Cadaveric surgery in core gynaecology training: a feasibility study

It is now an expectation that an integral part of surgical training should include meaningful simulation prior to live patient operating wherever possible. Training time in obstetrics and gynaecology has been reduced over the past 20 years following the introduction of shorter training programmes and work hour restrictions from bodies like the European Working Time Directive (EWTD) and the Accreditation Council for Graduate Medical Education (ACGME). As such there is an increasing opportunity for realistic surgical simulation to improve clinical training [1‐9].

There are a number of simulation methods that suit acquisition of various skills. For example, neoprene surgical pads or animal tissue may be used to learn suturing and tissue handling, and laparoscopic ‘boxes’ or virtual simulation may improve hand-eye co-ordination [10]. There is difficulty, however, in simulating core procedures such as salpingectomy, which is one of the mandatory competencies in the curriculum for gynaecology trainees. Animal models lack anatomical accuracy and artificial models lack the realism of live tissue [11]. Fresh frozen cadaver training has been proposed as a better model than virtual reality simulators in laparoscopy training [12].

The use of cadaveric material was at one time a cornerstone of medical training, including undergraduate medical school anatomy teaching. More recently, students and trainees have little, if any, exposure to cadaveric material, those who do often only see prosected or preserved specimens. The concept of ‘procedure-specific’ cadaveric surgical training has been recently introduced in several specialities, including orthopaedics, trauma medicine and head and neck surgery [12‐14]. This has become possible by advances in preserving human tissue for teaching purposes. Cadaveric simulation in gynaecology has been applied in some surgical settings such as gynaecological oncology, targeted at advanced surgical trainees and established consultant specialists [7, 8] but not at junior trainees who are still at the stage of familiarising basic surgical skills and procedures.

The benefit of this training intervention is not easy to quantify, but it is postulated that improved self-belief in a task enhances self-confidence [15]. Self-confidence, for trainees, is the trust in one’s abilities, qualities and judgement. Social cognitivist theory refers to this belief of self-ability as ‘perceived self-efficacy’, and this is one of the cognitive mechanisms underlying behavioural change [16]. Importantly, in this context, it is also one of the factors that predict performance success [17]. Literature suggests that those who expect to do well, demonstrating a high belief in their own self-efficacy, are more likely to do well than those who expect to do poorly [18]. Therefore, with the increasing constraints on surgical gynaecological training, educators must identify relevant factors that can increase skill acquisition and self-efficacy, or surgical confidence [16]. In the context of this study, it is anticipated that improved surgical confidence may be linked to surgical expertise and, therefore, competence. For educators, being aware of this relationship and, designing training programmes accordingly, is essential to surgical expertise and, ultimately, patient outcomes [19].

We aimed to explore the relationship between cadaveric surgical training and increased surgical confidence. We report the feasibility of introducing cadaveric surgical training into a basic training programme at year 3. To our knowledge, the use of cadaveric material in basic gynaecology training has never been reported.

Using a survey methodology, the relationship between cadaveric surgical training and improved confidence was explored. A mixed methods approach was used, which facilitated the collection of both quantitative and qualitative data.

Data from the nine trainees at ST year 3 level within the HEE NE training programme who attended both days of the 2-day programme are reported. Figure 2 shows the linear changes in mean delegate SCS for the seven surgical competencies over the four time points. This is presented as a visual representation of all the results. A more detailed analysis is given in Tables 1, 2, 3 and 4 and in the text below.

This was intended as a feasibility study, and we have had an opportunity to demonstrate from here that cadaveric surgery improves surgical confidence.

Analysis of SCS at different stages of the study gives some insight into the value of cadaveric surgical simulation training. Firstly, it is noted that there was a universal improvement in confidence scores for all skills assessed (Table 1). The greatest improvement appeared to be for oophorectomy, salpingectomy and hysterectomy. These are procedures that year 3 trainees are often only just starting to undertake as supervised clinical cases, which may explain why the baseline SCS prior to day 1 were lower than for other procedures. Whereas for procedures that year 3 trainees were likely to be already experienced in, such as opening and closing the abdomen and optimising the surgical field (skills used in caesarean section), the baseline SCS prior to day 1 was higher and therefore the overall improvement was less as a result.

