Uppal, Shitanshu MD; Harmanli, Oz MD; Rowland, Jennifer MD; Hernandez, Enrique MD; Dandolu, Vani MD, MPH
From the Department of Obstetrics and Gynecology, Temple University Hospital, Philadelphia, Pennsylvania; the Department of Obstetrics and Gynecology, Bay State Medical Center, Springfield, Massachusetts; Temple University School of Medicine, Philadelphia, Pennsylvania; and the Institute for Clinical Simulation and Patient Safety, Temple University, Philadelphia, Pennsylvania.
Corresponding author: Vani Dandolu, MD, MPH, Department of Obstetrics and Gynecology, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140; e-mail: firstname.lastname@example.org.
Financial Disclosure: The authors did not report any potential conflicts of interest.
OBJECTIVE: To estimate objectively the proficiency of obstetrican–gynecologist (ob–gyn) residents in third-degree perineal tear repair.
METHODS: A total of 40 ob–gyn residents from 13 residency programs demonstrated their technique of perineal laceration repair on a modified beef tongue model. Two faculty members with expertise in repairing obstetric anal sphincter injury evaluated the residents using a checklist. The checklist identified three key steps of the procedure, including 1) repair of the internal anal sphincter; 2) selection of proper suture material; and 3) repair of the external anal sphincter, further evaluated using three subcomponents.
RESULTS: The overall pass rate was 42.5% (17/40). Many residents missed critical steps of the repair. Year of training (P=.763), parent residency program (P=.5), and prior experience (P=.48) had no significant effect on the pass rate. There was greater than 90% concordance between the evaluators (r=0.9, P<.001). Satisfaction with the modified beef tongue model was higher than with current training methods in their program (7.81 compared with 6.92 on a scale of 1–10, P=.001).
CONCLUSION: Ob–gyn residents demonstrated substandard skill in repairing anal sphincter laceration. The low pass rate of 42.5% suggests lack of adequate training in repair. The model had a high resident satisfaction, and high interobserver correlation was noted using the checklist. Thus, identification and evaluation of key steps using a standardized checklist may lead to standardization of repair and ensures consistency and quality.
LEVEL OF EVIDENCE: III
Obstetric anal sphincter injury, encompassing third- and fourth-degree perineal tears, is a serious complication of vaginal delivery. The incidence of obstetric anal sphincter laceration is reported to vary from 2.2% to 19% of vaginal births.1–5 Despite primary repair, a large proportion of these patients are found to be incontinent at short-term follow-up.6–9 The reason for the poor outcome after repair is use of inappropriate technique, lack of operator expertise, or missed diagnosis. Obstetricians who are appropriately trained are more likely to provide a consistent, high standard of anal sphincter repair and contribute to reducing the extent of morbidity and litigation associated with anal sphincter injury.10,11 Approximately 60% of obstetrican–gynecologist (ob–gyn) residents in residency programs in the United States admitted to not having any didactic teaching on episiotomy repair and no formal teaching on pelvic floor anatomy and, when engaged in the repair, were supervised only one out of three times.12 One can argue that the decreasing number of operative vaginal deliveries results in fewer opportunities for the residents to adequately learn repair of advanced perineal tears. The prevalence of lacerations has decreased in the past decade from 189,619 third- and fourth-degree lacerations in 1997 to 102,586 in 2007.13 Given the fact that residents often repair most perineal tears, we undertook this project to objectively evaluate their technique of third-degree perineal tear repair using a standardized procedure checklist. We used a modified beef tongue perineal laceration repair model.
