 nurses, 9/11 gynecologists, 14/63 anesthesiologists). Opinions of operative data capture were generally positive (5-point Likert scale, mean = 3.81, SD = 0.91). Nurses tended to have more favorable opinions of the OR Black Box as compared to gynecologists and anesthesiologists, though this did not reach statistical significance (4.15 vs. 3.67 vs 3.43, p = 0.06). Impostor syndrome characteristics correlated with concerns about litigation related to recording (r = - 0.32, p = 0.04). CONCLUSION: There are personal and professional attributes of the OR team that impact perceptions of the OR Black Box and implications around privacy and litigation. Addressing these concerns may facilitate successful implementation of the OR Black Box and improve team communication and patient safety in the OR.

Health Care Practitioners' Attitudes and Knowledge Regarding Trial of Labour After Cesarean Delivery (TOLAC): A Survey of Canadian Obstetrical Care Providers.

OBJECTIVES: To understand current attitudes and practice patterns of obstetrical care providers regarding trial of labour after cesarean (TOLAC) and to assess misconceptions regarding eligibility for and risks associated with TOLAC. METHODS: A survey was developed based on published literature, validated by a statistician, and piloted with Canadian obstetricians. French and English versions were distributed via the mailing list of the Society of Obstetricians and Gynaecologists of Canada and social media. Practising obstetrical care providers with an office antenatal practice were eligible to participate. Data were analyzed using descriptive statistics and correlational and multiple regression analyses. RESULTS: A total of 381 people responded, with representation from every Canadian province and territory. Obstetrician-gynaecologists (239, 63%), family physicians (100, 26%), and midwives (42, 11%) responded. Most participants (277, 78%) thought that TOLAC should be actively encouraged. Only 141 (40%) used a decision aid when counselling patients, although most respondents (250, 71%) thought it would be useful. Providers were less comfortable offering oxytocin induction compared with cervical foley or amniotomy (P < 0.001) and offering TOLAC to patients with an unknown uterine scar (P < 0.001). Providers in western Canada reported more comfort offering TOLAC to patients with more than 1 previous cesarean delivery compared with other regions. Two hundred nine participants (62%) reported that they had had at least 1 patient with a uterine rupture, with the minority of cases (13, 6%) resulting in litigation. CONCLUSIONS: This study offers new information on current national practice patterns and provider attitudes regarding TOLAC. These results can be used to guide future educational initiatives to increase TOLAC rates.

Predictors of Persistent Postsurgical Pain After Hysterectomy-A Prospective Cohort Study.

STUDY OBJECTIVE: To determine sociodemographic, surgical, and psychologic risk factors, including pain sensitivity, for persistent postsurgical pain (PPSP) after hysterectomy. DESIGN: A prospective cohort study. SETTING: Canadian academic medical center. PATIENTS: Patients (N = 200) who underwent hysterectomy (vaginal, laparoscopic, robotic, or open) between 2013 and 2014. INTERVENTIONS: Participants completed preoperative questionnaires assessing baseline pain scores and psychologic factors, including the Pain Sensitivity Questionnaire, Brief Pain Inventory Interference Items, the Beck Depression Inventory, the Numeric Rating Scale (NRS), and the Pain Catastrophizing Scale. Pain was recorded 1 and 24 hours postoperatively using the NRS. Patients were reassessed at 6 weeks postoperatively and completed the Brief Pain Inventory Interference Items, Patient Global Impression of Change, and the NRS. Patients who reported pain at 6 weeks were reassessed at 12 weeks using the above-mentioned questionnaires. MEASUREMENTS AND MAIN RESULTS: Of 200 study participants, 58 (32%) met the definition for PPSP (NRS ≥ 1 at 12 weeks), and 11 (6.1%) met the definition for moderate to severe postsurgical pain (NRS ≥ 4 at 12 weeks). Risk factors for PPSP included baseline pain scores, depression, pain catastrophizing, uterine mass, open surgical approach, acute postoperative pain, history of chronic pain, and having a hysterectomy due to pain. Multivariate regression analysis revealed that depression, pain catastrophizing, open surgical approach, and acute postoperative pain at 1 hour represent independent predictors of PPSP. Pain sensitivity was not associated with PPSP but was associated with acute and severe acute (NRS≥4) pain at 24 hours. CONCLUSION: Patients at risk for PPSP after hysterectomy can be identified preoperatively using validated questionnaires. This information can be used to guide targeted perioperative interventions to mitigate their risk.

