- Email: [email protected]
An Evaluation of the Utility of Robotic Virtual Reality Simulation in Gynecologic Resident Surgical Education
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Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S45–S90
Table 2 Adjusted odds ratios for hospital readmission after outpatient surgery
281
Risk factor for readmission
Adjusted Odds Ratio
95% Confidence Interval
P-value
Black race Hispanic ethnicity Tobacco smoking Steroid use History of bleeding disorder Evidence of frailty (Frailty Index >0) BMI > 30 (kg/m2) Age > 80 years old
1.266 0.700 1.699 2.356 3.329
0.868-1.847 0.424-1.155 1.267-2.280 1.076-5.160 1.412-7.849
0.221 0.163 \0.001 0.032 0.006
Minimally Invasive Gynecologic Surgical Training and Surgeon Volume: Effects on Perioperative Outcomes Opoku-Anane J, Moawad G, Grant-Wisdom T, Felfalan R, Robinson JK. Obstetrics and Gynecology, George Washington University, Washington, District of Columbia
1.416
1.076-1.862
0.013
0.886 0.728
0.678-1.157 0.227-2.332
0.374 0.593
body mass index (BMI) were not significantly different between both populations. After adjusting for potential confounders, tobacco smoking, steroid use, history of bleeding disorders, and evidence of frailty were each significantly associated with increased risk for readmission [Table 2]. Race, ethnicity, body mass index, and age were not significantly different between both populations. Conclusion: Tobacco smoking, current systemic steroid use, a history of bleeding disorders, evidence of patient frailty, increased operative time, intra-abdominal surgery, and increased surgical complexity increase the risk of hospital readmission after outpatient gynecologic surgery. 280
Open Communications 14 - Laparoscopy (3:03 PM - 3:08 PM)
Evolving Practice Patterns in Minimally Invasive Hysterectomy: Where Are We Now Hershberger DW, Doyle NM, Genesen MC. Obstetrics and Gynecology, University of Oklahoma - Tulsa, Tulsa, Oklahoma Study Objective: Hysterectomy is one of the most commonly performed procedures with 1 in 9 women participating. Traditionally, abdominal (AH), vaginal (VH), laparoscopic assisted vaginal (LAVH), or total laparoscopic (TLH) used. Robotic assisted (RATLH) has recently been introduced as an alternative minimally invasive surgery (MIS). We sought to evaluate current approaches and MIS impact through a pilot survey. Design: A 28 question survey was developed and distributed among surgeons at the 2012 ACOG District VII advisory council meeting and the Alabama/Mississippi postgraduate course to gather information from practicing Gynecologists on their training experiences, preferred surgical approach, cuff closure/complications, and patient counseling information. Setting: Surgeon Experience: 79% private practice, 21% academic setting. Years in Practice: 20 years: 46%, 11 to 20 years: 23%, 6 to 10 years: 13%. Measurements and Main Results: 79 / 90 distributed surveys completed (88%). Adequate resident training reported in AH 99%, VH 94%, LAVH 48%, TLH 12% and RATLH 16%. 100% said AH/VH mastered in residency. 62% stated RATLH was industry sponsored learning. LAVH / TLH equal mixture resident / industry training. 90% use MIS. 50% said VH preferred for family member. 40% VH preferred. Reasons cited for no robot: no worth (47%), lack training/time/ technology (15 – 34%). Most denied increase in, but reported higher complication rates amongst their peers in ureteral/ bowel/thermal injury with MIS. A variety of cuff closure techniques reported for AH, VH, LAVH, and TLH. RATLH: 87% agreement barbed double layer cuff closure. 93% agreed a perioperative checklist would help. 81% noted MIS created opportunities for plaintiffs. Conclusion: RATLH has added another tool in Minimally Invasive Surgeon’s armamentarium. Training appears to be predominately industry sponsored and in the resident setting is likely insufficient at this time. A uniform approach to MIS including a perioperative checklist may improve outcomes.
