Assessment of a Low-cost Canine Uterine Simulator as a Tool for Teaching the Ovariohysterectomy Technique to Veterinary Students.

The acquisition of skills to perform an ovariohysterectomy (OVH) is crucial for veterinary medicine students. It has been demonstrated that the most effective way to develop these skills is through repetitive training on simulators. Unfortunately, commercial simulators are expensive, limiting their use and highlighting the need for the development of more cost-effective alternatives. This study aimed to assess the effectiveness of a low-cost, easily constructed textile-based simulator for the canine ovaries and uterus in training veterinary students on the OVH technique. The impact of tutor guidance on student learning was also assessed. Participants were divided into two groups: simulator and tutor guidance (SG) and simulator only (SO). Each student performed 20 repetitions of the three-clamp OVH technique, and the number of errors and execution time were quantified. The SG group reached the learning curve plateau in terms of minimum errors on the 7th repetition and attained the fastest time on the 6th repetition. The SO group reached the learning curve plateau in terms of minimum errors and attained the fastest time both on the 15th repetition. From individuals in the SG group, there were no requests for tutor guidance from the 11th attempt. This low-cost simulator is ideal for training veterinary students in the early stages of surgical learning, as it effectively facilitates learning the OVH procedure without the use of live animals.

Guidelines for Implementing a Low-Cost Volunteer Desexing Skills Training Program for Veterinary and Veterinary Technology Students.

Although desexing surgeries are considered a core clinical skill for small animal veterinary practice, it can be challenging for veterinary schools to provide students with adequate training opportunities in the traditional curriculum. At the Massey University School of Veterinary Science, we recently established an innovative extracurricular volunteer program designed to have students teaching other students how to perform different elements of desexing procedures as they progress through their degree. This program includes administrative and assistant roles for first-year students (responsible for client communication, patient restraint, and medical record keeping), physical exam and recovery roles for second-year students (responsible for assessing patient fitness for surgery, drawing up anesthetic drugs, and monitoring patients in recovery), anesthesia and neuter surgeon roles for third-year students (responsible for inducing, preparing, and monitoring spay patients and performing cat neuter surgeries), and spay surgeon roles for fourth- and fifth-year students (responsible for performing cat spay surgeries, discharging patients, and following up with clients to monitor recovery). This program has been successful in improving student confidence and competence while also providing a valuable low-cost desexing service to the community. In this article, we discuss the practical considerations and processes involved in implementing this program, including mapping the existing surgical curriculum, recruiting patients, setting up the surgical facilities, purchasing equipment and supplies, establishing standard operating procedures, developing training materials, maintaining clinic records, and monitoring program outcomes. These resources can serve as guidelines for other veterinary schools looking to expand desexing surgery training opportunities for students.

Learning curve of high-complexity surgery for advanced ovarian cancer.

OBJECTIVE: We investigated the learning curve for a monodisciplinary surgical team consisting of gynecologic oncologists performing cytoreductive surgery for advanced ovarian cancer, involving high-complexity procedures with bowel resection and upper abdominal surgery. METHODS: We investigated 271 consecutive patients with ovarian, fallopian tube, and peritoneal carcinoma undergoing cytoreductive surgery for stage III/IV disease. All operations were performed by a team consisting of only gynecologic oncologists. Patients were classified into 2 groups depending on the surgical complexity score (a cumulative score based on complexity and number of procedures performed). Learning curves for patients with moderate (4-7, 63 patients) and high scores (8-18, 208 patients) were evaluated using cumulative sum (CUSUM) analysis of operative time, total blood loss, and perioperative complications. RESULTS: Operative time and total blood loss showed a learning curve. The CUSUM curve for operative time peaked at the 28th and 51st case in the moderate- and high-score groups, respectively. The CUSUM curve for total blood loss peaked at the 16th and 55th case in the moderate- and high-score groups, respectively. The CUSUM curve for complications (Clavien-Dindo ≥ IIIb) showed a downward slope after the 6th case in the high-score group and remained within the acceptable range throughout the study. CONCLUSION: Proficiency in performing high-complexity surgery was achieved after approximately 50 cases and this number is greater than the number of cases required to perform moderate-complexity surgery. Acceptable rates of severe perioperative complications were observed even during the initial learning period in cases of high-complexity surgery.

