An evaluation of a laparoscopic ectopic simulation by trainees

Abstract

Tubal pregnancy is responsible for 8.95% of direct maternal deaths and the incidence is rising. Despite a grade A recommendation from the Royal College of Obstetricians and Gynaecologists (RCOG) that the majority of ectopic pregnancies should be managed via the laparoscopic approach, in only 13% of hospitals does this happen routinely. As a reason for this, trainees cite the inability to consolidate and practise the techniques learnt on approved courses well enough to have the confidence to undertake procedures on their own.

A highly realistic training simulation, simple and cheap enough to be available in every gynaecological unit, would allow trainees to practise skills learnt on RCOG-accredited courses on returning to their own hospitals. This would complement supervised training on live patients. Ectopic pregnancy often presents as an emergency, out of hours, when RCOG-accredited preceptors are unavailable to take juniors through the laparoscopic approach. The simulation would be ready for use at all times.

Limbs & Things (Bristol, UK), a company with acknowledged expertise in the development and construction of medical simulations, has developed an ectopic pregnancy simulation, in collaboration with two RCOG-accredited level 3 minimal access surgeons with experience in training in laparoscopic surgery for ectopic pregnancy. Special attention has been given to the achievement of a realistic appearance and fabrication of a material with the potential to allow monopolar and bipolar diathermy. The simulation was evaluated by 52 trainees of different grades and levels of experience in minimal access surgery (MAS), at the National Trainees' Meeting in Obstetrics and Gynaecology, May 1999. Assessment was done, using visual analogue scores, for realism in appearance, cutting, dissection and diathermy, after trainees had performed a standardized exercise directed by a tutor.

Overall, 51 trainees felt this was a valuable exercise in training (98%), and the combined realism score of the simulation was 64.7% (range 40–85%) (SD 13.85%). The MAS level 3 group scored the simulation much more highly at 78.75%, and showed much more consistency (range 75–85%) (SD 2.67%). All members of this group had previously used ectopic simulations, compared with 73% in the level 2 group and 42% in the level 1 group. The level 3 surgeons were not necessarily the most senior grades: 47% were specialist registrar grade 3 (SpR3) or less. Of the senior grades SpR4 and SpR5, 11 of 19 (58%) felt unable to perform laparoscopic salpingectomy with independent competence.

The level 3 trainees demonstrated themselves to be the only discerning group able to consistently score the simulation; they assessed the realism highly and felt this could be a valuable method for training in laparoscopic ectopic surgery. Despite RCOG recommendations that all trainees should be independently able to perform salpingectomy and salpingotomy, only 42% of years 4 and 5 were able to do so. The advantages of the laparoscopic approach are accepted. We have demonstrated a need for the necessary training and assessed an effective method for providing this. The system is cheap, and utilizes the equipment already present in all hospitals. We commend the this laparoscopic ectopic training simulation as a possible practicable adjunct to widespread training in laparoscopic ectopic surgery.