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Original article
Hysteroscopic resection on virtual reality simulator: What do we measure? P. Panel a, M.-E. Neveu a,b, C. Villain c,d, F. Debras e, H. Fernandez b,d, E. Debras a,b,* a
Department of Gynecology and Obstetrics, Centre Hospitalier de Versailles, 78157 Le Chesnay Cedex, France Department of Gynecology and Obstetrics, Hoˆpital Biceˆtre, GHU Sud, AP-HP, 94276 Le Kremlin-Biceˆtre, France c Delegation for Clinical Research and Investigation, Centre Hospitalier de Versailles, 78157 Le Chesnay Cedex, France d Inserm, Centre of Research in Epidemiology and Population Health (CESP), U1018, 94276 Le Kremlin-Biceˆtre, France e Ecole Normale Supe´rieure, CRAL, UMR CNRS 5574, 69364 Lyon Cedex 07, France b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 18 October 2017 Received in revised form 13 February 2018 Accepted 27 February 2018 Available online xxx
Objective. – The objective was to compare results of two groups of population (novices and experts) on a virtual reality simulator of hysteroscopy resection for different metrics and for a multimetric score to assess its construct validity. Materials and methods. – Nineteen gynecologist who had at least 5 years of experience with hysteroscopy and self-evaluated their expertise at 4/5 or 5/5 were included as expert population. Twenty first-year gynecology residents in Paris were included as novice population. A standardized set of 4 hysteroscopy resection cases (polypectomy, myomectomy, roller ball endometrial ablation and septum resection) was performed on a virtual reality simulator (HystSimTM) by the group of novices and experts. Results obtained on the simulator for overall score and for the parameters were compared by applying the Mann–Whitney test. Results. – Overall score of novices and experts were significantly different for three resection cases (polypectomy P < 0.001, myomectomy P < 0.001, roller ball endometrial ablation <0.001). The overall score was not different in the septum resection (P = 0.456). For the four cases, the economy score (included cumulative path length, procedure time and camera alignment) were statistically different between novices and experts (polypectomy P < 0.001, myomectomy P = 0.001, roller ball endometrial ablation P < 0.001, septum resection P < 0.001). Conclusion. – The overall score on HystSimTM was able to discriminate novices between experts on polypectomy, myomectomy and roller ball endometrial ablation cases but not on septum resection. The economy score was the more reliable to reflect the surgeon experience. It could be used to evaluate and to train students on hysteroscopic resection on a virtual reality simulator.
C 2018 Elsevier Masson SAS. All rights reserved.
Keywords: Surgical education Hysteroscopy Virtual reality Validity method
Introduction Surgery residents spend less and less time in the operating room (OR) to learn technical skills [1]. Obstetrics-gynecology residents must become proficient in both surgical and obstetrical procedures, and advances in technology require them to learn more skills in less time [2]. Most gynecological procedures are now performed endoscopically [3]. Specific training is needed to acquire endoscopic surgery skills [4,5]. Hysteroscopy is a widely
* Corresponding author at: Service de gyne´cologie obste´trique, Centre hospitalier de Versailles, 177 rue de Versailles, 78150 Le Chesnay, France. E-mail address:
[email protected] (E. Debras).
performed endoscopic procedure and must therefore be taught effectively to all gynecology residents [6]. Many recommendations underline the importance of developing new training methods that residents can use outside the OR [7–10]. Virtual reality (VR) simulation has proved effective in improving laparoscopic surgery skills [11–16]. HystSimTM is a VR simulator designed by VirtaMed1 (Zurich, Switzerland) to replicate many hysteroscopic surgical procedures [17]. HystsimTM seems to meet the five requirements of VR simulators [18] first described by Richard Satava [19]. An important advantage of VR simulators is that they provide automated feedback to the trainee, in the form of a score based on a variety of parameters [20]. Scoring based on multiple parameters has been shown to discriminate effectively between experts and novices [21–23]. The mutimetric score system (MMSS)
https://doi.org/10.1016/j.jogoh.2018.02.005 C 2018 Elsevier Masson SAS. All rights reserved. 2468-7847/
Please cite this article in press as: Panel P, et al. Hysteroscopic resection on virtual reality simulator: What do we measure? J Gynecol Obstet Hum Reprod (2018), https://doi.org/10.1016/j.jogoh.2018.02.005
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provided by HystSimTM was based on the opinion of two experts, and its cut-off values were defined arbitrarily. Its construct validity has been established only for diagnostic and Essure1 procedures [24,25] and not for resection procedures [26]. On different studies the overall score was not discriminating between levels of experience in performing polyp or myoma resection [27,28]. Here, the objective was to test the discrimination between experts and novices of MMSS of HystSimTM on a standardized course of four resection cases (polypectomy, myomectomy, septum, endometrial ablation). The discrimination of experts and novices from the MMSS will confirm the construct validity of the resection cases but also allow to set up a training program for novices on this simulator with a valid evaluation tool.