Key concerns among pregnant individuals during the pandemic: Online cross-sectional survey.

OBJECTIVE: To determine common sources of concern among pregnant individuals during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: A cross-sectional, open, online electronic survey from May 9, 2020, to June 14, 2020. SETTING: Electronic survey open internationally and advertised through Canadian-based social media platforms. PARTICIPANTS: Eligible participants understood English and had been pregnant during the COVID-19 pandemic (ie, were pregnant at the time of survey completion or had delivered an infant on or after March 11, 2020). MAIN OUTCOME MEASURES: Potential sources of concern related to the pandemic, calculated as the proportion of participants who endorsed each concern among those for whom the concern was relevant. Differences in the proportion of individuals endorsing each concern were compared by parity using modified Poisson regression. Frequency of concerns was examined in terms of level of distress, as per the Kessler Psychological Distress Scale (K6), using multivariable linear regression. RESULTS: Out of 1477 participants, 87.3% were Canadian. Top concerns included the following: hospital policies related to support persons during labour (80.9%), not being able to introduce the baby to family and friends (80.1%), and developing COVID-19 while pregnant (79.2%). Primiparous participants were more likely than multiparous participants to be concerned about accessing in-person prenatal classes (51.5% vs 13.3%; relative risk = 3.88; 95% CI 2.02 to 4.98) and cancellation of hospital tours (35.0% vs 5.6%, relative risk = 6.26; 95% CI 4.25 to 9.20), among other concerns. The mean (SD) K6 score was 6.7 (3.8) within the moderate to high distress range. Number of concerns reported was associated with K6 score in both primiparous (ß = 0.24; 95% CI 0.20 to 0.29; P < .0001) and multiparous (ß = 0.30; 95% CI 0.24 to 0.36; P < .0001) individuals. CONCLUSION: Pregnant individuals have unique concerns during the COVID-19 pandemic and the findings indicate the importance of targeted support strategies to meet the particular needs of both primiparous and multiparous pregnant individuals.

Effect of a Surgical Teaching Video on Resident Performance of a Laparoscopic Salpingo-oophorectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To assess the effect of a surgical teaching video on junior resident knowledge and performance of a laparoscopic salpingo-oophorectomy (LSO). DESIGN: Randomized controlled trial. SETTING: Urban tertiary care academic obstetrics and gynecology department. PATIENTS: First- and second-year gynecology residents. INTERVENTIONS: Access to an education video on LSO for 1 week before performing this surgery in the operating room. MEASUREMENTS AND MAIN RESULTS: Twenty-four junior residents were recruited and randomized to either the educational video group or traditional residency training group. All participants completed a demographic survey and knowledge questionnaire before performing an LSO, which was video-recorded. Video recordings of surgical performance were analyzed using the Objective Structured Assessment of Technical Skills (OSATS; 20 points) and an LSO-specific tool (30 points). Participants completed a self-assessment questionnaire before completing the procedure. The primary outcome measure was the difference in OSATS scores. The secondary outcomes were the knowledge questionnaire scores and self-assessed confidence scores. There were no significant differences between demographic variables of the 2 groups. The primary outcome revealed no significant differences in mean (standard deviation) OSATS scores (10.64 [2.05] vs 11.55 [1.85], p = .3) or LSO-specific tool scores (16.45 [2.68] vs 17.85 [2.63], p = .24). However, there was a significant difference in mean knowledge scores between the video and the traditional training (8.42 [0.79] vs 7.11 [1.36], p = .01) groups. In addition, residents in the video group had more confidence in their knowledge of pelvic anatomy (3.83 [0.39] vs 3.00 [1.00] out of 5.00, p = .04). CONCLUSION: For junior learners, the use of an LSO video improved knowledge and confidence in anatomy but did not translate to improved surgical performance in the operating room. Surgical videos are a useful adjunct and complement hands-on technical teaching.

