Introduction
Hysteroscopy is one of the most common outpatient gynecologic surgeries that can be performed in office, ambulatory, or hospital-based operating room (OR) settings. It comprises introduction of an endoscope through the endocervical canal and into the uterine cavity using a fluid distension medium to visualize the endometrium and manage associated pathology. Adverse events associated with hysteroscopy are rare, with a reported incidence of 0.24-0.28%, with more complex pathology or involved hysteroscopic procedures resulting in higher complication rates.1 Uterine perforation is one of the more common complications associated with hysteroscopy,1 which can result in early termination of the procedure or damage to surrounding vascular or visceral structures with associated consequences.1 Examples of described morbidities associated with uterine perforation include mechanical or thermal injuries to the bowel and intra-operative hemorrhage from damage to surrounding vascular structures, which may require emergent laparoscopy or laparotomy to diagnose and manage.1–3 Recognizing risk factors for uterine perforation and tailoring the hysteroscopic approach to each patient can help mitigate these risks and associated morbidities. In order to respond quickly and effectively, it is important that all involved OR personnel, including surgeons, anesthesia providers, OR nurses, and scrub technologists, are aware of this potential complication. This is especially crucial when hysteroscopy is performed in outpatient ambulatory surgical settings where resources for emergency response and resuscitation can be limited.4
Interdisciplinary simulations and drills have been suggested as a form of active preparedness for common surgical emergencies, as these may help to facilitate an efficient response to prevent an adverse outcome.5 The American College of Obstetricians and Gynecologists (ACOG) Committee on Patient Safety and Quality Improvement issued a statement emphasizing the importance of emergency preparedness. In this document, they provided examples of tools including but not limited to conducting emergency drills, maintaining a centralized location for emergency equipment, and designating first responders.5 A 2007 meta-analysis demonstrated a substantial proportion (39.6%) of in-hospital adverse events were attributed to operative care, with gynecologic surgery comprising a median of 6.2% of hospital adverse events (IQR 5.7-6.7%).6 Despite this known risk and call for active emergency response education, there is a paucity of literature regarding education and awareness of the needed emergency response to gynecologic surgery-related adverse events. In an era of vast access to video-based surgical curricula, there are no published studies assessing gynecologic surgery emergency preparedness nor are there any response videos that could serve as valuable educational tools. Recognizing this gap, the goal of this study is to analyze the effectiveness of a novel surgical safety video describing uterine perforation and its emergency response as an educational tool for OR personnel.
Methods
This is a prospective pilot pre- and post-video survey study. This study was reviewed and approved by the Benaroya Research Institute institutional review board for publication as a quality improvement project deemed exempt from IRB approval as human subjects’ research.
Video production
The video titled, “Surgical Safety Series in Gynecology: Uterine Perforation During Hysteroscopy in Ambulatory Surgery Centers,” was independently produced by the Minimally Invasive Gynecologic Surgery (MIGS) division at Virginia Mason Franciscan Health. The 7-minute video introduced uterine perforation as a potential adverse event of hysteroscopy and outlined ways to recognize and respond to this complication. The goal of the video was to use this as an educational tool for providers and operative staff involved in hysteroscopic procedures. This video was reviewed by surgeons and fellows within the MIGS division and feedback was incorporated for video production. The video was presented at the Society of Gynecologic Surgeons 2025 annual scientific meeting and is available upon request.7
Survey Description
The survey was distributed and self-administered through REDCap. Survey questions were not validated, given the pilot nature of this survey study. The survey was optional with participants providing voluntary consent, and was anonymous with no identifiable information collected, recorded, or distributed during this study. The survey consisted of 6 demographic questions: participant age, gender, race, ethnicity, level of education, and job title. Participants were also asked about how long they have been working in a gynecology OR and in which primary OR setting (hospital versus ambulatory).
The participants were then asked four pre-video questions. A 5-point Likert-scale survey consisting of four questions was constructed to assess respondents’ awareness of uterine perforation as a potential emergent complication (primary outcome), familiarity with risk factors and signs of uterine perforation, and supplies needed to respond to a uterine perforation emergency (Table 1). A link was provided to the 7-minute-long video within the REDCap survey, which was also projected during an OR didactic session. Immediately after watching the video, participants were asked to answer the same series of post-video survey Likert-scale questions.
