SIMULATION LAB TRAINING – THE WAY FORWARD

The ability to acquire surgical skills requires consistent practice, and evidence suggests that many of these technical skills can be learnt away from the operating theatre. Surgical simulation offers the opportunity for trainees to practice their surgical skills prior to entering the operating theatre, allowing detailed feedback and objective assessment of their performance. This enables better patient safety and standards of care. Simulation of surgical procedures and human tissue, if perfect, would allow complete transfer of techniques learnt in a skills laboratory directly to the operating theatre.

Types of Simulators

Surgical simulation models can be low- or high-fidelity, reflecting the closeness of the model to reality. Low-fidelity models only allow practice of individual skills or techniques rather than an entire operation, while high-fidelity models can replicate an entire surgery with a high degree of realism.

Surgical simulators can be divided into organic or inorganic simulators. Organic simulators, consisting of live animal and fresh human cadaver models, are considered to be of high-fidelity. The microsurgery lab training on rabbits, frogs, mice, pigs, lambs and dogs fall in this category as do vessel anastomosis and training of use of venous couplers in placental blood vessels. Inorganic simulators comprise virtual reality simulators and synthetic bench models and these are used extensively in laparoscopic surgery training.

Current simulation models, including cadaveric, animal, bench-top, virtual reality (VR) and robotic simulators are being increasingly used in surgical training programmes in all premier medical institutions. Newer training programmes are being developed such that the educational curriculum that can incorporate surgical simulators. With the advances in telesurgery, three-dimensional (3D) printing, and the incorporation of patient-specific anatomy, simulators will be integral components of surgical training in the future. Simulation is not a complete replacement for intra-operative experience but an important adjunct and it clearly represents an important advance in current surgical education.

Why is it needed?

Surgical training consists of developing cognitive, clinical, and technical skills, the latter being traditionally acquired through mentoring. Fewer mentoring opportunities have led to the use of models, cadavers, and animals to replicate surgical situations and, more recently, to development of surgical skills centres or laboratories. However, the effectiveness of skills laboratories in teaching basic surgical skills (eg. instrument handling, knot tying, and suturing) requires careful supervision, evaluation and accreditation.

An important goal of surgical education is the acquisition of skill and skill sets that can adapt to new technology during and, importantly, after resident training. The result of such increased skill should be improved clinical outcomes. The rich history of surgical education repeatedly demonstrates the ability to adapt to change. Advances in pharmaceuticals, such as antibiotics, muscle relaxants, and vasopressors, have paralleled development of technology, such as cardiopulmonary bypass, imaging techniques, and laparoscopy. These advances have been associated with, if not required, rapid and efficient changes in surgical techniques, procedures, and decision making. Likewise, surgical education has adapted to rapid information access technology through computer learning, telemedicine, and adaptation to the technical advancements mentioned. 

What is the cost?

A typical skill laboratory

While the costs of simulation systems can be high, ranging from about U.S. $5000 for most laparoscopic simulators to up to U.S. $200,000 for highly sophisticated anaesthesia simulators, traditional Halstedian training is not without cost either. Bridges and Diamond in a study calculated that the cost of training a surgical resident in the operating room for 4 years was nearly U.S. $50,000 (measured by the additional time that the resident took to complete procedures). 

Which is the target group?

So, at which stage of training would simulation training help. It so seems that not only resident training but this technology is useful for practicing surgeons as well, who intend to progress by learning a newer technology. So many general surgeons of my generation switched to laparoscopic surgery later in life and so many of my plastic surgery colleagues picked up the skill of microsurgery from the established training labs. The American Surgical Association recognized the importance of training (and credentialing) surgeons during the course of their careers, addressing specifically the issues of new technology and maintenance of skills. The American Surgical Association Study Group advocated for new and revised educational programs using simulation techniques to allow learning and maintaining skills with agreed metrics of performance. As a direct result of the report, new programs, such as Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery were developed.

Simulation might well offer inter-professional team training that would allow participants to acquire, practice, and refine technical skills as well as communication and efficiency of team performance. Video recordings of team assessment can be used for trauma education in the emergency setting. The American Association of Medical Colleges has supported the use of multidisciplinary simulation for team training involving patient care, interpersonal communication, and critical thinking. Video tapes are critically reviewed and feedback is immediate and directed to issues where improvement is needed.

Coaching is another arena in which simulation is coming up in a big way. The American College of Surgeons has supported efforts by “senior” surgeons, nearing or in retirement, to train as “coaches” for their younger colleagues. Several programs have established courses using simulation models. It is always challenging to offer medical educators, especially in the surgical world, the concept of “centralized” educational or clinical programmes. The loss of proximity or local control is often met with considerable resistance. However, with the sophistication of telemetry, Internet, and other “distance learning” techniques, the world of surgical educators must re-evaluate how a larger audience can be reached. Additionally, the impact of centralized learning “institutes” or “academies” should be recognized. So the centre of excellence may be in Coimbatore or Delhi or Lucknow but a microsurgery trainee can be coached, guided, helped and eventually evaluated even when he is practicing his microsurgery skills in remote medical institutions which do not have a microsurgeon!

And much more

In my own Alma mater, King George’s Medical University in Lucknow the Simulation lab is doing wonders. Besides training surgical residents it is training Basic Life Support (BLS) care to other doctors, nurses, technicians, ambulance drivers, paramedics, police, teachers and health workers.  These first-responders, healthcare providers and public safety professionals are trained to anyone who is experiencing cardiac arrest, respiratory distress or an obstructed airway. The doctors who are interested are trained and certified for Advanced Trauma Life Support (ATLS), a programme conceived by American College of Surgeons to teach a systematic, concise approach to the care of a trauma patient. The simulation lab is also used to teach medical and nursing students and interns skills like endotracheal intubation, surgical crico-thyroidotomy, needle thoracocentesis and pericardiocentesis, putting in an inter-castal drainage tube and an intraosseous line. Student doctors and nurses are trained to put in a naso-gastric tube, an intravenous line, an intramuscular injection and on a pregnancy simulator they are trained to conduct normal deliveries!

Simulation training offers innovative and rewarding possibilities for the future of surgical educators and learners. There are many stakeholders, including students, residents, practitioners, but also administrators and, most importantly, patients. With the increasing sophistication of devices, cost-effectiveness becomes more important. What appears most necessary is the identification of the appropriate learners and to use the most relevant, goal-oriented simulation programs or technique for that group. The overall goal must necessarily be a demonstrable increase in the skills that are being evaluated in concert with definable results on improvement in clinical outcomes.