An Observation of a Resident-as-Teacher Combined with Tutor Guided Hysteroscopy Teaching Program for Standardized Residency Training (SRT) in Obstetrics and Gynecology.

Objectives: The standardized residency training (SRT) program in China is an important link for continuing education and clinical work training for graduate students. The purpose of our study was to enable educators to maintain the effectiveness of hysteroscopy teaching techniques and make the standardized residency training students well experienced in surgery, thus demonstrating that higher efficiency of teaching can lead to better proficiency for surgery. Methods: We generated resident-as-teacher teaching round and tutor guided hysteroscopic surgery as well as a questionnaire based on the mastery degree of the basic theoretical knowledge and operational skills of hysteroscopy among seven junior residents and five senior residents of the Obstetrics and Gynecology Department, including four attending gynecologic surgeons of a hysteroscopy teaching program. Results: Senior residents felt confident to teach, while junior residents learned effectively through the teaching round. There were statistically significant differences in the whole operation time and the volume of distension fluid used between junior and senior residents (p < 0.05). Conclusions: This study acknowledges the need for new approaches to medical education for better characterization of the link between the use of teaching rounds through problem-based learning (PBL) discussion dominated by the residents themselves and overall surgical skills of teaching and learning.

Prospective Evaluation of the Accuracy of A Training Program in Image Recognition by Narrow-Band Imaging Guided Hysteroscopy of Endometrial Neoplasms.

INTRODUCTION: Narrow-band imaging (NBI) hysteroscopy by experienced hysteroscopists (EH) is useful for diagnosing endometrial neoplasms. OBJECTIVE: We investigated whether the diagnostic reliability of NBI could be improved by specific professional training. METHODS: Three levels of trainees who were Surgeons at our hospital were selected. Level I: 6 trainees had no prior hysteroscopic experience; level II: 6 trainees had experience with <100 cases; and level III: 6 trainees had <500 cases. The two-hour training program for white light hysteroscopy (WLH) and NBI included information on the classifications of diseases of the uterine cavity and on the features of diagnostic images. Images from 529 patients were evaluated independently by trainees with 3 levels of before and after training, and by EH. Trainees and EHs had to analyze and arrive at a hysteroscopic diagnosis for each image that was compared to the pathological diagnosis for diagnostic accuracy. RESULTS: After training, all levels achieved higher diagnostic accuracy with NBI than was seen with WLH. Level III trainees achieved diagnostic accuracy and kappa values for NBI that were equivalent to those of EH. CONCLUSIONS: Training can increase the diagnostic skill of all trainees using NBI, especially for trainees with prior hysteroscopic experience.

The value of virtual reality simulators in hysteroscopy and training capacity: a systematic review.

The aim of this study is to summarize evidence on the effectiveness of virtual reality simulators for experienced and novice surgeons in improving their hysteroscopic skills. Three types of hysteroscopic simulators were evaluated: Hyst Sim VR, Virtual Reality Uterine Resectoscopic Simulator, Essure Sim TM. Virtual reality simulators have been assessed to be highly relevant to reality and all surgeons attained significant improvements between their pre-test and post-test phases, independent of their previous level of experience, demonstrating more improvement among novices than experts. Available evidence supports the effectiveness of virtual simulators in increasing the diagnostic and surgical skills of gynaecologists, independent from their starting level of expertise.

Essentials in Minimally Invasive Gynecology Manual Skills Pilot Validation Trial.