Open Communications 14 - Laparoscopy (3:09 PM - 3:14 PM)
Study Objective: To compare surgical outcomes between generalist and minimally invasive trained gynecologists. Design: Retrospective cohort study. Setting: Large academic teaching practice in an urban setting. Patients: Patients presenting for management of benign gynecologic disorders between January of 2012 and June of 2013 were assessed by a provider within our gynecology practice. Patients who subsequently underwent surgery at our two affiliated hospitals were included in the study. Intervention: Initial presentation and past medical history was collected from the medical record. Outcomes evaluated included conversions to laparotomy, ICU admissions, perioperative complications, transfusions, and length of stay. Surgeon volume was categorized according to high (HVS), medium (MVS), and low (LVS) average annual volumes. Perioperative outcomes were compared between LVS generalist obstetrician gynecologists (OB/GYNs), LVS generalist OB/GYNs who completed a minimally invasive gynecology (MIGS) fellowship (MLVS), and HVS gynecologists who completed a MIGS fellowship. Measurements and Main Results: Five hundred twenty-two surgeries were performed during the study period. The average age and BMI of the cohort was 43 years and 29, respectively. Sixty-two percent of patients were operated on by HVS, 14% by MLVS, and 24% by LVS. Amongst major gynecologic procedures, there was no difference in rates of conversion from laparoscopy to laparotomy, however overall perioperative complications were highest amongst the LVS (5.7%) compared to the MLVS (1.4%) and HVS (1.6%) (p = 0.04). After adjusting for surgical complexity of cases, HVS were less likely than LVS to have perioperative complications (OR 0.31, 95% CI 0.12, 0.88; p = 0.0024). MLVS did show a trend toward improved perioperative outcomes, however this was not statistically significant. Conclusion: Advance training in MIGS and high surgical volume is associated with improved perioperative outcomes.
282
Open Communications 15 - Education (2:15 PM - 2:20 PM)
An Evaluation of the Utility of Robotic Virtual Reality Simulation in Gynecologic Resident Surgical Education Vogell A, Wright V, Wright K. Gynecology, Lahey Hospital, Burlington, Massachusetts Study Objective: To evaluate the da Vinci Skills Simulator (dVSS), Intuitive Inc., Sunnyvale, CA, as an effective component of resident physician robotic training. Design: IRB approved prospective study of gynecology resident’s simulation and surgical skill. Setting: Tertiary care academic hospital in suburban Boston. Patients: Obstetrics and gynecology resident physicians in their third postgraduate year during 10 week gynecology rotation. Intervention: Utilization of the dVSS and task performance scores assigned by the simulator were recorded for four residents. Study participant’s operating skill was assessed by two blinded expert laparoscopic surgeons during video review of their robotic assisted vaginal cuff closure using Objective Structured Assessment of Technical Skills (OSATS) scores, a validated global rating scale for operative performance. Measurements and Main Results: Participating residents (R1, R2, R3, R4) utilized the simulator for an average of 4.3 hours and performed 5 to 7 cuff closures. Three of 4 participants achieved 90% efficiency on all tasks in 98 to 263 minutes.
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S45–S90 Resident Simulator and Operative Participation Resident Utilization Time (min) Time to 90% (min) Cuff Closures (n) 1 2 3 4
115.95 263.53 553.42 107.08
98.27 263.53 186.4 –*
7 7 5 6
*Resident did not achieve a score of 90% on each task by the end of the block Residents completed robotic assisted vaginal cuff closure within 10 minutes 84% of the time. OSAT scores were averaged at each cuff closure and plotted over time. A linear regression analysis modeled the relationship between resident’s scores and time spent utilizing the simulator.