Delphi Approach for the Design of an Intraoperative Blood Conservation Pathway for Open Myomectomy.

OBJECTIVE: Myomectomy is offered for treatment of symptomatic uterine fibroids in women who desire to maintain fertility. An open approach, sometimes necessitated by the size or number of fibroids, is associated with a high rate of perioperative blood transfusion. Our goal was to obtain expert consensus on interventions aimed at reducing blood loss and subsequent transfusion in open myomectomy for inclusion in an intraoperative care pathway. METHODS: A two-round modified Delphi approach was used to generate consensus on a pathway of interventions to reduce blood loss in open myomectomy. A multidisciplinary expert panel consisting of anaesthesiologists, hematologists, and gynaecologic surgeons rated interventions for inclusion in or exclusion from the pathway (Canadian Task Force Classification III). RESULTS: Twenty-three expert panel members participated in the Delphi. Consensus was achieved in both the Delphi's first (Cronbach α = 0.92) and second (Cronbach α = 0.94) rounds. Of 11 proposed interventions, five (dilute vasopressin, tranexamic acid, pericervical tourniquet, cell saver, and restrictive transfusion practice) reached consensus for inclusion in the pathway. CONCLUSION: A modified Delphi consensus approach was used to inform the development of an intraoperative pathway to reduce blood loss and subsequent transfusion in women undergoing open myomectomy. Future studies will investigate the effect of this intraoperative blood conservation pathway on reducing intraoperative blood loss and blood transfusion rates among women undergoing open myomectomy.

Decreasing Cesarean Delivery Rates Using a Trial of Labour After Cesarean (TOLAC) Bundle.

OBJECTIVE: To develop and implement a trial of labour after cesarean delivery (TOLAC) bundle-a group of interventions aimed at decreasing cesarean delivery (CD) for women who have had a prior CD (Robson group 5). METHODS: A TOLAC bundle was developed that included: (1) educational rounds for health care providers, (2) a physician-patient TOLAC discussion aid, and (3) patient-centred educational resources. A before-and-after study design was employed. A one-year chart review determined baseline CD rates in Robson group 5 patients at a tertiary care academic centre. Following this, from February 1, 2018 until May 31, 2019, each bundle intervention was sequentially introduced every four to six months and modified based on provider feedback. Obstetricians were provided with their individual CD rates using an audit-and-feedback approach prior to the introduction of the next intervention. RESULTS: The baseline CD rate for Robson group 5 patients was 71% (175/247 eligible patients). Following the introduction of the bundle, the CD rate decreased to 61% (131/214 eligible patients). This was a 10% decrease in the CD rate (P = 0.029). A significant increase in rate of induction was noted, from 5% pre-intervention to 11% post-intervention (p = 0.017). There were no significant decreases in the rate of vaginal birth after CD or increases in the rates of uterine rupture or NICU admission. CONCLUSIONS: A TOLAC bundle, consisting of provider education, a TOLAC discussion aid, and patient resources, combined with audit and feedback, decreased CD for Robson group 5 patients.

The State of Needlestick Training for Undergraduate Medical Students at Canadian Universities.

Canadian undergraduate medical students sustain needlestick injuries, which have adverse implications, including blood-borne illnesses and personal anxiety. This study sought to determine students' needle handling efficacy and to examine the prevalence of formal training around needlestick safety and reporting procedures both nationally and, specifically, within the University of Toronto in Toronto, Ontario (U of T). A seven-question survey electronic survey was distributed to 116 undergraduate medical education (UME) leaders practising in high-risk rotations at 13 Canadian universities. Additionally, an eight-question survey was delivered electronically to 428 residents, fellows, and faculty in the Department of Obstetrics and Gynaecology at the U of T. A total of 34% of UME leaders and 36% from the U of T responded. Of UME respondents, 53% reported that their institution lacks needlestick training, and 35% were unsure whether their institution provides reporting instruction. At the U of T, 53% were "concerned" or "very concerned" that students pose a risk to themselves, and 27% "disagreed" or "strongly disagreed" that students handle instruments correctly. Our findings suggest that needlestick safety training for medical students across Canadian universities is insufficient. It is concerning that students are frequently exposed to patients in high-risk and surgically intensive rotations, despite their inexperience with needles. Furthermore, non-reporting among students may prevent them from receiving early prophylaxis or treatment. There is a need for the national implementation of a standardized and formalized needlestick safety curriculum for medical students before and during clerkship.

