Simulation Training in Hysteroscopic Surgery

Abstract

Hysteroscopy detects uterine cavity pathology by direct visualisation of the endometrial lining, making use of a vaginally inserted endoscope. The additional insertion of an instrument through the endoscope provides the opportunity for obtainment of histology and treatment of pathologies, and for sterilisation of women. It is therefore an essential diagnostic and therapeutic tool in the current practice of gynaecology. Even though hysteroscopic skills are often perceived to be less complicated in comparison to laparoscopy, they are far from innate abilities. Psychomotor skills and spatial abilities need to be trained to overcome the barriers that are known for endoscopy in general and for hysteroscopy in particular. Training without involvement of a patient is increasingly valued and implemented in residency for various disciplines in endoscopic surgery. Parts of the technical learning curve can be overcome outside the patient setting, in order to decrease errors and time when the patient is involved. Laparoscopy is the main example, but simulators are also being used for robotic surgery, colonoscopy, bronchoscopy and cystoscopy. It seems illogical and unethical to let novices train all competencies from the start with involvement of patients, when there are models and manners to simulate the procedure outside the patient setting. However, the development, validation and use of hysteroscopic training models seem to lag far behind in daily practice. In this thesis we investigated various aspects of simulation training in hysteroscopic surgery. Our survey demonstrated that in the Netherlands the residency training for basic hysteroscopic procedures is judged as adequate. However, gynaecologists pointed at simulation training as the most important factor that could be enhanced for optimal acquirement of hysteroscopic skills. A comparative study showed that camera navigation in hysteroscopy and laparoscopy should be trained separately to reach adequate levels of expertise for each procedure. A plastic model (box trainer) provides a relatively inexpensive, simple and reusable facility for skills training, but limited realism can be a drawback. Our study on a new box trainer for hysteroscopic camera navigation indicated an adequate training capacity and construct validity. A virtual reality simulator has the additional advantage of procedural training and provides objective feedback of performance. Disadvantages can be the relatively high costs and lack of haptic feedback. In two studies, we validated a new training module for hysteroscopic sterilisation. Realism and training capacity were awarded with high scores, while the construct validity and learning curves showed moderate results. In a multicentre study, we investigated the clinical learning curve of expert gynaecologists for a new hysteroscopic procedure. The results indicated that it seem unlikely for experts to benefit from simulation training. It is therefore only recommended for novices. Further validation research is needed to answer the question whether the hysteroscopic simulators translate into improved skills in the real-time performance. If so, the box trainer could be used for basic skills training. The virtual reality simulator could play an important role in procedural training of both basic and advanced hysteroscopies.