Abstract
Background: Laparoscopic hysterectomy gained popularity over time; however, the literature on costs, postoperative pain, and healthcare resource utilization still favored the vaginal approach. Despite the surgical benefits of vaginal hysterectomy, the rates of vaginal hysterectomy have decreased over the years. Decreasing rates of vaginal hysterectomy have been attributed to multiple factors, which prohibit effective resident training. Such factors include, but are not limited to, access to the operative fields while the patient is in lithotomy, the need for tactile appreciation of structures, and ubiquitous access to laparoscopic surgical tools. Residency graduates do not feel competent in their vaginal hysterectomy skills, and as a result are less likely to offer this surgical approach. In one cohort of recent Obstetrics and Gynecology graduates, individuals reported that 16.1% of the hysterectomies they performed were vaginal. Gressel et al. reported increased difficulty for residents seeking exposure to abdominal and vaginal approaches, accompanied by an increase in laparoscopic hysterectomies. Despite decreased rates of abdominal and vaginal hysterectomies, the Accreditation Council for Graduate Medical Education (ACGME) requires 15 cases for each hysterectomy. Our aim was to create a vaginal hysterectomy simulator that would enable Obstetrics and Gynecology trainees to practice the pertinent steps and identify tactile landmarks utilized in a vaginal hysterectomy.
Methods: The HystAssist utilized the following components: a bony pelvis housed in a plastic shell, a silicone external genitalia component, and a replaceable internal genitalia component. The bony pelvis provided the structure and bony landmarks for the simulator and fixation of ligaments. The external genitalia component provided a realistic surgical view. The internal genitalia included the cervix, uterus, broad ligament, utero-ovarian ligaments, fallopian tubes, and ovaries. These components were modeled in computer aided design (CAD) to create the negative impressions for molds. By consolidating the components into an internal genitalia mold, our team created multiple, identical silicone models. To validate our design criteria, we performed consumer testing on residents, the consumers who would be most frequently in contact with our product. A preliminary iteration of the model was shared with PGY-2 Obstetrics and Gynecology residents at Carle Foundation Hospital. Residents answered survey questions using a Likert scale.
Results: To evaluate the HystAssist accuracy, a survey with quantitative questions utilizing Likert scale and open-ended qualitative questions was created. Our preliminary validation performed with two PGY-2 Obstetrics and Gynecology residents. Our responses averaged greater than three, a neutral response. Two questions received a below average response regarding the ability to perform instrumentation on the pelvic ligaments and the likelihood that the trainee would recommend the HystAssist to fellow residents. In assessing the qualitative feedback, these two questions highlighted the central point for improvement in our design: improved pelvic ligament fixation. Improving our pelvic ligaments would improve the fidelity of the procedure sequence and, thus, the fidelity of our model. We hope to continue providing trainees with the opportunity to test our model and provide feedback with the standardized questions. From this, we can continue to iterate and improve the HystAssist.
Qualitative questions were also included in the survey. Through these open-ended questions, we discovered that trainees prefer increased similarity to the anatomy for the pelvic ligaments, which would allow trainees to better understand the sequence and skill necessary to perform a vaginal hysterectomy. Additionally, a larger vaginal opening was requested to improve cervical visualization. While our anterior and posterior fornices are appropriate for training and creating an initial colpotomy, improved silicone layering internally to create anterior and posterior tissue planes would benefit the uterus’s excision.
Conclusion: HystAssist is in the process of meeting its intended purpose as a vaginal hysterectomy simulator. Its current iteration models the pertinent pelvic anatomy and allows Obstetrics and Gynecology residents to practice the preliminary steps of the vaginal hysterectomy. These qualities were validated by trainees in the field. Our device has an internal genitalia component that can be inserted into the external pelvic device. This practice is consistent with the current gold standard of simulators which employ porcine biologic tissues disposed of after a single use. Additionally, our current product can be used in different external models. The cost-effectiveness and reproducibility of our internal genitalia model meet our requirement of creating a device that costs less than current vaginal hysterectomy training models.
While the visual and tactile function of our product has met the preliminary requirements, honing in the sequence of the case and creating a tissue plane encasing the internal genitalia are two points for improvement that would revitalize our design. Improvements to the internal genitalia model would allow us to improve trainee access to practicing the main steps of the vaginal hysterectomy.