Simulation and virtual reality in surgical education: real or unreal?

Rapid change is under way on several fronts in medicine and surgery. Advances in computing power have enabled continued growth in virtual reality, visualization, and simulation technologies. The ideal learning opportunities afforded by simulated and virtual environments have prompted their exploration as learning modalities for surgical education and training. Ongoing improvements in this technology suggest an important future role for virtual reality and simulation in surgical education and training.     

Laparoscopic and robotic surgical training in urology

The most important change in urology during the past decade was the development of minimally invasive surgery, particularly laparoscopy. However, the main drawback of laparoscopy is a steep learning curve, which results from the significant changes in the surgical environment. Although laparoscopy can provide important advantages for the patient, including decreased length of hospitalization, decreased analgesic requirement, and a shortened postoperative convalescence, one concern has been whether laparoscopic techniques should be learned solely in the operating room. For example, sports, music, and aviation are practiced before an actual performance is ever undertaken. In this review, the advantages and limitations of all available training modalities in minimally invasive surgery are described. Testing basic laparoscopic skills on inanimate models, becoming familiar with the principles of dissection and hemostasis on living animals, and studying surgical anatomy on cadavers should be considered as indispensable and complementary elements for laparoscopic training in the future. In addition, telementoring with the help of modern image processing and virtual reality eventually may become the basis of tomorrow’s surgical instruction.     

Patient safety for the surgical trainee

This article highlights some key principles in patient safety for the surgical trainee. The incidence of harm in healthcare and surgical practice in particular are outlined. The importance of clinical human factors is highlighted along with how this discipline has helped healthcare workers improve the care they provide to patients. Concepts of systems thinking are introduced; patient harm rarely comes from the isolated action of an individual but from deficiencies in the systems of which they are a part and with which they interact. The shifting paradigm of patient safety thinking is highlighted’ with an increasing focus on reducing risk (safety II) rather than eliminating harm (safety I). Strategies for recording, analysing and learning from patient harms are discussed. Examples are provided of commonly used systems models to help clinicians in this area. A number of strategies that have been developed to enhance safety, trap errors and mitigate potential harm to surgical patients are discussed. Information is provided on several key national and international patient safety initiatives that have been instrumental in enhancing patient care by disseminating learning and collaboration between individual units, hospitals and health services.     

Surgical training 2.0: How contemporary developments in information technology can augment surgical training

BackgroundThe current surgical trainee is faced with reduced training time compared to predecessors as a result of changes in working practices. The past decade has seen marked developments in the information technology sector. This editorial will review how modern technological innovations could augment current surgical training.MethodsWe review the literature and summarize important developments in information technology that could assist the modern surgical trainee. We also look at some of the challenges faced by use of this technology.FindingsDevelopments in mobile internet connectivity will improve access to online resources for the surgical trainee. Web 2.0 will revolutionise the way trainees interact with textbooks, journals, webpages and each other. Simulators could help to fill gaps created by reduced operating hours. To maximize the effectiveness of these resources they need to be accessible and incorporated into training in a structured way, ensuring patient safety and accuracy of information.ConclusionContemporary developments in technology offer benefits to the surgical trainee and could fill gaps left by reduced operating times. In order to ensure efficient use of technology and patient safety, bodies such as the Royal Colleges and Training Programmes must embrace these developments.     

Minimally invasive surgical training: Challenges and solutions

Treatment options for urological malignancies continue to increase and include endoscopic, laparoscopic, robotic, and image-guided percutaneous techniques. This ever expanding array of technically demanding management options coupled with a static training paradigm introduces challenges to training the urological oncologist of the future. Minimally invasive learning opportunities continue to evolve, and include an intensive experience during residency, postgraduate short courses or mini-apprenticeships, and full time fellowship programs. Incorporation of large animal surgery and surgical simulators may help shorten the necessary learning curve. Ultimately, programs must provide an intense hands-on experience to trainees in all minimally invasive surgical aspects for optimal training.     