Introduction of Physician-Nurse Bedside Rounding and Ward Task List to Improve Quality of Care in Gynaecology: Prospective, Single-Blinded, Pre- and Post-Intervention Study.

OBJECTIVE: This study sought to determine whether physician-nurse bedside rounds and ward task list improve quality of care as measured by patient satisfaction, earlier discharge, and reduced trainee interruptions. METHODS: This prospective, single-blind, pre- and post-intervention study included patients admitted to the gynaecology ward at St. Michael's Hospital in Toronto, Ontario, involving a 6-week baseline, 6-week intervention, and 2-week second baseline phase. During the intervention phase, a chief resident and charge nurse rounded at the bedside simultaneously daily. Nurses recorded non-urgent issues on a ward task list. Patients completed a subset of the National Research Corporation Picker satisfaction questionnaire, discharge times were noted, and residents recorded pages (Canadian Task Force Classification II-2). RESULTS: There were 89, 104, and 30 admissions during baseline care, intervention, and second baseline phases, respectively. Mean discharge time in the intervention phase was significantly earlier than baseline (11:18 am ± 1 hour 59 minutes vs. 12:37 pm ± 2 hours 37 minutes, P < 0.001), with early discharges doubling (69% vs. 36%, P < 0.001). Discharge times returned to baseline after the intervention (12:36 pm ± 2 hours 39 minutes). Intervention phase patients appreciated bedside care plans (86 of 94 patients, 92%), with improved National Research Corporation Picker responses, which diminished post-intervention. Paging interruptions were lower during the intervention phase compared with the baseline phase (1.0 ± 1.1 vs. 3.4 ± 2.1, P < 0.001), with non-urgent pages decreasing most (0.5 ± 0.8 vs. 3.0 ± 2.0, P < 0.001). CONCLUSION: Combining physician-nurse bedside rounds and ward task list reduces trainee interruptions, positively affects patient satisfaction, and promotes early discharge. Following these initiatives, discharge time, patient satisfaction, and resident paging interruptions returned to baseline.

Bridging the Gap: Incorporating Simulation into Obstetrics and Gynaecology Undergraduate Medical Education.

INTRODUCTION: Currently, simulation training is not part of the clinical clerkship rotation in obstetrics and gynaecology (OB/GYN) at the University of Toronto. Instead, students are taught formally through lectures and informally on the ward or in the operating room. This study aimed to incorporate simulation using a high fidelity postpartum hemorrhage (PPH) workshop into the teaching curriculum, with the goal of improving both medical knowledge of PPH and nontechnical skills (NTS). METHOD: A novel teaching session was introduced for the third-year clerks on their OB/GYN rotation. Students (n = 88) were invited to participate in the research component to evaluate the effectiveness of this session. Students' (n = 83) baseline knowledge of PPH and teamwork attitudes were measured using a multiple-choice questionnaire (MCQ) and the TeamSTEPPS Questionnaire. Students participated in small-group learning about PPH and NTS, followed by a high-fidelity PPH simulation using a Laerdal SimMom Mannequin in a mock operating room. Students were debriefed, followed by a different MCQ and the TeamSTEPPS Questionnaire. RESULTS: Statistically significant improvements in students' comprehension (MCQ scores 63.9% vs. 76.5%, P < 0.05) and NTS (4.35/5 vs. 4.51/5, P < 0.05) were noted after simulation. The majority (92%) of students agreed that this method of learning was more enjoyable than traditional methods. CONCLUSIONS: Simulation in undergraduate education offers an exciting alternative to deliver information that is traditionally taught with didactic sessions while incorporating essential NTS. The authors hope that this study will encourage discussion of current simulation practices across Canada and standardized simulation techniques in OB/GYN.

