Opportunities for multimodal simulation in surgical training

Editorial

Hell J Surg. 2024 Oct-Dec;94(4):181–182
doi: 10.59869/24045

Lachlan Dick1, Elizabeth Ward2, Andrew G. Robertson2

1Medical Education Directorate, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK,
2Clinical Department of Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK

Correspondence:  Lachlan Dick MBChB MRCS(Ed), Medical Education Directorate, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK, EH16 4SA, Tel.: +441315361000, e-mail: lachlan.dick3@nhs.scot

Key Words: Simulation, surgical training, innovation, technical skills, non-technical skills

Submission: 15.01.2025, Acceptance: 11.03.2025

Simulation has an increasingly vital role in surgical training, allowing trainees to develop and hone fundamental skills and providing exposure to high-stakes scenarios which surgeons must be able to manage effectively. Reduced training opportunities, driven by workforce pressures and competing training demands, has further fuelled the emergence of simulation in modern-day surgical curricula. Traditional modalities, such as simple suturing models and cadavers are now complemented by emerging technology-enhanced and innovative new approaches. Integration of multimodal simulation into training pathways presents opportunities to create comprehensive and effective learning, which could improve training, enhance development of skills and thereby advance patient care.

The most basic modes of simulation have been around for decades. Often, the primary learning outcome is the development of basic surgical skills. For example, laparoscopic box trainers allow trainees to become familiar with laparoscopic instruments and tackle simple tasks (e.g., laparoscopic cutting). These forms of simulation are widely available due to the relatively low cost, simplicity and ability for trainees to use at a time convenient for them. However, without a structured programme of learning, engagement can be poor, considerably limiting the effectiveness of this simulation modality [1]. The lack of feedback during independent practice can also be a barrier for some trainees. With implementation of effective guidance and development of software which can provide trainees with feedback, these basic forms of simulation can help in skill acquisition and prime trainees for the operating room environment [2].

The rapid rise in robotics platforms also provides avenues for trainees to develop minimally invasive skills through simulation. Increasingly based on advanced, virtual reality (VR) models, they create a more realistic learning environment compared to earlier simulation approaches, albeit at a greater cost and reduced flexibility. The addition of performance metrics (e.g. economy of motion, penalties for technical errors), generated through kinematic data and video analytics [3], could provide deeper granularity to assessments. By providing feedback through an alternative lens, specific learning needs can be identified [4]. The current challenges in robotics simulation include the variable exposure to platforms, particularly in low-income countries and lack of standardised training milestones. As robotic-assisted surgery becomes more established, there will be greater structure and use of robotic simulation to meet growing clinical demands.

Cadaveric-based simulation has a long history, particularly for open-surgical skill training. Not only does this modality provide maximal fidelity (i.e., the degree to which simulation replicates reality), through realistic interaction with anatomy and tissue planes, it also allows for procedural simulation rather than the skill-based only, offered by other approaches. Rarely is an operation a singular event, and providing opportunities for trainees to perform entire procedures or phases in simulation can allow progression from more basic tasks. Patient benefit, through greater accuracy of implant positioning and reduced need for postoperative blood transfusion, has also been established in trainees undergoing cadaveric hip fracture-based training, compared with those following the standard curriculum [5]. Undoubtedly, cadaveric-based simulation is associated with higher costs and resources, while availability of donors and, in some areas, ethical considerations, can limit trainee exposure.

Positive outcomes following surgery rely on an array of attributes beyond technical skills. The importance of incorporating non-technical skills (e.g. communication, decision-making) in surgical simulation is becoming increasingly acknowledged [6]. Mannequin based simulation can be used to blend both technical and non-technical skills together and facilitate interdisciplinary communication and teamwork. New technologies can also provide novel approaches to learn these crucial skills. Immersive simulation using VR can provide trainees with realistic scenarios mirroring real-life practice. In one application, trainees join a simulated surgical briefing via a VR headset and watch as the surgical team prepares for an operation [7]. Debriefing following the simulation could focus on patient safety, communication amongst the team and wider Human Factors. Although currently most allow the learner to be a passive bystander in scenarios, development in technology will likely see interactive simulation, adding further training benefits.