Wii-habilitation: Is there a role in trauma?

Rehabilitation forms an essential component of the therapeutic continuum in multiply injured patients. Effective rehabilitation programmes assist patients in optimising their level of physical, psychological and social function, while also reducing the length of patient stay, re-admission rates and use of primary care resources.A recent report from the National Audit Office on trauma care within the UK highlighted rehabilitation as an area of trauma patient care that frequently fell short of the standards expected. The current decline in the economy is likely to impact upon the financial resources available to address these concerns particularly recognising the high dependency on human resources. As a result, those involved in the rehabilitation of injured patients will need to develop new, innovative, cost-effective strategies to improve the current rehabilitation programmes available.These programmes need to intervene early and provide task-orientated training along with high repetition intensity. Such programmes not only test patient motivation, but also frequently demand a high degree of therapist supervision. Efforts logically should therefore focus on designing interventions that engage and motivate patients and encourage increased therapist-independent patient rehabilitation.Virtual reality (VR) offers a possible solution. VR is a technology that allows the user to directly interact with a computer-simulated environment. This technology, developed initially for military training, has now become widely available through video games. The potential for VR interfaces to create an environment that encourages high repetition intensity has been exploited by numerous vocational training programmes, such as laparoscopic surgical skill training. It is now conceivable that computer-based rehabilitation programmes could be developed using current, widely available, affordable virtual reality platforms, such as the Nintendo^® Wii.This review aims to discuss the use of modern computer technology in patient rehabilitation and how this may be applied to trauma patients.     

Computers and virtual reality for surgical education in the 21st century

Surgeons must learn to perform operations. The current system of surgical resident education is facing many challenges in terms of time efficiency, costs, and patient safety. In addition, as new types of operations are developed rapidly, practicing surgeons may find a need for more efficient methods of surgical skill education. An in-depth examination of the current learning environment and the literature of motor skills learning provides insights into ways in which surgical skills education can be improved. Computers will certainly be a part of this process. Computer-based training in technical skills has the potential to solve many of the educational, economic, ethical, and patient safety issues related to learning to perform operations. Although full virtual-reality systems are still in development, there has been early progress that should encourage surgeons to incorporate computer simulation into the surgical curriculum.     

Simulation‐based surgical education in cardiothoracic training

Simulation has emerged as a feasible adjunct to surgical education and training for most specialties. It provides trainees with an immersive, realistic way to learn a variety of skills in a safe environment with the end goal of improving patient safety. There are three broad types of simulators: full mannequin simulators, part‐task trainers or bench models and virtual reality systems. This review aims to describe the current use of simulation in cardiothoracic surgical education and training. We identified multiple procedures that can be simulated in cardiothoracic surgery using a combination of the above simulators, three‐dimensional printing and computer‐based simulation. All studies that assessed the efficacy of simulators showed that simulation enhances learning and trainee performance allowing for repetitive training until the acquisition of competence but further research into how it translates into the operating theatre is required. In Australia, cardiac surgery simulation is not yet part of the training curricula, but simulators are available for certain tasks and procedures.     

Assessment of medical simulators as a training programme for current surgical education

Aim-Background

The rapid evolution of minimally invasive surgery has demonstrated the need for training surgical skills outside the operating room using animal model simulators. There is increasing evidence that educating trainee surgeons by simulation is preferable to traditional operating-room training methods with actual patients.

Methods

A critical and systematic review of the literature was performed to assess whether medical simulators can represent a current validated tool for surgical training. A search of the literature was conducted using the PubMed search engine. Further articles were obtained by manually searching the reference lists of identified papers.

Results

Training by simulation can provide some unique benefits, such as greater control over the training procedure and more easily defined metrics for assessing proficiency, reducing costs and risks to patients. Virtual reality simulators are now playing an increasing role in surgical training, Satisfactory and pertinent levels of physical realism, case complexity and performance assessment can lend simulation as an effective advanced surgical training and assessment tool. While the aim of all simulators is to the training of psychomotoric skills, some simulators also allow training in decision-making and anatomical orientation.

