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Introduction There is a growing emphasis on proficiency‐based progression within surgical training. To enable this, clearly defined metrics for those newly acquired surgical skills are needed. These can be formulated in objective assessment tools. The aim of the present study was to systematically review the literature reporting on available tools for objective assessment of minimally invasive gynecological surgery (simulated) performance and evaluate their reliability and validity. Material and methods A systematic search (1989–2022) was conducted in MEDLINE, Embase, PubMed, Web of Science in accordance with PRISMA. The trial was registered with the Prospective Register of Systematic Reviews (PROSPERO) ID: CRD42022376552. Randomized controlled trials, prospective comparative studies, prospective single‐group (with pre‐ and post‐training assessment) or consensus studies that reported on the development, validation or usage of assessment tools of surgical performance in minimally invasive gynecological surgery, were included. Three independent assessors assessed study setting and validity evidence according to a contemporary framework of validity, which was adapted from Messick's validity framework. Methodological quality of included studies was assessed using the modified medical education research study quality instrument (MERSQI) checklist. Heterogeneity in data reporting on types of tools, data collection, study design, definition of expertise (novice vs. experts) and statistical values prevented a meaningful meta‐analysis. Results A total of 19 746 titles and s were screened of which 72 articles met the inclusion criteria. A total of 37 different assessment tools were identified of which 13 represented manual global assessment tools, 13 manual procedure‐specific assessment tools and 11 automated performance metrices. Only two tools showed substantive evidence of validity. Reliability and validity per tool were provided. No assessment tools showed direct correlation between tool scores and patient related outcomes. Conclusions Existing objective assessment tools lack evidence on predicting patient outcomes and suffer from limitations in transferability outside of the research environment, particularly for automated performance metrics. Future research should prioritize filling these gaps while integrating advanced technologies like kinematic data and AI for robust, objective surgical skill assessment within gynecological advanced surgical training programs. There is a plethora of objective assessment tools in minimally invasive gynecological surgery. Further validation of already existing tools and integration of advanced technologies like kinematic data, should increase the usability in training curriculums.

Introduction Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure‐specific simulation skills, vs usual training, result in improved operative competence. Material and methods We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self‐confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05). Clinicaltrials.gov: Registration no. NCT05887570. Results We randomized 83 residents to intervention or control and 55 completed the trial (2011–23). Baseline characteristics were similar, except for more fourth‐year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2–16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8–22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self‐confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups. Conclusions Compared to usual training, procedure‐specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters. Vaginal surgery has a superior outcome profile compared with other surgical routes, yet vaginal surgery skills are declining because of low case volumes. Our randomized controlled trial showed operative transferability of skills acquired through procedure‐specific low‐fidelity simulation in novice gynecology residents. Several other skill parameters also improved through training.

BackgroundThe use of robotic surgery for minimally invasive procedures has increased considerably over the last decade. Robotic surgery has potential advantages compared to laparoscopic surgery but also requires new skills. Using virtual reality (VR) simulation to facilitate the acquisition of these new skills could potentially benefit training of robotic surgical skills and also be a crucial step in developing a robotic surgical training curriculum. The study's objective was to establish validity evidence for a simulation-based test for procedural competency for the vaginal cuff closure procedure that can be used in a future simulation-based, mastery learning training curriculum.MethodsEleven novice gynaecological surgeons without prior robotic experience and 11 experienced gynaecological robotic surgeons (> 30 robotic procedures) were recruited. After familiarization with the VR simulator, participants completed the module ‘Guided Vaginal Cuff Closure’ six times. Validity evidence was investigated for 18 preselected simulator metrics. The internal consistency was assessed using Cronbach’s alpha and a composite score was calculated based on metrics with significant discriminative ability between the two groups. Finally, a pass/fail standard was established using the contrasting groups’ method.ResultsThe experienced surgeons significantly outperformed the novice surgeons on 6 of the 18 metrics. The internal consistency was 0.58 (Cronbach’s alpha). The experienced surgeons’ mean composite score for all six repetitions were significantly better than the novice surgeons’ (76.1 vs. 63.0, respectively, p < 0.001). A pass/fail standard of 75/100 was established. Four novice surgeons passed this standard (false positives) and three experienced surgeons failed (false negatives).ConclusionOur study has gathered validity evidence for a simulation-based test for procedural robotic surgical competency in the vaginal cuff closure procedure and established a credible pass/fail standard for future proficiency-based training.

BackgroundThe purpose of this study was to validate the eoSim, an affordable and mobile inanimate laparoscopic simulator with instrument tracking capabilities, regarding face, content and construct validity on complex suturing tasks.MethodsParticipants recruited for this study were novices (no laparoscopic experience), target group for this training (surgical/gynaecologic/urologic residents, > 10 basic and < 20 advanced laparoscopic procedures) and experts (> 20 advanced laparoscopic procedures). Each participant performed the intracorporeal suturing exercise (Task 1), an upside down needle transfer (Task 2, developed for this study) and an anastomosis needle transfer (Task 3). Following, the participants completed a questionnaire regarding their demographics and opinion on the eoSim in terms of realism, didactic value and usability. Measured outcome parameters were time, distance, percentage of instrument tip off-screen, working area, speed, acceleration and smoothness.ResultsIn total, 104 participants completed the study, of which 60 novices, 31 residents and 13 experts. Face and content validity results showed a mean positive opinion on realism (3.9 Task 1, 3.6 Task 2 and 3.7 Task 3), didactic value (4.0, 3.4 and 3.7, respectively) and usability (4.2. 3.7 and 4.0, respectively). There were no significant differences in these outcomes between the specified expertise groups. Construct validity results showed significant differences between experts, target group or novices for Task 1 in terms of time (means 339, 607 and 1224 s, respectively, p < 0.001) and distance (means 8.1, 15.6 and 21.7 m, respectively, p < 0.001). Task 2 showed significant differences between groups regarding time (p < 0.001), distance (p 0.003), off-screen (p < 0.001) and working area (p < 0.001). Task 3 showed significant differences between groups, after subanalyses, on total number of stitches (p < 0.001), time per stitch (p < 0.001) and distance per stitch (p < 0.001).ConclusionsThe results of this study indicate that the eoSim is a potential meaningful and valuable simulator in the training of suturing tasks.

