Content Assessment of Surgical-Education Videos on YouTube for Total Laparoscopic Hysterectomy

Abstract

Objective:

This study assessed the content of online videos as educational supplements for gynecology trainees for total laparoscopic hysterectomy (TLH).

Materials and Methods:

A cross-sectional analysis was performed of relevant YouTube videos. The key words laparoscopic total hysterectomy surgical training and laparoscopic total hysterectomy surgical education were used to retrieve the top 60 videos per search query. Videos without live surgical footage, audio, or written narration; or with commercial intent were excluded. Two independent reviewers evaluated the videos, using a modified version of the Objective Scale Specific for the Assessment of Technical Skills for Laparoscopic Hysterectomy (H-OSATS) to assess inclusion of necessary steps; the Objective Structured Assessment of Technical Skills (OSATS) for laparoscopy to assess surgical technique; and a 3-point Likert scale to assess surgical difficulty.

Results:

A total of 12 videos were analyzed: 11 (91.6%) videos were created by physicians without academic affiliations and 1 was from an academic center. The mean H-OSATS and OSATS scores were 21.75/53 (41%) and 16.05/20 (82.5%), respectively. Inter-rater agreement was rated at 95.3% with a Cohen's κ of 0.90. All videos included appropriate instruction on division of the major uterine blood supply (100%). Conversely, very few videos included information about preoperative instruction for patient positioning (5.56%), abdominal entry (12.50%), trocar insertion (14.58%), and inspection of the peritoneal cavity (20.83%). Mean surgical difficulty was rated as easy (1.6/3).

Conclusions:

Online surgical videos demonstrate adequate surgical skill and technique, but do not provide thorough inclusion of the steps required to perform TLH. There is a need to produce open-access high-quality comprehensive videos for TLH instruction. (J GYNECOL SURG 39:190)

Introduction

Within surgical education, direct instruction by a staff surgeon in the operating room (OR) learning environment is the foundation for trainee skill development. This conventional apprenticeship model is invaluable for surgical training; however, growth in this setting requires sufficient opportunities for trainees to develop under the instruction of an experienced surgeon. Modern barriers to optimal learning include limited OR access, prioritizing patient safety, and an increased trainee-to-surgeon ratio.

Advancements in multimedia, however, provide surgical trainees with a variety of supplemental learning resources, including virtual-reality simulations, mobile applications, multimedia modules, and online videos.¹ Videos are most-frequently relied upon by surgical residents as both primary and supplementary resources for foundational surgical education.² Access to these tools varies from institutional websites to open-sharing platforms, such as YouTube. YouTube is the second most-frequently visited website on the internet and enables users to browse, upload, and view videos through multiple devices, including personal computers and smartphones.³ YouTube is the preferred platform for surgical trainees, with almost 95% of residents relying exclusively on this resource to learn and prepare for surgical cases.² Although educational videos pose certain advantages, videos on open-access platforms, such as YouTube, are not subject to formal peer-review or a standardized quality assessment process prior to uploading on the internet. This leads to significant variability in their accuracy, quality, and educational utility for surgical trainees.

Total laparoscopic hysterectomy (TLH) is a fundamental and technically advanced gynecologic procedure that obstetrics and gynecology residents aim to master in their final years of training. This study systematically evaluated the educational utility, in terms of instructional comprehensiveness, surgical technique, and surgical difficulty, of TLH videos on YouTube.

Materials and Methods

Ethics

Formal ethics approval not required as this study used public access data, and did not include patient involvement.

Search strategy and video selection

Search methods were applied that were similar to analogous studies assessing YouTube videos as a teaching tool for procedures.^4,5 A comprehensive search was conducted on YouTube* on May 19, 2020, using the search terms laparoscopic total hysterectomy surgical training and laparoscopic total hysterectomy surgical education. Prior to each search query, the internet browser was put into incognito mode and was cleared of caches and cookies to reduce the influence of previous searches on subsequent queries. Search results were listed in descending order from the most-viewed to the least-viewed, and each page displayed links to 20 videos. Given that studies report that 90% of internet consumers will not search beyond the first 3 pages when conducting a search, videos from only the first 3 pages were included, resulting in a total of 60 videos per search query.⁶

Video characteristics, including information source (i.e., academic center, academic society, non-academically affiliated health provider), date uploaded, video length, view count, and the number of likes and dislikes were recorded. Two independent reviewers (K.K. and A.K.) screened each video and excluded videos without live surgical footage, composed primarily of slides, without audio narration or descriptive subtitles, not in English, and with commercial intent.

