• 1.
  

  a) T b) T c) T d) T e) F

A curriculum approach drawing on competencies of knowledge, skills and attitudes will provide a basis for training teams. A simulation-based strategy can use a number of training methods, including a team-centred approach, and can lead to a better prepared team. A number of simulation-based studies on procedural training have demonstrated the feasibility of skill transference to the operating room. Such a strategy leads to reduced errors and improved performance characteristics. During laparoscopic surgery, the operative and visual axes are misaligned. Proper alignment of the display monitor, based on sound understanding of ergonomics and performance, leads to improved comfort levels and procedural efficiency. Preoperative checklists provide a template for a consistent approach to minimising surgical risk. Compelling evidence suggests that application of checklists can lead to a reduction in morbidity and mortality. Sterile cockpit communication protocols are designed to mechanise the operating room communication during periods of high mental load. This is another concept derived from the aviation industry. As yet, only one study has examined its efficacy. This strategy may improve the perceived mental effort of the team but, as yet, no evidence suggests that it improves clinical outcome.

• 2.
  

  a) T b) T c) F d) T e) T

Evidence from observational studies suggests that poor ergonomics can lead to physical, cognitive and perceptual problems. Improved understanding of ergonomics in the operating room and the effect this could have on surgical teams is critical to achieving a safer environment. Chronic pain syndromes among laparoscopic surgeons is well recognised. Better designed instruments and monitor displays will reduce physical complaints. This is a component of the occupational health agenda that is often overlooked.

• 3.
  

  a) T b) T c) T d) F e) F

Simulation avoids risks to patients, and trainees can practice in a risk-free environment with minimal anxiety, and focus on psychomotor tasks and improving manual dexterity. Although learning curves for the inexperienced group are longer and steeper, they achieve the same level of skills as more senior surgeons at the end of the training period. This allows them to bypass the early learning curve, which has higher risk of complications. In the study by Aggrawal et al. the learning curves for the experienced group plateaued at the second session, although more sessions were needed for the intermediate (seven) and novice (nine) group to achieve the same standards. Trainees using box trainers show improved performance on virtual-reality simulators and vice versa (i.e. the skills are somehow transferrable).

• 4.
  

  a) F b) F c) T d) T e) T

Face validity measures the degree of realism of the simulator. It shows how similar the simulation is compared with real-life events (i.e. actual surgery). Content validity measures the appropriateness of the simulator as a teaching modality. Construct validity assesses if a simulation method is able to identify the difference between inexperienced and experienced operators. Consequential validity indeed measures whether the test predicts future performance

• 5.
  

  a) F b) T c) T d) F e) T

Expert summary feedback (i.e. feedback given at the completion of the task) is more efficacious than concurrent feedback. Frequent, shorter sessions (e.g. 1 h per week) are more beneficial than infrequent courses lasting for 1–2 days. Distributed practice sessions improve acquisition and transfer of a learned skill and help the skill to consolidate between training sessions. The efficacy of competency-based rather than time-based training has been well documented. Assessing motor tasks at varying levels of difficulty has been shown to enhance learning, and this should be considered when designing the curriculum. As simulation is a safe environment for learning then feedback in the form of formative assessment intrinsically aids learning as opposed to pass/fail summative judgements.

• 6.
  

  a) F b) F c) T d) F e) T

A meta-analysis in 2002 looking at laparoscopic entry techniques showed a lower rate of vascular injury using an open entry technique compared with closed entry. The same meta-analysis showed that more bowel injuries occur with open compared with closed entry, although this may be due to selection bias. Currently, insufficient evidence is available to comment on mortality rates.

• 7.
  

  a) F b) T c) F d) F e) F

Retrospective studies show a rate of bowel (visceral) injury in gynaecologic laparoscopy of between 1.6 and 7 per 1000, or about 0.3%.

• 8.
  

  a) F b) F c) T d) F e) T

Secondary trocars should be inserted under direct visualisation to avoid injury to blood vessels and viscera. The woman should be lying flat for laparoscopic entry to keep the position of the major abdominal and pelvic vessels in a predictable position compared with the abdominal wall to avoid injury. In lean women, the aortic bifurcation is in closer proximity to the umbilicus and so it is safer to guide the Veress needle at a 45° angle. Vascular injury has been known to occur even during skin incision and, as a result, it is suggested to avoid downward stabbing motions, but rather cut with an upward pulling motion.