STUDY OBJECTIVE: To evaluate the Essentials in Minimally Invasive Gynecology (EMIG)- Fundamentals of Laparoscopic Surgery Laparoscopic Simulation System and the EMIG Hysteroscopy Simulation System for face validity and functionality in a pilot testing environment. DESIGN: A prospective controlled pilot study. SETTING: Three teaching institutions in the US Southwest. SUBJECTS: Twenty-seven residents and gynecologists, with 22 fitting who fit 1 of 4 categories of exposure to hysteroscopic and laparoscopic surgery and surgical simulation. Eleven were postgraduate year 1 and 5 postgraduate year 3, 1 was American Board of Obstetrics & Gynecology certified, and 5 were either fellows in-training or had completed a fellowship in minimally invasive gynecologic surgery. INTERVENTIONS: After completing a screening survey, each subject was exposed to a structured orientation to the 2 simulation systems and then tested with proctor supervision on the 5 laparoscopic and 2 hysteroscopic exercises. A short 5-point Likert questionnaire designed to determine face validation and question clarity was administered to each subject at sites 2 and 3. MEASUREMENTS AND MAIN RESULTS: Face validity was high for each of the 7 exercises (means ranged from 4.8 to 4.9 of 5), and subjects considered instructions to be clear (means from 4.7 to 4.9). The recorded exercise times generally reduced with increasing levels of training, although the sample sizes were not designed to determine significance given the pilot design. Similarly, exercise errors were generally less frequent with increasing experience. The systems, including the devices and recording mechanisms, performed well, and proctor evaluation and training were satisfactory. CONCLUSION: The EMIG laparoscopic and hysteroscopic simulations systems were considered to have good face validity and appear to be suitable for a construct validation trial to confirm their utility in distinguishing among trainees and practitioners with a wide spectrum of endoscopic surgical experience. The recording and specimen storage mechanisms will allow for multiple proctors to rate a candidate's performance, thereby enhancing evaluation consistency and quality.

Variability in gynecologic case volume of obstetrician-gynecologist residents graduating from 2009 to 2017.

BACKGROUND: Residency training in obstetrics-gynecology has changed significantly over time, with residents expected to master an increasing number of surgical procedures. Residency operative case logs are tracked by the Accreditation Council for Graduate Medical Education, which sets case minimums for all procedures. In 2018, the Accreditation Council for Graduate Medical Education created a combined minimally invasive hysterectomy category and now requires graduating residents to complete a minimum of 70 minimally invasive hysterectomies. OBJECTIVES: The objectiges of the study were to evaluate the range of operative gynecological experience across graduating obstetrician-gynecologist residents in the United States and to estimate the number of residents able to meet new Accreditation Council for Graduate Medical Education minimum hysterectomy cases. STUDY DESIGN: Accreditation Council for Graduate Medical Education surgical case logs of graduating obstetrician-gynecologist residents from 2009 to 2017 were analyzed for case volume trends. RESULTS: The average total number of gynecological cases per resident decreased from 438.2 to 431.5 (P < .0001). Minimally invasive hysterectomy averages increased from 43.6 to 69.3 (P < .0001), a trend driven principally by an increase in total laparoscopic hysterectomies. Mean case log decreases were noted in invasive cancer (70.7 to 54.3), incontinence and pelvic floor (85.6 to 56.7), and total abdominal hysterectomies (74.4 to 42.9); (P < .0001 for all). Mean increases were seen in total laparoscopic (118.8 to 146.3) and operative hysteroscopy (68.6 to 77.1) cases (P < .0001 for all). The ratio of the 90th percentile to the 10th percentile of resident case logs showed substantial variation in surgical volume for all procedures, although this ratio decreased over time. Graduates who logged 70 minimally invasive hysterectomy cases were estimated to fall at the 51st percentile in 2017; this was down from the 91st percentile in 2009. CONCLUSION: Nationwide, graduates of obstetrician-gynecologist residency experience significant variability in their surgical training. Based on our extrapolation of Accreditation Council for Graduate Medical Education data, approximately half of residency graduates fell below the 70 case minimally invasive hysterectomy minimum in 2017. Meeting the new Accreditation Council for Graduate Medical Education hysterectomy minimums may be challenging for a significant proportion of residency programs. Understanding the scope and variability of gynecology training is needed to continue to improve and address gaps in resident education.

Using virtual-reality simulation to ensure basic competence in hysteroscopy.