Study Participants and Survey Collection
The REDCap survey was distributed to hospital and ambulatory OR staff across a tertiary care center and two ambulatory surgery centers affiliated with the Virginia Mason Franciscan Health MIGS Fellowship Program in Seattle, Washington from January through March 2025. Surveys were distributed by surgeons and fellows within the fellowship program. OR staff involved in gynecologic surgery were approached during the collection period, including anesthesiologists, certified registered nurse anesthetists, OR nurses, and surgical technologists. Gynecologic surgeons and trainees including residents and fellows were excluded from the study. Participants were provided with QR-code links to REDCap for survey access on their personal smartphone. QR codes were distributed in-person through enveloped survey handouts distributed during shiftwork and during a scheduled operating room didactic session at the single hospital facility.
Outcomes
The primary outcome of this study was awareness of uterine perforation as an emergent surgical complication of hysteroscopy before and after watching the video. Secondary outcomes included familiarity with risk factors for and signs of uterine perforation, as well as supplies needed to respond to this complication.
Statistical Analysis
Descriptive statistics (frequency and percentages) were used for reporting study participant characteristics. Statistical analysis was performed using R (version 4.4.1). Given the pilot nature of the study, a sample size goal was not pre-determined prior to distribution of surveys. A power analysis was performed to estimate the minimum effect size detectable by this study for changes in Likert scores before and after the video intervention. Using a paired t-test framework with a two-sided alpha of 0.05, 80% power, and the observed sample size, the analysis determined that the minimum detectable standardized effect size (Cohen’s d) was approximately 0.38. This corresponds to a mean change in Likert score of 0.49. Our study was sufficiently powered to detect moderate or larger changes in participant knowledge regarding uterine perforation following the video intervention.
In this analysis, we first calculated the average Likert scores for each outcome variable before and after the intervention. Next, we computed the change in scores for each participant by subtracting the pre-intervention score from the post-intervention score and then averaged these change scores across participants. To assess the statistical significance of the observed changes, we performed paired t-tests for each outcome variable. Confidence intervals for the paired differences were calculated based on the t-distribution with degrees of freedom equal to n-1, where n represents the number of paired observations. Additionally, we calculated Cohen’s D to provide an estimate of the effect size. A subgroup analysis was performed using the Kruskal-Wallis test, with a p-value < 0.05 indicating statistical significance.
Results
A total of 42 enveloped paper surveys were distributed across ambulatory and inpatient OR’s during the survey period, with 13 total responses from this mode of survey distribution for a response rate of 30%. During the scheduled didactic session, all attending OR personnel voluntarily participated in the survey and watched the presented video, with 44 responses from the session, for a total of 57 survey responses used in this analysis.
Participant characteristics are presented in Table 2. The majority of participants were between the ages of 30-45 years (N = 29, 51%), women (N = 44, 77%), white (N = 30, 54%), and not Hispanic or Latino (N = 47, 92%). Most participants had at least a college degree (N = 26, 46%) and were registered nurses (N = 31, 54%) working in an inpatient OR setting (N = 49, 88%). Regarding experience in gynecology OR’s, most reported having less than 10 years of experience (N = 41, 72%).
The average changes in Likert scores for each outcome measure pre- and post-video are presented in Table 3. Paired t-tests were conducted for each outcome measure. For each measure, the mean Likert scale response increased significantly as the confidence intervals did not cross zero, representing an average positive shift towards stronger agreement. Average changes were all statistically significant, with familiarity with required supplies demonstrating the largest average change of Likert score by 1.51 (d= 1.51, 95% CI [1.14-1.87]). For the primary outcome, awareness of uterine perforation as a potential emergent complication of hysteroscopy, the mean response increased from 4.14 to 4.58 on the 5-point Likert scale, representing an average change of 0.44 points towards a stronger agreement (d = 0.46, 95% CI [0.15-0.73]). While individual responses changed by whole numbers, the average change across all participants was 0.44 points on the 5-point scale.
Table 4 tabulates changes in Likert scores for each outcome measure. Majority of participants (N=32 (56%)) had no change in Likert score for the primary outcome of awareness of uterine perforation, however for the remaining outcome measures, majority of participants had a positive change in Likert score by at least 1 point before and after the video intervention. For the primary outcome, 37% of participant responses increased by at least 1 point. We did not apply correction for multiple comparisons across secondary outcomes; however, the consistent direction of effects and the exploratory nature of this pilot study mitigate this concern.