Improved laparoscopic skills in gynaecology trainees following a simulation-training program using take-home box trainers.

BACKGROUND: Lack of time and access to equipment are recognised barriers to simulation training. AIM: To investigate the effect of a take-home laparoscopic simulator training program on the laparoscopic skills of gynaecology trainees. METHOD: Participants (n = 17 in 2015, n = 16 in 2016) were supplied with a box trainer, associated equipment and instructions on self-directed training. A program was designed and implemented in 2015 comprising of ten weekly laparoscopic skills tasks and modified in 2016 to eight monthly tasks. Half of the participants were randomly allocated a supervisor. Participants performed baseline and post-training assessments of laparoscopic skills in a box trainer task (thread transfer) and virtual reality simulator tasks (laparoscopic tubal ligation and bilateral oophorectomy). RESULTS: Trainees in 2015 demonstrated an improvement in the median time to complete the laparoscopic tubal ligation task (baseline 124 s vs post-training 91 s, P = 0.041). There was no difference in the number of tubal ligation bleeding incidents, or in the time taken to complete the box trainer thread transfer task. In 2016 trainees demonstrated improvement in tubal ligation time (baseline 251 vs 71 post-training, P = 0.021) and bilateral oophorectomy time (baseline 891 s vs 504 post-training, P = 0.025). There was no significant difference in other outcome measures. There was no difference found in performance when groups were compared by supervisor allocation. CONCLUSION: A take-home box trainer simulation-training program was associated with improvement in laparoscopic skills. This type of program may improve trainee access to simulation training.

Experience and confidence of final year veterinary students in performing desexing surgeries.

AIMS: To describe the level of experience and confidence of veterinary students in performing canine and feline desexing procedures at the end of their final clinical year. METHOD: A cross-sectional survey was conducted with veterinary students at Massey University in November 2017 after completion of their final clinical year. The questions included career plans after graduation, number of assisted and unassisted desexing procedures performed, approximate time to complete desexing surgeries, level of confidence with different aspects of desexing surgeries, what aspects of their desexing surgery training were most helpful, and what could be done to improve training in desexing surgical skills in veterinary school. RESULTS: The survey was completed by 70/95 (74%) students in their final clinical year. Among respondents, 55/70 (70%) had performed >2 unassisted feline neuters before graduation. However 38/70 (54%) students had never performed an unassisted feline spay, 31/70 (44%) had never performed an unassisted canine neuter, and 44/70 (63%) students had never performed an unassisted canine spay. The median reported times to complete a feline neuter, feline spay, canine neuter, and canine spay were 9, 40, 30 and 60 minutes, respectively. The median level of confidence for these procedures were 9, 6, 7 and 5 (on a scale from 1=least confident to 10=most confident), respectively. The reported time to complete procedures and the confidence in performing procedures did not change markedly with increasing total number of procedures performed. Students were most concerned about their ability to perform the desexing procedures in a reasonable amount of time and to prevent post-operative bleeding from occurring. Students were least concerned with their ability to manage post-operative pain in patients and to select the appropriate suture material. Free-text comments revealed that 62/70 (89%) students wanted more hands-on surgical experience prior to graduation. CONCLUSION AND CLINICAL RELEVENCE: Many students are currently completing veterinary school with limited experience and low confidence with performing routine canine and feline desexing procedures. Further research is needed to identify the most effective ways for addressing this issue within the constraints of the veterinary curriculum and teaching hospital resources.

