Simulation and Training in Minimal Access Surgery

Fig. 3.1
Physically contextualised minimal access surgical simulation training using a video (box) trainer and ex vivo porcine tissue

In situ simulation (performed in the actual clinical setting) is still in its infancy, but has demonstrated potential for use in multidisciplinary team training e.g., trauma and cardiopulmonary resuscitation scenarios [37]. However, in situ simulation for surgery is limited by the accessibility of the operating theatre with respect to cost and clinical demand. Many teaching hospitals have therefore established static simulation facilities with dedicated staff, but these can also prove costly, difficult for trainees to access, and are subsequently often under-used. More recently, portable and mobile simulation facilities have been designed to counter such issues [38]. These modalities specifically target trainees who would otherwise struggle to routinely access specialist centres, with evidence to suggest that the facilities and participant experiences are comparable to their more illustrious, and expensive, counterparts [3941].

We have previously considered the various simulation modalities available for minimal access surgery training. However, it is also of vital importance for training that surgeons are able to perform simulated procedures in the manner, and with the tools, that they would use in real life.

Physical contextualisation can therefore range from the simple towel draping of a virtual reality surgical simulator, to hybrid models that enable actual surgery to be performed by providing local context of the operative field. Examples include using a synthetic silicone skin over the outer casing of a video (box) trainer, coupled with an internal anatomical model that permits modular substitution of anatomy with e.g., porcine tissue, such as the liver and gallbladder or a section of small bowel. This flexibility permits more authentic surgical simulation through the facilitation of modern surgical practices and procedures.

However, physical contextualisation can be resource and faculty intensive. By incorporating roles for anaesthetic and scrub staff, who add authenticity to the simulation by recreating the social aspect of surgery, the educational value of the exercise and participant immersion are increased whilst the financial costs per group may be reduced.

Temporal Context and Sequential Simulation

Temporal context relates to time. Whilst a patient’s surgical journey may take weeks, months, or even years to complete, simulation offers an opportunity to distil this sequence of events in a process called “sequential simulation” [42]. For instance, a trainee may be asked to consent a simulated patient (medically trained actor or actress) pre-operatively, participate in a fully immersive operative team simulation for that procedure, and then examine the same simulated patient post-operatively.

The benefits of this approach are two-fold. Firstly, by contextualising the operation in time, place, and person, trainee engagement is increased. Secondly, concomitant factors e.g., communication skills can be taught and/ or tested. Such a holistic approach transcends the technical task, testing the trainees’ understanding and explanation of a procedure, through effective communication of its indications, risks, and benefits to a patient. Faculty have the opportunity to standardise operative scenarios across training grades, or tailor them according to trainee performance – pushing stronger candidates and supporting weaker ones. Post-operatively, a prosthetic and make-up artist is able to deliver authentic surgical wounds, such that trainees’ ability to identify and manage potential complications is addressed, where appropriate (Fig. 3.2).


Fig. 3.2
A simulated patient’s post-operative abdomen with a (silicone) end colostomy

Whilst such simulations may appear financially and logistically demanding to implement routinely, the results of pilot studies performed at Imperial College London in association with the London Deanery support plans for wider trainee access to this form of training modality.

Surgical Simulation – the Future

There are a number of exciting new developments that may impact upon the future of simulation training for minimal access surgery. These developments have been driven by working time restrictions reducing the exposure of surgical trainees to clinical and operative episodes, an increased emphasis on improving patient safety and the rapid evolution of technology. Six of the most practical and innovative ideas are discussed here.

Specialist Simulation Training Centres

Given the current climate affecting surgical education, and high level support in favour of simulation training, there is a growing trend towards establishing specialist simulation centres [43]. These centres offer trainees the facilities to consolidate and supplement their clinical experience, often through co-ordinated and structured regional training programmes. Other centres provide trainees with unrestricted access and the opportunity for self-directed learning. At present, there is no clear evidence in favour of one approach over the other [44, 45].