Table 5 presents the mean change in scores across the four outcome variables before and after watching the educational video, stratified by key demographic and professional characteristics. P-values presented in the table were calculated using the Kruskal-Wallis test. The only statistically significant results were that having more gynecologic OR experience was associated with decreased increases in Likert scores for the “signs” and “supplies” outcomes. Notably, although not statistically significant, the data showed numerical trends suggesting that younger staff may have larger knowledge gains across all outcome variables, and that less educated staff may have larger knowledge gains regarding recognition of risk factors, signs, and supplies.
Discussion
Our study demonstrates the effectiveness of a novel surgical safety educational video in helping to improve awareness of uterine perforation as a complication of hysteroscopy. In addition, we have shown that this video helps OR staff to recognize associated signs and risk factors of this complication as well as supplies needed for an emergency response. Within the field of gynecologic surgery, this is the first study to assess the impact of a surgical emergency educational video on overall knowledge of OR staff to recognize and respond to the emergency at-hand. In this study, we show that an easily accessible video can be a cost-effective and efficient tool in increasing OR staff awareness and familiarity regarding a potentially catastrophic complication of a commonly performed outpatient gynecologic surgery.
Prior studies have demonstrated the advantage of simulation-based training in obstetrics and gynecology to help enhance surgical or clinical skills, however there is no study within gynecologic surgery that examines the impact of didactic or simulation curriculum on surgical emergency responses in particular, such as vascular or visceral injury.8–11 As market pressures increasingly shift outpatient gynecologic surgery to free-standing ambulatory surgery centers, there may be additional safety risks due to decreased access to resources or administrative oversight in the event of an emergency. Quick access to an effective educational medium becomes crucial in this setting.12 Educational videos have previously been shown to help improve adherence to safety-critical tasks within anesthesiology13 and we show that this teaching tactic can be implemented in gynecologic surgery safety education as well. Simulation training can be labor- and time-intensive to arrange and execute, therefore an educational video can increase accessibility for OR staff in a demanding surgical environment with hopes to help expedite the emergency response and ultimately improve patient safety.
Strengths of our study include its novelty in introducing an educational video that addresses surgical emergency preparedness for a rare but dangerous gynecologic surgical complication. This is a cost-effective alternative to simulation-based training with a larger potential audience to include numerous busy OR personnel. Most participants had less than a decade of experience working in a gynecology OR setting, demonstrating a potential gap in knowledge that can be bridged by incorporating an educational video curriculum. In addition, our robust sample size was helpful to establish statistically significant results for knowledge-based outcomes. Our population was largely limited to inpatient OR personnel at a single institution, given a majority of survey responses were during the didactic session in an inpatient hospital setting, and therefore may not be representative of or generalizable to outpatient OR staff from different surgical centers. In addition, baseline awareness of uterine perforation as the primary outcome of our study was already high (mean score 4.14/5.0). This ceiling effect may reflect appropriate baseline knowledge among experienced OR staff or limitations of the Likert scale in discriminating among highly aware respondents. Secondary outcomes with lower baseline scores, particularly familiarity with required supplies (mean 2.98), demonstrated greater capacity for improvement and may represent more actionable targets for future educational interventions. Another limitation of our study was its high survey attrition rate after distribution of paper survey handouts, limiting the number of outpatient participating OR staff included in the study. Feedback was received that OR staff found it particularly difficult to find time outside of work to watch the video and complete the survey. Therefore, an effort was made to improve the overall survey response rate and participant outreach by projecting the video and distributing the survey during a scheduled inpatient OR didactic session, which greatly improved survey participation. Inherent to pre- and post- survey designs is the response-shift bias, which may be attributed to some changes in Likert survey responses observed in this study as well. In the future, a post-video assessment rather than a survey-based pre- and post- video questionnaire could help to better gauge video knowledge-based outcomes and help eliminate this bias. Furthermore, we assessed knowledge immediately following the video intervention. Whether these gains are retained over time and translate to improved performance during an actual emergency remains unknown.
Our goal is to see this study serve as a segue towards creating a standardized surgical safety educational video curriculum covering multiple surgical emergency topics, such as complications of laparoscopic entry, for example. In the future, a multi-center study involving outpatient, ambulatory surgery center OR staff would help to assess the efficacy of this video medium in a setting where gynecologic surgery has a large presence, with a goal of optimizing emergency preparedness and patient safety in this setting.
Conclusion
A surgical safety educational video presented to OR personnel improved self-reported awareness of uterine perforation as a complication of hysteroscopy, in addition to recognition of risk factors, signs, and supplies needed for an adequate emergency response.