Beyond technology, innovative methods of simulation have been developed in recent years. Tabletop simulations are low in resources and frequently used to replicate complex and critical situations. Examples in surgical training include the use of a tabletop simulation to enhance decision-making training in mass trauma scenarios [8]. Some of the latest simulation designs have yet to be utilised in surgical training. Shadowbox is a video-based simulation which allows learners to witness scenarios performed by experts. At critical decision points, the scenario is paused to allow learners to propose next steps. After watching the scenario conclude, the debrief focuses on identifying differences in decision making between the learners and the expert [9]. The wealth of operative video available could be harnessed for Shadowbox simulation, and encompass decision-making in high-risk scenarios (e.g., failure to achieve a critical view of safety in laparoscopic cholecystectomy) or unexpected surgical events (e.g., intraoperative bleeding).

Simulation has evolved considerably over time to become an essential component in surgical training. From basic models to advanced simulators, there is now a broad range of options available, each offering different opportunities to meet curricular needs. Through careful consideration of the strengths and weaknesses of each, bespoke simulations could be developed to cater for all stages of training, specialties and learning styles. It is now the responsibility of surgical colleges, institutions and educators to incorporate multimodal simulation into standard practice at low cost for participants to benefit trainees and ultimately further enhance patient care.

REFERENCES
  1. Walker KG, Shah AP, Brennan PM, Blackhall VI, Nicol LG, Yalamarthi S, et al. Scotland’s ‘Incentivised Laparoscopy Practice’ programme: Engaging trainees with take-home laparoscopy simulation. Surgeon. Elsevier BV; 2023 Jun; 21(3):190–7.
  2. Keni S, Ilin R, Partridge R, Hughes MA, Brennan PM. Using automated continuous instrument tracking to benchmark simulated laparoscopic performance and personalize training. J Surg Educ. Elsevier BV; 2021 May-Jun;78(3):998–1006.
  3. Dick L, Boyle CP, Skipworth RJE, Smink DS, Tallentire VR, Yule S. Automated analysis of operative video in surgical training: Scoping review. BJS Open. 2024 Sep;8(5):zrae124.
  4. Seeliger B, Pavone M, Schröder W, Krüger CM, Bruns CJ, Scambia G, et al. Skill progress during a dedicated societal robotic surgery training curriculum including several robotic surgery platforms. Surg Endosc. 2024 Sep;38(9):5405–12.
  5. James HK, Pattison GTR, Griffin J, Fisher JD, Griffin DR. Hip fracture surgery performed by cadaveric simulation-trained versus standard-trained orthopaedic trainees: a preliminary multicentre randomized controlled trial. Bone Jt Open. 2023 Aug;4(8):602–11.
  6. Dick L, Hughes K, Yule S. Integrating non-technical skills with technique is essential for mastery in robotic-assisted surgery. BJS Academy [Internet]. BJS Foundation Limited; 2024 Nov [cited 2024 Nov 1]; Available from: https://doi.org/10.58974/bjss/azbc061
  7. Fukuta J, Gill N, Rooney R, Coombs A, Murphy D. Use of 360° video for a virtual operating theatre orientation for medical students. J Surg Educ. 2021 Mar-Apr;78(2):391–3.
  8. Achatz G, Friemert B, Trentzsch H, Hofmann M, Blätzinger M, Hinz-Bauer S, et al. Terror and disaster surgical care: training experienced trauma surgeons in decision making for a MASCAL situation with a tabletop simulation game. Eur J Trauma Emerg Surg. 2020 Aug;46(4):717–24.
  9. Mutch CP, Oliver N. Virtual simulation of communication skills challenges using a shadowbox technique. Int J Healthc Simul. Adi Health+Wellness; 2022 Oct;1(Supp):S22–4.