Background Effective humanitarian surgeons require skills in general surgery, OB/GYN, orthopedics, and urology. With increasing specialization, it is unclear whether US general surgery residents are receiving exposure to these disparate fields. We sought to assess the preparedness of graduating American surgical residents for humanitarian deployment. Methods We retrospectively analyzed cases performed by American College of Graduate Medical Education general surgery graduates from 2009 to 2015 and cases performed at select Médecins Sans Frontières (MSF) facilities from 2008 to 2012. Cases were categorized by specialty (general surgery, orthopedics, OB/GYN, urology) and compared with Chi-squared testing. Non-operative care including basic wound and drain care was excluded from both data sets. Results US general surgery residents performed 41.3% MSF relevant general surgery cases, 1.9% orthopedic cases, 0.1% OB/GYN cases, and 0.3% urology cases; the remaining 56.4% of cases exceeded the standard MSF scope of care. In comparison, MSF cases were 30.1% general surgery, 21.2% orthopedics, 46.8% OB/GYN, and 1.9% urology. US residents performed fewer OB/GYN cases ( p  < 0.01) and fewer orthopedic cases ( p  < 0.01). Differences in general surgery and urology caseloads were not statistically significant. Key procedures in which residents lacked experience included cesarean sections, hysterectomies, and external bony fixation. Conclusion Current US surgical training is poorly aligned with typical MSF surgical caseloads, particularly in OB/GYN and orthopedics. New mechanisms for obtaining relevant surgical skills should be developed to better prepare American surgical trainees interested in humanitarian work.

Purpose The primary objective of this study was to establish a benchmark by collecting baseline data on surgical education in obstetrics and gynecology in Germany, including factual number of operations performed. Materials and methods A nationwide anonymous survey was conducted in Germany between January 2019 and July 2019 utilizing a specially designed questionnaire which addressed both residents and senior trainers. Results A total of 601 participants completed the survey, comprising 305 trainees and 296 trainers. The trainees reported performing a median of 125 non-obstetric surgeries (IQR: 41–332) and 75 obstetric procedures (IQR: 27–168) independently. While most last-year residents managed to meet the targeted numbers for minor surgical procedures outlined in the logbook, they fell short of achieving the required numbers for major operations, such as hysterectomies or more complex laparoscopies. Although both trainees and trainers emphasized the significance of surgical training, the overall quality of the training was rated poorly, particularly by trainees. This was attributed to a high proportion of administrative tasks and a deficiency in teaching time within the operating theater. External fellowship and mentoring programs, as well as the implementation of regular, centralized reviews of residency training, were identified as potentially beneficial by both trainees and trainers. Conclusion The findings of this survey should serve as a wake-up call both within and outside of Germany, highlighting the importance of comprehensive and structured surgical training to enhance long-term patient care and increase satisfaction among obstetrics and gynecology trainees.

Low self-confidence in surgical residents can be associated with poor self-efficacy and perceptions of sub-optimal preparedness for practice at graduation. The influence of social and biologic determinants of confidence deserves further study. Through a randomized controlled trial of procedure-specific didactic and low fidelity simulation training for vaginal surgery, we showed positive correlations between self-confidence and objective performance in the real operating room for three different surgical procedures and through validated scales. This demonstrates an accurate ability of novice surgeons to self-monitor in a high-stakes environment. Our trial results (described in full elsewhere), combined with our multiple one-on-one teaching interactions with surgical trainees through the trial, incentivized us to evaluate self-confidence in view of optimizing it through directed training and feedback. The current opinion piece summarizes our main findings for surgical educators and emphasizes their role engaging with trainees at extremes of confidence.

Robot-assisted surgery (RAS) in gynaecology has undergone exponential growth in recent decades, with utility in treating both benign and malignant gynaecological conditions. The technological complexities and amended theatre dynamics that RAS demands mean that effective non-technical skills (NTS) are vitally important to overcome these unique challenges. However, NTS have been neglected in RAS-training programmes with focus placed instead on the exclusive acquisition of technical skills (TS). NTS include teamwork, communication, leadership, situational awareness, decision-making and stress management. Communication is the most frequently cited NTS impacted during RAS, as the physical limitations imposed by the robotic hardware make communication exchange difficult. The full immersion that RAS enables can contribute to situational awareness deficits. However, RAS can complement communication and teamwork when multidisciplinary (MDT) surgeries (such as complex endometriosis excisions) are undertaken; dual-console capabilities facilitate the involvement of specialties such as general surgery and urology. The development of NTS in RAS cannot be achieved with in-situ experience alone, and current training is poorly standardised. RAS-training programmes and curricula for gynaecology do exist, however the integration of NTS remain limited. Simulation is a viable tool to facilitate enhanced-NTS integration, yet cost implications form a barrier to its wider implementation. However, given that RAS will continue to occupy a greater proportion of the gynaecological caseload, integration of NTS within gynaecological RAS training curricula is necessary. Patients undergoing gynaecological RAS would benefit from the improved safety standards and enhanced surgical outcomes that would result.