Pearson correlation coefficients (r) determined significance. R3 maintained the greatest overall utilization of the simulator and achieved the greatest improvement in skill over time(1 tailed test p = 0.03, 2 tailed test p = 0.07). R4 used the simulator the least and achieved only a marginal, insignificant score improvement(1 tailed test p= 0.53, 2 tailed test p = 0.28). Conclusion: Resident utilization of the dVSS correlated with improved OSAT scores on video recording of robotic assisted vaginal cuff closure. To affirm this technology as an effective means of training a greater number of participants requires further evaluation. 283
Open Communications 15 - Education (2:21 PM - 2:26 PM)
A Comprehensive 4-Phase Robotic Gynecologic Surgery Curriculum Congruent with PGY Levels Leads to Certification and Credentialing Saldivar JS. Obstetrics & Gynecology-Division of Gynecology Oncology, Texas Tech University Health Sciences Center El Paso, El Paso, Texas Study Objective: There is a paucity of standardized robotic surgery curriculums in gynecology. We present a 4-Phase comprehensive resident robotic surgery curriculum in gynecology that leads to certification and credentialing. Design: Residents are exposed to a Phase I-IV robotic training curriculum that coincides with their PGY level aimed at being completed within the four years of residency training or less. Setting: Exposure to the curriculum involves online videos, robotic simulation training, system preparation and OR clinical training at university and community hospitals. Patients: All OB GYN residents (total n=15) currently enrolled at Texas Tech University Health Sciences Center at El Paso residency program. Intervention: Residents are exposed to the following: PGY1-Phase I: introduction to robotic surgery online community system (1-2 hours). PGY2-Phase II: preparation & system training on-line and on-site with robotic clinical specialist (2+8 hours). PGY3-Phase III: simulation training (3-5 hours). PGY4-Phase IV: clinical training with patient-side assist 5 cases; console surgeon 10 cases (5 deconstructed/5 primary surgeon). Measurements and Main Results: All but one resident (n=15) are enrolled in the pathway. To date, 12/15 (80%) residents that have completed Phase I,
S85
9/15 (60%) completed Phase II, 5/15 (33%) completed Phase III, 3/15 (20%) completed Phase IV, and 1/15 (6%) resident will receive certification of completion. Time from inception of the curriculum has been 4 months. Preliminary data on completion of hysterectomy and simulation module scores will be presented. Conclusion: We introduce a comprehensive 4-Phase resident robotic surgery curriculum in gynecology that outlines the pathway to develop knowledge and skills in minimally invasive surgery, and ultimately certification and credentialing. 284
Open Communications 15 - Education (2:27 PM - 2:32 PM)
Physician Perceptions of the Role of Minimally Invasive Gynecologic Surgeons in General Ob/Gyn Farrow MR, Nimaroff M. North Shore University Hospital, Manhasset, New York Study Objective: To assess physician knowledge of the fellowship in minimally invasive gynecologic surgery and to understand perceptions of the role of these physicians in the field of OBGYN. Design: Prospective, survey study. Setting: Large multi-setting health system. Patients: Physicians currently practicing Obstetrics and/or Gynecology in the North Shore Long Island Health System. Intervention: A standard email describing the study and containing a link to the anonymous online survey was created. This standard email was sent to the OBGYN department chair at each facility within the North Shore Health System and was forwarded to the physicians affiliated with their facility. The survey consisted of 20 multiple choice questions with options for free responses. Measurements and Main Results: Preliminary data obtained 31 survey respondents. The majority of respondents currently practice obstetrics and gynecology (64%), have been in practice over 10 years (75%), and have not completed any formal post-residency training in minimally invasive surgery (78%). Approximately 80% of respondents were familiar with the AAGL Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS) and 48% have previously worked with a graduate of the program. When asked based on the fellowship mission statement if they would find it valuable to hire an FMIGS graduate to their current or future practice, most responded ‘‘Yes’’ or ‘‘Maybe’’ (81%). However, the majority of respondents would refer less than 25% of surgical procedures to such a physician. The most common procedure types for referral were robotic surgery (77%), laparoscopy for endometriosis (59%), and laparoscopic myomectomy (54%). Conclusion: While it is clear that most OBGYN physicians may find the FMIGS graduate to be a valuable asset in theory, the referral patterns suggest that there are still barriers to establishing a defined role in the field. 285
