Due to the declining procedural volume of vaginal surgery with mesh following the FDA warning, educational simulation programs are necessary to improve knowledge and skill and to facilitate competence in vaginal surgery with meshes prior to trainee graduation or specialization in urogynecology. Several options have been proposed. Between them: low fidelity models (for example made in silicone), animal models  and cadaveric models. The objective was to evaluate the usefulness of simultaneous laparoscopic assistance to improve understanding of the nonvisible surgical steps in Thiel-embalmed cadaver models for training in vaginal surgery using vaginal mesh kits and to evaluate student opinions of this surgical learning procedure in comparison with other learning models. In our knowledge, it is the first time that a didactic video of these characteristics is made with the double simultaneous approach: vaginal and laparoscopic

Simultaneous recording of anterior compartment prolapse repair with vaginal mesh kits using an external camera simultaneously with laparoscopic vision during the execution of the procedure on a Thiel-embalmed cadavers, which allowed abdominal cavity pneumoinsufflation and more exact reproduction of the surgical technique, by both vaginal and laparoscopic approaches. Posterior dissection of important anatomical relations of the sacrospinous ligament was performed. Afterward, a final video was made integrating both simultaneous views of the procedure. To measure the usefulness of this procedure, we designed an anonymous online survey that was made available to program participants via a computer application (a link to Video 1 and the survey was  available at encuesta@um.es).

A total of 72 surveys were returned. Sixty-six percent (66.7%) of participants surveyed were specialists in urogynecology. The mean of years of experience was 15.52.  Of the participants, 63.9% had received specific theoretical and practical training in surgery with mesh, and 16.7% did not have any training with mesh. Of those who had received specific training, 50 % had used the cadaveric model, and 27.8 % had used animal models for this training. After watching the video, 97.2 % agreed having the laparoscopic vision combined with the vaginal approach was useful for learning this surgical technique, and 95.8 % agreed they had learned details of the surgical anatomy of the pelvis (Figure 1). In addition, 90.3% were more aware of the surgical risks associated with this intervention. All participants agreed it should be mandatory to train in these techniques in cadavers prior practice in live patients. Furthermore, 84.7% responded that the cadaveric model was superior to animal and other types of models, and 66,7% agreed that use of the cadaverous model was the most efficient (cost / benefit ratio) model for training in this surgical technique (Figure 2).

Laparoscopic inspection of the procedure performed with the vaginal approach allows a better understanding of the surgical technique by making "visible" the anatomical structures that are commonly only palpated. In addition, the posterior dissection of the sacrospinous ligament allows for better understanding of its anatomical relationships, making the surgeon more aware of the dangers of this technique and providing methods to avoid possible complications

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