A Novel Approach to Simulation-Based Perineal Repair in Undergraduate Medical Education.

INTRODUCTION: There is no formalized hands-on teaching of suturing skills for clerkship students during their dedicated obstetrics and gynaecology (OB/GYN) teaching sessions at the University of Toronto. Nevertheless, the students are exposed to suturing during gynaecologic surgery, Caesarean sections, and perineal repairs. As a result, a formal pilot workshop on knot-tying and perineal laceration repair was developed for incorporation into the third-year clerkship curriculum with the goals of increasing students' knowledge and technical skills. METHODS: Participants consisted of students enrolled in their OB/GYN clerkship rotation at St. Michael's Hospital at the University of Toronto from December 2016 to August 2017. Prior to the workshop, students' (n = 82) baseline knowledge of perineal lacerations was assessed with a pre-test quiz and their knot-tying speeds (two hand-ties and two instrument ties) were recorded. Students were then taught perineal anatomy, laceration types and repair techniques, suturing, and knot-tying. Under direct supervision, students practiced the technical skills for 45 minutes. Knowledge and knot-tying speeds were then reassessed following the educational session. RESULTS: There was a statistically significant improvement in both knowledge (51% to 71%; P < 0.05) and technical skills (258.8 seconds to 197.4 seconds; P < 0.05) after the workshop. Importantly, 94% of students "agreed" or "strongly agreed" that this method of learning was more enjoyable than traditional methods. CONCLUSIONS: This pilot project demonstrates that a formal hands-on workshop improves medical knowledge, technical skills, and student satisfaction. This has the potential for students to have increased opportunities at the bedside, with higher patient acceptance and safety.

Implementation and validation of a retroperitoneal dissection curriculum.

BACKGROUND: Competency-based education requires educators to use simulation training for the purposes of education and assessment of resident trainees. Research demonstrates that improvement in surgical skills acquired in a simulated environment is transferrable to the operative environment. Laparoscopic retroperitoneal dissection, opening the retroperitoneal space and identifying the ureter, is a fundamental skill for gynecologists. Integrating simulation models into a formal and comprehensive curriculum for teaching ureterolysis could translate to increased surgical competency. OBJECTIVE: Our goal was to validate a comprehensive curriculum for laparoscopic retroperitoneal dissection for the purpose of identification of the ureter by evaluating intraoperative performance. STUDY DESIGN: A comprehensive curriculum, encompassing didactic and technical skills components and using a previously developed pelvic model, was designed to teach laparoscopic ureterolysis. Novice surgeons (postgraduate years 3-5) were recruited. Participants completed precurriculum and postcurriculum multiple-choice questionnaires to evaluate a didactic component. Preperformance and postperformance on the model was video-recorded. As part of the technical component, participants received constructive feedback from expert surgeons on how to perform laparoscopic retroperitoneal dissection using the simulation model. Participants were then video-recorded performing laparoscopic retroperitoneal dissection in the operating room within 3 months of the curriculum. All videos were blindly assessed by an expert using the Objective Structured Assessment of Technical Skills tool. At the conclusion of the study, participants completed a course evaluation. RESULTS: Thirty novice gynecologic surgeons were recruited. High baseline knowledge of ureteric anatomy and injury (multiple-choice question score median and interquartile range) still significantly increased from 7 (5-7.25) precurriculum to 8 (7-9) postcurriculum (P < .001). The median (interquartile range) technical Objective Structured Assessment of Technical Skills score increased significantly from 24.5 (23-28.25) precurriculum to 30 (29.75-32) postcurriculum (P < .001). Video-recordings were completed for 23 participants performing laparoscopic retroperitoneal dissection in the operating room. Intraoperative Objective Structured Assessment of Technical Skills scores (median of 29 [interquartile range 27-32]) correlated with postcurriculum Objective Structured Assessment of Technical Skills scores on the model (r = 0.53, P = .01). The ureter was identified intraoperatively by 91% (n = 21/23) of participants. The majority of residents (81%, n = 21/26) were more comfortable completing a supervised retroperitoneal dissection as a result of participating in the curriculum. Residents believed that this model would be useful to enhance skills acquisition prior to performing the skill in the operating room (65%, n = 17/26). CONCLUSION: A comprehensive retroperitoneal dissection curriculum showed improvement in cognitive knowledge and technical skills, which also translated to competent performance in the operating room. In addition to the objective measures, residents believed that their skills acquisition was improved following course completion.