Increasingly, trainees are purchasing, or being provided with, their own personal minimal access training devices. This negates the need, and cost, of a specialised centre whilst permitting the trainee to practice at their own convenience. However, in the absence of feedback from a trainer, there is a risk of uncorrected mistakes and poor technique becoming habitual.

Simulation Curriculum

The development of a comprehensive, valid and reliable, simulation curriculum for surgical training is not a new concept. Whilst excellent basic skills courses exist e.g., Fundamentals of Laparoscopic Surgery program [46], and significant efforts towards developing procedure specific curricula have been made [47], as yet, no definitive simulation curriculum for advanced minimal access surgical skills training exists. The current state of the art relates to specific tasks, performed on specific simulators, even though there is little cross comparison between simulators or evidence correlating simulation competence with clinical competence across a range of procedures. It has therefore been proposed that curriculum development should be embraced as an iterative process that requires concurrent validation [48].

The London Deanery general surgery training programme is unique in following an integrated simulation curriculum extending over the entire duration of surgical training. It is taught by specialist trainers, trainee attendance and performance is monitored throughout, individualised feedback is provided, and trainees’ progress is recorded through regular appraisals. However, at present, only feasibility and participant acceptability have been established [49].

Competence for Clinical Practice

Whilst simulation is championed as an adjunct to, rather than a substitute for, clinical experience, a controversial yet potential next step is for surgical trainees to be required to demonstrate competence in simulation prior to being permitted to perform clinical procedures on patients. This transition makes sense from an ethical and patient safety perspective, with regard to moving the trainees’ skill acquisition out of theatre and maximising the value of subsequent clinical episodes. However, it would be difficult to enforce given existing workplace pressures.

Procedure Rehearsal

First described in 2001, patient specific virtual reality procedural rehearsal is a potentially revolutionary emergent technology. The technique involves surgeons using patient scans for pre-operative procedural planning tailored to the individual patient’s anatomy and pathology. It facilitates cognitive and psychomotor rehearsal, and improves the prospects of success for complex procedures by easing the burden of intra-operative decision-making and allowing surgeons to select the most appropriate surgical approach in advance of the operation, thereby optimising patient safety and achievable patient outcomes [50].

Testing and Integration of New Technologies

Technological advancements have been a key driver for innovation in minimal access surgery, but safely translating promising research to the operating theatre is a major issue. Simulation offers one viable solution for trialling new technology in a realistic clinical environment. Scientists are afforded the opportunity to iron-out previously unforeseen potential difficulties, whilst end-users can learn to use the technology under supervision, ask questions, and voice concerns away from the pressures of the clinical workplace and without risk to patient safety. Indeed patients and the lay public may be invited, and even encouraged, to join in this process [51]. This approach has been successfully piloted at Imperial College London and opens up potential new avenues for how clinical trials may be run in the future.

Tuition and Maintenance of Open Surgical Skills

As a generation of surgeons are predominantly trained in minimal access approaches to surgery, an interesting development has been the loss of traditional open surgical skills. However, the potential requirement for conversion to an open approach remains and dictates that open surgical skills must still be taught and maintained. Simulation is the ideal environment for practicing rare and once-in-a-lifetime scenarios, often with tuition from trainers who performed such procedures when they were commonplace e.g., open cholecystectomy. Consequently, the requirements of surgical simulation training are expected to come full circle [52].

Chapter Summary

Minimal access surgery is a rapidly evolving field. As such, it is imperative that surgical education and training responds in an innovative and timely manner, for present surgical trainees to be adequately and appropriately prepared for the demands of their nascent careers. Simulation offers one potential solution.

This chapter has adopted a broad perspective in considering the role that simulation has to play in minimal access surgery training. It has explored its relevance to modern surgical practice, identified evidence for the strengths and weaknesses of existing training modalities, and discussed several of its conceivable future directions.



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Sep 26, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Simulation and Training in Minimal Access Surgery
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