Open Communications 15 - Education (2:33 PM - 2:38 PM)
Impact of Simulator Training on General Laparoscopic and Gynecologic Skills: A Systematic Review Jones-Cox C,1 Paka C,2 Chou B,2 Fashokun T,2 Lockrow E,1 Zahn C,1 Murray C,2 Dattilo J,2 Chen G,2 Singh S,2 Chen CCG.2 1Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland; 2Obstetrics and Gynecology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland Study Objective: To conduct a systematic review of the impact of simulator training on general laparoscopic skills and laparoscopic skills specific to gynecology. Design: This review was designed, performed and analyzed in accordance with the PRISMA standards. With no beginning date cutoff, a systematic search of the literature was conducted on April 4, 2013 using PubMed MEDLINE, Embase, and SCOPUS incorporating a combination of Medical Subject Headings (MeSH), Emtree terms, and keywords. The searches were limited to clinical trials by creating filters for each of the databases. Two reviewers independently reviewed all studies and a third
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S45–S90
Table 2 Adjusted odds ratios for hospital readmission after outpatient surgery
281
Risk factor for readmission
Adjusted Odds Ratio
95% Confidence Interval
P-value
Black race Hispanic ethnicity Tobacco smoking Steroid use History of bleeding disorder Evidence of frailty (Frailty Index >0) BMI > 30 (kg/m2) Age > 80 years old
1.266 0.700 1.699 2.356 3.329
0.868-1.847 0.424-1.155 1.267-2.280 1.076-5.160 1.412-7.849
0.221 0.163 \0.001 0.032 0.006
Minimally Invasive Gynecologic Surgical Training and Surgeon Volume: Effects on Perioperative Outcomes Opoku-Anane J, Moawad G, Grant-Wisdom T, Felfalan R, Robinson JK. Obstetrics and Gynecology, George Washington University, Washington, District of Columbia
1.416
1.076-1.862
0.013
0.886 0.728
0.678-1.157 0.227-2.332
0.374 0.593
body mass index (BMI) were not significantly different between both populations. After adjusting for potential confounders, tobacco smoking, steroid use, history of bleeding disorders, and evidence of frailty were each significantly associated with increased risk for readmission [Table 2]. Race, ethnicity, body mass index, and age were not significantly different between both populations. Conclusion: Tobacco smoking, current systemic steroid use, a history of bleeding disorders, evidence of patient frailty, increased operative time, intra-abdominal surgery, and increased surgical complexity increase the risk of hospital readmission after outpatient gynecologic surgery. 280
Open Communications 14 - Laparoscopy (3:03 PM - 3:08 PM)
Evolving Practice Patterns in Minimally Invasive Hysterectomy: Where Are We Now Hershberger DW, Doyle NM, Genesen MC. Obstetrics and Gynecology, University of Oklahoma - Tulsa, Tulsa, Oklahoma Study Objective: Hysterectomy is one of the most commonly performed procedures with 1 in 9 women participating. Traditionally, abdominal (AH), vaginal (VH), laparoscopic assisted vaginal (LAVH), or total laparoscopic (TLH) used. Robotic assisted (RATLH) has recently been introduced as an alternative minimally invasive surgery (MIS). We sought to evaluate current approaches and MIS impact through a pilot survey. Design: A 28 question survey was developed and distributed among surgeons at the 2012 ACOG District VII advisory council meeting and the Alabama/Mississippi postgraduate course to gather information from practicing Gynecologists on their training experiences, preferred surgical approach, cuff closure/complications, and patient counseling information. Setting: Surgeon Experience: 79% private practice, 21% academic setting. Years in Practice: 20 years: 46%, 11 to 20 years: 23%, 6 to 10 years: 13%. Measurements and Main Results: 79 / 90 distributed surveys completed (88%). Adequate resident training reported in AH 99%, VH 94%, LAVH 48%, TLH 12% and RATLH 16%. 100% said AH/VH mastered in residency. 62% stated RATLH was industry sponsored learning. LAVH / TLH equal mixture resident / industry training. 90% use MIS. 50% said VH preferred for family member. 40% VH preferred. Reasons cited for no robot: no worth (47%), lack training/time/ technology (15 – 34%). Most denied increase in, but reported higher complication rates amongst their peers in ureteral/ bowel/thermal injury with MIS. A variety of cuff closure techniques reported for AH, VH, LAVH, and TLH. RATLH: 87% agreement barbed double layer cuff closure. 93% agreed a perioperative checklist would help. 81% noted MIS created opportunities for plaintiffs. Conclusion: RATLH has added another tool in Minimally Invasive Surgeon’s armamentarium. Training appears to be predominately industry sponsored and in the resident setting is likely insufficient at this time. A uniform approach to MIS including a perioperative checklist may improve outcomes.