A Randomized Multicenter Study Assessing the Educational Impact of a Computerized Interactive Hysterectomy Trainer on Gynecology Residents.

STUDY OBJECTIVE: To assess the improvement of cognitive surgical knowledge of laparoscopic hysterectomy in postgraduate year (PGY) 1 and 2 gynecology residents who used an interactive computer-based Laparoscopic Hysterectomy Trainer (Red Llama, Inc., Seattle, WA). DESIGN: A multicenter, randomized, controlled study (Canadian Task Force classification I). SETTING: Five departments of obstetrics and gynecology: Keck School of Medicine of the University of Southern California, Los Angeles, CA; University of California, Los Angeles, Los Angeles, CA; University of Washington, Seattle, WA; University of British Columbia, Vancouver, British Columbia, Canada; and University of Toronto, Toronto, Ontario, Canada. PARTICIPANTS: Gynecology residents, fellows, faculty, and minimally invasive surgeons. INTERVENTIONS: The use of an interactive computer-based Laparoscopic Hysterectomy Trainer. MEASUREMENTS AND MAIN RESULTS: In phase 1 of this 3-phase multicenter study, 2 hysterectomy knowledge assessment tests (A and B) were developed using a modified Delphi technique. Phase 2 administered these 2 online tests to PGY 3 and 4 gynecology residents, gynecology surgical fellows, faculty, and minimally invasive surgeons (n = 60). In phase 3, PGY 1 and 2 gynecology residents (n = 128) were recruited, and 101 chose to participate, were pretested (test A), and then randomized to the control or intervention group. Both groups continued site-specific training while the intervention group additionally used the Laparoscopic Hysterectomy Trainer. Participant residents were subsequently posttested (test B). Phase 2 results showed no differences between cognitive tests A and B when assessed for equivalence, internal consistency, and reliability. Construct validity was shown for both tests (p < .001). In phase 3, the pretest mean score for the control group was 242 (standard deviation [SD] = 56.5), and for the intervention group it was 217 (SD = 57.6) (nonsignificant difference, p = .089). The t test comparing the posttest control group (mean = 297, SD = 53.6) and the posttest intervention group (mean = 343, SD = 50.9) yielded a significant difference (p < .001, 95% confidence interval, 48.4-108.8). Posttest scores for the intervention group were significantly better than for the control group (p < .001). CONCLUSION: Using the Laparoscopic Hysterectomy Trainer significantly increased knowledge of the hysterectomy procedure in PGY 1 and 2 gynecology residents.

A Case of Epidural Lipomatosis in Pregnancy: Management during Labour and Caesarean Section.

BACKGROUND: Spinal epidural lipomatosis (SEL) is a rare condition of adipose tissue accumulation in the epidural space. As a result of excess adipose tissue, neuraxial anaesthesia has been reported to behave unpredictably in patients with this condition. CASE: A 36-year-old woman had worsening postural headaches during pregnancy. MRI revealed SEL involving the thecal sac between L3/L4 and L5/S1. She had induction of labour but ultimately required a CS for delivery. Her anaesthesia was managed with an epidural inserted at L3/4. She developed a high block with relative sacral sparing. CONCLUSION: Although neuraxial anaesthesia was thought to be contraindicated in patients with SEL, it can be done safely. Care must be taken to provide slow epidural titration to avoid high sensory block in patients with this condition.

The development of a retroperitoneal dissection model.