• 9.
  

  a) F b) T c) F d) T e) T

The Manchester repair is a vaginal operation that preserves the uterus. Traditionally, the gold standard operation for treating uterine prolapse was vaginal hysterectomy; however, Manchester repair was an option for women who were keen on uterine preservation.

A more recent retrospective study comparing a modified Manchester technique with vaginal hysterectomy showed no middle-compartment recurrences in the modified Manchester group and 4% in the hysterectomy group at 12 months’ follow up. The main modification was the plication of the uterosacral ligaments by a deep suture. This contrasts to the original Manchester procedure, where the ligaments are cut and transposed.

• 10.
  

  a) F b) F c) F d) F e) F

Sacrospinous hysteropexy is usually carried out with the use of either absorbable or non-absorbable sutures. Bilateral sacrospinous hysteropexy has been reported, although it was initially described unilaterally and to the right uterosacral liagment. Only one RCT has compared the two methods. The primary outcome was recovery time. The participants who underwent sacrospinous hysteropexy were associated with earlier recovery (43 days v 66 days; P = 0.02); however, no differences were found in quality of life or functional outcomes between the two procedure groups at 1-year follow up. The investigators concluded that the vaginal hysterectomy group experienced fewer high-grade and low-grade prolapse recurrences than the sacrospinous hysteropexy group. Because the primary outcome of this study was return to work, the conclusion of objective anatomical outcomes need to be interpreted with caution. Sacrospinous hysteropexy was first described in 1989 by Richardson.

• 11.
  

  a) F b) T c) F d) F e) F

Few case reports have been published of pregnancies and their outcomes after laparoscopic uterine suspension. The procedure does usually involve suspending the uterus to the sacral promontory. No RCTs have compared laparoscopic uterine suspension with vaginal hysterectomy or with abdominal hysteropexy.

• 12.
  

  a) F b) F c) F d) F e) F

Laparoscopic mesh hysteropexy usually involves attaching the mesh to the cervix. No studies have assessed bowel function after laparoscopic sacrohysteropexy. Laparoscopic sacrohysteropxy is an operation to treat middle compartment prolapse. No long- term studies have been conducted on laparoscopic sacrohysteropexy. No comparative studies between vaginal sacrospinous hysteropexy and laparoscopic sacrohysteropexy have been conducted.

• 13.
  

  a) F b) F c) T d) F e) F

The rectum is more frequently involved than the sigmoid. The most frequent symptoms are dysmenorrhea, dyspareunia and non-menstrual chronic pelvic pain. Lesions larger than 3cm and stenosis are among the most frequent indications of radical treatment. The evidence of the role of stomas in bowel resection is usually based on different subsets of patients: e.g. cancer, elderly patients etc. Endometriosis is a benign disease that arises in younger patients, and the resection techniques are more reduced. Consequently the indication for stomas is evaluated in each case and is mainly related to specific technical difficulties during surgery and the level of the resection. The compromise of the mucosa by endometriosis in general is low. Ultrasound and MRI provides more accurate and useful information. Colonoscopy is particularly relevant in the differential diagnosis of malignancy or alternative pathology.

• 14.
  

  a) F b) T c) T d) T e) T

Exposure in Laparoscopy is more than Trendelenburg and pneumoperitoneum. It implies several actions that allow the surgeon to free the assistant to help, improving the surgical performance and saving time. The main objective of the low-residue diet is to facilitate field exposure. The symptomatology and the imaging findings must be correlated with the physical examination. The physical examination under anaesthesia provides important information to tailor the surgical strategy. The dissection of the physiological attachment of the sigmoid to the abdominal wall gives accesses to the left ureter, adnexa and para-rectal fossa. The role of organ suspension is to improve the exposure of the field, freeing at the same time to the assistant to help the surgeon during the dissection.

• 15.
  

  a) F b) F c) F d) T e) F

Evidence based medicine establishes cystectomy as the gold standard in the management of endometriomas. The main concern related to this technique is the potential reduction of the ovarian reserve due to the un-intentional removal of the ovarian parenchyma. A meticulous technique and selective coagulation are fundamental in the reducing these risks. The ovarian reserve may be evaluated by means of AMH and an antral follicular count particularly in cases of sub-fertility and bilateral and recurrent ovarian endometriomas.