Materials and methods Simulated resection procedures We used HystSimTM with the pelvic model. The simulator has several resection cases with different level of difficulty which are numbered. We had selected four resection training cases available on HystSimTM (Fig. 1) based on their realism, average difficulty level, and educational value in accordance with a curriculum developed using the Delphi method in a previous study [29]. The study participants had to perform the set of four simulation procedures. After a short standardized briefing about the simulator, the participants were allowed 10 min of familiarization with
HystSimTM, during which they could perform the procedure of their choice, except for the 4 cases selected. Then, each participant performed the four selected procedures: polypectomy (medium 4), myomectomy (difficult 4), roller ball endometrial ablation (medium 1), and advanced resection – septum. Each procedure was performed once. Participants could decide to stop at the end of the procedure of their choice instead of completing all four procedures. Study participants The study was approved by the gynecology ethics committee (CEROG 201-GYN-1203). Written informed consent was obtained from each participant before study inclusion. All data were recorded anonymously. Each participant completed a questionnaire about skill level and experience in hysteroscopy. We enrolled two groups of participants: experts and novices. The experts participated in the study during an international congress. All gynecologists who agreed to participate were included if they had at least 5 years of experience with hysteroscopy, self-evaluated their expertise at 4/5 or 5/5. Novices were recruited among all first-year gynecology residents in Paris, France. Criteria of judgment On the HystsimTM the overall score of MMSS includes five subset scores: resection score, safety score, economy score, visualization score and fluid handling score. Each subset score
Fig. 1. Four cases used to assess performance on HystSimTM.
Please cite this article in press as: Panel P, et al. Hysteroscopic resection on virtual reality simulator: What do we measure? J Gynecol Obstet Hum Reprod (2018), https://doi.org/10.1016/j.jogoh.2018.02.005
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includes between two or five parameters. For each parameter, a score is built by the simulator. The addition of the several parameter scores gives the subset score. The addition of the subset scores gives the overall score. The overall score is on 340 points or polypectomy and myomectomy, on 320 points for the roller ball endometrial ablation and on 350 for the septum resection. The primary endpoint was the overall score reported in the simulator of experts and novices for the four cases. The secondary endpoints were the results of the subset scores (resection, safety, economy, visualization, fluid handling) or of the separate parameters. In case of uterine perforation during one procedure, the case was not validated and the total score was zero. Statistics The results were described as mean (confidence interval 95%). Values of P lower than 0.05 were considered significant. The Mann–Whitney test was chosen to compare means.
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myomectomy and 3 on the septum. For the experts group, there was no perforation. For the experts group, all the experts did not performed the entire standardized course. One expert did not perform the myomectomy and two the endometrial ablation. We compared the scores obtained by the experts and novices for each case. Results for overall score, subset score and parameters value for polypectomy, myomectomy, roller ball endometrial ablation and septum resection was shown respectively in Tables 1– 4. The results of the parameter score was not reported because in most case there was few difference in P value between the parameter value and the parameter score. In some cases, the parameter score become no different whereas the parameter value was statically different especially for polypectomy (time uterus collapsed), myomectomy (camera alignment, left ostium), roller ball endometrial ablation (coagulation uterine surface, tool active without contact, cumulative path length, right ostium) and septum (left ostium, right ostium, time uterus collapsed).
