In this presentation, we will discuss the design and creation of a cost-effective, reproducible, and novel vaginal hysterectomy model for residents and surgical trainees. Total vaginal hysterectomy is the recommended route of performing a hysterectomy according to the American College of Obstetrics and Gynecology. Total vaginal hysterectomy has been shown to result in fewer complications, decreased morbidity and decreased recovery times, all at a lower cost than other methods of hysterectomy. The median number of total vaginal hysterectomies performed during training has decreased from 29 to 17 from 2008 to 2013. This is related to the increase in the number of robotic and laparoscopic hysterectomies performed each year. The requirement to graduate from a residency program in obstetrics and gynecology is 15 vaginal hysterectomies performed as the primary surgeon. However, studies have shown that residents require at least 21 vaginal hysterectomies to become competent. We created a vaginal hysterectomy model to best mimic difficult surgical steps such as entry into the posterior cul-de-sac and entry into the anterior cul-de-sac with proper bladder retraction. Also, our goal was to imitate proper clamp placement for initial and subsequent pedicles while having pedicles tied down laterally so that the next clamp can be placed medial to the previous pedicle. Our model allows for the proper amount of traction on the uterus, which would yield appropriate uterine descent and ultimately delivery of the specimen while providing the ability to cinch down pedicles with appropriate pedicle ligation and knot tying. In the following slides, we will demonstrate construction of our total vaginal hysterectomy model. Construction of each model entails using a rubber 4-inch to 6-inch plumbing joint as the pelvis. This was mounted to a wooden board for stability. The working end of the model is the 4-inch portion and the 6-inch portion served as the upper pelvis. A hole was drilled at the 12 o'clock position in order to facilitate creation of a bladder. Holes were cut at the positions displayed here in order to facilitate suspension of the uterus within the model via the broad ligaments, utero-sacral ligaments, and infundibulopelvic ligaments. Examples of these insertion sites are highlighted in yellow here. For the bladder, a white 12-inch latex balloon was threaded through the hole and filled with 30 milliliters of water. At the 6 o'clock position, we used a tubular structure of wefting to represent rectal mucosa and cream-colored thin cotton quilt batting to represent rectal sclerosa, dyed pink here for better visualization. A uterus was hand-sculpted using EpoxySculpt and a mold was cast with Mold Max 30 silicone rubber. FlexFoam IT17, a pourable flexible foam, was poured into the mold to create a uterus that could be inserted into the model. This foam uterus contained uterus, cervix, tubes, ovaries, IP ligaments, utero-ovarian ligaments, broad ligaments, and utero-sacral ligaments. Multiple holes were made in the foam uterus at the points displayed in order to facilitate suspension of the uterus within the pelvis. Rubber bands were threaded through the holes and knotted as displayed here. The use of rubber bands provided the ability to place traction on the uterus during simulation. Ovarian arteries were represented using small segments of red rubber catheters. Here you see attachment of the uterus to the pelvis via the utero-sacral ligaments. The utero-sacral ligaments are threaded through the respective insertion sites within the pelvis. A rubber band is threaded through each hole that was previously made within the utero-sacrals. The rubber band is tied on one side and then the contralateral utero-sacral rubber band is pulled at maximum tension and tied. The final result shown in the center image. The purpose of this tension is to have the utero-sacral ligaments fall laterally after transection. Similarly to the utero-sacral ligament, the broad ligament rubber bands are pushed through their insertion sites on the pelvis and proximal and distal rubber bands are tied together bilaterally. A small amount of polyester fill is used anteriorly after the underside of the bladder and the anterior surface are sprayed with 3M45 general purpose glue in order to create an anterior dissection plane. GLAD press and seal is used to cover the distal, vaginal and proximal peritoneal sides of the model. Wefting is used as vaginal mucosa and is placed over the distal portion of the model, taking care to leave the rectum exposed. The cervix on vulva skin is affixed to the model and the cervix is drawn on the model with a sharpie. The following video illustrates some of the key features of this model. Observe the learner performing a rectal exam. The cervix is grasped with a tenaculum and a circumferential incision is made in the vaginal mucosa. Traction is placed on the cervix to gain access to the peritoneum posteriorly. Gently pushed back with an opened raytec in order to safely isolate the first pedicle. After clamping and suture ligation of the first pedicle bilaterally, the anterior peritoneum is isolated and entered sharply. As you can see, a learner is able to ligate and cut pedicles in the usual fashion as during a vaginal hysterectomy. The pedicles are able to be cinched down as they normally would be during a transvaginal hysterectomy. The pedicles are also able to be deflected medially and then laid flat laterally as demonstrated here. One important feature of our model, as you can see here, is that appropriate adequate tension and traction can be placed on the uterus as serial pedicles are taken down bilaterally, ultimately with the goal of being able to deliver the entire specimen. Demonstrated here is the vaginal hysterectomy model prior to closure of the vaginal cuff. There is a clear line of suture, ligated pedicles, cephalad to caudad. We demonstrate closure of the vaginal cuff using a running locked suture. The final product is shown here after closure of the vaginal cuff. The total cost for 60 models, enough for each resident to do them twice throughout the academic year, is approximately $500, with a $300 initial investment, with each model costing approximately $3 for materials thereafter. As mentioned earlier, there is a great need for total vaginal hysterectomy models that accurately simulate complicated surgical steps and dissections. With proper material selection, we created a total vaginal hysterectomy model that is low cost and fairly easy to assemble. Future directions for this model include plans for further interrogation of the model with validity testing and incorporating this model into annual simulation training and monthly surgical skills curriculum.

vaginal hysterectomy

surgical trainees

cost-effective model

reproducible model

training programs