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Please cite this paper as: Geoffrion R, Gebhart J, Dooley Y, Bent A, Dandolu V, Meeks R, Baker K, Tang S, Ross S, Robert M. The mind's scalpel in surgical education: a randomised controlled trial of mental imagery. BJOG 2012;119:1040-1048. Objective To evaluate the role of mental imagery (MI) in resident training for a complex surgical procedure. Design Randomised controlled trial. Setting Eight centres across Canada and the USA. Population Junior gynaecology residents who had performed fewer than five vaginal hysterectomies (VH). Methods After performing a pretest VH, junior gynaecology residents were randomised to standard MI versus textbook reading (No MI) and then performed a test VH. Surgeons blinded to group evaluated resident performance on the pretest and test VH via global rating scales (GRS), procedure-specific scales and intraoperative parameters. Residents evaluated their own performance. Main outcome measure Change in surgeon GRS score from pretest to test VH. The study was powered to detect a 20% difference in score change. Results Fifty residents completed the trial (24 MI, 26 No MI). There was no difference in GRS score change via blinded assessment from pretest to test evaluation between groups (mean change 13% [SD 17] versus 7% [SD 14], P = 0.192). There was no difference in procedure-specific score change. There was a significant difference in self-scored GRS score change between groups (mean change 19% [SD 12] versus 9% [SD 11], P = 0.005). Residents also felt more confident performing a VH (mean change 19% [SD 16] MI versus 11% [SD 10] No MI, P = 0.033). Conclusions No difference was observed in the surgical performance of residents after MI. Improved resident self-confidence may be attributable to MI or the effect of unblinding on trial participants. [ABSTRACT FROM AUTHOR]

A response from the author of the article "Methodological Issues Surrounding the Mind's Scalpel in Surgical Education: A Randomised Controlled Trial of Mental Imagery" is presented.

Purpose: To report a case of transvaginal small intestinal hernia following abdominal sacrocolpopexy and review this clinical presentation in the current literature. Methods: A review of our case and a literature review of vaginal evisceration were carried out. Results: The patient underwent sacrocolpopexy and a Burch procedure. Six months later, a recurrent enterocele through a 1 cm defect in the vaginal vault was diagnosed. Several weeks later she presented with an incarcerated and strangulated loop of small intestine extending beyond the introitus. This required an urgent exploratory laparotomy, ileocecal resection, and vaginal vault closure. Postoperatively, she experienced gradual prolapse recurrence and is currently successfully managed with a pessary. Risk factors that include vaginal atrophy, chronic constipation, and previous pelvic surgery may have contributed to the evisceration, mesh erosion, and may have caused the breakdown in the vaginal vault mucosa ultimately responsible for the evisceration. In addition, placement of the sacrocolpopexy mesh without tension, and utilization of an interposition graft to reinforce the weakened vaginal vault tissue, are aspects of the surgical procedure that may influence outcomes. At the time of evisceration repair, the best approach to resuspend the vaginal vault, and prevent recurrent prolapse or evisceration, is currently unknown. Conclusion: Vaginal evisceration is a potential complication of abdominal sacrocolpopexy. Early recognition and treatment of this complication is critical, and prolapse recurrence may occur even after surgical repair. [ABSTRACT FROM AUTHOR]