Journal of Surgical Simulation 2021; 8: 89 - 102

Published: 21 February 2022


Original article

Major vascular injury during minimally invasive gynecologic surgery: simulation-based approach to teaching surgical crisis management skills

Cara R. King, Annie Kim, Nicole Donnellan and Veronica Lerner
Corresponding author: Veronica Lerner, Montefiore Medical Center/Albert Einstein College of Medicine, 1300 Morris Park Ave, Block 632, Bronx, NY 10461, USA. Email:


Background: Major vascular injury (MVI) in gynecologic surgery is a rare catastrophic complication. We developed and implemented MVI simulation and conducted it at the 2019 AAGL Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS) Annual Bootcamp. Postgraduate year (PGY) 6 fellows participated as learners. FMIGS faculty conducted the simulation.

Methods: We developed a scenario, built a simulated abdomen including pelvic structures, designed the simulation setup given available space and resources, and created schedules for participant flow. Participants were expected to recognize an MVI that occurred during laparoscopic entry, resuscitate the patient, perform compression of the bleeding vessel, and call for a vascular surgery consult for vascular repair. A workshop was conducted for course faculty 1 week before the event and a rehearsal session was performed 1 day before the live simulation for all faculty. Participating fellows were divided into groups of 10, each session lasted 90 min and consisted of pre-briefing, simulation, and a debrief. Pre- and post-simulation survey responses were compared using McNemar’s test. Median and interquartile ranges were calculated on responses collected via a Likert scale (1–5).

Results: A total of 34 fellows (median age, 31.5 years) and 8 faculty (median age, 37.5 years) responded. Fellows reported a median of 8 h per year spent  participating in simulation team training and a median of 5 h per year spent teaching in this context. All fellows believed that simulation training is an essential part of clinical practice and patient safety; 94.1% (n=32) thought that simulation team training should be a part of the boot camp; 94.1% (n=32) also thought that the training should be part of the fellowship curriculum at their respective institutions. Before the simulation, 97.1% (n=33) of the fellows desired to learn more about simulation training and curriculum development. After the simulation, all fellows felt that knowledge gained could be transferred to the clinical setting, felt more confident in responding to a critical intraoperative event, learned techniques to communicate more effectively during a critical event, and felt that the simulation content was relevant to their training and clinical practice. Most of the fellows felt more confident in managing intraoperative hemorrhage (median, 5; interquartile range, 4–5) after the simulation.

Conclusion: MVI training in gynecologic surgery is feasible and viewed favorably by participants. Further work should focus on performance assessment and clinical outcomes to allow for the growth of simulation training within the field of gynecology.


major vascular injury; simulation; minimally invasive gynecology fellows; surgical bootcamp

Supplementary material

Supplementary files: Surveys. Available at; Supplementary video 1. Pump assembly, abdomen construction, operating room set up and simulation of bleeding from a major vessel. Available from