Veterinary Student Confidence after Practicing with a New Surgical Training Model for Feline Ovariohysterectomy.

Lack of confidence and self-efficacy are the main causes of negative emotions experienced by veterinary students when performing surgery. A surgical training model (STM) was developed to test the hypothesis that practical training on an STM before performing live surgery would enhance the students' confidence. In addition, low-cost and easily accessible materials were used for the construction. In the STM, neodymium magnets that were detached if too much traction was applied were used to ensure careful tissue handling during ligation of the ovarian pedicles and cervix. A pilot study was performed to evaluate veterinary undergraduate students' confidence when using the STM before performing their first live feline ovariohysterectomy (OHE) as lead surgeon. The results showed that the students rated their confidence level higher after performing feline OHE if they had practiced with the STM before surgery. Voluntary written comments revealed that live surgery as a learning situation could have a very negative emotional impact on some students.

Evaluation of Veterinary Student Surgical Skills Preparation for Ovariohysterectomy Using Simulators: A Pilot Study.

This paper describes the development and evaluation of training intended to enhance students' performance on their first live-animal ovariohysterectomy (OVH). Cognitive task analysis informed a seven-page lab manual, 30-minute video, and 46-item OVH checklist (categorized into nine surgery components and three phases of surgery). We compared two spay simulator models (higher-fidelity silicone versus lower-fidelity cloth and foam). Third-year veterinary students were randomly assigned to a training intervention: lab manual and video only; lab manual, video, and $675 silicone-based model; lab manual, video, and $64 cloth and foam model. We then assessed transfer of training to a live-animal OVH. Chi-square analyses determined statistically significant differences between the interventions on four of nine surgery components, all three phases of surgery, and overall score. Odds ratio analyses indicated that training with a spay model improved the odds of attaining an excellent or good rating on 25 of 46 checklist items, six of nine surgery components, all three phases of surgery, and the overall score. Odds ratio analyses comparing the spay models indicated an advantage for the $675 silicon-based model on only 6 of 46 checklist items, three of nine surgery components, and one phase of surgery. Training with a spay model improved performance when compared to training with a manual and video only. Results suggested that training with a lower-fidelity/cost model might be as effective when compared to a higher-fidelity/cost model. Further research is required to investigate simulator fidelity and costs on transfer of training to the operational environment.

The positive impact of structured teaching in the operating room.

BACKGROUND: A survey of obstetric and gynaecology trainees in Australia found the trainee's opinion of the consultants' teaching ability for laparoscopic procedures and procedures dealing with complications as 'poor' in 21.2% and 23.4% of responses, respectively (Aust NZ J Obstet Gynaecol 2009; 49: 84). Surgical caseload per trainee is falling for a variety of reasons. Strategies need to be adopted to enhance the surgical learning experience of trainees in the operating room. AIMS: We describe the use of a structured encounter template to facilitate the teaching of surgery in the operating room and report the response of the trainees to this intervention. METHODS: Trainees attached to a gynaecologic surgery unit all underwent surgical training using a set format based on the surgical encounter template, including briefing, goal setting and intra-operative teaching aims as well as debriefing. Data on the trainees' experience and perception of their learning experience were then collected and analysed as quantitative and qualitative data sets. RESULTS: The trainees reported satisfaction with the use of a structured encounter template to facilitate the surgical teaching in the operating room. Some trainees had not received such clarity of feedback or the opportunity to complete a procedure independently prior to using the structured encounter template. CONCLUSIONS: A structured surgical encounter template based on andragogy principles to focus consultant teaching in the operating room is highly acceptable to obstetric and gynaecology trainees in Australia. Allowing the trainee the opportunity to set objectives and receive feedback empowers the trainee and enhances their educational experience.

Introducing a laparoscopic simulation training and credentialing program in gynaecology: an observational study.