MATERIALS AND METHODS
A regional resident education day was organized by the Obstetrical Society of Philadelphia for all ob–gyn residents in the Delaware Valley tristate area. The theme was surgical simulation, and the event was held at the Center for Clinical Simulation and Patient Safety of Temple University School of Medicine in April 2009. Approximately 130 residents from 17 programs participated in the event. There were several simulation stations, including amniocentesis demonstration, shoulder dystocia drill, forceps delivery demonstration, laparoscopy skill assessment, B-Lynch suture placement, urodynamics, and hysteroscopy stations. Residents signed up for the station on a first-come, first-serve basis. This was one of the most popular simulation stations that day. Because of time and space constraints, the first 40 residents to sign up were enrolled. They were told about the study after they chose the perineal laceration repair model, and none declined to participate in the study.
An exemption was obtained from Temple University Institutional Review Board.
The beef tongue model has been described in the literature as an economical and effective tool to demonstrate repair of severe perineal tears.14 The original model, although superior to many commercially available pelvic floor repair trainers for its resemblance to the real-life situation, lacked a clear demarcation of the internal anal sphincter. We addressed this shortcoming by modifying the model by adding a layer of bacon to represent the internal anal sphincter (Fig. 1).
To identify the key steps necessary to develop a procedure checklist, an extensive literature search was performed, and standard obstetric textbooks were referred to, including TeLinde's Operative Gynecology and Williams Obstetrics. Three key steps were identified: 1) repair of the internal anal sphincter; 2) selection of proper suture material; and 3) repair of the external anal sphincter, further evaluated using three subcomponents: a) grasping the external sphincter with Allis forceps, b) inclusion of both muscular and the capsular parts of external anal sphincter, and c) the order of suture placement/tying when repairing the external anal sphincter. These key points were then used in formulating the standardized checklist. Failure to perform steps 1 and 2 was considered an automatic fail. Failure to complete one or two components of step 3 was considered an acceptable repair. However, failure to complete all three components of the third step was also considered a fail.
Residents were given a preassembled beef tongue model, the necessary instruments, and a variety of sutures to choose from, including chromic catgut, silk, polydiaxonone, and polyglactin. Each beef tongue cost approximately $12 and could make two to three models, which we used only once.
The model was prepared as described by Sauerwein et al (Sauerwein M, Maier R. Teaching advanced episiotomy repair with beef tongue model [Central Washington Family Medicine, Yakima, WA] March 2007, unpublished data) and involved the following steps: 1) a stab wound was made through the body of the tongue, and a vinyl tube (rectum) was inserted using hemostat; 2) a vertical episiotomy incision was made from the superior surface of the tongue to just above the rectal tube to mimic a third-degree perineal laceration; 3) two stab wounds were made superior to the rectum and in juxtaposition with the inferior apex of the episiotomy incision, and a piece of surgical tubing was pulled from inside the incision through the stab wounds outside to create the rectal sphincter muscle. Bacon was inserted along the length of the laceration to create the internal anal sphincter (Fig. 1).
A standard clinical scenario was read to all the residents, and the model was briefly described with particular emphasis on the individual structural components. The residents were asked to repair a IIIc perineal tear (complete laceration of external anal sphincter and internal anal sphincter). Two faculty members who specialize in pelvic floor disorders independently evaluated the residents performing the procedures. The residents were assessed on the key components of the procedure, and the results were categorized based as shown in Figure 2. Accordingly, the residents” performances were divided into the following categories: perfect repair, near perfect repair, acceptable repair, and unacceptable repair. For the final analysis, the first three categories were considered a pass, and an unacceptable repair was considered a fail.
After completion of the session, the residents were surveyed regarding their level of training (PGY level), parent training program, prior experience in repairing perineal tears, level of confidence in their repair, and prior experience working with a perineal tear repair model. A numeric visual analog scale (1–10) was used to measure the degree of satisfaction with the beef tongue model and any other model used at their parent institution. Statistical analysis was performed with SPSS 16.0 for OS X (SPSS Inc., Chicago, IL).
