Simulation-based Training Curriculum for the Management of Vaginal Cuff Dehiscence and Evisceration

Objective Vaginal cuff dehiscence with evisceration (VCDE) is a serious, life-threatening complication of hysterectomy. Due to the high volume of hysterectomies performed in the U.S each year, it is likely that a practitioner will encounter VCDE during their career. Due to its infrequent occurrence, residents receive little exposure to it during training. Delayed diagnosis of VCDE can impede proper management and lead to severe, long-term complications or death. Our goal was to provide an opportunity for resident physicians to identify VCDE and practice performing a reduction of prolapsed bowel and vaginal cuff repair through hands-on simulation in hopes that the simulation would improve the residents' confidence and knowledge in recognizing and managing future VCDE cases. Methods Obstetrics and Gynecology residents postgraduate year (PGY) 1-4 participated in this study (n=13). Before and after the simulated case, a knowledge test covering VCDE recognition and management and a confidence survey were given to the participants. A gynecologic mannequin was modified by placing simulated bowel into the abdominal cavity with a portion extending through a vaginal cuff and protruding from the vaginal introitus. For the simulation, a hemodynamically unstable patient presented with findings consistent with a VCDE. Once the decision to proceed to surgery was made, participants were transferred to a simulated operating room where they performed a reduction of prolapsed bowel and vaginal cuff closure either laparoscopically or vaginally on the mannequin. A debriefing session was held post-simulation to discuss management and thought processes, as well as reflect on their performance and discuss improvement strategies for future cases. Finally, the residents participated in a brief didactic lecture on education about the incidence, presentation, and management of VCDE. Results Analysis of the knowledge questionnaires showed the median score and interquartile range (IQR) pre- and post-simulation was 15(12-28) and 20(19-22) respectively, with a median score increase (and IQR) of 5(3.5-8.5) (p=0.001). The confidence score had pre- and post-simulation median scores (and IQRs) of 28(20-34.5) and 40(37.5-46) respectively, with a median score increase (and IQR) of 15(8-20.5) (p=0.001). Conclusions Our intervention improved residents' knowledge and confidence in recognizing VCDE, identifying the need for surgical management, and performing a reduction of prolapsed bowel and vaginal cuff repair.