Poster presented at ESGE, Budapest, October 2016

1. Alcmaeon of Croton
in (mid-fifth century B.C.)
He laid down a background for
medical and anatomical science
with the dissection of animals
Wolfe et al.
in 1988
First described the advantages of the
pig uterus and bladder model
discussed, such as:
• The trainee can learn where and
how to make incisions
• The trainee can train to remove
tissue from a cavity
• The trainee can experience what
happens to tissue under the
influence of various energy forms
such as bipolar or monopolar
electro-surgery
• The range of actual simulations is
limited only by the imagination of
the trainers.
Ewies and Khan
in 2015
First described the advantages of the
cattle uterus model as a teaching
model for endoscopic surgery, as:
• the similarity in size of the uterine
body with the human uterus
• the realistic tissue resistance and
tactile sensation
• the presence of a uterine septum
that allows training in septum
resection
• Low cost of setup
• Easy and quick to setup
Advanced hysteroscopic surgery procedures have
a slow learning curve and a narrow margin for error.
Recently, due to reduced training opportunities, a
major shift in surgical training is towards the use of
virtual reality simulation over animal (wet-lab)
models. There is limited evidence in favour of one
over the other.
We have validated, evaluated and reviewed every
single modality available for training in hysteroscopic
surgery and present our findings in favour of the
animal models over virtual reality simulation.
Advantages of Animal Models
Offers a realistic platform to develop eye-hand-foot coordination
and manual dexterity skills
Replicates actual tissue elasticity, resistance and tactile sensation
Offers simulated intra-operative difficulties for real-life events
• obscuration of vision due to debris
• overhang of the tissue to the wire loop, or
• saline bubbling
Easy to setup
Cheap to setup
Does not incur the financial cost and operating time of teaching
the trainee in the operating theatre
The only disadvantage of the Cattle Uterus Model, and other
animal laboratory models, is that they do not simulate the in vivo
human condition as regards to bleeding.
Other teaching models
included
Virtual Reality simulators
included
IntroductionMethod
Animal Models
included
Cattle Uterus Model
All the Candidates (27 in total) attending the
courses were instructed to complete
customised Likert Scale based psychometric
feedback questionnaires, to assess Face
(training capacity) and Content
(performance) validity for each of the
practical skills stations.
They were also given an opportunity to
provide an overall score for each station
and elaborate with free comments.
The feedback was collected from courses
held over a two year period.
9.465
9.365
8.985
8.185
8.775
8.53
8.375
8.26
8.45
7.5
8
8.5
9
9.5
10
Results
Simulation of hysteroscopic resection using cattle uterus scored
the highest overall score of 94.65%
This is markedly better than virtual reality and computer graphic
based simulation stations that scored an average of 83.88%!!
Highest Score – 9.70, for the Cattle Uterus model for resection
Lowest Scores:
7.77, for the PolyTrainer for fibroid resection
7.85, for the Essure Virtual Reality Simulator
7.92, for the HystSim Virtual Reality Simulator
Overall Average Scores
from 2 years of feedback
Not just about tactile feedback
The PolyTrainer for MyoSure
resection training has been
developed with the specific
purpose of improving tactile
feedback and aid training in
this advanced hysteroscopic
procedure.
This was one of the original
stations that featured in the
course over both years and
scored the lowest overall
average score of 77.7%!
Candidates preferred the
realism of the resection on the
‘Cattle Uterus Model’ with
comments in favour of the
simulation model such as . . .
‘Excellent…’
‘a great experience…’
‘a real feel of how it works…’
We organised a three-day international
hands-on advanced hysteroscopic
surgery course at the Birmingham City
Hospital, every year, for 2 years.
Every modality available for training
in Hysteroscopic surgery was made
available to the trainees.
It was attended by 14 consultants and
senior trainees in gynaecology from the
United Kingdom and overseas in the
first year, 13 in year two
Drawbacks of
Virtual Reality Simulators
Cost of system
Cost of maintenance premium
No realistic tissue resistence
Repeatedly breaking down
Requiring expert troubleshooting
Lacks realism of electrosurgery
Unrealistic operator fearlessness
Despite the merits of virtual reality simulators, they are far from representing the real challenges encountered in
theatres. We believe that animal models such as the 'Cattle Uterus Model' will facilitate rapid acquisition of skills
complementing conventional surgical training, aiming to maximize clinical exposure and experience, so that
the trainees are able to finish their advanced training modules within the proposed 12 months duration.
The advantages of using the cattle uterus
as an animal laboratory model for the
purpose of advanced hysteroscopic
surgery training are the similarity in size of
the uterine body with the human uterus,
the realistic tissue resistance and tactile
sensation created a genuine training
model which cannot be provided by the
“Pig Bladder” model or simulation, and
the presence of a uterine septum that
allows training in septum resection; a
surgical skill that is difficult to obtain given
its rarity of occurrence in human.
Why the Cattle Uterus?
Join us at the next Advanced Hysteroscopic Surgery Workshop in Bimingham in 2017!
Are animal laboratory models superior to virtual reality
simulation in Advanced Hysteroscopic Surgery training?
Dr Zahid Khan
ST5 Registrar
Mr Ayman Ewies
Consultant
advancedhysteroscopy@gmail.comAyman A. A. Ewies and Zahid R. Khan, “Cattle Uterus: A Novel Animal Laboratory Model for Advanced Hysteroscopic Surgery Training,” Obstetrics and Gynecology International, vol. 2015, Article ID 967693, 4 pages, 2015. doi:10.1155/2015/967693