title: Development of an evidence-based training program for laparoscopic hysterectomy on a virtual reality simulator.
abstract: Substantial evidence in the scientific literature supports the use of simulation for surgical education. However, curricula lack for complex laparoscopic procedures in gynecology. The objective was to evaluate the validity of a program that reproduces key specific components of a laparoscopic hysterectomy (LH) procedure until colpotomy on a virtual reality (VR) simulator and to develop an evidence-based and stepwise training curriculum.
  
  
  
  This prospective cohort study was conducted in a Marseille teaching hospital. Forty participants were enrolled and were divided into experienced (senior surgeons who had performed more than 100 LH; n = 8), intermediate (surgical trainees who had performed 2-10 LH; n = 8) and inexperienced (n = 24) groups. Baselines were assessed on a validated basic task. Participants were tested for the LH procedure on a high-fidelity VR simulator. Validity evidence was proposed as the ability to differentiate between the three levels of experience. Inexperienced subjects performed ten repetitions for learning curve analysis. Proficiency measures were based on experienced surgeons' performances. Outcome measures were simulator-derived metrics and Objective Structured Assessment of Technical Skills (OSATS) scores.
  
  
  
  Quantitative analysis found significant inter-group differences between experienced intermediate and inexperienced groups for time (1369, 2385 and 3370 s; p < 0.001), number of movements (2033, 3195 and 4056; p = 0.001), path length (3390, 4526 and 5749 cm; p = 0.002), idle time (357, 654 and 747 s; p = 0.001), respect for tissue (24, 40 and 84; p = 0.01) and number of bladder injuries (0.13, 0 and 4.27; p < 0.001). Learning curves plateaued at the 2nd to 6th repetition. Further qualitative analysis found significant inter-group OSATS score differences at first repetition (22, 15 and 8, respectively; p < 0.001) and second repetition (25.5, 19.5 and 14; p < 0.001).
  
  
  
  The VR program for LH accrued validity evidence and allowed the development of a training curriculum using a structured scientific methodology.
authors.affiliation: Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Marseille, La Conception Hospital, Aix Marseille Université, 147 Boulevard Baille, 13005, Marseille, France. pcrochet.marseille@gmail.com.
authors.forename: Patrice
authors.identifier: 0000-0002-7618-653X
authors.initials: P
authors.lastname: Crochet
authors.affiliation: Department of Surgery, Arnold and Blema Steinberg Medical Simulation Centre, McGill University, Montreal, Canada.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Aggarwal
authors.affiliation: Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Marseille, La Conception Hospital, Aix Marseille Université, 147 Boulevard Baille, 13005, Marseille, France.
authors.forename: Sophie
authors.initials: S
authors.lastname: Knight
authors.affiliation: CERC, IFSTTAR, LBA UMR_T 24, Aix Marseille Université, 13916, Marseille, France.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Berdah
authors.affiliation: Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Marseille, La Conception Hospital, Aix Marseille Université, 147 Boulevard Baille, 13005, Marseille, France.
authors.forename: Léon
authors.initials: L
authors.lastname: Boubli
authors.affiliation: Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Marseille, La Conception Hospital, Aix Marseille Université, 147 Boulevard Baille, 13005, Marseille, France.
authors.forename: Aubert
authors.initials: A
authors.lastname: Agostini
mesh_terms: D000328:Adult; D002983:Clinical Competence; D003479:Curriculum / Q000592:standards; D004502:Education, Medical, Continuing / Q000379:methods*; D055317:Evidence-Based Practice; D005260:Female; D006176:Gynecology / Q000193:education; D006801:Humans; D007044:Hysterectomy / Q000193:education* / Q000379:methods; D010535:Laparoscopy / Q000193:education*; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D016730:Program Development; D011446:Prospective Studies; D000076142:Virtual Reality
keywords: Education; Laparoscopic hysterectomy; Simulation; Virtual reality