Development and Evaluation of a Cesarean Hysterectomy Simulation Model
Authors: Chen Geoffrey , Heisler Elise , Zoma Marim , Chuang Meleen , Frenn Recia , Zoorob Dani 
Published: June 2024

Introduction: Cesarean hysterectomy is a life-saving procedure considered during postpartum hemorrhage in cases of uterine atony refractory to management, placenta accreta spectrum, or other obstetric complications. The procedure has high morbidity and mortality despite the rising rates of worldwide and in the United States. A high percentage of OB/GYN residents graduate without preparedness to perform this procedure post-residency, citing insufficient residency exposure as the primary contributor. This study aims to use evaluation and assessment tools to validate a low-cost, low-fidelity cesarean hysterectomy model at multiple OB/GYN residency training sites across the United States to increase resident confidence and proficiency in performing this critical procedure. Materials and Methods: Model Design and Development: Gynecologic surgeons from two OB/GYN residencies reviewed the literature for cesarean hysterectomy education and simulation. A low fidelity, anatomically accurate model was developed for cesarean hysterectomy simulation purposes. Efforts were made to optimize for anatomic layout and realistic feel, particularly for the anatomic structures relevant to cesarean hysterectomy: uterine vessels, anterior and posterior peritoneum, relation of anterior uterus to the bladder and ureters. Study Design: The study received institutional board review exemption at the Loyola University Medical Center (LUMC) and the University of Toledo (UT). During the last two months of the academic calendar, OB/GYN residents were offered the opportunity to perform a cesarean hysterectomy on the model. Demographics were collected in addition to the number of cesarean and abdominal hysterectomies performed as well as the confidence in cesarean hysterectomies independently. A uniform set of surgical instruments with both appropriate and inappropriate tools were made available for residents to choose from. Throughout the simulation, residents were asked to verbalize each step being performed. One faculty rater at each institution was trained to use the objective and standardized assessment tools and had completed an inter- and intra-rater reliability assessment. All residents were evaluated using the same two objective assessment tools. The two validated assessment tools used to evaluate resident performance using the model were the Task Specific Checklist and the Global Rating Scale. The former assessed residents on a “performed or not” basis on 14 surgical steps specific to cesarean hysterectomy. The latter used a scale of 1 to 5, with higher values representing more advanced skill, to evaluate respect for tissue handling, time and motion, instrument handing, knowledge of instrument selection, operation flow, assistant use, and familiarity with the procedure. Results: A total of 26 residents, 18 of 19 at LUMC and 8 of 17 at UT, completed the cesarean hysterectomy simulation between May and June 2022. At LUMC, no graduating residents had performed a cesarean hysterectomy in their residency. At UT, graduating residents had performed up to 2. All of the residents, including PGY-4s, stated that they either disagree or strongly disagree with the statement “I feel confident performing cesarean hysterectomy independently.” As hypothesized, the median resident scores on the Task Specific Checklist and Global Rating scale correlated with increasing PGY level. The combined TSC+GRS score was a median of 40 out of 49 total for the PGY-4 class, while the PGY-1 class had a median combined TSC+GRS score of 12 of 49. The PGY-2 and -3 class had TSC+GRS scores of 14 and 28 respectively. The simulation model was well-received with a median 4/5 rating for improving comfort level with cesarean hysterectomy and a median 4/5 rating for model realism. Each uterine model cost $6.00 and took approximately 20 minutes to build. The optional base constructed for supporting the model, cost a one-time fee of $160. All materials used for construction were easily available online. Discussion: This study validated an affordable, easily reproducible model that highlights the most important anatomy relevant to a cesarean hysterectomy. The model was developed, produced, and tested at two residency programs with a total of 26 residents participating in the study. This is the first low-fidelity cesarean hysterectomy model inclusive of relevant surgical steps and offers near-real visceral feel that has been developed and assessed for validity. This multisite study created a realistic model with high reproducibility at a low cost. Limitations of this study included the fact that only 27 residents participated in the study from only two institutions. In addition, faculty evaluators were not blinded to the residents they rated. The model is a reliable and affordable way to introduce this procedure at residency programs, particularly those that do not perform a substantial number of cesarean hysterectomies.