BACKGROUND: Simulation training in laparoscopic surgery has been shown to improve surgical performance. AIMS: To describe the implementation of a laparoscopic simulation training and credentialing program for gynaecology registrars. MATERIALS AND METHODS: A pilot program consisting of protected, supervised laparoscopic simulation time, a tailored curriculum and a credentialing process, was developed and implemented. Quantitative measures assessing simulated surgical performance were measured over the simulation training period. Laparoscopic procedures requiring credentialing were assessed for both the frequency of a registrar being the primary operator and the duration of surgery and compared to a presimulation cohort. Qualitative measures regarding quality of surgical training were assessed pre- and postsimulation. RESULTS: Improvements were seen in simulated surgical performance in efficiency domains. Operative time for procedures requiring credentialing was reduced by 12%. Primary operator status in the operating theatre for registrars was unchanged. Registrar assessment of training quality improved. CONCLUSIONS: The introduction of a laparoscopic simulation training and credentialing program resulted in improvements in simulated performance, reduced operative time and improved registrar assessment of the quality of training.

The SimSpay-Student Perceptions of a Low-Cost Build-It-Yourself Model for Novice Training of Surgical Skills in Canine Ovariohysterectomy.

Practical and ethical considerations have led to an increased use of artificial substitutes for live animals in veterinary surgical skills training. However, commercially produced models are expensive and homemade models often require full-time staff to produce enough models for training large groups of students. In the Department of Veterinary Clinical and Animal Sciences of the University of Copenhagen, a low-cost build-it-yourself model, the SimSpay, was developed for novice training of surgical skills in canine ovariohysterectomy. The model did not require the use of trained technical staff or costly, hard-to-source supplies. The SimSpay was developed and implemented in the clinical veterinary curriculum in 2013. In 2014, 54 students participated in a questionnaire study to investigate their perception of the usefulness of the SimSpay as a learning tool. On a five-point Likert-type scale, students were asked to rate their perceived levels of competence, confidence, and anatomic knowledge before and after SimSpay training. Results demonstrate a strongly significant (p<.0001) increase in all three areas after training on the SimSpay. By increasing students' perceived levels of competence, confidence, and anatomic knowledge, the low-fidelity SimSpay is a useful, low-cost learning tool for teaching ovariohysterectomy.

Teaching veterinary anesthesia and surgery: the impact of instructor availability on anesthesia, operative, and recovery times in dogs undergoing ovariohysterectomy or castration.

Veterinary students learning to perform elective ovariohysterectomy (OVH) and castration procedures have traditionally been taught by a few instructors supervising many student groups simultaneously. This study, using a historical control group, explored the impacts of having a dedicated instructor with each student group for anesthetic induction and an entire surgical procedure. Our hypothesis was that preparation, surgical, and anesthesia times would be shorter and, consequently, post-operative recovery times would be shorter with a dedicated instructor compared to traditional methods. Anesthesia records of dogs undergoing elective surgery by third-year veterinary students were reviewed over 3 consecutive years. Traditional instruction was used in year 1 (Y1), and a dedicated instructor per student group was used in year 2 (Y2) and year 3 (Y3). Anesthesia time, surgical time, recovery time, and pre- and post-operative rectal temperature were analyzed, and a stepwise regression model was developed for factors influencing recovery time. Of 206 records reviewed (Y1, 33; Y2, 98; Y3, 75), there were 101 OVH procedures and 105 castration procedures. Preparation, surgery, and anesthesia times were longer in animals undergoing surgery in Y1, when the traditional instruction method was used. Recovery time was not influenced by instructor assignment. Using dedicated instructors to teach OVH and castration to third-year veterinary students decreased overall anesthesia time by 36 to 49 minutes for OVH and 29 to 32 minutes for castration. A teaching model of dedicated instructors requires excellent coordination between surgeons and anesthesiologists to ensure that a similar number of animals can undergo procedures in the time allotted for teaching.

Successful incorporation of robotic surgery into gynecologic oncology fellowship training.