Table 2 demonstrates that SCS retention over 8 months was variable for different competencies. This retention of confidence is likely to be related to the trainees’ actual surgical experiences over the 8-month interim. For example, trainees were almost as confident at the start of day 2 as the end of day 1 for procedures that were simple and likely to be a common part of supervised clinical training, such as sterilisation and opening and closing the abdomen. The greatest reduction in SCS between the two training days was for hysterectomy. This is likely to be because hysterectomy is more complex to undertake and trainees have less opportunities for supervised clinical training. Table 3 shows that despite some loss of confidence for some of the surgical competencies, trainees were universally more confident at the start of day 2 than day 1. This would suggest that the intervention of cadaveric simulation combined with supervised clinical training is an effective approach to teaching surgical procedures. Simulation training is an important adjunct rather than an alternative to clinical experience [24] but is likely to be of greatest value when simulation is timed to clinical exposure.

Three main themes emerged from the qualitative data: self-concept, social persuasion and stability of task. These are described in detail in the “Results” section. The responses were overwhelmingly positive, suggesting that trainees felt better equipped to engage with supervised clinical training. Not only did trainees highlight the value of real-time surgery and real anatomy but also the interaction with trainers and working in an environment where mistakes can be made before operating on live patients. This would suggest that it is not just the use of cadavers are important but also the structure of the training days.

Our study report results from the first nine participants to undertake both training days as a group. This was limited in part by the regional workforce for the population and also our intention to study a homogenous group of trainees of similar level of experience. All delegates had more than 2 years but less than 3 years equivalent of full-time training within obstetrics and gynaecology. As this was a pilot intended as a feasibility study with a small sample size, we are cautious in claiming generalisability or drawing conclusions surrounding the benefit of cadaveric surgical training. As a feasibility study, the aim was to produce findings that help determine whether this intervention could be recommended for further studies.

This study suggests that more advanced surgical trainees can be trained with a similar model on more complex advance procedures. The process of training a surgeon to a level of higher confidence can also be supplemented with this model. Our group have begun work in implementing a more regular set of training days around similar models with cadaveric work throughout the training programme for the region.

In the absence of clinical training, confidence level varies greatly [25]. Clanton et al. reported in a study involving 150 medical students in basic surgical skills that there is a strong association between confidence and competence [19]. Hutton et al. reported a similar relationship between confidence and competence in chest tube insertion by junior doctors [26].

The values of surgical simulation training have been established in other medical disciplines [10, 11, 27, 28]. Palter et al. described 25 colorectal surgical residents who received ex vivo simulation training and demonstrated improved technical knowledge and performance in the operating room compared to conventional residency training [29]. Ahmed et al. described a series of 81 urology residents having undergone a cadaveric surgical programme. They reported that human cadaveric surgery was the best mode of simulation-based training with improvements in skills that were transferrable to the operating theatre based on evaluation surveys only [30]. This study may be criticised for its heterogeneity because of the varied levels of experience of the participating residents and that evaluation survey was the only tool they used to assess the success of the programme. However, it does demonstrate an appetite for realistic simulation training.

Our study demonstrates that it is feasible to integrate cadaveric surgery into core training curriculum. It is already accepted that trainees should have the opportunity to develop skills by simulation prior to operating on live patients. However, insufficient literature addresses the relationship between confidence and surgical skills [19]. The results presented here address this gap and demonstrate that cadaveric surgery may improve the confidence of trainees when introduced as an adjunct to conventional training. This is valuable as there is evidence that improved confidence in a task enhances self-efficacy [15]. Furthermore, an association between surgical skills and confidence has both educational and clinical implications [19]. We recognise that this is a study with a small sample size; however, using a mixed methods approach, we have assessed the complex construct of confidence and plan further studies with a larger cohort of trainees.

We acknowledge that surgical confidence depends on many factors within a training environment. We were not able to determine the relative merits of procedure-specific cadaver training versus dedicated skill training in the lab with a consultant surgeon in this study. Also, no comparison was made with other synthetic or virtual reality training tools. However, the results demonstrate that cadaveric surgical training is well received by trainees and appears to be an effective intervention.

In light of the findings of this study, we can conclude that it is feasible to integrate cadaveric surgical training into conventional gynaecology surgical training. Our next priority would be to reinforce the hypothesis of quantitative confidence improvements by incorporating a larger cohort of delegates.

This study gives some support to the notion that simulation training improves surgical technique; however, the concept of surgical competence is complex and whether simulation is an effective tool to teach or assess competence is beyond the scope of this study. It is therefore important to acknowledge that although cadaveric surgical training can serve as a valid adjunct to conventional training, it does not supersede live surgical training. This is expected to be addressed in the more senior years of training in the clinical environment.

It is pragmatically feasible to provide procedure-specific cadaveric surgical training alongside supervised clinical training. Assessment of this training can be achieved by a mixed quantitative and qualitative approach. This study will form the basis of a larger study. This work has implications surrounding the improvement of self-confidence and assisting educators in implementing interventions to optimise success and self-confidence during surgical skills acquisition.