BACKGROUND: Hysteroscopy is a technically challenging procedure. Specialty curricula of obstetrics and gynaecology appraise hysteroscopy for trainees but there is no present evidence-based training program that certifies the fundamental technical skills before performance on patients. The objectives of this study were to develop and gather validity evidence for a simulation-based test that can ensure basic competence in hysteroscopy. METHODS: We used the virtual-reality simulator HystMentor™. Six experts evaluated the feasibility and clinical relevance of the simulator modules. Six modules were selected for the test and a pilot study was carried out. Subsequently, medical students, residents, and experienced gynaecologists were enrolled for testing. Outcomes were based on generated simulator metrics. Validity evidence was explored for all five sources of evidence (content, response process, internal structure, relations to other variables, consequences of testing). RESULTS: Inter-case reliability was high for four out of five metrics (Cronbach's alpha ≥ 0.80). Significant differences were identified when comparing the three groups' performances (p values < 0.05). Participants' clinical experience was significantly correlated to their simulator test score (Pearson's r = 0.49, p < 0.001). A single medical student managed to achieve the established pass/fail score (6.7% false positive) and three experienced gynaecologists failed the test (27.3% false negative). CONCLUSIONS: We developed a virtual-reality simulation-based test in hysteroscopy with supporting validity evidence. The test is intended to ensure competency in a mastery learning program where trainees practise on the simulator until they are able to pass before they proceed to supervised training on patients.

From the dry lab to the operating room: the first transferability study of hysteroscopic skills.

OBJECTIVE: The aim of this study is to prove that a short dry lab training prior to the surgery is efficient to acquire basic hysteroscopic skills and that these skills are transferable directly to the operation theater. METHODS: Thirty-nine gynecologists who never attended a training course or practiced hysteroscopy before were evaluated. Participants were randomly divided into trainees (n = 21) and control (n = 18). Trainees attended a short time dry lab prior the exposure to the OR. The controls went directly to the OR. Participants were asked to identify the different landmarks of the uterine cavity and to perform a punch biopsy under the supervision of a gynecologist expert in hysteroscopy. A video recording for all the exercises was done, and showed independently to two expert surgeons in hysteroscopy for evaluation. The experts were also asked to distinguish between the trainees and the control. RESULTS: For both experts, the trainees' performance was statistically better than that of the controls (p < 0.001) for the identification of the uterus land marks and the punch biopsy. The two experts identified 80.9 and 85.7%, respectively, of the trainees. The participants' subgroup ID and the experts' identification were statistically correlated (p < 0.001). CONCLUSION: A short time dry lab is efficient to acquire basic hysteroscopic skills and these skills are transferable directly to the OR.

Simulation for Training and Assessment in Hysteroscopy: A Systematic Review.

Hysteroscopy simulation complements conventional training on patients, yet evidence-based recommendations about its implementation and use are lacking. This systematic review analyzes and critically discusses hysteroscopy simulation literature published over the last 30 years. Systematic searches on PubMed, Embase, PsychINFO, ERIC, and the Cochrane Library produced 27 original articles published through 2017. Strategies based on different simulation models (e.g., animal organs, vegetables, synthetic uteri, virtual reality) were evaluated by users and appeared to facilitate learning. Observational studies have suggested a large impact on the knowledge and technical skills of novices for a wide range of hysteroscopic procedures, including for diagnosis, resection, and sterilization. Pretest/posttest studies show large improvements in performance time (6 studies; pooled effect size, 1.45; 95% confidence interval, 1.06-1.85) and overall performance scores (4 studies; pooled effect size, 3.19; 95% confidence interval, 1.45-4.94). Additionally, performance assessment on simulated models distinguishes novices from experts. Caution should be exercised because the available evidence largely originates from heterogeneous studies with weak designs, conducted in experimental settings with nonclinical participants (i.e., medical students). Moreover, neither clinical outcomes nor the clinical value of simulation-based assessment has been addressed. Hysteroscopy simulation may be supported ethically and pedagogically, but its role should be evaluated in pragmatic contexts, with robust interventional studies and broader competence-defining outcomes that include nontechnical skills.

Hysteroscopic resection on virtual reality simulator: What do we measure?