BACKGROUND: The increasing role of robotic surgery in gynecologic oncology may impact fellowship training. The purpose of this study was to review the proportion of robotic procedures performed by fellows at the console, and compare operative times and lymph node yields to faculty surgeons. METHODS: A prospective database of women undergoing robotic gynecologic surgery has been maintained since 2008. Intra-operative datasheets completed include surgical times and primary surgeon at the console. Operative times were compared between faculty and fellows for simple hysterectomy (SH), bilateral salpingo-oophorectomy (BSO), pelvic (PLND) and paraaortic lymph node dissection (PALND) and vaginal cuff closure (VCC). Lymph nodes counts were also compared. RESULTS: Times were recorded for 239 SH, 43 BSOs, 105 right PLNDs, 104 left PLNDs, 34 PALND and 269 VCC. Comparing 2008 to 2011, procedures performed by the fellow significantly increased; SH 16% to 83% (p<0.001), BSO 7% to 75% (p=0.005), right PLND 4% to 44% (p<0.001), left PLND 0% to 56% (p<0.001), and VCC 59% to 82% (p=0.024). Console times (min) were similar for SH (60 vs. 63, p=0.73), BSO (48 vs. 43, p=0.55), and VCC (20 vs. 22, p=0.26). Faculty times (min) were shorter for PLND (right 26 vs. 30, p=0.04, left 23 vs. 27, p=0.02). Nodal counts were not significantly different (right 7 vs. 8, p=0.17 or left 7 vs. 7, p=0.87). CONCLUSIONS: Robotic surgery can be successfully incorporated into gynecologic oncology fellowship training. With increased exposure to robotic surgery, fellows had similar operative times and lymph node yields as faculty surgeons.

Learning curves for single-site laparoscopic ovarian surgery.

STUDY OBJECTIVE: To compare learning curves for laparoendoscopic single-site surgery (LESS) for ovarian tumors according to the type of procedure (oophorectomy vs cystectomy). DESIGN: A prospective cohort study. (Canadian Task Force Classification II-2). SETTING: University hospital. PATIENTS: One hundred fifteen patients who planned to undergo LESS for ovarian tumors by a surgeon between May 2008 and August 2010. INTERVENTIONS: LESS. MEASUREMENTS AND MAIN RESULTS: The learning curve was assessed through the graph between the operative time and sequence of cases. Proficiency, defined as the point at which the slope of the learning curve became less steep, and surgical outcome were compared between the two surgery groups. LESS was successfully completed in 103 of 115 patients (94.8%). Learning curve for oophorectomies (n = 59) showed a continued slow slope with no apparent proficiency, suggesting oophorectomies did not pose an initial technical challenge. However, proficiency in cystectomies (n = 56) was evident at the thirty-third case. Furthermore, the oophorectomy group had a shorter operative time and less need for additional ports than the cystectomy group (69.4 minutes vs 100.1 minutes; 5.1% vs 14.3%). CONCLUSION: Oophorectomy rather than cystectomy is recommended as the initial procedure to start with LESS for ovarian tumors.

Post fellowship training in "new-to-them" surgical techniques: assessment of learning curve characteristics.