Discussion Results Participants In May 2015, 25 gynecologists from several countries of the world accepted to participate. Among them, 6 were excluded, because of a self-evaluation score <4/5 (n = 4) or less than 5 years’ experience with hysteroscopy (n = 2). The remaining 19 gynecologists had a mean self-evaluation score of 4.5/5 0.4 and a mean number of years of practice of 12.6 8.1. There were 16 men and 3 women, with a mean age of 42.3 7.8 years. Between January 2016 and February 2016, all the first-year gynecology residents in Paris (n = 48), France, were contacted. The 20 who responded first to our invitation were included. There were 3 men and 17 women, with a mean age of 24.7 1.2 years and a mean self-evaluation score of 0.6/5 0.7. Results for the novices and experts In case of perforation, the total score was zero. For the novices group, there were 2 perforations on the polypectomy, 2 on the
On HystSimTM, a multimetric score system (MMSS) is included, based on quantitative parameters measured automatically by the device. This score was based on the opinion of two experts, and its cut-off values were defined arbitrarily. Bajka et al. [24] had established the construct validity of the MMSS for the diagnostic hysteroscopy on HystSimTM but not for the operative hysteroscopy. Our work consisted in determining if the overall score or the separate parameters can discriminate surgeon level on hysteroscopic resection. The overall score was statically different between novices and experts for the polypectomy, the myomectomy and the roller ball endometrial ablation but not for the septum resection. For the septum, the MMSS requires a resection whereas current recommendations suggest to perform only a section. The parameter resection for the septum counts 100 points on an overall score of 350. Thus, the majority of the experts had performed a section of the septum and were severely penalized on the overall score. This parameter is not conform to the reality and the recommendations. The overall score for the septum cannot be included in a global course to evaluate student with these parameters. The economy score, was significantly
Table 1 Results of 19 experts and 20 novices for the polypectomy (medium 4). Polypectomy
Novices (n = 20) Mean [CI 95%]
Experts (n = 19) Mean [CI 95%]
P
Total score/340 Polypectomy score/100 Resected pathology (%) Average cut time (s) Safety score/80 Tool active without contact (s) Tool active when pushing Cervix contacts Cavity contacts Economy score/80 Procedure time(s) Cumulative path length (mm) Camera alignment (%) Visualization score/40 Uterine cavity (%) Left ostium (s) Right ostium (s) Fluid handling score/40 Time view obscured (s) Time uterus collapsed (s) Distension media used (ml)
235.4 (219.2–251.5) 100 (0) 100 (0) 37.8 (34.46–41.1) 65.9 (60.5–71.3) 0.1 (0–0.2) 1.4 (0–3.1) 0.3 (0.1–0.6) 7.2 (3.4–10.9) 31.8 (23.3–40.4) 347.0 (279.8–414.2) 1982.3 (1512.2–2452.4) 90.4 (84.36–96.6) 20.8(15.7–25.9) 69.4 (62.9–76.0) 9.4 (5.3–13.6) 1.5 (0.2–2.8) 24.5 (20.8–28.2) 23.9 (8.7–39.2) 243.2 (165.0–321.5) 903.6 (713.6–1093.6)
287.4 100 100 40.7 75.7 0 0 0.3 3.2 72.7 149.9 778.3 95.5 13.1 61.6 4.2 0.5 25.9 27.6 64.2 340.3
<0.001 1 1 0.253 0.006 0.330 0.034 0.433 0.034 <0.001 <0.001 <0.001 0.013 0.049 0.083 0.050 0.063 0.336 0.542 <0.001 <0.001
(277.6–297.2) (0) (0) (39.06–42.4) (73.1–78.3) (0) (0) (0–0.6) (0.6–5.7) (69.1–76.3) (131.5–168.4) (633.0–923.6) (87.1–100) (8.1–18.1) (55.4–67.8) (1.6–6.7) (0–1.2) (21.9–29.8) (16.2–38.9) (40.9–87.4) (285.7–395.0)
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Table 2 Results of 18 experts and 20 novices for the myomectomy (difficult 4). Myomectomy
Novices (n = 20) Mean [CI 95%]
Experts (n = 18) Mean [CI 95%]
P
