The Effect of Hands-On Cadaver and Live Surgery Practice on Surgeons' Performance in Urogynecologic Operations: One-Year Follow-Up

Introductıon

Given that each patient is unique, with an individual history and anatomy, a combination of knowledge and hands-on practice is a significant factor for success for surgeons in their areas of interest. ¹ This experience and practice is mainly gained during residency programs. It is commonly agreed that gynecologic-surgery residency programs have some deficits with respect to adequate training of well-qualified surgeons. ² These deficits could be attributed to several factors. First, hostile attitudes of senior surgeons to residents can impede learning. ³ Second, an increasing lack of importance is being placed on hands-on practice, due to impressions that technology will soon render manual operations obsolete. ⁴ Third, study time is often inadequate in subdivisions such as urogynecology or obstetric hemorrhage, allowing enough time to learn only a few types of main procedures in gynecology. ⁵ Another issue is that patients often insist being operated by an experienced surgeon. ⁵ It has been reported that a large number of urology and gynecology trainees did not carry out urinary-incontinence or pelvic organ prolapse (POP)–repair surgeries during their residencies, despite these procedures being considered basic gynecologic operations.^4,6

Furthermore, there are gynecologic surgeons who finish their residency education without practicing a vaginal hysterectomy.^4,6 Insufficiently educational training programs force residents to have additional education or fellowship programs in more-specific areas to become skilled physicians in their fields. Approximately 75% of general-surgery residents attend post-training certification programs in the United States. ³ The surgeons' skills, knowledge, and self-confidence are often developed after post-training surgical educational courses. ⁷

Cadaver courses provide the opportunity to learn surgical anatomy and operational techniques without the anxiety caused by the risk of surgery-induced bleeding, as well as not having time constraints related to use of anesthesia.

This study compared 2 educational approaches' effectiveness for training obstetrics and gynecology physicians in urogynecologic surgery.

Materials and Methods

This study was designed as a prospective cohort study. Bahcesehir University (Istanbul, Turkey) Medical Faculty's anatomy laboratory and conference hall were arranged for theoretical lectures and cadaver practice, and VM Medical Park Izmit Hospital (Kocaeli) was organized for live surgery education. Originally, 60 residents had planned to participate, and they were divided into 2 groups, with each group having 30 residents. One trainee in group 1 and 1 trainee in group 2 canceled due to last minute changes in their programs. Fifty-eight surgeons remained, including general gynecologists in practice; the surgeons attended the course and were again divided into 2 groups based on their preferences. In addition to these 58 participants, 2 obstetrics and gynecology residents attended the course for theoretical lectures. They were not included in the study. Group 1 had 10 hours of theoretical education on pelvic anatomy and urogynecologic techniques on the first day of the course and watched 8 live surgeries in 2 operating theaters on the third day. Group 2 had the 10 hours of theoretical education together with Group 1, plus a 1-day cadaver workshop in five stations and 34 hands-on live surgeries in 6 operating theaters.

There was a Whatsapp group discussion 1 month before the course started for both groups. Different anatomical pictures were provided (1 picture per day) to the trainees and experts (professors and associate professors) 1 month before the course. These pictures were photographs taken during surgery, diagrams, or photographs taken during cadaveric dissections, to explain surgical steps or pelvic anatomy. On the first day of the course, before the training was initiated, the surgeons who attended to the program were asked about their educational backgrounds and experiences with main urogynecologic procedures. The numbers and types of specified urogynecologic operations performed and the demographic data were added to SPSS from the beginning of the participants' careers as obstetrics and gynecology specialists to date.

The first day of the course started with theoretical education, which involved 4 hours of 8 lectures, each of which lasted for 30 minutes, on abdominal pelvic anatomy; perineal anatomy; and functional anatomy with respect to integral theory, including presacral area, pararectal and paravesical spaces, ureter traces, obturator foramen, Retzius space, paravaginal anatomy, sacrospinous ligaments, obturator canal, fascia, nerves, arteries, and veins of the perineum and pelvis. During these 8 lectures, laparoscopic and laparotomy applications of sacrocolpopexy, sacrocervicopexy, lateral suspensions, uterosacral-ligament procedures, midurethral slings, procedures in the Retzius space (such as Burch, Marshall-Marchetti-Krantz), vaginal native-tissue repair, vaginal-mesh applications in the anterior and posterior compartments, sling procedures, and cystoscopy were discussed. Each lecture included surgical anatomy, techniques descriptions, diagnoses, and management of complications.