Conclusion

In the not too distant future, virtual reality simulators may constitute a integral tool in the training and validation of surgical skills and monitoring of training progress. Proper validation and increased recognition by the medical profession of their potential value are crucial if they are to be incorporated in surgical training curricula.     

Twenty-first century surgery using twenty-first century technology: surgical robotics

INTRODUCTION: The "Nintendo" surgery revolution, which began in 1987, has impacted every surgical specialty. However, our operating rooms remain isolated worlds where surgeons use awkward, primitive, rigid instruments with suboptimal visualization. We need "smart instruments," "smart technology," and "smart imaging." Is surgical robotics the answer? METHODS: We provide an analysis of current surgical technology and skills, propose criteria for what the next generation of surgical instruments and technology should achieve, and then examine the evolution and current state of surgical robotic solutions, assessing how they answer future surgical needs. Finally we report on the U.S. Military's early experience with surgical robotics and the lessons learned therein. RESULTS: Current surgical robotic technology has made remarkable progress with miniaturization, articulating hand-imitating instruments, precision, scaling, and three-dimensional vision. The specialty-specific early clinical applications reviewed are promising, but they do have limitations. Surgical robotics offers enormous military application potential. Needed future refinements are identified, including haptics, communications, infrastructure, and information integration. CONCLUSIONS: Laparoscopic surgery is a transition technology, constrained by instrument, equipment, and skill limitations. Surgical robotics or, more properly, computer-assisted surgery may be the key to the future. The operating room of the future will be an integrated environment with global reach. Surgeons will operate with three-dimensional vision, use real-time three-dimensional reconstructions of patient anatomy, use miniaturized minimally invasive robotic technology, and be able to telementor, teleconsult, and even telemanipulate at a distance, thus offering enhanced patient care and safety.     

Video recording of cardiac surgical procedures: what the surgeon needs to know

In the past, rudimentary devices were used to record surgical operations. Currently, the introduction of technologic advances such as high-definition television and the miniaturization of high-resolution digital video cameras provides an opportunity for making significantly enhanced surgical records. These enhancements, coupled with the recent advances in telemedicine and surgical simulation, will improve cardiac surgery training and skill acquisition, decrease operative times and costs, minimize morbidity, and improve overall patient care. The present paper provides a discussion of the media technology offered to surgeons for recording a surgical procedure on video. Hardware technology, including different types of cameras and analogical or digital post processing methods, are reviewed with a surgical 'eye'. This 'how to' paper provides practical suggestions to surgeons in order to enhance surgical video recording.     

Methods and tools for objective assessment of psychomotor skills in laparoscopic surgery

Training and assessment paradigms for laparoscopic surgical skills are evolving from traditional mentor-trainee tutorship towards structured, more objective and safer programs. Accreditation of surgeons requires reaching a consensus on metrics and tasks used to assess surgeons' psychomotor skills. Ongoing development of tracking systems and software solutions has allowed for the expansion of novel training and assessment means in laparoscopy. The current challenge is to adapt and include these systems within training programs, and to exploit their possibilities for evaluation purposes. This paper describes the state of the art in research on measuring and assessing psychomotor laparoscopic skills. It gives an overview on tracking systems as well as on metrics and advanced statistical and machine learning techniques employed for evaluation purposes. The later ones have a potential to be used as an aid in deciding on the surgical competence level, which is an important aspect when accreditation of the surgeons in particular, and patient safety in general, are considered. The prospective of these methods and tools make them complementary means for surgical assessment of motor skills, especially in the early stages of training. Successful examples such as the Fundamentals of Laparoscopic Surgery should help drive a paradigm change to structured curricula based on objective parameters. These may improve the accreditation of new surgeons, as well as optimize their already overloaded training schedules.     