Video analyses

All included videos were analyzed by 2 independent reviewers (E.S. and E.D.) in each of 3 domains: (1) instructional comprehensiveness; (2) surgical technique; and (3) surgical difficulty. Any discrepancies were discussed to reach consensus between the lead authors.

Analysis of instructional comprehensiveness

Instructional comprehensiveness, which evaluates if a TLH video demonstrated all of the necessary surgical steps, was assessed using a modified version of the Objective Scale Specific for the Assessment of Technical Skills for Laparoscopic Hysterectomy (H-OSATS).⁷ The H-OSATS is a validated assessment tool that was developed using expert consensus, hierarchical task analysis, and Delphi questionnaire methods.⁷ The H-OSATS outlines 53 essential steps, organized into 15 categories, to conduct a TLH (Table 1). Scores of either 1 or 0 were assigned corresponding to whether a discussion and/or demonstration of each step was present or absent, respectively, for a maximum score of 53.

Table 1.

Modified version of the Objective Scale Specific for the Assessment of Technical Skills for Laparoscopic Hysterectomy (H-OSATS) with the 15 categories and corresponding essential steps to conduct a Total Laparoscopic Hysterectomy

Category (N = 15)	Essential steps (N = 53)
1. Patient positioning	1. Spread legs apart. 2. Tuck both arms alongside. 3. Place buttocks slightly over the edge of the operating table.
2. Abdominal access	4. Achieve intraperitoneal access using a recognized method (Veress needle, open technique, etc.). 5. Create appropriate pneumoperitoneum.
3. Inspection of peritoneal cavity	6. Perform diagnostic laparoscopy (including liver & diaphragm) 7. Put patient in Trendelenburg position allowing appropriate exposure.
4. Trocar insertion	8. Avoid epigastric vessels. 9. Insert 3 operating trocars. 10. Use ergonomic trocar placement. 11. Look for injuries from port placement.
5. Inspection of the pelvis	12. Expose pelvis: retract small bowel & sigmoid colon; perform adhesiolysis if necessary. 13. Inspect uterus & adnexa. 14. Insert uterine manipulator. 15. Check that uterine manipulator allows appropriate exposure. 16. Check access to the pouch of Douglas and subovarian fossas. 17. Check ureter's path in the pelvis.
6. Division of the round ligaments (left & right)	18. Manipulator: push uterus cranially & laterally toward the opposite side. 19. Coagulate transect the round ligament. 20. Individualize the front and back fold of the anterior leaf of the broad ligament.
7. Division of IP ligament or utero-ovarian ligament (left & right)	21. Manipulator: push uterus cranially & laterally toward the opposite side. 22. Expose IP ligament or utero-ovarian ligament. 23. Coagulate using an appropriate energy source or suture. 24. Section the IP ligament or the utero-ovarian ligament.
8. Creation of the bladder flap	25. Manipulator: push uterus cranially & laterally to the opposite side (left and right). 26. Open the anterior fold of the broad ligament on both sides down to the level of the vesico-uterine reflection. 27. Manipulator: push uterus cranially & posteriorly. 28. Section the peritoneum down to the lower uterine segment. 29. Grasp the bladder at the midline, applying an anterior–superior traction. 30. Open the vesico-uterine space at the midline until the cervico-vaginal margin is exposed.
9. Opening of the posterior peritoneum (left & right)	31. Manipulator: push uterus anteriorly & cranially toward the opposite side 32. Dissect & section the posterior leaf of the broad ligament toward the insertion of the utero-sacral ligaments on each side.
10. Division of the uterine vessels (left & right)	33. Manipulator: push uterus cranially & to the opposite side. 34. Optimize exposure of the uterine vessels. 35. Skeletonize uterine vessels at the ascending portion of the uterine artery. 36. Coagulate the uterine vessels using an appropriate energy source or suture. 37. Section uterine vessels in the ascending portion, at the level of the colpotomizer. 38. Divide cervical attachments of the cardinal ligaments.
11. Colpotomy	39. Manipulator: push uterus cranially. 40. Identify the cervicovaginal delineation from the colpotomizer. 41. Check that there are no interposed elements around the vaginal fornices & complete dissection if necessary. 42. Proceed to circumferential colpotomy using an appropriate energy source.
12. Uterus retrieval & vault closure	43. Retrieve specimen vaginally.
13. Hemostasis & inspection	44. Irrigate & aspirate the pelvis. 45. Check vascular pedicles, bladder reflection & vaginal cuff under low abdominal pressure; secure hemostasis if needed. 46. Check that there is no damage to surrounding structures.
14. Port removal & skin closure	47. Remove trocars under direct visualization & inspect port sites for hemostasis. 48. Evacuate pneumoperitoneum. 49. Suture fascia for trocars ≥10 mm. 50. Close skin incisions with any acceptable method.
15. Order	51. Perform tasks 1 (patient positioning) to 5 (inspection of the pelvis) in chronological order. 52. Perform tasks 10 (division of the uterine vessels) to 14 (port removal) in chronological order. 53. Start Task 11 (colpotomy) before task 10 (division of the uterine vessels).