Open Communications 14 - Laparoscopy (3:09 PM - 3:14 PM)
Study Objective: To compare surgical outcomes between generalist and minimally invasive trained gynecologists. Design: Retrospective cohort study. Setting: Large academic teaching practice in an urban setting. Patients: Patients presenting for management of benign gynecologic disorders between January of 2012 and June of 2013 were assessed by a provider within our gynecology practice. Patients who subsequently underwent surgery at our two affiliated hospitals were included in the study. Intervention: Initial presentation and past medical history was collected from the medical record. Outcomes evaluated included conversions to laparotomy, ICU admissions, perioperative complications, transfusions, and length of stay. Surgeon volume was categorized according to high (HVS), medium (MVS), and low (LVS) average annual volumes. Perioperative outcomes were compared between LVS generalist obstetrician gynecologists (OB/GYNs), LVS generalist OB/GYNs who completed a minimally invasive gynecology (MIGS) fellowship (MLVS), and HVS gynecologists who completed a MIGS fellowship. Measurements and Main Results: Five hundred twenty-two surgeries were performed during the study period. The average age and BMI of the cohort was 43 years and 29, respectively. Sixty-two percent of patients were operated on by HVS, 14% by MLVS, and 24% by LVS. Amongst major gynecologic procedures, there was no difference in rates of conversion from laparoscopy to laparotomy, however overall perioperative complications were highest amongst the LVS (5.7%) compared to the MLVS (1.4%) and HVS (1.6%) (p = 0.04). After adjusting for surgical complexity of cases, HVS were less likely than LVS to have perioperative complications (OR 0.31, 95% CI 0.12, 0.88; p = 0.0024). MLVS did show a trend toward improved perioperative outcomes, however this was not statistically significant. Conclusion: Advance training in MIGS and high surgical volume is associated with improved perioperative outcomes.
282
Open Communications 15 - Education (2:15 PM - 2:20 PM)
An Evaluation of the Utility of Robotic Virtual Reality Simulation in Gynecologic Resident Surgical Education Vogell A, Wright V, Wright K. Gynecology, Lahey Hospital, Burlington, Massachusetts Study Objective: To evaluate the da Vinci Skills Simulator (dVSS), Intuitive Inc., Sunnyvale, CA, as an effective component of resident physician robotic training. Design: IRB approved prospective study of gynecology resident’s simulation and surgical skill. Setting: Tertiary care academic hospital in suburban Boston. Patients: Obstetrics and gynecology resident physicians in their third postgraduate year during 10 week gynecology rotation. Intervention: Utilization of the dVSS and task performance scores assigned by the simulator were recorded for four residents. Study participant’s operating skill was assessed by two blinded expert laparoscopic surgeons during video review of their robotic assisted vaginal cuff closure using Objective Structured Assessment of Technical Skills (OSATS) scores, a validated global rating scale for operative performance. Measurements and Main Results: Participating residents (R1, R2, R3, R4) utilized the simulator for an average of 4.3 hours and performed 5 to 7 cuff closures. Three of 4 participants achieved 90% efficiency on all tasks in 98 to 263 minutes.
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S45–S90 Resident Simulator and Operative Participation Resident Utilization Time (min) Time to 90% (min) Cuff Closures (n) 1 2 3 4
115.95 263.53 553.42 107.08
98.27 263.53 186.4 –*
7 7 5 6
*Resident did not achieve a score of 90% on each task by the end of the block Residents completed robotic assisted vaginal cuff closure within 10 minutes 84% of the time. OSAT scores were averaged at each cuff closure and plotted over time. A linear regression analysis modeled the relationship between resident’s scores and time spent utilizing the simulator.