OBJECTIVE: The objective was to compare results of two groups of population (novices and experts) on a virtual reality simulator of hysteroscopy resection for different metrics and for a multimetric score to assess its construct validity. MATERIALS AND METHODS: Nineteen gynecologist who had at least 5 years of experience with hysteroscopy and self-evaluated their expertise at 4/5 or 5/5 were included as expert population. Twenty first-year gynecology residents in Paris were included as novice population. A standardized set of 4 hysteroscopy resection cases (polypectomy, myomectomy, roller ball endometrial ablation and septum resection) was performed on a virtual reality simulator (HystSim™) by the group of novices and experts. Results obtained on the simulator for overall score and for the parameters were compared by applying the Mann-Whitney test. RESULTS: Overall score of novices and experts were significantly different for three resection cases (polypectomy P<0.001, myomectomy P<0.001, roller ball endometrial ablation <0.001). The overall score was not different in the septum resection (P=0.456). For the four cases, the economy score (included cumulative path length, procedure time and camera alignment) were statistically different between novices and experts (polypectomy P<0.001, myomectomy P=0.001, roller ball endometrial ablation P<0.001, septum resection P<0.001). CONCLUSION: The overall score on HystSim™ was able to discriminate novices between experts on polypectomy, myomectomy and roller ball endometrial ablation cases but not on septum resection. The economy score was the more reliable to reflect the surgeon experience. It could be used to evaluate and to train students on hysteroscopic resection on a virtual reality simulator.

Standardizing hysteroscopy teaching: development of a curriculum using the Delphi method.

BACKGROUND: Hysteroscopy is performed often and in many indications but is challenging to learn. Hands-on training in live patients faces ethical, legal, and economic obstacles. Virtual reality simulation may hold promise as a hysteroscopy training tool. No validated curriculum specific in hysteroscopy exists. The aim of this study was to develop a hysteroscopy curriculum, using the Delphi method to identify skill requirements. METHODS: Based on a literature review using the key words "curriculum," "simulation," and "hysteroscopy," we identified five technical and non-technical areas in which skills were required. Twenty hysteroscopy experts from different French hospital departments participated in Delphi rounds to select items in these five areas. The rounds were to be continued until 80-100% agreement was obtained for at least 60% of items. A curriculum was built based on the selected items and was evaluated in residents. RESULTS: From November 2014 to April 2015, 18 of 20 invited experts participated in three Delphi rounds. Of the 51 items selected during the first round, only 25 (49%) had 80-100% agreement during the second round, and a third round was therefore conducted. During this last round, 80-100% agreement was achieved for 31 (61%) items, which were used to create the curriculum. All 14 residents tested felt that a simulator training session was acceptable and helped them to improve their skills. CONCLUSIONS: We describe a simulation-based hysteroscopy curriculum focusing on skill requirements identified by a Delphi procedure. Its development allows standardization of training programs offered to residents.

The role of simulation and warm-up in minimally invasive gynecologic surgery.

PURPOSE OF REVIEW: The purpose of the review is to update the reader on the current literature and recent studies evaluating the role of simulation and warm-up as part of surgical education and training, and maintenance of surgical skills. RECENT FINDINGS: Laparoscopic and hysteroscopic simulation may improve psychomotor skills, particularly for early-stage learners. However, data are mixed as to whether simulation education is directly transferable to surgical skill. Data are insufficient to determine if simulation can improve clinical outcomes. Similarly, performance of surgical warm-up exercises can improve performance of novice and expert surgeons in a simulated environment, but the extent to which this is transferable to intraoperative performance is unknown. Surgical coaching, however, can facilitate improvements in performance that are directly reflected in operative outcomes. SUMMARY: Simulation-based curricula may be a useful adjunct to residency training, whereas warm-up and surgical coaching may allow for maintenance of skill throughout a surgeon's career. These experiences may represent a strategy for maintaining quality and value in a lower volume surgical setting.

Cumulative summation test for learning curve (LC-CUSUM) in outpatient hysteroscopy.