Knowledge of ureteric anatomy is essential for ureteric injury prevention in laparoscopic gynecologic surgery. Rates of injury increase with limited surgical experience and reduced surgical volume. Currently, there are no low-fidelity or high-fidelity simulation models for teaching and practicing ureteric dissection. Our goal was to design a laparoscopic simulation model for retroperitoneal anatomy with high face validity that is low-cost and easily reproducible. A low-fidelity 3-dimensional simulation model was developed that represents key anatomic structures encountered during retroperitoneal dissection and ureteric identification. Materials, construction steps, and costs were determined. The models were trialed by expert laparoscopic surgeons. Demographic information that included age, gender, surgical experience, and complex laparoscopic case volumes was collected. Face validity was assessed with a 5-item Likert-scale. The total cost of 1 model ranged from $65 to $75. The majority of the materials that were used were reusable, except for 2 components that cost <$1 per use. Seven expert surgeons participated in the study, all of whom were fellowship-trained minimally invasive gynecologic surgeons or currently enrolled in this type of fellowship program. Participants agreed or strongly agreed that the model resembled the texture of the ureter, vessels, and peritoneal layer (n=6; 86%), approximated the correct anatomic course of the ureter (n=7; 100%), and closely approximated live surgery (n=5; 71%). They also agreed or strongly agreed that the model would be useful for teaching laparoscopic retroperitoneal dissection (n=7; 100%), for assessing a learner's ability before performing in the operating room (n=6; 86%), was low-cost (n=7; 100%), and was easily reproducible (n=6; 86%). This unique model fills a gap in laparoscopic simulation training. No other low- or high-fidelity models for laparoscopic retroperitoneal ureteric dissection have been identified in the literature. This simulation model is low-cost, easily reproducible, closely resembles retroperitoneal dissection during laparoscopic gynecologic surgery, and can be used for education and assessment.

Comparing two Uterine Manipulators During Total Laparoscopic Hysterectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To compare 2 different types of uterine manipulators (i.e., tight fitting vs loose fitting) used for total laparoscopic hysterectomy (TLH). DESIGN: A randomized controlled trial. The primary end points were time for colpotomy, time from skin incision to detachment of the uterus, and histologic assessment of thermal damage to the vagina (Canadian Task Force classification I). SETTING: A university teaching hospital. PATIENTS: All consecutive women scheduled for TLH from May 2014 to December 2015. Patients were excluded if pregnancy or malignancy was suspected or uterine size exceeded 20 weeks' gestation. INTERVENTIONS: Patients were randomized to undergo TLH with 1 of the following uterine manipulators: (1) Colpo-Probe Vaginal Fornix Delineator (Cooper Surgical, Inc, Trumbull, CT) or (2) Hohl manipulator (KARL STORZ AG, Tuttlingen, Germany). MEASUREMENTS AND MAIN RESULTS: A total of 91 patients, 49 in the Hohl manipulator group and 42 in the Colpo-Probe group, were included in the final analysis. There was no difference in patient characteristics, uterine weight, or estimated blood loss. The median time for insertion of the manipulator (2 minutes [interquartile range (IQR), 2-5 minutes] vs 6 minutes [IQR, 5-7], p < .001), the median time from skin incision to detachment of the uterus (55 minutes [IQR, 41-70] vs 65 minutes [IQR, 58-79], p = .004), and the median time for colpotomy (7 minutes [IQR, 5-10] vs 12 [IQR, 8-17], p < .001) were shorter with the Hohl manipulator. Thermal damage to the vagina varied greatly and ranged from 32 µm to 5232 µm but was not significantly different between groups (median maximum thermal damage = 1043 µm [IQR, 682-1934] vs 1522 µm [IQR, 884-2144], p = .211). CONCLUSION: Use of the Hohl manipulator results in a shorter operative time from skin incision to detachment of the uterus during TLH. Although the colpotomy time is shorter using the Hohl manipulator, this did not translate to less thermal damage to the vaginal cuff. Further studies comparing uterine manipulators are warranted to find the optimal instrument for ease of surgery and decreased thermal spread.