Overall score/340 Myomectomy score/100 Resected pathology (%) Average cut time (s) Safety score/80 Tool active without contact (s) Tool active when pushing Cervix contacts Cavity contacts Economy score/80 Procedure time (s) Cumulative path length (mm) Camera alignment (%) Visualization score/40 Uterine cavity (%) Left ostium (s) Right ostium (s) Fluid handling score/40 Time view obscured (s) Time uterus collapsed (s) Distension media used (ml)
285.9 88.1 96.0 36.1 76.2 0.1 0.1 0.4 1.4 71.2 227.5 1119.5 98.1 31.3 79.3 6.2 9.0 20.6 60.1 165.1 566.3
305.0 93.8 97.8 33.0 76.7 0 0 0.2 2.8 79.8 100.3 534.7 100 24.5 70.2 1.3 4.6 30.2 31.2 57.4 267.0
<0.001 0.039 0.011 0.401 0.517 0.345 0.163 0.385 0.295 0.001 <0.001 <0.001 0.04 0.051 0.034 0.014 0.095 0.005 0.375 <0.001 <0.001
(276.4–295.3) (83.8–92.4) (95.2–96.8) (31.7–40.5) (72.4–80.0) (0.0–0.3) (0.0–0.3) (0.1–0.8) (0.3–2.6) (64.4–78.0) (185.0–270.0) (796.6–1442.4) (95.6–100.0) (27.3–35.3) (74.1–84.6) (3.3–9.0) (4.9–13.1) (15.5–25.6) (32.8–87.4) (132.9–197.2) (470.1–662.4)
(298.4–311.6) (89.8–97.9) (96.7–98.8) (28.6–37.4) (74.6–78.8) (0) (0) (0.0–0.4) (1.3–4.4) (79.3–80.0) (80.9–119.8) (415.5–653.8) (0) (19.4–29.6) (65.1–75.3) (0.7–2.0) (2.8–6.4) (26.7–33.8) (18.5–43.9) (33.6–81.2) (213.4–320.6)
Table 3 Results of 17 experts and 20 novices for the roller ball endometrial ablation (medium 1). Roller ball endometrial ablation
Novices (n = 20) Mean [CI 95%]
Experts (n = 17) Mean [CI 95%]
P
Overall score/320 Rollerball ablation score/100 Coagulated uterine surface (%) Coagulated cervix surface (%) Coagulation quality (%) Safety score/60 Tool active without contact (s) Cervix contacts Cavity contacts Economy score/80 Procedure time (s) Cumulative path length (mm) Camera alignment (%) Visualization score/40 Uterine cavity (%) Left ostium (s) Right ostium (s) Fluid handling score/40 Time view obscured (s) Time uterus collapsed (s) Distension media used (ml)
246.1 75.5 74.1 11.2 62.3 38.8 6.1 9.9 12.5 63.6 528.2 2539.2 94.7 40 98.6 32.6 38.3 28.2 0 436.2 1382.7
280.8 83.8 81.5 12.6 69.9 41.2 2.1 4.4 11.6 79.1 242.0 1406.9 95.5 39.1 95.6 28.0 24.5 37.6 0 49.2 418.5
<0.001 0.028 0.049 0.691 0.047 0.769 0.026 0.253 1 <0.001 <0.001 0.008 0.521 0.129 0.229 0.419 0.042 <0.001 1 <0.001 <0.001
(231.5–260.6) (69.5–81.5) (67.4–80.8) (4.4–17.9) (58.2–66.4) (31.7–45.9) (1.8–10.4) (4.6–15.2) (7.1–17.8) (57.4–69.8) (434.6–621.7) (1888.7–3189.7) (90.3–99.1) (0) (98.3–98.9) (24.1–41.1) (28.7–47.9) (26.0–30.3) (0) (331.3–541.1) (1093.5–1671.9)
(271.0–290.6) (75.6–92.0) (71.9–91.1) (3.6–21.7) (64.5–75.4) (35.5–46.9) (0.4–3.9) (1.6–7.1) (6.5–16.8) (77.9–80.3) (203.4–280.6) (1142.3–1671.6) (89.0–100) (37.6–40.5) (92.0–99.1) (20.9–35.1) (16.3–32.7) (35.6–39.7) (0) (1.3–97.2) (274.8–562.3)
Table 4 Results of 19 experts and 20 novices for the septum (advanced resection). Septum
Novices (n = 20) Mean [CI 95%]
Experts (n = 19) Mean [CI 95%]
P
Overall score/350 Septum dissection score/100 Removed septum (%) Economy score/110 Procedure time (s) Cumulative path length (mm) Safety score/60 Tool active without contact (s) Cervix contacts Cavity contacts Visualization score/40 Uterine cavity (%) Left ostium (s) Right ostium (s) Fluid handling score/40 Time view obscured (s) Time uterus collapsed (s) Distension media used (ml)
250.8 72.1 91.7 61.5 356.4 1422.7 57.2 1.4 0.6 0.6 31.1 80 16.6 10.5 29.6 2.6 222.1 770.9
250.4 24.5 76.1 108.1 164.2 763.1 59.2 0.4 0.1 0.3 24.4 72.5 3.9 3.4 34.3 2.2 37.1 300.0
0.456 0.001 0.004 <0.001 <0.001 <0.001 0.210 0.277 0.126 0.060 0.092 0.113 <0.001 0.004 <0.001 0.774 0.001 <0.001
(228.8–272.7) (50.8–93.4) (85.0–98.4) (42.2–80.9) (296.6–416.1) (1161.5–1683.9) (54.5–60.0) (0.2–2.5) (0–1.2) (0.2–0.9) (26.7–35.4) (74.5–85.5) (10.2–23) (6.6–14.5) (27.3–32) (1.7–3.5) (135.6–308.6) (563.9–977.9)
(232.6–268.2) (6.2–42.7) (692–829) (106.6–109.5) (146.1–182.4) (660.8–865.4) (58.2–60.1) (0–0.9) (0–0.3) (0–0.7) (19.0–29.8) (663–788) (2.4–5.4) (1.9–4.9) (32.2–36.4) (1.2–3.2) (18.2–56) (236.1–363.9)