Among the 40 participants, there were 37.5% (15/40) PGY-1, 22.5% (9/40) PGY-2, 17.5% (7/40) PGY-3, and 22.5% (9/40) PGY-4 residents. Only six residents (15%) had previously used a simulation/model for learning to repair obstetric anal sphincter injury. The overall pass rate was 42.5% (17/40). The participants missed several key steps in the repair of third-degree perineal repair, as shown in Figure 2. Twenty-two percent (9/40) did not repair the internal anal sphincter, 2.5% (1/40) did not use polydiaxonone or polyglactin (used silk), and 32.5% (13/40) missed the three components of step 3 (ie, grasping the external anal sphincter with Allis forceps, placing the sutures, and tying the sutures in the order that did not hinder further repair). Among the nine participants (22%) who failed to repair the internal anal sphincter, six also failed to grasp the external anal sphincter with Allis forceps, and five failed to take the sutures in correct order. Only 20% (8/40) used to Allis forceps to grasp the external anal sphincter, whereas 42.5% (17/40) placed the sutures in an order that did not hinder the repair. Among the 80% (32/40) who did not use Allis forceps to grasp the external anal sphincter, 28 did not repair the internal anal sphincter, and 22 did not take sutures in the correct order.
Year of training (P=.763), parent training institution (P=.47), and prior experience (P=.48) did not have significant effect on the pass rate (Tables 1 and 2). For the entire cohort, the satisfaction with the beef tongue model when compared with the current methods used in their parent residency program yielded an overall significantly higher satisfaction with the model (7.81 compared with 6.92, P=.001). Satisfaction with the beef tongue model was significantly higher in those who passed as compared with those who failed (8.40 compared with 7.41, P=.02). Satisfaction with the current methods of teaching used by their parent residency program was not significantly different between those who failed and those who passed (7.13 compared with 6.77, P=.56). There was greater than 90% correlation between the two examiners (Spearman r=0.901, P<.001).
Our study shows an unacceptably poor skill level of ob–gyn residents in the repair of severe perineal tears. The low pass rate of 43% suggests a lack of adequate training in the repair of third- and fourth-degree lacerations in our ob–gyn residency programs. Few residents (6/40, 15%) indicated prior training on either a similar or a different model. The analysis of reasons for failures suggests that most of those who failed got many of the steps in the checklist wrong, which again suggests limited exposure to these tears in real life or to training on a model/simulator.
Our results are similar to those of Siddighi et al,15 where approximately 81% of the residents undertaking perineal repair failed their criteria for successful repair. Of the nine PGY-4 participants (from seven different residency programs), five failed. Four of these five took either two or three random sutures through the external anal sphincter in an attempt to approximate the sphincter, which is referred to in TeLinde's Operative Gynecology: “to accomplish with force.” This subset had a reasonably high reported number of supervised (mean 12) and unsupervised (mean 5) prior repairs. This challenges the traditional apprenticeship teaching model and should encourage us to explore other teaching methods, especially outside the operating and delivery rooms.
Using surgical models for surgical procedures where case load is decreasing is no longer a novel concept. Therefore, we attribute the high failure rate in our study to lack of surgical skills curricula rather than to the unchangeable problem of decreasing numbers of some surgical cases and shorter hours of training. Study after study in the recent literature has highlighted the importance of structured curricula in various surgical specialties.16–18 The residency review committee in general surgery now mandates surgical skill training in simulation laboratories. Other surgical specialties, including ob–gyn, will likely have similar requirements in the near future.
The limitations of our study are the intrinsic inadequacies of using a model to mimic the actual perineum. With the use of simulated model in lieu of a live patient, the representation of anatomical structures may not be identical to that found in reality. However, an exact reproduction may not be necessary, as demonstrated by Roberts et al,19 who reported that for laryngeal mask airway insertion, training on a mannequin was just as effective as training on anesthetized patients. Although this may not translate directly to perineal repair, it is intuitive that the critical steps of several surgical procedures can be taught using simulators. Our sample size of only 40 participants is respectable for an education-type research study that provides some insight of possible deficiencies in our residency training programs.
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