Pearson correlation coefficients (r) determined significance. R3 maintained the greatest overall utilization of the simulator and achieved the greatest improvement in skill over time(1 tailed test p = 0.03, 2 tailed test p = 0.07). R4 used the simulator the least and achieved only a marginal, insignificant score improvement(1 tailed test p= 0.53, 2 tailed test p = 0.28). Conclusion: Resident utilization of the dVSS correlated with improved OSAT scores on video recording of robotic assisted vaginal cuff closure. To affirm this technology as an effective means of training a greater number of participants requires further evaluation. 283
Open Communications 15 - Education (2:21 PM - 2:26 PM)
A Comprehensive 4-Phase Robotic Gynecologic Surgery Curriculum Congruent with PGY Levels Leads to Certification and Credentialing Saldivar JS. Obstetrics & Gynecology-Division of Gynecology Oncology, Texas Tech University Health Sciences Center El Paso, El Paso, Texas Study Objective: There is a paucity of standardized robotic surgery curriculums in gynecology. We present a 4-Phase comprehensive resident robotic surgery curriculum in gynecology that leads to certification and credentialing. Design: Residents are exposed to a Phase I-IV robotic training curriculum that coincides with their PGY level aimed at being completed within the four years of residency training or less. Setting: Exposure to the curriculum involves online videos, robotic simulation training, system preparation and OR clinical training at university and community hospitals. Patients: All OB GYN residents (total n=15) currently enrolled at Texas Tech University Health Sciences Center at El Paso residency program. Intervention: Residents are exposed to the following: PGY1-Phase I: introduction to robotic surgery online community system (1-2 hours). PGY2-Phase II: preparation & system training on-line and on-site with robotic clinical specialist (2+8 hours). PGY3-Phase III: simulation training (3-5 hours). PGY4-Phase IV: clinical training with patient-side assist 5 cases; console surgeon 10 cases (5 deconstructed/5 primary surgeon). Measurements and Main Results: All but one resident (n=15) are enrolled in the pathway. To date, 12/15 (80%) residents that have completed Phase I,
S85
9/15 (60%) completed Phase II, 5/15 (33%) completed Phase III, 3/15 (20%) completed Phase IV, and 1/15 (6%) resident will receive certification of completion. Time from inception of the curriculum has been 4 months. Preliminary data on completion of hysterectomy and simulation module scores will be presented. Conclusion: We introduce a comprehensive 4-Phase resident robotic surgery curriculum in gynecology that outlines the pathway to develop knowledge and skills in minimally invasive surgery, and ultimately certification and credentialing. 284
Open Communications 15 - Education (2:27 PM - 2:32 PM)
Physician Perceptions of the Role of Minimally Invasive Gynecologic Surgeons in General Ob/Gyn Farrow MR, Nimaroff M. North Shore University Hospital, Manhasset, New York Study Objective: To assess physician knowledge of the fellowship in minimally invasive gynecologic surgery and to understand perceptions of the role of these physicians in the field of OBGYN. Design: Prospective, survey study. Setting: Large multi-setting health system. Patients: Physicians currently practicing Obstetrics and/or Gynecology in the North Shore Long Island Health System. Intervention: A standard email describing the study and containing a link to the anonymous online survey was created. This standard email was sent to the OBGYN department chair at each facility within the North Shore Health System and was forwarded to the physicians affiliated with their facility. The survey consisted of 20 multiple choice questions with options for free responses. Measurements and Main Results: Preliminary data obtained 31 survey respondents. The majority of respondents currently practice obstetrics and gynecology (64%), have been in practice over 10 years (75%), and have not completed any formal post-residency training in minimally invasive surgery (78%). Approximately 80% of respondents were familiar with the AAGL Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS) and 48% have previously worked with a graduate of the program. When asked based on the fellowship mission statement if they would find it valuable to hire an FMIGS graduate to their current or future practice, most responded ‘‘Yes’’ or ‘‘Maybe’’ (81%). However, the majority of respondents would refer less than 25% of surgical procedures to such a physician. The most common procedure types for referral were robotic surgery (77%), laparoscopy for endometriosis (59%), and laparoscopic myomectomy (54%). Conclusion: While it is clear that most OBGYN physicians may find the FMIGS graduate to be a valuable asset in theory, the referral patterns suggest that there are still barriers to establishing a defined role in the field. 285
Open Communications 15 - Education (2:33 PM - 2:38 PM)
Impact of Simulator Training on General Laparoscopic and Gynecologic Skills: A Systematic Review Jones-Cox C,1 Paka C,2 Chou B,2 Fashokun T,2 Lockrow E,1 Zahn C,1 Murray C,2 Dattilo J,2 Chen G,2 Singh S,2 Chen CCG.2 1Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland; 2Obstetrics and Gynecology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland Study Objective: To conduct a systematic review of the impact of simulator training on general laparoscopic skills and laparoscopic skills specific to gynecology. Design: This review was designed, performed and analyzed in accordance with the PRISMA standards. With no beginning date cutoff, a systematic search of the literature was conducted on April 4, 2013 using PubMed MEDLINE, Embase, and SCOPUS incorporating a combination of Medical Subject Headings (MeSH), Emtree terms, and keywords. The searches were limited to clinical trials by creating filters for each of the databases. Two reviewers independently reviewed all studies and a third