IP, infundibulopelvic.

Analysis of surgical technique

Surgical technique was assessed using the Objective Structured Assessment of Technical Skills (OSATS). The OSATS is a validated and reliable surgical performance assessment tool, with high inter-rater reliability used commonly to evaluate surgical technique in laparoscopy.⁸ The OSATS consists of 4 domains: (1) economy of movement; (2) confidence of movement; (3) respect for tissue; and (4) precision of operative technique. Each domain was evaluated using a 5-point Likert scale (Table 2).

Table 2.

Objective Structured Assessment of Technical Skills (OSATS) with the 4 domains Used for Assessment of Technical skill Along with Their Likert-Scale ratings

Domain (N = 4)	5-point Likert scale ratings
1. Economy of movement (time & motion)	1. Many unnecessary moves 2. — 3. Efficient time/motion but some unnecessary moves 4. — 5. Economy of movement and maximum efficiency
2. Confidence of movement (instrument handling)	1. Repeatedly makes tentative or awkward moves with instruments 2. — 3. Competent use of instruments, although occasionally appeared stiff or awkward 4. — 5. Fluid moves with instruments and no awkwardness
3. Respect for tissue	1. Frequently used unnecessary force on tissue or caused damage by inappropriate use of instruments 2. — 3. Careful handling of tissue but occasionally caused inadvertent damage 4. — 5. Consistently handled tissues appropriately with minimal damage
4. Precision of operative technique (flow of operation)	1. Imprecise, wrong technique in approaching the operative interventions 2. — 3. Careful technique with occasional errors 4. — 5. Fluent, secure, & correct technique in all stages of the operative procedure

Analysis of surgical difficulty

Surgical difficulty was evaluated using a 3-point Likert scale with the following descriptive anchors: a score of 1 was considered easy with well-defined planes and no scar tissue or edema; a score of 2 was moderately difficult in terms of uterus size and degree of scar tissue; and a score of 3 was extremely difficult with excessive scarring or lack of planes.

Statistical analysis

Data were compiled with Microsoft® Excel spreadsheets (Microsoft Corp, Redmond, WA, USA). Categorical variables were defined with frequency distributions (number, percentage) and continuous variables were defined with descriptive statistics (mean, standard deviation [SD]). For Likert-type items, the mean and SD were calculated for each item. A 1-way analysis of variance was used to compare group differences, with a p < 0.05 considered to be statistically significant. Inter-rater reliability was evaluated using Cohen's κ.

Results

The initial search included a total of 120 videos. After exclusions, 12 videos were included in the final analysis (Fig. 1). Exclusions were: duplicates (54); lacking surgical technique (20); lacking narration or descriptive subtitles (13); commercial intent (7); lacking educational intent (13); and non-English content (1). The descriptive characteristics of the included videos are shown in Table 3. Overall, 11 videos were from surgeons without academic affiliations, and 1 was from an academic center. On average, videos were 18:03 minutes long (range: 7:35–1:14:35 minutes) and had an average view count of 39,677 views (range: 824–159,521). The videos received a mean of 13 comments (range: 0–46), with more likes (mean: 86.42; range: 2–270) than dislikes (mean: 11.75; range: 0–42).