On the second day of education, which only Group 2 attended, a cadaveric course was organized as 5 stations of cadavers, which included 6 trainees and 1 tutor for 1 fresh cadaver at each station. The sixth cadaver was spared for cystoscopy training and any other procedures that were not done on that cadaver. Participants dissected different anatomical regions in each cadaver and changed their stations every 90 minutes to see a new technique at the next station. All the procedures were done in each cadaver. In each cadaver, both groups dissected a new region every 90 minutes. The group 2 participants practiced cystoscopy during the breaks. All trainees performed transobturator tape (TOT) and tension-free vaginal tape (TVT) procedures, and used mini-slings with original equipment. The participants learned to repair bladder and ureter lacerations and double-J applications.

On the third day of the course, live surgeries were performed. Thirty-four operations were performed in 6 operating theaters with live broadcasts from the 2 of the operating rooms. These 34 patients were told about the educational course and signed informed-consent forms. In Group 2, 1 tutor and 2 trainees performed each operation according to detailed explanations they were given about each step; other trainees who were not performing operations had the opportunity to watch the procedure in the operating theater. The tutor operated and the trainees actively assisted in all steps of all surgeries except for the midurethral sling, which had 1 trainee on each side. All trainees performed 1 midurethral-sling procedure individually on either the right or left side, under the supervision of the tutors.

The operations lasted a total of 14 hours. Three patients had single-side bladder perforations and 1 patient had a double-side bladder perforation during the TVT procedures. These patients were managed uneventfully with replacements of the meshes and 10 days of Foley catheter drainage of their bladders. One patient had ileus after a sacrocolpopexy procedure; this patient had had dense intra-abdominal adhesions of the intestines due to her previous operations. The remaining 29 patients were fine after the operations.

The group 1 participants, who watched live surgeries through broadcasting, saw 8 surgeries, including sacrocolpopexy, anterior- and posterior-mesh repairs, a vaginal hysterectomy, a mini-sling procedure, TVT, TOT, sacrospinous fixation, a posterior intravaginal sling procedure, Manchester and Burch operations, cystoscopy, management of bladder perforation, and culdoplasty; the operations were performed by trainees in group 2 and their tutors. Given that the tutors were explaining every step to the assisting participants, group 1 also learned about the important points of these surgeries from the tutors.

One year after the educational program, each surgeon was called and asked about the types and numbers of urogynecologic operations that he or she was performing during the year after the course.

Data analysis was carried out via IBM SPSS Statistics for Windows, version 24.0. IBM Corp., Armonk, NY. As a consequence of not normally distributed demographic data, demographic variables were analyzed by a nonparametric Mann–Whitney-U test, and standard errors are indicated in Table 1 with a 95% confidence interval. In order to compare the equality of past surgical experiences of group 1 and group 2, a χ ² test was applied. The groups self-evaluated the number of surgeons who performed the procedures before the course and after the course; this evaluation was performed with McNemar's test. The p-value was determined to be statistically significant if it was p < 0.05.

Düzce University Ethics Committee approval was applicable for this research (Decision number: 2018/60).

Results

Groups 1 and 2 were similar with respect to participants' ages, types of hospitals (e.g., university or training hospitals) in which they carried out their residencies, years as obstetricians and gynecologists, occupational experiences, malpractice cases, malpractice fines, number of daily urogynecologic examinations, and number of monthly performed urogynecologic pelvic floor surgeries (p > 0.05; Table 1). The only notable difference between the groups was in total years worked in private hospitals. Doctors in group 2 had more experience in private hospitals than doctors in group 1 (p = 0.01; Table 1).

When the number of surgeons who performed these operations before the course was compared between group 1 and group 2, there was no statistically significant difference (p > 0.05).

In Group 1, the number of surgeons who performed any of the anterior-compartment repair procedures increased by 3.4% after the course (p = 1; Table 2). Applications of any midurethral slings were similarly increased by 13.8% after the course (p = 0.125). Total colposuspension procedures increased by 6.9% after the educational intervention (p = 0.5). The number of surgeons who carried out posterior-compartment repair, LeFort colpocleisis, complication management, and cystoscopy procedures did not differ between the pre- and postcourse times (p = 1).

In Group 2, anterior-compartment repair cases increased by 6.9% after the course (p = 0.50; Table 2). Surgeons practicing any of the midurethral sling operations increased by 20%, a statistically significant increase (p = 0.03). With respect to midurethral slings, TVT utilization increased by a statistically significant 44.8% after the course (p < 0.001). Number of surgeons who performed any of the colposuspension procedures increased by 13.8% after the course (p = 0.125). Complication management and cystoscopy procedures increased by 10.4% after the educational course (p = 0.25). LeFort colpocleisis and posterior-compartment repair utilization was identical between before and after the course (p = 1).

Discussion

This research was conducted to evaluate 2 different educational strategies for learning new techniques in the field of urogynecology. One of the strategies is commonly practiced theoretical education plus observation of live surgeries, and the other strategy is a threefold approach of theoretical education, as well as cadaver training and performing live surgery.