OBJECTIVE: To evaluate surgically related quality outcomes during the learning curve for board-certified or board-eligible gynecologic oncologists developing "new-to-them" surgical techniques. METHODS: The study design was a retrospective review of patients with endometrial cancer clinically limited to the uterus and/or cervix undergoing TLH-BSO or TAH-BSO, aortic and pelvic lymphadenectomy(APLNDx), peritoneal washings with/without omentectomy from May 1996 to April /2006. A "senior" surgeon taught three board-certified or board-eligible gynecologic oncologists a "new-to-them" technique to perform both TLH-BSO and TAH-BSO with APLNDx using argon beam coagulation and endoscopic staplers in patients with early-stage endometrial cancer. The main outcome measures were: a) length of surgery; b) surgical measures, e.g. lymph node count; and c) peri-operative morbidity. A comparison of outcomes with the "senior" surgeon was undertaken. The learning curve characteristics were analyzed by ANOVA and curve estimate analysis. RESULTS: The mean operative times associated with learning a new technique to perform TLH-BSO with APLNDx and TAH-BSO with APLNDx were 155.39+/-26.32 and 102.28+/-34.22 min, respectively, with significant improvement after 20 cases (150.27+/-26.68 vs. 172.30+/-22.28, p=0.030) and 30 cases (93.30+/-24.97 vs. 124.63+/-29.73, p=0.030), respectively. Intra- and peri-operative morbidity and lymph node count were unaffected by experience. CONCLUSION: While mean operative times decreased, outcome measures of surgical quality were not adversely affected during the learning curve for post-fellowship training while acquiring "new-to-them" surgical techniques. This study emphasizes the need for "senior" surgical supervision during the initial training period. The results of this study are likely transferable to fellowship-trained gynecologic oncologists learning other "new-to-them" surgical techniques and procedures.

Evaluation of the learning curve for natural orifice transluminal endoscopic surgery: bilateral ovariectomy in dogs.

OBJECTIVE: Study the learning curve for canine Natural Orifice Transluminal Endoscopic Surgery (NOTES) ovariectomy by evaluating operative times and complications. STUDY DESIGN: Preclinical research study. ANIMALS: Adult female dogs (n=20). METHODS: NOTES ovariectomy procedures were performed as follows: Feasibility Group 1 (n=5), Feasibility Group 2 (n=5), and Early Clinical Group 3 (n=10). Six steps of the procedure were identified, timed separately, and the overall time was recorded from introduction to removal of the endoscope. Complications were recorded. Repeated measures analysis of variance using ranked data compared the effect of group (3 levels) on the time for each step. Nonlinear regression using an exponential model with nonzero asymptote was used to model the operative time-procedure number relationship. RESULTS: Overall median operative time was significantly longer for Group 1 (195 minutes; range, 160-265 minutes) than Group 2 (108 minutes; range, 81-148 minutes; P=.048) and Group 3 (77 minutes; range, 41-136 minutes; P=.0008). The estimated asymptotic operative time was 71 minutes (95% confidence interval, 41-100 minutes); this time was reached after 10 procedures. Gastric cleansing and removing the left ovary took significantly longer in Group 1 than in Group 2 or 3. Operative complications included incomplete ovarian excision, dropping an ovary during retrieval, and conversion to an open procedure. No intraoperative complications occurred in Group 3. CONCLUSION: NOTES procedures result in longer operative times in the early part of the learning curve and require considerable experience before reaching proficiency.

New strategies in ovarian cancer: uptake and experience of women at high risk of ovarian cancer who are considering risk-reducing salpingo-oophorectomy.

Here, we review factors associated with uptake of risk-reducing salpingo-oophorectomy by women at increased hereditary risk for ovarian cancer, as well as quality of life issues following surgery. Forty-one research studies identified through PubMed and PsychInfo met inclusion criteria. Older age, having had children, a family history of ovarian cancer, a personal history of breast cancer, prophylactic mastectomy, and BRCA1/2 mutation carrier status increase the likelihood of undergoing surgery. Psychosocial variables predictive of surgery uptake include greater perceived risk of ovarian cancer and cancer-related anxiety. Most women report satisfaction with their decision to undergo surgery and both lower perceived ovarian cancer risk and less cancer-related anxiety as benefits. Hormonal deprivation is the main disadvantage reported, particularly by premenopausal women who are not on hormonal replacement therapy (HRT). The evidence is mixed about satisfaction with the level of information provided prior to surgery, although generally, women report receiving insufficient information about the pros and cons of HRT. These findings indicate that when designing decision aids, demographic, medical history, and psychosocial variables need to be addressed in order to facilitate quality decision making.