Maryse Larouche

Teaching Vaginal Surgery to Junior Residents: Initial Validation of 3 Novel Procedure-Specific Low-Fidelity Models

OBJECTIVE Competency-based surgical education relies on operative models to teach surgical skills within a curriculum. Low fidelity simulation has been shown to improve surgical performance. Our objectives were: to develop procedure-specific models to teach anterior repair (AR), posterior repair (PR), and vaginal hysterectomy (VH) to junior residents; to establish model reliability and validity. DESIGN Residents were randomized to control (no training) and intervention (model training) groups. They were filmed while performing a series of tasks. Experts were also filmed. Each video was scored by 2 blinded raters. SETTING Multicenter collaboration within the Western Society of Pelvic Medicine (Vancouver, Calgary, and Edmonton). Face and content validity were evaluated. A standard scoring tool was developed for performance evaluation. Interrater reliability was assessed using intraclass correlation coefficient. Cronbach α was calculated for internal consistency. Jonckheere-Terpstra test verified whether the scores increased with operator skill level. PARTICIPANTS A total of 14 junior gynecology residents, 2 urogynecology fellows, and 3 staff urogynecologists were rated by a total of 6 gynecologic surgeons who scored 42 videos each. RESULTS Experienced pelvic surgeons from 3 participating sites agreed the models captured essential elements of real surgical skills (face validity) and of the true procedures (content validity). Intraclass correlation coefficient was adequate (AR = 0.86, PR = 0.90, and VH = 0.87). Cronbach α for the total scores was adequate (AR = 0.85, PR = 0.8, and VH = 0.71). Performance score increased with operator skill level for all 3 procedures (AR, p = <0.001; PR, p = 0.008; and VH, p = 0.007). CONCLUSIONS Our low fidelity procedure-specific vaginal surgery models had adequate initial validity. Future research will investigate transferability of acquired skills to the operating room.

Aggressive angiomyxoma presenting as massive irreducible vaginal prolapse

A 66-year-old woman, with a history of a previous cesarean section and total hysterectomy with bilateral salpingooophorectomy, was urgently referred to our tertiary urogynecology center for irreducible vaginal prolapse. Two weeks earlier, she had presented to a peripheral emergency department with acute urinary retention, preceded by 1 year of occasional reducible vaginal bulging. The next day, during a bowel movement, a large soft mass protruded vaginally (Fig. 1). Prolapse reduction attempts were unsuccessful even under general anesthesia. Imaging was then undertaken and computed tomography (CT) demonstrated a poorly enhancing lesion prolapsing through the posterior vagina. Magnetic resonance imaging (MRI) showed a predominantly high T2 lesion with swirled internal architecture in the left ischiorectal fossa. An initial report (without full knowledge of the surgical history) described possible ovarian and broad ligament herniation through the levator plate, without bowel in the hernia sac (Fig. 2). At our center, scans were reviewed and a mass was diagnosed rather than prolapsed tissue. An excision was performed 24 days after the initial presentation. Intraoperatively, the solid mass, measuring 12 × 10 × 4.5 cm externally (prolapsed), and 9 × 3 × 1 cm internally (ischiorectal fossa), was excised vaginally without complications. The distended vaginal mucosa enveloping the mass was completely excised. A frozen section was indeterminate. Final pathology revealed an aggressive angiomyxoma, invading up to the vaginal stroma, but with overlying mucosal resection margins negative for tumor (Fig. 3). The patient recovered well. MRI 3 months postoperatively confirmed complete excision with a small residual hematoma. * Maryse Larouche maryse.larouche@gmail.com