A virtual-reality-based haptic surgical training system.

To improve training facilities for surgeons, a surgical training system based on virtual reality techniques has been developed. The goal of the developed system is to improve education of surgeons by making the knowledge of expert surgeons directly available to trainees. The system realizes two different approaches: the library and the driving school paradigm. In its current form, the system consists of two modules. The main module combines the virtual reality kernel KISMET, a visual and haptic display, and a database of different operations and/or techniques. The master station is a copy of the input and output facilities of the main module. Both modules communicate by a TCP/ IP-based connection. Initial tests demonstrated the feasibility of the chosen framework. Further developments include the gathering of data not only from virtual reality but also from real operations. Robotic-assisted surgery provides an attractive way of accomplishing this.     

Introduction, availability and role of simulation in surgical education and training: Review of current evidence and recommendations from the Association of Surgeons in Training

The utility of simulation in surgical training is now well-established, with proven validity and demonstrable transfer of skills to the clinical setting. Through a reduction in the technical learning curve, simulation can prepare surgeons for actual practice and in doing so it has the potential to improve both patient safety and service efficiency. More broadly, multi-disciplinary simulation of the theatre environment can aid development of non-technical skills and assist in preparing theatre teams for infrequently encountered scenarios such as surgical emergencies. The role of simulation in the formal training curriculum is less well-established, and availability of facilities for this is currently unknown. This paper reviews the contemporary evidence supporting simulation in surgical training and reports trainee access to such capabilities. Our national surgical trainee survey with 1130 complete responses indicated only 41.2% had access to skills simulator facilities. Of those with access, 16.3% had availability out-of-hours and only 54.0% had local access (i.e. current work place). These results highlight the paucity in current provision of surgical skills simulator facilities, and availability (or awareness of availability) varies widely between region, grade and specialty. Based on these findings and current best-evidence, the Association of Surgeons in Training propose 22 action-points for the introduction, availability and role of simulation in surgical training. Adoption of these should guide trainers, trainees and training bodies alike to ensure equitable provision of appropriate equipment, time and resources to allow the full integration of simulation into the surgical curriculum.     

Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training

SUMMARY BACKGROUND DATA: To inform surgeons about the practical issues to be considered for successful integration of virtual reality simulation into a surgical training program. The learning and practice of minimally invasive surgery (MIS) makes unique demands on surgical training programs. A decade ago Satava proposed virtual reality (VR) surgical simulation as a solution for this problem. Only recently have robust scientific studies supported that vision METHODS: A review of the surgical education, human-factor, and psychology literature to identify important factors which will impinge on the successful integration of VR training into a surgical training program. RESULTS: VR is more likely to be successful if it is systematically integrated into a well-thought-out education and training program which objectively assesses technical skills improvement proximate to the learning experience. Validated performance metrics should be relevant to the surgical task being trained but in general will require trainees to reach an objectively determined proficiency criterion, based on tightly defined metrics and perform at this level consistently. VR training is more likely to be successful if the training schedule takes place on an interval basis rather than massed into a short period of extensive practice. High-fidelity VR simulations will confer the greatest skills transfer to the in vivo surgical situation, but less expensive VR trainers will also lead to considerably improved skills generalizations. CONCLUSIONS: VR for improved performance of MIS is now a reality. However, VR is only a training tool that must be thoughtfully introduced into a surgical training curriculum for it to successfully improve surgical technical skills.     

