Development and validation of a laparoscopic hysterectomy cuff closure simulation model for surgical training

Published:November 27, 2015DOI:


      The number of robotically assisted hysterectomies is increasing, and therefore, the opportunities for trainees to become competent in performing traditional laparoscopic hysterectomy are decreasing. Simulation-based training is ideal for filling this gap in training.


      The objective of the study was to design a surgical model for training in laparoscopic vaginal cuff closure and to present evidence of its validity and reliability as an assessment and training tool.

      Study Design

      Participants included gynecology staff and trainees at 2 tertiary care centers. Experienced surgeons were also recruited at the combined International Urogynecologic Association and American Urogynecologic Society scientific meeting. Participants included 19 experts and 21 trainees. All participants were recorded using the laparoscopic hysterectomy cuff closure simulation model. The model was constructed using the an advanced uterine manipulation system with a sacrocolopexy tip/vaginal stent, a vaginal cuff constructed from neoprene material and lined with a swimsuit material (nylon and spandex) secured to the vaginal stent with a plastic cable tie. The uterine manipulation system was attached to the fundamentals of laparoscopic surgery laparoscopic training box trainer using a metal bracket. Performance was evaluated using the Global Operative Assessment of Laparoscopic Skills scale. In addition, needle handling, knot tying, and incorporation of epithelial edge were also evaluated. The Student t test was used to compare the scores and the operating times between the groups. Intrarater reliability between the scores by the 2 masked experts was measured using the interclass correlation coefficient.


      Total and annual experience with laparoscopic suturing and specifically vaginal cuff closure varied greatly among the participants. For the construct validity, the participants in the expert group received significantly higher scores in each of the domains of the Global Operative Assessment of Laparoscopic Skills Scale and for each of the 3 added items than did the trainees. The median total Global Operative Assessment of Laparoscopic Skills Scale score (maximum 20) for the experts was 18.8 (range, 11–20), whereas the median total Global Operative Assessment of Laparoscopic Skills Scale score for the trainees was 10 (range, 8–18) (P = .001). The overall score that included the 3 new domains (maximum 35) was 33 (range, 18–35) for the experts and 17.5 (range, 14–31.5) for trainees (P = .001). For the face validity testing, the majority of the study participants (32 [85%]) agreed or strongly agreed that the model is realistic and all participants agreed or strongly agreed that the model appears to be useful for improving technique required for this task. For the interrater reliability, the scores assigned by each observer had an interclass correlation coefficient of 0.8 (95% confidence interval, 0.7–0.93).


      This model is easily constructed and has an acceptable cost. We have demonstrated evidence of construct validity. This is a valuable education tool that can serve to improve skills, which are essential to the gynecological surgeon but are often lacking in residency training because of national changes in practice patterns.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Uccella S.
        • Ghezzi F.
        • Mariani A.
        • et al.
        Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature.
        Am J Obstet Gynecol. 2011; 205: 119.e1-119.e12
        • Tunitsky-Bitton E.
        • King C.
        • Ridgeway B.
        • et al.
        Development and validation of a laparoscopic sacrocolpopexy simulation model for surgical training.
        J Minim Invasive Gynecol. 2014; 21: 612-618
        • Vassiliou M.C.
        • Feldman L.S.
        • Andrew C.G.
        • et al.
        A global assessment tool for evaluation of intraoperative laparoscopic skills.
        Am J Surg. 2005; 190: 107-113
        • Wright J.D.
        • Ananth C.V.
        • Lewin S.N.
        • et al.
        Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease.
        JAMA. 2013; 309: 689-698
        • Kho R.M.
        • Akl M.N.
        • Cornella J.L.
        • Magtibay P.M.
        • Wechter M.E.
        • Magrina J.F.
        Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures.
        Obstet Gynecol. 2009; 114: 231-235
        • Fuchs Weizman N.
        • Einarsson J.I.
        • Wang K.C.
        • Vitonis A.F.
        • Cohen S.L.
        Vaginal cuff dehiscence: risk factors and associated morbidities.
        JSLS J Soc Laparoendosc Surg. 2015; 19 (e2013.00351)
        • Arden D.
        • Hacker M.R.
        • Jones D.B.
        • Awtrey C.S.
        Description and validation of the Pelv-Sim: a training model designed to improve gynecologic minimally invasive suturing skills.
        J Minim Invasive Gynecol. 2008; 15: 707-711
        • King C.R.
        • Donnellan N.
        • Guido R.
        • Ecker A.
        • Althouse A.D.
        • Mansuria S.
        Development and validation of a laparoscopic simulation model for suturing the vaginal cuff.
        Obstet Gynecol. 2015; 126: 27S-35S
        • Fried G.M.
        • Feldman L.S.
        • Vassiliou M.C.
        • et al.
        Proving the value of simulation in laparoscopic surgery.
        Ann Surg. 2004; 240 (discussion 525-8): 518-525
        • McCluney A.L.
        • Vassiliou M.C.
        • Kaneva P.
        • et al.
        FLS simulator performance predicts intraoperative laparoscopic skill.
        Surg Endosc Other Interv Tech. 2007; 21: 1991-1995
        • Sroka G.
        • Feldman L.S.
        • Vassiliou M.C.
        • Kaneva P.
        • Fayez R.
        • Fried G.M.
        Fundamentals of laparoscopic surgery simulator training to proficiency improves laparoscopic performance in the operating room—a randomized controlled trial.
        Am J Surg. 2010; 199: 115-120
        • Okrainec A.
        • Soper N.J.
        • Swanstrom L.L.
        • Fried G.M.
        Trends and results of the first 5 years of Fundamentals of Laparoscopic Surgery (FLS) certification testing.
        Surg Endosc Other Interv Tech. 2011; 25: 1192-1198
        • Hur H.-C.
        • Arden D.
        • Dodge L.E.
        • Zheng B.
        • Ricciotti H.
        Fundamentals of laparoscopic surgery: a surgical skills assessment tool in gynecology.
        JSLS. 2011; 15: 21-26
        • Zheng B.
        • Hur H.-C.
        • Johnson S.
        • Swanström L.L.
        Validity of using Fundamentals of Laparoscopic Surgery (FLS) program to assess laparoscopic competence for gynecologists.
        Surg Endosc. 2010; 24: 152-160