• 16.
  

  a) F b) T c) F d) F e) T

No one mode of surgery guarantees long-term benefits. The main benefit of robotic surgery is an excellent ergonomic environment for the surgeon; however, for various reasons, other methods of minimal-access surgeries are more popular in the developed world. Randomised-controlled trials have not shown that open surgery has better outcome compared with laparoscopic surgery in either cervical or endometrial cancer. The main limitation of single-port laparoscopy is restriction of surgeons mobility when accessing instruments.

• 17.
  

  a) T b) F c) F d) T e) T

Radical de-bulking has been accepted as an effective mode of surgical treatment in managing advanced-stage ovarian, tubal and peritoneal cancers. No Gynecologic Oncology Group surgical standard is available on the management of these cancers. Upper abdominal procedures carry higher morbidity figures compared with routine pelvic de-bulking surgeries, but they are not unacceptable. No macroscopic disease has the best surgical outcome in both primary and interval de-bulking surgery.

• 18.
  

  a) F b) F c) F d) F e) T

Defining criteria for radical trachelectomy is one of key elements in patient selection for fertility-sparing surgery. Women not meeting the criteria for radical trachelectomy have increased risk of cancer recurrence. All fertility-sparing surgery should have close follow up and investigation depending on any relevant symptoms. No significant data are available on fertility-sparing surgery for endometrial cancer to make comparisons with cervical or ovarian cancer. This is one of the most important prognostic factors in cervical cancer, and positive pelvic lymph nodes are a clear contraindication for fertility-sparing surgery.

• 19.
  

  a) F b) T c) T d) F e) T

Exenteration carries significant morbidity and is offered mainly with curative intent. This is one of the main reasons why careful patient selection is important, as surgery-related morbidity can compromise quality of life. Central recurrence is one of the traditional criteria for exenteration, but similar outcomes have resulted with pelvic side-wall recurrence, hence side-wall recurrence is not a contraindication for pelvic exenteration. Histological confirmation is vital before embarking on a definitive exenteration procedure.

• 20.
  

  a) F b) F c) F d) T e) F

Carrying out systematic salpingectomy in cases of hydrosalpinges before IVF can remove good-prognosis tubes, thereby preventing women from conceiving spontaneously. Prospective randomised studies have shown that the presence of hydrosalpinges have a negative effect on IVF outcome, so starting IVF treatment before evaluating and treating the tubes should be avoided. The tubal mucosa should be evaluated before removal of the tubes. Therefore, opening of the tube at the distal end is necessary, and the tubal mucosa should be carefully inspected. Previous data on salpingoscopy showed a positive correlation between the degree of tubal normal mucosa and the probability of spontaneous pregnancies. A salpingostomy, if prognosis of hydrosalpinges is good, offers the possibility of spontaneous conception. Ultrasound visibility of hydrosalpinges is not a pathognomonic sign of a bad prognosis hydrosalpinx; on the contrary, it is mostly thick-walled hydrosalpinges that are not visible that have a poor prognosis and should always be removed.

• 21.
  

  a) F b) F c) T d) F e) F

Studies have shown that it is economically more beneficial to carry out ovarian drilling instead of ovulation induction with gonadotrophins. The costs are also lower because multiple pregnancies are avoided. The results of transvaginal drilling are comparable to the results of laparoscopic ovarian diathermy. Ovarian drilling is indeed considered a second-line treatment, together with ovulation induction with gonadotrophins. The risk of postoperative adhesion formation is lower after transvaginal ovarian drilling, because the damage to the ovarian capsule is minimised by using a bipolar needle measuring 0.2 mm in diameter, and because the entire procedure is conducted under water. In the absence of other fertility-impairing factors, such as male subfertility, IVF is only the third choice of treatment.

• 22.
  

  a) T b) F c) T d) T e) T

For studies to be reliable and generalisable, they would have to be free of bias, large and multi-centred. Multi-centred studies allow for rapid recruitment due to the potentially higher number of participants. Single centre studies may be smaller and subject to bias.

• 23.
  

  a) F b) T c) T d) T e) F

The number of trials in obstetrics and gynaecology are increasing although multi-centre trials have plateaued. Gynaecological trials have improved in terms of power and methods of randomisation and concealment. It is ideal for both the patient and clinician or care-giver to be blinded to the treatment but this can be difficult when using surgical interventions. It can also be difficult to use a suitable placebo or sham treatment similar to the intervention being assessed, so comparators are not essential in effectiveness studies but are preferable.