OBJECTIVES: Outpatient hysteroscopy has become an integral part of postgraduate training in gynecology. It is an operator-dependent procedure, however there are no recommendations regarding total number of performed procedures to reach proficiency. MATERIAL AND METHODS: This study aimed to assess the learning curve (LC) using cumulative summation test for learning curve (LC-CUSUM). RESULTS: A success rate of 97% a failure rate ≥ 10% were established to denote an adequate and an inadequate performance. A third-year trainee needed 56 procedures to reach the predefined level of performance. CONCLUSIONS: As the length of the LC for outpatient hysteroscopy seems highly variable, it is reasonable to provide tailored monitoring while training.

Operative and diagnostic hysteroscopy: A novel learning model combining new animal models and virtual reality simulation.

CONTEXT: Hysteroscopy is one of the most common gynaecological procedure. Training for diagnostic and operative hysteroscopy can be achieved through numerous previously described models like animal models or virtual reality simulation. We present our novel combined model associating virtual reality and bovine uteruses and bladders. STUDY DESIGN: End year residents in obstetrics and gynaecology attended a full day workshop. The workshop was divided in theoretical courses from senior surgeons and hands-on training in operative hysteroscopy and virtual reality Essure® procedures using the EssureSim™ and Pelvicsim™ simulators with multiple scenarios. Theoretical and operative knowledge was evaluated before and after the workshop and General Points Averages (GPAs) were calculated and compared using a Student's T test. RESULTS: GPAs were significantly higher after the workshop was completed. The biggest difference was observed in operative knowledge (0,28 GPA before workshop versus 0,55 after workshop, p<0,05). All of the 25 residents having completed the workshop applauded the realism an efficiency of this type of training. The force feedback allowed by the cattle uteruses gives the residents the possibility to manage thickness of resection as in real time surgery. Furthermore, the two-horned bovine uteruses allowed to reproduce septa resection in conditions close to human surgery CONCLUSION: Teaching operative and diagnostic hysteroscopy is essential. Managing this training through a full day workshop using a combined animal model and virtual reality simulation is an efficient model not described before.

Assessing Resident Surgical Volume Before and After Initiation of a Female Pelvic Medicine and Reconstructive Surgery Fellowship.

OBJECTIVES: The effect of fellowship programs on resident training for gynecologic surgery volume has not been clearly defined. The purpose of our study is to assess resident surgical volume for laparoscopic and vaginal hysterectomy before and after initiation of a female pelvic medicine and reconstructive surgery (FPMRS) fellowship. DESIGN: A retrospective review of Accreditation Council for Graduate Medical Education Resident Case Logs of obstetrics and gynecology residents who graduated in the 3 years before and after initiation of a FPMRS fellowship was performed. Mean values of vaginal and laparoscopic hysterectomies were compared using two-tailed t-tests with statistical significance set at p < 0.05. SETTING: Obstetrics and gynecology resident case logs at the Ronald Reagan University of California Los Angeles (UCLA) Medical Center were assessed. The UCLA Medical Center, located in Los Angeles, CA, is a tertiary referral center with a graduating class of 7 obstetrics and gynecology residents yearly. PARTICIPANTS: Obstetrics and gynecology residents who graduated from residency 3 years before and after imitation of a FPMRS fellowship were included. In the 3 years before the start of the fellowship, 20 residents graduated, whereas 21 residents graduated after the start of the fellowship. RESULTS: Residents who graduated in the 3 years after the start of the FPMRS fellowship, finished with 4.6 less vaginal hysterectomies compared with residents who graduated before the fellowship (p = 0.022). Residents who graduated in the 3 years after the start of the FPMRS fellowship finished with 3.2 more laparoscopic hysterectomies compared with residents who graduated before the fellowship although this was not significant (p = 0.25). CONCLUSIONS: Resident surgical volume was significantly decreased for vaginal hysterectomy after the initiation of a FPMRS fellowship, whereas laparoscopic hysterectomy volume was not significantly changed. Longer follow-up and a national assessment are necessary to determine the broader effect of fellowship training on resident surgical experience.

Integration and Validation of Hysteroscopy Simulation in the Surgical Training Curriculum.

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.

Training and Assessment of Hysteroscopic Skills: A Systematic Review.

