Essay on Simulation in Surgical Training

Role of Laparoscopy & transfer of Surgical Skills to clinical practice

Introduction

Simulation is defined as a technique to mimic or amplify real experiences with guided experiences, that evoke or replicate substantial aspects of the real world in a fully interactive manner (Brown, 2016). In health care, the term refers to a device or an object that presents the human body or organs and interact appropriately with the actions taken by the participant.

For the past few decades, simulation has become a fundamental tool in the training of healthcare professionals and enhancing patient safety. A safe method for training and assessing doctors, it allows them to make mistakes, to ask the “what if?” questions, and to learn and reflect on such situations without risking patient safety.

Recent advances in technology have raised the potential of simulation to revolutionise surgery. Therefore, we will discuss the parturition of simulation, its role in the surgical field, and its advantages and disadvantages in our present-days.

History of simulation in surgical training

In 1927, Edwin Link was the first person to pitch an idea of a flight simulator that could be used to teach trainees on the ground, And in World War ll, it became a linchpin for training pilots. Many may assume simulation was a discipline learnt from the Aerospace World. In verity, medicine has historically been far ahead of aviation in simulation.

Corpse dissection has been an epitome of anatomic and procedural training since the 16th century. One of the first documented instances of surgical simulation was the use of leaf and clay models in India around 600 B.C. to ponder nasal reconstruction with a forehead flap (Owen, 2012) (Persin and Evans, 2007).

It was not until the early 90’s when a surge of evolution in medical simulation technologies established a new era. as constructing the latest techniques of surgical procedures, innovations in medical technology, and discovery of new advanced materials were necessary predecessors.

Types of simulation available

Surgical simulations models can be low – or high-fidelity, reflecting the closeness of the model to reality. Low-fidelity models allow repetitive simulation of a specific skill to achieve mastery of individual techniques while High-fidelity ones give an image almost actual to reality and haptic feedback. The level of fidelity should be appropriate to the type of task and training stage (Munshi, 2015).

Advantages of simulation

Simulators can provide a safe method of training for surgeons without putting the health of patients at risk. A cutting-edge technology that it gives surgeons the ability to experience a realistic setting, getting engaged with the tasks in the procedures to mimic reality and making them accustomed with different scenarios.

It has always been said “Practice makes perfect”, but perhaps “Practice does not make perfect. Only perfect practice makes perfect” – Vince Lombardi. Simulation under expertise’ guidance and supervision enhances psychomotor skills, hand-eye coordination, and ambidexterity of the trainees. These are the pillars along with good practice and profound knowledge to achieve a successful procedure.

On the other hand, the learning curve for surgical skills and procedures can be reduced in a risk-free setting (Seymor and Satava, 2002) (De Win et al., 2017), which then can be translated to the operating theatre leading to shorter operative time, fewer complications, and reducing the probability of converting to open surgery. Which in turn reflects directly on the patient by decreasing the risk of unnecessary complications, and minimising hospital stay.

Many studies have shown the superiority of simulation over other teaching methods for trainees’ performance in clinical practice. One of these studies done in 2010 by Benjamin Zendejas to evaluate the outcome of a simulation-based curriculum compared to standard practice curriculum (Zendejaz et al., 2011). 50 surgical trainees from different levels participated in the study. Before assessing all the trainees on performing Total Extraperitoneal inguinal hernia repair, 26 of them received formal simulation training. As a result, the study concluded that trainees who received simulation-based curriculum training had decreased operative time (on average 6 minutes faster), improved their performance, decreased intra- and postoperative complications and overnight stay in the hospital (Zendejaz et al., 2011).

Mean Time in minutes

The chart shows the evaluation in subsequent TEPs. Trainees who received simulation training were able to accelerate their learning curve and progressively decrease their operative time compared to those with only standard training.

Disadvantages of simulation 

Despite the enormous advantages and advancement in simulation, few factors are considered challenging which could put limitations to its expansion.

The human body is very complex and diverse. Hence simulators can never match it completely. Although high fidelity simulators are as close in mimicking reality as possible, they could be costly and not affordable by many teaching hospitals.

Trainees tend to ignore the bigger picture when they focus on the technical tasks in the simulation. Forget about the importance of vital signs of the patient, communication with other team members in the operating room especially the anaesthetist which is crucial to ensure patient safety and flawless procedure.

Training on simulators without haptics can lead to distortion of the manipulation forces one applies (Chmarra et al., 2008). A concern trainees do not pay attention to. Tasks completion can be successful in simulation, but in reality, excessive force applied by the instruments can be disastrous and life-threatening.

Simulation facilities vary widely among hospitals. Some surgical trainees get the opportunity to practice on the latest simulators in the market, while others may be limited to basic and obsolete ones. This results in a “postcode lottery” (Agha and Fowler, 2015). Therefore not all trainees get the same adequate amount of training on simulation.

Only a few papers reported negative or equivocal findings for the use of simulators in medical education such as (Gordon et al., 2006) (Morgan et al., 2002). However, the available evidence is still weak as most of the studies are low powered and the parameters assessed are subjective based on participants feedback (Krishnan, 2017).

Conclusion

In a word, Researches have shown that recent advances in technology aided simulation to improve learning and made it a vital tool in surgical training in a way that satisfies the regulatory needs of the profession.

However, the judgment of the “right thing to do” cannot always be easily taught in the classroom or on a simulator. Surgical practice is complex, and requires a profound experience decision making, not just a series of steps to follow according to “the book”. Hence, simulation should be part of the learning curriculum but cannot replace the clinical experience guided by good mentors and the knowledge a trainee surgeon needs on the operating floor.