Fig 1.

Flow diagram outlining video selection process.

Table 3.

Characteristics of Online Educational videos on YouTube for Total Laparoscopic Hysterectomy & Primary outcomes

Sources, characteristics & outcomes	n	%
Upload sources
Academic center/professional society (n)	1	—
Nonacademically affiliated physicians and/or health groups (n)	11	—
Video characteristics
Views (n; mean ± SD)	39,577.00 ± 54,244.12	—
Length (sec; mean ± SD)	799.50 ± 420.29	—
Comments (n; mean ± SD)	13.00 ± 18.01	—
Likes (n; mean ± SD)	86.42 ± 101.67	—
Dislikes (n; mean ± SD)	11.75 ± 13.00	—
Non-English videos	1	—
Videos without narration	13	—
Videos without demonstration of surgical technique	20	—
Not intended for surgical education	13	—
Videos with commercial intent	7	—
Primary outcomes
H-OSATS (mean ± SD)	21.75 ± 4.45	41.04
OSATS (mean ± SD)	16.05 ± 2.02	82.5
Surgical difficulty (mean ± SD)	1.58 ± 0.79	52.67

SD, standard deviation; sec., seconds; H-OSATS, Objective Scale Specific for the Assessment of Technical Skills for Laparoscopic Hysterectomy; OSATS, Objective Structured Assessment of Technical Skills.

The primary outcomes were comprehensiveness, technique, and surgical difficulty, as evaluated by the H-OSATS, OSATS, and 3-point Likert scale, respectively. The mean H-OSATS was 20.2/53 (41.0%), the mean OSATS was 16.1/20 (82.5%), and the mean surgical difficulty was 1.58/3 (52.67%). Cohen's κ for H-OSATS, OSATS, and surgical difficulty was 0.90, 0.33, and 1.0, respectively. There were no significant differences in the primary outcomes when the videos were grouped by the number of views (Table 4).

Table 4.

Primary Outcomes Grouped by View counts

Outcomes	< 5000 views n = 5	5000–50,000 views n = 4	> 50,000 views n = 4	p-Value
View count (n) mean ± SD	1668.2 ± 1134.9	26,817.5 ± 28,704.5	120,171.0 ± 35,826.1	0.0002^*
H-OSATS (n) mean ± SD	20.2 ± 5.7	20.3 ± 3.8	22.7 ± 3.5	0.64
OSATS (n)mean ± SD	15.7 ± 2.2	16.3 ± 2.6	18.2 ± 0.76	0.33
Surgical difficulty (n) mean ± SD	1.6 ± 0.9	1.5 ± 0.6	1.7 ± 1.1	0.97

Values are presented as n or mean ± SD.

p < 0.05 is considered statistically significant.

SD, standard deviation; H-OSATS, Objective Scale Specific for the Assessment of Technical Skills for Laparoscopic Hysterectomy; OSATS, Objective Structured Assessment of Technical Skills.

Table 5 distributes the H-OSATS scoring by category. Of the 15 categories, division of the round ligament, division of the infundibulopelvic (IP) or utero-ovarian ligament, creation of the bladder flap, division of the uterine vessels, uterus retrieval, and vault closure had mean H-OSATS scores of >50%. In contrast, the initial components of a TLH, including patient positioning, obtaining abdominal access, and trocar insertion, had mean scores of <25%. There were no instructions on port removal or skin closure in any of the videos. Table 6 distributes the H-OSATs scoring by the individual essential surgical steps. Of the 12 included videos, 10 (83.3%) did not provide instruction on achieving intraperitoneal access and 11 (91.7%) did not show establishment of pneumoperitoneum. Similarly, only 2 videos provided instruction on avoiding epigastric vessels on trocar entry, while 0 videos commented on evaluating injuries following trocar placement.

Table 5.

