Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

The objective of this article is to review the published literature on the diagnosis and management of interstitial pregnancies (IPs). IPs account for 2-6% of all ectopic pregnancies and have the potential to cause life-threatening haemorrhage resulting in a 2-5% mortality rate. There is little consensus on the best practice for diagnosing and managing interstitial pregnancies. By reviewing the published data, we set out to determine what the best evidencebased practice for the management of interstitial ectopic pregnancies is, what protocols can be used and whether this improves post-operative outcomes and future fertility rates.

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high‐ (HICs) and low‐ and middle‐income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7‐day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.

Unique psychomotor and perceptual challenges of laparoscopysuch as marred depth perception, the requirement for advanced hand-eye coordination and the use of long instrumentsmean that laparoscopic trainees face a steep learning curve. The difficulties that trainees encounter in meeting required laparoscopic competencies may, in part, be overcome through the use of laparoscopic simulation training (LST), with benefits for trainees, patients, consultant staff and hospital budgets. There is growing evidence that LST improves patient outcomes, such as shorter operative duration, fewer intraoperative errors and cancellations, and reduced litigation. In 2017, the British Society for Gynaecological Endoscopy formally adopted the European Academy of Gynaecological Surgery's Gynaecological Endoscopic Surgical Education and Assessment programme; this programme is likely to play an increasing role in trainees' attainment and validation of laparoscopic skills. Learning objectives To understand the role of laparoscopic simulation training in modern gynaecological training. To know about the European Academy of Gynaecological Surgery's Gynaecological Endoscopic Surgical Education and Assessment programme. Ethical issues How does laparoscopic simulation training benefit patient safety? How can trainees' access to laparoscopic simulation training be standardised?

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