大专护生外科护理学实训虚拟现实系统应用效果评价

目的 提高大专护生外科护理学实训效果及体验。方法 在2021级护理专科班4个班的护生中招募研究对象并以班为单位随机分为对照组（n=40）和观察组(n=37)。在外科护理学16学时的实训教学中,对照组依托学习通教学平台采用自主学习视频和入镜示范模式,观察组采用自主学习视频和虚拟现实系统训练模式。比较两组学习效果,并对观察组11名护生进行半结构访谈,以了解参与虚拟现实教学的体验。结果 教学后观察组操作成绩、教学满意度显著优于对照组（均P<0.05）,两组对线上教学系统和虚拟现实系统的可用性评价差异无统计学意义（P>0.05）。观察组护生参与虚拟现实教学的体验提取3个主题：参与的感受（积极和双赢）,参与的益处（沉浸和创新）,参与的影响因素（动力和障碍）。结论 应用虚拟现实系统可以提高大专护生外科护理学在线实训教学效果。     

Credentialing of surgical skills centers

Major imperatives regarding quality of patient care and patient safety are impacting surgical care and surgical education. Also, significant emphasis continues to be placed on education and training to achieve proficiency, expertise, and mastery in surgery. Simulation-based surgical education and training can be of immense help in acquiring and maintaining surgical skills in safe environments without exposing patients to risk. Opportunities for repetition of tasks can be provided to achieve pre-established standards, and knowledge and skills can be verified using valid and reliable assessment methods. Also, expertise and mastery can be attained through repeated practice, specific feedback, and establishment of progressively higher learning goals. Simulation-based education and training can help surgeons maintain their skills in infrequently performed procedures and regain proficiency in procedures they have not performed for a period of time. In addition, warm-ups and surgical rehearsals in simulated environments should enhance performance in real settings.Major efforts are being pursued to advance the field of simulation-based surgical education. New education and training models involving validation of knowledge and skills are being designed for practicing surgeons. A competency-based national surgery resident curriculum was recently launched and is undergoing further enhancements to address evolving education and training needs. Innovative simulation-based surgical education and training should be offered at state-of-the-art simulation centers, and credentialing and accreditation of these centers are key to achieving their full potential.     

Challenges to the development of complex virtual reality surgical simulations

Virtual reality simulation in surgical training has become more widely used and intensely investigated in an effort to develop safer, more efficient, measurable training processes. The development of virtual reality simulation of surgical procedures has begun, but well-described technical obstacles must be overcome to permit varied training in a clinically realistic computer-generated environment. These challenges include development of realistic surgical interfaces and physical objects within the computer-generated environment, modeling of realistic interactions between objects, rendering of the surgical field, and development of signal processing for complex events associated with surgery. Of these, the realistic modeling of tissue objects that are fully responsive to surgical manipulations is the most challenging. Threats to early success include relatively limited resources for development and procurement, as well as smaller potential for return on investment than in other simulation industries that face similar problems. Despite these difficulties, steady progress continues to be made in these areas. If executed properly, virtual reality offers inherent advantages over other training systems in creating a realistic surgical environment and facilitating measurement of surgeon performance. Once developed, complex new virtual reality training devices must be validated for their usefulness in formative training and assessment of skill to be established.     

Virtual reality simulators: current status in acquisition and assessment of surgical skills

Medical technology is currently evolving so rapidly that its impact cannot be analysed. Robotics and telesurgery loom on the horizon, and the technology used to drive these advances has serendipitous side-effects for the education and training arena. The graphical and haptic interfaces used to provide remote feedback to the operator--by passing control to a computer--may be used to generate simulations of the operative environment that are useful for training candidates in surgical procedures. One additional advantage is that the metrics calculated inherently in the controlling software in order to run the simulation may be used to provide performance feedback to individual trainees and mentors. New interfaces will be required to undergo evaluation of the simulation fidelity before being deemed acceptable. The potential benefits fall into one of two general categories: those benefits related to skill acquisition, and those related to skill assessment. The educational value of the simulation will require assessment, and comparison to currently available methods of training in any given procedure. It is also necessary to determine--by repeated trials--whether a given simulation actually measures the performance parameters it purports to measure. This trains the spotlight on what constitutes good surgical skill, and how it is to be objectively measured. Early results suggest that virtual reality simulators have an important role to play in this aspect of surgical training.