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better for the experts in comparison with the novices for the four cases. This score included time, cumulative path length and camera alignment is probably the best criteria to discriminate surgeon level. New methods for training residents in the increasing number of required endoscopic surgery skills are needed, and among them VR simulators hold considerable promise [30–32]. VR simulators automatically provide feedback about how well the trainee performed, by scoring a variety of parameters, some of which cannot be obtained in the OR, such as path length traveled by the endoscope or visualization tie [24]. These parameters are important to evaluate safety (correct visualization, cervix and cavity contact) or cost (distension media used) or ergonomy (cumulative path length) of the trainee. Developing optimal scoring methods based on these parameters is a major challenge [33,34]. The MMSS available on HystSimTM failed to separate novices from experts [27,28] for resection procedures on previous studies. Neis et al. [27] had tested 39 gynecologist, separated on a ‘‘basic group’’ (<10 operative hysteroscopy) and an ‘‘advanced group’’ (>10 operative hysteroscopy) on a polyp and a myoma resections on HystSimTM. Both group had improved their results during the three rounds but there was no difference linked to the experience on the overall score (P = 0.329) or on the ‘‘time of procedure’’ (P = 0.154) or on the ‘‘cumulative path length’’ (P = 0.277). Only the ‘‘quantity of distension media used’’ was different in the two groups (P = 0.034). Maybe the lack of difference could be due to the small experience of the ‘‘advanced group’’. Elessawy et al. [28] had tested 42 novices (no prior experience in hysteroscopy) compared to 15 experts (more than 2 years of experience of advanced hysteroscopy operations) on a myomectomy resection on HystSimTM. In pretest, there was no difference in the overall score (P = 0.902) or in the safety score (P = 0.203) or in the economy score (P = 0.753) or in the fluid handling score (P = 0.217) but there was a significant difference in the myomectomy score (P = 0.001) and the visualization score (P = 0.028). These results was confirm in the posttest, except for the overall score (P = 0.002) and the safety (P = 0.039). In this study, the results of the different scores was very low with a very high standard deviation compared to our study. The homogeneity of the two groups of population appear to be an important bias of this study. To ensure that the participating experts had a high level of performance in everyday practice, we selected them based on a self-evaluation of their performance and on their number of years of experience. A potential bias of selection was a previous experience of experts on this simulator which was not recorded. The collection of the data was based on parameters measured automatically by HystSimTM. This point guarantees the reliability of this study. The four training cases included in the standardized course were chosen based on work performed previously by our group to develop a hysteroscopy curriculum based on opinions of experts collected during Delphi rounds [29]. These four cases provided a realistic picture of the diverse resection procedures performed hysteroscopically in everyday practice. The statistically significant differences between the scores obtained by experts and novices established the good construct validity of overall score for polypectomy, myomectomy and roller ball endometrial ablation. Whereas the overall score for the septum resection need to be improved. Faurant et al. [32] had found a significant improvement in the hysteroscopic performance of novice surgeons after training on HystSimTM as well as student satisfaction. This result encourages us to continue our study by training a group of novice surgeons on HystSimTM integrated into a valid curriculum.