Objective Scale Specific for the Assessment of Technical Skills for Laparoscopic Hysterectomy Scoring Grouped by Categories

Category	# of essential steps	Mean (n)	%
1. Patient positioning	3	0.17	5.56%
2. Abdominal access	2	0.25	12.50%
3. Inspection of peritoneal cavity	2	0.42	20.83%
4. Trocar insertion	4	0.58	14.58%
5. Inspection of the pelvis	6	1.50	25.00%
6. Division of the round ligaments (left & right)	3	1.92	63.89%
7. Division of IP ligament or utero-ovarian ligament (left & right)	4	2.92	72.92%
8. Creation of the bladder flap	6	3.92	65.28%
9. Opening of the posterior peritoneum (left & right)	2	1.00	50.00%
10. Division of the uterine vessels (left & right)	6	4.58	76.39%
11. Colpotomy	4	2.00	50.00%
12. Uterus retrieval & vault closure	1	0.75	75.00%
13. Hemostasis & inspection	3	0.42	13.89%
14. Port removal & skin closure	4	0.00	0.00%
15. Order	3	1.33	44.44%

IP, infundibulopelvic.

Table 6.

Objective Scale Specific for the Assessment of Technical Skills for Laparoscopic Hysterectomy scoring distributed by Essential Steps

	Present
Essential steps (n = 53)	n	%
1	1/12	8.3%
2	1/12	8.3%
3	0/12	0.0%
4	2/12	16.7%
5	1/12	8.3%
6	3/12	25.0%
7	2/12	16.7%
8	2/12	16.7%
9	3/12	25.0%
10	2/12	16.7%
11	0/12	0.0%
12	4/12	33.3%
13	5/12	41.7%
14	3/12	25.0%
15	0/12	0.0%
16	2/12	16.7%
17	4/12	33.3%
18	1/12	8.3%
19	12/12	100.0%
20	10/12	83.3%
21	0/12	0.0%
22	11/12	91.7%
23	12/12	100.0%
24	12/12	100.0%
25	1/12	8.3%
26	12/12	100.0%
27	1/12	8.3%
28	11/12	91.7%
29	11/12	91.7%
30	11/12	91.7%
31	1/12	8.3%
32	11/12	91.7%
33	4/12	33.3%
34	11/12	91.7%
35	11/12	91.7%
36	12/12	100.0%
37	12/12	100.0%
38	5/12	41.7%
39	3/12	25.0%
40	8/12	66.7%
41	1/12	8.3%
42	12/12	100.0%
43	9/12	75.0%
44	4/12	33.3%
45	0/12	0.0%
46	1/12	8.3%
47	0/12	0.0%
48	0/12	0.0%
49	0/12	0.0%
50	0/12	0.0%
51	4/12	33.3%
52	10/12	83.3%
53	2/12	16.7%

Discussion

Surgical trainees currently face multiple barriers to learning within the traditional apprenticeship model, including an increased trainee-to-surgeon ratio and limited OR time.⁹ As a result, residents must seek additional resources to supplement their learning, with 64% of surgical residents preferring instructional videos over other resources.² YouTube is the most-popular source; however, this platform is not subject to quality control.¹⁰

This study evaluated quality—in terms of comprehension, technical skill, and surgical difficulty—of videos uploaded to YouTube for instruction on performance of TLH. Comprehensiveness was overall poor with a mean H-OSATS score of <50%. The initial steps of a TLH lacked instructions, such as for patient positioning, obtaining abdominal access, peritoneal-cavity inspection, and trocar insertion. Most laparoscopic complications occur during the initial phase of surgery, involving the establishment of pneumoperitoneum and trocar placement.¹¹ Despite this risk of injury, 83.3% of videos omitted discussion of appropriate landmarking to avoid pertinent vessels upon trocar entry, and no videos discussed port removal at the end of the procedure. Ideally, comprehensive educational videos should demonstrate the preoperative setup, including patient positioning, bladder drainage, optimal pneumoperitoneum pressure, and trocar insertion.^12–14

While assessing the comprehensiveness of each video, however, it was important to consider the varied needs of junior and senior residents. Junior residents prefer didactic instruction and procedural narration when learning from video sources; however, only 27% of the videos included this approach.¹⁵ Furthermore, uterine manipulation is critical for visualization and surgical progression, and is often the responsibility of a junior resident.¹⁶ Only 4/12 videos included instruction content regarding the manipulator despite its essential role in 6 of the 53 TLH steps. Therefore, for junior surgical residents, these videos may not be sufficient in providing instruction for tasks reflective of their role when participating in TLH and may not translate into improved surgical performance in the OR.