Role of Laparoscopy & How the Surgical Skills Transfer to Clinical Practice

Introduction

The Swedish surgeon; Hanz Jacobaeus, is credited for coining the term “Laparoscopy”. It is derived from two Greek words, Laparo, means the soft tissue in the flank quadrants, and skopie, means to visualise and examine.

Incredibly, laparoscopy has been almost neglected by surgeons in the early 20th century. “The degree to which we as surgeons ignore this sophisticated technology and refuse to test its suitability for surgical application is astonishing” (Svanvik, 2003). These were the words of Hans Troidl at the International Congress on Surgical Endoscopy in 1988.

The development of laparoscopic instruments was a gradual process, and its evolution attributed to surgical advances in how internal processes are perceived and depicted. Today, laparoscopy has a broad application in General Surgery practice for diagnosis and management and became the preferred method over open technique for various conditions.

This paper will discuss the advantages and the role of laparoscopy in surgery, and how surgical skills are transferred to clinical practice.

Advantages of Laparoscopy

Laparoscopy has the advantages of avoiding large open incisions, and less traumatic manipulation to the tissues, thus decreasing blood loss, pain, and postoperative complications.

The incisions made for laparoscopy are smaller compared to open surgery. Hence, the risk of intra- and post-operative bleeding and the likelihood for blood transfusion are reduced.

The smaller incisions reduce the associated postoperative pain and the unnecessary need for strong analgesics. On the other hand, the formation of scars are less and smaller, therefore reduces the risk of infection and vulnerability for herniation.

For these reasons, many healthcare systems are implementing the use of laparoscopy in their guidelines as a preferred mode of entry to improve patient safety and healthcare quality.

Role of laparoscopy

For the past century, rapid development and growth were noticed in laparoscopy. In 1901, Georg Kelling performed the first Celioscopy on a dog to determine the effect of pneumoperitoneum on the organs, soon afterwards he performed it on humans, and they were successful.

His innovation was the spark to a new revolution in surgery. For many, laparoscopy would spell the demise of open surgery.

The range of operations now extends beyond expectations when it was first introduced, from a simple appendectomy to more complex ones such as radical prostatectomy.

The role of laparoscopy and advancement of imaging in diagnosis and management in a variety of specialities is growing since its conception. It allowed many conditions to be approached laparoscopically and defer the patient from an open approach.

 “After a period of rather slow initial acceptance by general surgeons, laparoscopy has suddenly burst on to the surgical scene” (Regan and Anderson, 2018). Nowadays it is being used widely in the speciality in different aspects; from emergency to elective bariatric surgeries.

When the decision to operate is uncertain laparoscopy not only identifies those patients who do not require laparotomy but also reveals those who need surgery which might otherwise have been delayed (Paterson-Brown, 1991). Many abdominal conditions requiring emergency management; such as appendicitis, perforation, blunt or penetrating trauma, or where there is a diagnostic dilemma, laparoscopy can be an ideal alternative to laparotomy. Studies showed that surgeries done laparoscopically have better results than open surgeries; less surgical site infections, complications, hospital stay, and less postoperative pain (Balen and Herrera, 2005).

Oncology has a quite good share in the employment of laparoscopy in its field, not only for management purposes but for staging the disease as well, and its use helped to avoid unnecessary laparotomies. A study of 41 patients with GI malignancies undergone Diagnostic Laparoscopy. 5 of which had benign diseases and did not require any further surgical intervention (Nair and Kothari, 2012).

Although laparoscopy allows for faster recovery of bowel function, better immunologic response, and overall accelerated recovery for the patients, the most important goal of these procedures is cancer-free survival. A randomised controlled clinical trial compared between Open and Laparoscopic approach surgery for cancer patients was done in 2010, and it concluded: “ Cancer free survival was comparable or better in the laparoscopic groups” (Angst et al., 2010).

Transfer of surgical skills to clinical practice

Acquiring surgical skills in laparoscopy is an integral aspect of surgical training, and a number of centres have invested in facilities promoting training through various courses. Surgical skills training allows for detailed feedback, and objective assessment of performance.

Transferable skills to clinical practice are numerous, and every skill is a discipline by itself. Laparoscopic training, for instance, allows understanding the relationship between technology and patients. It teaches surgeons to be ambidextrous, and appreciate 3D workspace on a 2D feedback image. These are crucial skills for surgeons to acquire and to transfer into their practice.

On the other hand, it encourages skills in orientation and anatomical understanding which are considered the pillars in surgical practice.

An extensive study was established in Dundee, United Kingdom and it was concluded in 2018 stated: “A dedicated laparoscopic urological surgery course run over a decade had a significant impact on the skills of participants, and most participants were able to establish clinical practice catering to a large proportion of the UK population as well as a few centres internationally” (Khan et al., 2018).

Another study showed the impact of surgical training into clinical practice, and the results showed that it enhanced the learning curve and reduced the total time to achieve proficiency (Dawidek et al., 2017).

Last but not least, surgical training imparts the fundamentals of positive behaviour and attitude to surgeons in improvising in various situations in the operating theatre, either as remaining calm when controlling bleeding or managing distraction from other factors.

Conclusion

To summarise, although the role of laparoscopy was minimal and neglected as a technique by surgeons in the last century, nowadays it extends its involvement in a variety of specialities, and it has been proven that it has numerous advantages in the practice which in turn had a positive impact on patients’ health, and their surgical outcome.

Laparoscopy is a discipline of itself, and studies showed that acquiring surgical techniques that are translated to the clinical practice are not limited to technical skills but also for learning positive behaviour and attitude in managing different situations.

References

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