Published 14 May 2009, doi:10.1136/bmj.b1001
Cite this as: BMJ 2009;338:b1001

Editorials

Surgical training using simulation

Early evidence is promising, but integration with existing systems is key

Surgery was traditionally learnt by repeated practice on patients. Trainee surgeons were exposed to innumerable operative cases over many years, with supervision tailored to their needs. This provided experience in coping with a wide range of operative approaches and complications, and it balanced trainees’ levels of experience with the demands of the procedure.

This process has changed radically in recent years. Minimally invasive surgical techniques have led to fast track and ambulatory surgery; service targets and reductions in working time have reduced training opportunities for young doctors; and strong ethical imperatives have made it unacceptable for novices to learn "on patients."¹ Traditional approaches are therefore no longer tenable. How then should surgeons learn their craft? In the linked randomised controlled trial (doi: 10.1136/bmj.b1802), Larsen and colleagues assess the effect of virtual reality training on surgical performance in laparoscopic surgery.²

Simulation offers obvious benefits, especially in mastering counterintuitive techniques such as minimal access surgery. Sophisticated virtual reality simulators can provide anatomically realistic recreations of many operations, with inbuilt metrics that enable technical performance to be recorded, measured, and used for feedback. Practice on such simulators, to a predefined level of proficiency, enables inexperienced trainees to acquire skills in a structured, educationally oriented manner without risk of harming patients.

Although simulation based training has been explored within the craft specialties since the 1970s, high quality evidence to support its widespread adoption within the curriculum is lacking.³ A key question is whether skills learnt on a simulator translate to improved performance on patients.

It is here that Larsen and colleagues make an important contribution to our understanding.² In their trial of junior gynaecology registrars, an intervention group (with no clinical experience of advanced laparoscopy) was trained to proficiency on a virtual reality simulator. When the registrars performed their first laparoscopic salpingectomy on a patient (under senior supervision), the virtual reality trained group performed to the level of intermediately experienced laparoscopists (20-50 patient cases), whereas the control group performed at the novice level (less than five cases) and took twice as long to complete the procedure. The inexperienced surgeons needed to perform 28 simulated salpingectomies to attain the same level of proficiency as those in the virtual reality training group, who were given seven hours of dedicated training outside the service setting.

Click on image to view video This video follows Sofie Leisby, a trainee surgeon, through laparoscopic surgery—from practising in VR to a real life procedure.

 
If simulation based practice can accelerate progress along the learning curve, it has obvious educational benefits.^{4 5} But caution is needed when interpreting the results of this study. Firstly, the study investigated manipulative surgical skills. Although these are essential, they are only a part of a wider set of skills that are fundamental to safe practice, such as communication, decision making, judgment, and leadership.⁶ Simulation based training that takes place outside the clinical setting risks isolating the trainee from the rest of the team and creating a misleading oversimplification of a complex reality.⁷ Secondly, Larsen and colleagues studied routine salpingectomy in selected patients who had no complications. But a major challenge of surgery is being able to cope with the unexpected. Would simulator trained surgeons be able to deal with scenarios such as distorted anatomy, unexpected bleeding, missing equipment, a dysfunctional team, or the pressures of operating in the middle of the night? Thirdly, this study is limited to one procedure in one specialty, so generalising the results to other procedures and specialties is unwise. And lastly, recently acquired skills deteriorate rapidly unless consolidated through repeated practice, so snapshot studies can provide only a partial picture.

The strength of simulation is as an adjunct rather than an alternative to clinical experience. Several current developments will probably increase its potential. These include putting virtual reality and benchtop models into clinical context by using actors to create human simulator hybrids in a clinical setting,⁸ using simulation for "warming up" before a procedure, and programming the patient’s own imaging data into simulation software so that rehearsal is patient specific. Other suggested applications include using simulation to give surgeons experience of particular procedures before they perform them clinically, and using objective measurements within a standardised case. This principle could extend to regular revalidation of surgeons and surgical teams, and perhaps even to selection into surgical training. Before we embrace such high stakes applications, however, many questions need to be answered.⁹

A key challenge is to integrate simulation within existing curricular structures to ensure that practice takes place within a robust educational framework.¹⁰ Simulation is costly in terms of equipment and teaching facilities. Although simulation centres can recreate operating theatres, delivery suites, endoscopy units, and interventional units, it is not feasible to provide a full range of settings in every medical centre. The establishment of simulation centres at key sites can enable trainees to participate in regular practice sessions which align with and reinforce their clinical training.

Simulation should be viewed as a parallel universe which mirrors and augments actual practice; it should place the learner at the centre of the process while ensuring patients do not experience avoidable harm. Mapping the dynamic association between the virtual reality centre, the simulated operating suite, and the real environment should become a priority for researchers and healthcare professionals.

Cite this as: BMJ 2009;338:b1001

¹ Department of Biosurgery and Surgical Technology, Imperial College London, London

Research, doi:10.1136/bmj.b1802

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Reznick RK, MacRae H. Teaching surgical skills—changes in the wind. N Engl J Med 2006;355:2664-9.[Free Full Text]
2. Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T, Schouenborg L, Ottose C, et al. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ 2009;338:b1802.[Abstract/Free Full Text]
3. Sutherland LM, Middleton PF, Anthony A, Hamdorf J, Cregan P, Scott D, et al. Surgical simulation: a systematic review. Ann Surg 2006;243:291-300.[CrossRef][Web of Science][Medline]
4. A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club. N Engl J Med 1991;324:1073-8.[Abstract]
5. Aggarwal R, Ward J, Balasundaram I, Sains P, Athanasiou T, Darzi A. Proving the effectiveness of virtual reality simulation for laparoscopic surgical training. Ann Surg 2007;246:771-9.[CrossRef][Web of Science][Medline]
6. Yule S, Flin R, Paterson-Brown S, Maran N. Non-technical skills for surgeons in the operating room: a review of the literature. Surgery 2006;139:140-9.[CrossRef][Web of Science][Medline]
7. Kneebone RL, Nestel D, Vincent C, Darzi A. Complexity, risk and simulation in learning procedural skills. Med Educ 2007;41:808-14.[CrossRef][Web of Science][Medline]
8. Kneebone R, Nestel D, Wetzel C, Black S, Jacklin R, Aggarwal R, et al. The human face of simulation: patient-focused simulation training. Acad Med 2006;81:919-24.[CrossRef][Web of Science][Medline]
9. Irvine D. Doctors in the UK: their new professionalism and its regulatory framework. Lancet 2001;358:1807-10.[CrossRef][Web of Science][Medline]
10. Grantcharov TP, Reznick RK. Teaching procedural skills. BMJ 2008;336:1129-31.[Free Full Text]

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