• 24.
  

  a) T b) F c) T d) T e) T

The use of research networks and social media can promote research activities, patient participation and encourage and motivate researchers to successfully recruit into clinical trials.

• 25.
  

  a) T b) T c) F d) F e) F

The main indication for single-port access laparoscopy (SPAL) is benign adnexal pathology. Most studies have evaluated the surgical treatment of various benign adnexal pathologies (benign ovarian tumours, hydrosalpinx, tubal sterilisations, and ectopic pregnancies). The results suggest that SPAL is a safe, feasible, and effective alternative to conventional laparoscopy, and also in cases of large adnexal tumours. Hysterectomy (e.g. total, supracervical or laparoscopically assisted vaginal) with SPAL is feasible and safe, even in large uteri. Owing to the absence of specific instrumentation (e.g. morcellator) and to suturing difficulties, myomectomy remains a difficult indication for SPAL. Currently, only five studies have been published on SPL myomectomy: two case reports and three case series. SPAL allows hysterectomy, salpingo-oopherectomy, and lymphadenectomy to be carried out, the latter in the hands of a skilled surgeon. The lack of randomised-controlled trials (RCTs) with long-term follow up, and the poor availability of SPAL in oncology centres limit the indications only for early endometrial cancer. No studies have been published on single-port management of ovarian cancer, except for borderline tumours.

• 26.
  

  a) F b) T c) T d) T e) F

The main characteristic of the endoscope used for SPAL is the ability to provide good vision in the pelvis, with minimal movement. In fact, whatever the type of trocar used, the space available for moving the tools or the optics is limited, and they are often different. So a 30°-camera with a 50-cm long endoscope is a good option for SPAL. Laparoscopes with a flexible distal tip are also available, which have a variable direction of view. These are better than traditional cameras, because they are stable when stationary, thus avoiding crowding into the trocar. The first report on SPAL was published in 1991. The same trocar used for conventional laparoscopy was used for this procedure. The trocars were placed into an umbilical-only incision, and a glove was used to preserve the pneumoperitoneum. The development of specific trocars has helped to eliminated gas leakage, improve ergonomics, and reduce fascial incisions. Many studies have confirmed the feasibility of SPS with conventional laparoscopic instruments, because they are thin (5 mm), and often long enough to reach the surgery site. To overcome the absence of triangulation and the instrument crowding, numerous specific instruments for SPS have been developed. Usually, these instruments are used concomitantly with conventional laparoscopes. To overcome ergonomic difficulties, robotic instruments have been developed for laparoscopy. This new technology can also be used in SPL. Further development and integration of SPAL, robotics and natural orifice transluminal endoscopic surgery, will certainly improve the dissemination of this approach. As with conventional laparoscopy, SPAL, can use both reusable and disposable instruments. The advantage of single-use equipment is sterility and quality, against a purchase price up. The reusable instruments reduce the cost of surgery, allow the use of more resistant materials and can withstand a greater workload, and therefore a greater tractive force.

• 27.
  

  a) F b) T c) F d) T e) F

SPAL produces a better aesthetic outcome of the surgery scar compared with laparotomy. The few RCTs that have compared the cosmetic result of SPAL versus conventional laparoscopic surgery, do not demonstrate any advantage. An unequivocal advantage of single umbilical access is that specimens can be removed more easily through a larger incision compared with the smaller incision used conventionally. In particular, it is easier to remove solid components of dermoid cysts, such as tooth, bone and cartilage therefore reducing the probability of spillage and need for morcellation. Single-port surgery may not be easy to learn, given the high level of skill and technical ability required to overcome many of the obstacles. This may lead to a difficult and long learning curve, and it is imperative that surgeons who attempt this new surgical approach be at least highly proficient in traditional laparoscopy. It is recommended that surgeons become familiar with the technique, first with dry and animal labs. This would facilitate familiarity of the surgeon with new instruments, different single port systems, and angulated optics. The most apparent advantage of SPAL is the reduction of the ancillary-port penetrating the abdominal wall, which means reducing operative complications related to trocar insertion (i.e. epigastric vessel injury, operative wound infection, haematoma, visceral organ herniation, and damage). In particular, bleeding from epigastric vessels is one of the major complications after laparoscopic surgery. SPAL is associated with low risk of major adverse events (2.4%); in particular, after 16 months, the rate of umbilical hernia detected was 2.4% and 0.5% in women without significant co-morbidities. The cost of each surgical intervention depends on the choice between disposable and reusable instruments.