OBJECTIVE: The aim of this systematic review was to identify studies on hysteroscopic training and assessment. DESIGN: PubMed, Excerpta Medica, the Cochrane Library, and Web of Science were searched in January 2015. Manual screening of references and citation tracking were also performed. Studies on hysteroscopic educational interventions were selected without restrictions on study design, populations, language, or publication year. A qualitative data synthesis including the setting, study participants, training model, training characteristics, hysteroscopic skills, assessment parameters, and study outcomes was performed by 2 authors working independently. Effect sizes were calculated when possible. Overall, 2 raters independently evaluated sources of validity evidence supporting the outcomes of the hysteroscopy assessment tools. RESULTS: A total of 25 studies on hysteroscopy training were identified, of which 23 were performed in simulated settings. Overall, 10 studies used virtual-reality simulators and reported effect sizes for technical skills ranging from 0.31 to 2.65; 12 used inanimate models and reported effect sizes for technical skills ranging from 0.35 to 3.19. One study involved live animal models; 2 studies were performed in clinical settings. The validity evidence supporting the assessment tools used was low. Consensus between the 2 raters on the reported validity evidence was high (94%). CONCLUSIONS: This systematic review demonstrated large variations in the effect of different tools for hysteroscopy training. The validity evidence supporting the assessment of hysteroscopic skills was limited.

Evaluation of the HystSim™-virtual reality trainer: an essential additional tool to train hysteroscopic skills outside the operation theater.

BACKGROUND: Minimally invasive surgery is a major pillar of gynecological surgery. However, there are very few training opportunities outside the operation theater (OR) due to the cost and equipment requirements of organ simulators, virtual reality trainers (VRT) are promising tools to fill this gap. METHODS: Experienced and inexperienced participants of a minimally invasive surgery course followed the standardized HystSim™-VRT training program. RESULTS: Performance of 39 Participants (15 inexperienced and 24 experienced) was evaluated in the standardized hysteroscopic program HystSim™. Tasks included three rounds of both a polyp and a myoma resection. Primary measurements were improvement in resection time, cumulative resection path length, and distention media use. CONCLUSION: The HystSim™-VRT is an effective tool to improve the psychomotor skills needed in hysteroscopic surgery for experienced and inexperienced surgeons prior to OR exposure. Additional organ models training is advisable for hysteroscopic haptic skills.

[Contribution of a virtual hysteroscopic simulator in the learning of hysteroscopic myoma resection]. / Apport d'un simulateur d'hystéroscopie virtuelle dans l'apprentissage de la résection hystéroscopique de fibrome.

OBJECTIVES: Uterine myomas are a frequent pathology affecting 20% of women of reproductive age. Myomas induce abnormal uterine bleeding, pelvic pain and increase the risk of infertility and obstetrical complications. Symptomatic sub-mucosal myomas are classically treated by hysteroscopic resection. Simulation is a method of education and training. It could improve quality and security of cares. The aim of this study is to assess the interest of a hysteroscopic simulator for the resection of myoma by novice surgeons. METHODS: Twenty medical students were recruited, in a prospective study, in august 2014. The virtual-reality simulator VirtaMed HystSim™ (VirtaMed AG, Zurich, Switzerland) was used to perform the hysteroscopic training. All students received a short demonstration of myoma resection. The practice consists of a submucous myoma type 0 resection. The procedure and the evaluation were performed before and after a specific training in hysteroscopic resection of sixty minutes long. The main outcome criteria were time for the resection before and after training. The second criteria were fluid quantity used, number of contact between optic and uterine cavity and uterine perforation. RESULTS: Twenty students aged from 22 to 24 years were included. The time for the procedure was significantly reduced after training (170s versus 335s, P<0.01). There is the same for fluid quantity used (335 mL versus 717mL, P<0.01) and the number of contact between optic and uterine cavity (0.2 contact versus 3, P=0.012). No perforation occurred in the simulation. CONCLUSION: The results suggest that hysteroscopic simulator enhances and facilitates hysteroscopic resection for novice surgeons.