When types and numbers of operations were evaluated via surveys filled out by participating surgeons both pre/post-course, the threefold approach of theoretical education, cadaver practice, and live surgery significantly increased the adaptation to—and practicing of—midurethral sling procedures, compared to theoretical education combined with live surgery observation.

When pre- and postcourse applications of any midurethral sling procedures were compared, there was a statistically significant increase in these procedures after the course. This suggests that surgeons who had primarily been using a midurethral sling (for example, TVT) had adapted to a different type of sling procedure after the course (e.g., TOT or mini-sling), or that surgeons who had not been applying any midurethral slings adapted and started to apply them. There was also an increase in the number of surgeons performing urogynecologic operations after the course. This effect was larger in group 2 as shown in Table 2. This indicates that the threefold approach was more beneficial for adaptation of new surgeries than classical theoretical education in addition to observation of live surgery.

In order to assess the benefits of the educational programs in other studies, patient well-being (in the terms of surgical results and complications) was recorded after the course and was compared between routine surgeries and surgeries that were done during educational courses. ⁴ However, there is currently no study that compared the outcomes in the field of gynecologic surgery. There is a single study that evaluated type of surgeries performed by participant surgeons pre- and post-course, but the educational intervention was an entire year long, so the evaluation was based on a 1-year mentoring period. ⁵ Therefore, the pre- and post-course numbers and types of procedures after the 3-day educational intervention were evaluated in the current study as a novel parameter.

It is important to focus on specific areas of interest, such as urogynecology, in wider surgical fields, such as obstetrics and gynecology, as increasing human population and patient requests for specialized surgeons increase demand for doctors experienced in specific surgical areas.^8,9

At this point, postresidency courses are beneficial to facilitate learning of new surgical techniques and the ability to use them in daily practice. One of the most important advantages of these courses is to maintain confidence in surgeons who have a general idea of all gynecologic procedures but have not committed to subspecialized areas.

The complication rates and surgical outcomes were equal when a senior surgeon group and senior-observed resident groups were compared. ¹ However, the aim is to train well-qualified surgeons who can perform the procedures on their own independently. Thus, postresidency courses provide confidence to surgeons who can perform the surgical techniques alone; therefore, more patients are served. Generally, postresidency education programs are based on theoretical lessons and cadaver practice or a combination of theoretical education and live surgery observation. In the first option, participant surgeons learn the root of the subject and study on cadavers, but do not have the opportunity to apply their knowledge on real patients. In the second, the surgeons are also informed of the theoretical basis of the subjects and learn how to apply the procedures properly, but this does not provide enough knowledge and confidence to practice the operations on their own. This example proves that postresidency educational programs do not provide enough hands-on practice. ⁵

The program in the current study had the benefit of combining three principal branches of teaching: (1) theoretical knowledge; (2) hands-on cadaver practice; and (3) real-time operations on patients. The comparison between group 1 and group 2 showed that the threefold approach of theoretical education, hands on cadaver practice, and live surgery experience was more beneficial than classical theoretical education plus live surgery observation in terms of confidence and application in daily practice.

There were some limitations in the current study. First, the groups were comprised based on participant doctors' preference. Randomization did not occur; thus, a self-selection bias was present. In order to minimize the effect of self-selection bias, these 2 groups were compared regarding their past experiences with urogynecologic operations. The 2 groups had similar experience with urogynecologic procedures. Additionally, both groups underwent the 1-day theoretical education, and all participants answered 20 multiple-choice questions designed to test their knowledge of the theoretical components that were taught. Every attendee scored 80% or higher on this test. Consequently, group 1 and group 2 had similar baselines of knowledge of urogynecology. Second, because the surgeons chose self-selected groups, participants who had chosen to perform live surgery might have been more motivated to incorporate these new procedures into their practices.

Precourse and postcourse number of performed operations did not differ in terms of certain procedures, such as LeFort colpocleisis and posterior repair in either group 1 or 2. The main fact to be taken into consideration is that many obstetrics and gynecology specialists are not chosen by patients because urogynecology is a specific area in the field and patients prefer well-known surgeons in this specific field. In addition, in terms of course participants, maintaining confidence postcourse required more effort than anticipated to allow surgeons to carry out operations that they were not performing before. This is due to the fact that urogynecologic procedures are not routinely practiced operations by obstetricians and gynecologists. However, a 1-year follow up period might not have been sufficient for the participant surgeons to carry out recently learned surgical techniques. In this relatively short time, it might have been impossible to find patients to apply each newly learned surgical technique. Finally, 1 day of live surgery experience might not be enough for participant surgeons to perform the procedures on their own.

Conclusions

The results of this study suggest that the threefold approach of theoretical education, cadaver practice, and live surgery experience is superior to classical surgical courses for adaptation of new surgical techniques in the field of urogynecology—especially midurethral sling applications. The use of this model could increase the effectiveness of surgical education programs.