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Conclusion We describe the first study comparing the multimetric score system results for two groups with different level of experience on a standardized course of four cases (polypectomy, myomectomy, roller ball endometrial ablation and septum) of resection on HystSimTM. The score is based on data provided automatically by the simulator during the cases. The overall scores were statistically different for the cases of polypectomy, myomectomy and roller ball endometrial ablation but not for septum resection. The economy score reliably reflects the level of experience of the operator in the four cases. Now we have a valid method to train and to evaluate students on resection case of hysteroscopy on a virtual reality simulator according to a curriculum. In the future, training and evaluation on a simulator will be the inevitably first step to improve technical skills for students, especially in hysteroscopy. It could be an essential tool for residents before operating patients. For hysteroscopic resection, the next step will be to develop a standardized training program for the residents on HystSim TM. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Disclosure of interest The authors declare that they have no competing interest. References [1] Jamal MH, Rousseau MC, Hanna WC, Doi SAR, Meterissian S, Snell L. Effect of the ACGME duty hours restrictions on surgical residents and faculty: a systematic review. Acad Med J Assoc Am Med Coll 2011;86:34–42. [2] Crochet P, Aggarwal R, Berdah S, Yaribakht S, Boubli L, Gamerre M, et al. Current and future use of surgical skills simulation in gynecologic resident education: a French national survey. J Gyne´cologie Obste´trique Biol Reprod 2014;43:379–86. [3] Campo R, Puga M, Meier Furst R, Wattiez A, De Wilde RL. Excellence needs training ‘‘Certified programme in endoscopic surgery. Facts Views Vis ObGyn 2014;6:240–4. [4] Fernandez GL, Lee PC, Page DW, D’Amour EM, Wait RB, Seymour NE. Implementation of full patient simulation training in surgical residency. J Surg Educ 2010;67:393–9. [5] Hiemstra E, Kolkman W, le Cessie S, Jansen FW. Are minimally invasive procedures harder to acquire than conventional surgical procedures? Gynecol Obstet Invest 2011;71:268–73. [6] Rackow BW, Solnik MJ, Tu FF, Senapati S, Pozolo KE, Du H. Deliberate practice improves obstetrics and gynecology residents’ hysteroscopy skills. J Grad Med Educ 2012;4:329–34. [7] van Hove PD, Tuijthof GJM, Verdaasdonk EGG, Stassen LPS, Dankelman J. Objective assessment of technical surgical skills. Br J Surg 2010;97:972–87. [8] De Wilde RL, Hucke J, Kolmorgen K, Tinneberg H. Gynecologic Endoscopy Working Group of the German Society of Obstetrics and Gynecology. Recommendations by the Gynecologic Endoscopy Working Group of the German Society of Obstetrics and Gynecology for the advancement of training and education in minimal-access surgery. Arch Gynecol Obstet 2011;283:509–12. [9] Singh SS, Marcoux V, Cheung V, Martin D, Ternamian AM. Core competencies for gynecologic endoscopy in residency training: a national consensus project. J Minim Invasive Gynecol 2009;16:1–7. [10] Loffer FD, Bradley LD, Brill AI, Brooks PG, Cooper JM. Hysteroscopic training guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc 2000;7:165. [11] Dawe SR, Pena GN, Windsor JA, Broeders JaJL, Cregan PC, Hewett PJ, et al. Systematic review of skills transfer after surgical simulation-based training. Br J Surg 2014;101:1063–76. [12] Nagendran M, Gurusamy KS, Aggarwal R, Loizidou M, Davidson BR. Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database Syst Rev 2013;8:CD006575. [13] Park J, MacRae H, Musselman LJ, Rossos P, Hamstra SJ, Wolman S, et al. Randomized controlled trial of virtual reality simulator training: transfer to live patients. Am J Surg 2007;194:205–11. [14] Aggarwal R, Ward J, Balasundaram I, Sains P, Athanasiou T, Darzi A. Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery. Ann Surg 2007;246:771–9.
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Please cite this article in press as: Panel P, et al. Hysteroscopic resection on virtual reality simulator: What do we measure? J Gynecol Obstet Hum Reprod (2018), https://doi.org/10.1016/j.jogoh.2018.02.005