In general, the content of these videos may be more useful for senior residents who are already comfortable with laparoscopic entry and uterine manipulation. On average, video content included the majority (> 50%) of steps related to the hysterectomy procedure, including division of the round ligament and the IP/utero-ovarian ligaments, creation of the bladder flap, and division of the uterine vessels (Table 5). In contrast to junior residents, senior surgical trainees prefer surgical demonstration of technique rather than didactic instruction, making surgical videos ideal for their specific learning needs.¹⁵ The included videos demonstrated good surgical technique with a mean OSATS score of 16.05 (82.5%), as well as moderate surgical difficulty (1.58/3), which are ideal characteristics for educational videos targeting senior learners.

Regardless of the postulated differences in educational utility for junior and senior residents, overall, no video was entirely comprehensive according to the H-OSATS score. This is consistent with similar studies of teaching videos on YouTube for laparoscopic procedures across different surgical specialties.^10,17 In gynecology, there was 1 analogous study that evaluated videos on YouTube for midurethral-sling placement wherein the researchers found that the videos were not comprehensive in outlining the necessary surgical steps to conduct this procedure.¹⁸

Almost all of the videos (11/12) were from nonacademic sources. Interestingly, the single video from an academic institution had the highest H-OSATS score, indicating inclusion of the most steps. When stratified by view count, there was no difference in comprehensiveness, technique, or difficulty. In fact, the video from the academic institution was among the lowest in terms of the number of views and viewer interactions despite having the highest H-OSATS rating. These findings have also been reported in similar studies, suggesting that highly viewed surgical instructional videos on YouTube are not necessarily of high quality and may vary in their level of comprehensiveness.^19,20 This is because YouTube ranks the search results according to an algorithm on parameters such as view count and comments rather than on quality.

It is possible that more-comprehensive TLH procedural videos have been developed but are not available on open-access platforms such as YouTube. For instance, there are 2 websites—1 developed by an academic institution^† and 1 developed by a professional society^‡—that offer instructional videos for gynecologic surgeries including TLH. These videos are subject to quality improvement and, in some cases—such as the gynecologic-surgery videos on the academic institution's site^†—have undergone extensive research to evaluate their effectiveness in improving surgical performance for residents.²¹ As such, academic institutions and professional societies should consider the use of websites such as YouTube as a source to upload and promote their training videos.

A limitation of the current study was the small sample size (N = 12), which reduced the study's statistical power. As YouTube is the most-popular platform for uploading surgical videos, this is most likely due to the lack of other videos available for open-access viewing. Given that videos evaluated were restricted to those that contained live surgical footage, the study did not evaluate the utility and quality of animation-based TLH instructional videos. Future studies evaluating the surgical and educational content of surgical videos should analyze videos posted to multiple video sharing platforms to increase the sample size further to enable for greater statistical power and improved generalizability of the findings.

Conclusions

This study demonstrated that surgical-education videos uploaded to YouTube are not comprehensive in providing instruction to conduct TLH, often lacking instructions on the initial steps of this procedure. However, the videos do demonstrate good surgical technique with cases being easy-to-moderate difficulty. While these videos may cater more to the needs of senior surgical learners, there is an overall need for the creation of high-quality, comprehensive, surgical educational videos that are open-access and fulfill the specific training requirements for both junior and senior surgical trainees.

Footnotes

Acknowledgments

This research was published as a meeting abstract at the AAGL (formerly the American Association of Gynecologic Laparoscopists) Virtual Conference on November 8, 2020.^¶

Authors' Contributions

All of the authors were involved in research on the content and data collection for this study, as well as writing and editing this article.

Author Disclosure Statement

No financial conflicts of interest exist.

Funding Information

No funding was received for this research.

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