We appreciate the comments of our reader in reference to our article pertaining to trainee involvement in laparoscopic hysterectomy. Our findings reveal an increased operative time in cases with trainee involvement. However, we are unable to comment on the specific reasons for this increase as this information is not available in the National Surgical Quality Improvement Program (NSQIP) database. Regardless, the interpretation of our reader that the additional time is required for training is not the conclusion, but the problem put forward by our study.

Over the years, various institutions have invested heavily in simulation programs; however, no formal curriculum has been developed specifically for the field of gynecology. Although the general surgery fundamentals of a laparoscopic surgery training program has been successfully implemented in gynecology. In addition, the Accreditation Council for Graduate Medical Education mandates a minimum of 20 laparoscopic hysterectomies prior to graduation of residents, however, no standard has been set forth on the minimum basic laparoscopy or robotics proficiency prior to scrubbing in to the first hysterectomy case. Much has been talked about regarding the safety of patients by instituting time-outs and mandatory checklists prior to surgery, however, very little attention has been given to ensure that the assistants and students have mandated basic skills training prior to assisting and learning in the operating room. We suspect that if these basic steps are taken, this excessive operating time could be shortened. Lastly, the mean age in our article is the mean age of the patients and not the surgeons. Unfortunately, the NSQIP data do not have access to attending surgeons’ age or level of expertise, both of which may have an impact on the surgical time.

The limitation of the NSQIP database leaves much to be learned, but the data available can certainly help us to understand what we still need to learn. We are hopeful that researchers and educators from all over the world will help us put the missing pieces together for a problem we have put forward.