• 28.
  

  a) T b) T c) T d) F e) T

Total Laparoscopic Hysterectomy definitely requires a long learning curve to master the technique. Literature evidence has confirmed a higher complication rate associated with Laparoscopic Hysterectomy. Laparoscopic Hysterectomy requires dedicated equipment. Use of disposable equipment leads to increased costs. Vaginal hysterectomy has significantly less complication rates than TLH and LH. Worldwide abdominal hysterectomy, despite its higher complication rate, has still remained the route of choice for hysterectomy, probably due to senior consultants not being familiar with vaginal hysterectomy and laparoscopic hysterectomy.

• 29.
  

  a) F b) F c) T d) T e) T

The probes are flexible in two planes by manipulating the control at the handle. Currently, preoperative lymphoscintigraphy and intraoperatively with a gamma probe have been most widely studied for the detection of pelvic SLN, before biopsy is undertaken. At present, contrast-enhanced ultrasound with or without power Doppler is the subject of interest and evaluation for the assessment of SLN using submicron or near-micron-diameter bubbles. This may be suitable and could be used as an alternative to current sentinel node detection methods. The application of FDG– PET and computed tomography for intraoperative tumour localisation and verification of tumour excision in recurrent ovarian cancer was later described in three women. The technique utilised a single injection of 18 F-FDG for PET and computed tomography imaging, and intraoperative gamma probe detection. Intraoperative imaging confirmed the full extent of disease, which was not fully apparent intraoperatively by gross palpation or inspection. Postoperative PET and computed tomography verified complete resection of the clinical and hypermetabolic lesions. Intraoperative ultrasound was reported to detect additional liver metastases in 10% of patients who had undergone preoperative multidetector computed tomography imaging. The detection was significantly higher in women with multiple (four or more) tumours and hypoechoic tumours. The usefulness of IOUS for the assessment of para-aortic lymph nodes in gynaecological malignancies compared with computed tomography and palpation during surgery was reported back in 2003. The investigators reported that intraoperative sonography had a sensitivity and negative predictive value of 100% and that if it had been used solely to detect swollen lymph nodes the number of para-aortic lymphadenectomies would have decreased without missing lymph node metastases.

• 30.
  

  a) F b) F c) F d) F e) T

Although hysterosalpingography is a common, readily available, and an easy test to carry out, it cannot assign the correct diagnosis in many types of Müllerian-duct anomalies. Although it outlines the uterine cavity contours effectively, and can display intracavitary lesions like fibroids, polyps, and adhesions, it doesn’t have the advantage of other imaging techniques, such as ultrasound and magnetic resonance imaging of outlining the outer uterine contours. Before embarking on surgical management in Müllerian-duct anomalies, the gold standard to make the diagnosis used to be combined hysteroscopy and laparoscopy procedures to outline the inner and outer uterine shapes. Recent studies have shown, however, that combined hysteroscopy and the three-dimensional reconstructed coronal view of the uterus can avoid the need for laparoscopic assessment to check the outer uterine contour in patients undergoing hysteroscopic metroplasty. Three-dimensional transvaginal ultrasonography has been found to be extremely accurate in the diagnosis of bicornuate, septate, and arcuate uterus, more than hysterosalpingography or office hysteroscopy. It provides visualisation of the uterine cavity with similar or better accuracy than standard hysterosalpingography in the office setting with lower cost and morbidity. Three-dimensional transvaginal ultrasonography was proposed as the only mandatory step in the assessment of the uterine cavity in women with a suspected septate or bicornuate uterus. Although three-dimensional ultrasound is accurate at detecting Müllerian-duct anomalies, some types of these anomalies are still better viewed and assessed with magnetic resonance imaging, such as vaginal atresia and vaginal septae, which three-dimensional ultrasound (e.g. transabdominal or transvaginal when feasible) can miss. Intraoperative imaging during hysteroscopic metroplasty for uterine septum resection has been recommended by some surgeons to identify a safe resection distance, and to reduce the risk of uterine perforation even after the correct diagnosis has been established.