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Role of Simu in Surgical EducationUlhas S. GadgilEx Programme Director, Ethicon Institute of Surgical EducationProfessional Education Consultant, Johnson & Johnson Medical IndiaÜÄÖ

SummaryTechnical progress in surgical training and ethical issues areexpected to replace traditional methods of residents learningsurgery by apprenticeship in the operating room in a stressfulatmosphere. With the development of Minimal Access Surgery(MAS) the surgical approach has changed totally, and curricu-lum-based, hands-on training is gaining importance in learningthese new skills. Economic factors and ethical issues of learn-ing basic skills on patients and animal models are driving pro-gressive replacement with clinically closer simulators. There isscope for medical colleges and simulator manufacturers towork together to develop scientific simulators and discouragethe use of animals for the acquisition of basic skills in surgery.This process can be accelerated only by incorporating simula-tor-based training modules in the curriculum ofmedical educa-tion. This change in curriculum can motivate the medicalcommunity to look for alternatives to animal use by acceptingthe 3R principles.

Zusammenfassung: Zur Bedeutung von Simulatoren in derChirurgen ausbildungDer technischer Fortschritt bei chirurgischen Übungen undethische Überlegungen lassen erwarten, dass die traditionellenAusbildungsmetoden in der gestressten Atmospähre des op-Saals abgelöst werden. Mit der Entwicklung der minimal-inva-siven Chirurgie hat sich Einstellung in der Chirurgiegrundsätzlich geändert, in den Studienplänen gewinnt diepraktische Ausbildung in diesen neuen Methoden immer mehran Bedeutung. Ökonomische Gründe und ethische Überlegun-gen führen dazu, dass anstelle er praktischen Übungen anPatienten und Versuchstieren klinisch sehr viel relevantereSimulatoren eingesetzt werden. Zweckmässige wäre eine engeZusammenarbeit der Kollegen in der Chirurgie mitden Herstellern von Simulatoren, um gemeinsam aufwissenschaftlicher Basis Simulatoren zu entwickeln und so dieVerwendung von Versuchstieren beim Erlernen der praktischenFähigkeiten in der Chirurgie zu vermeiden. Dieser Prozesskann nur beschleunigt werden, indem Simulator basiertesLernen in die Lehrpläne des Medizinstudiums aufgenommenwird. Diese Änderung in den Lehrplänen des Medizinstudiumskönnte die Ärztegemeinschajt insgesamt dazu anregen, nachAlternativen zu Tierversuchen Ausschau zu halten und das3R-Prinzip zu akzeptieren.

Keywords: Minimal Access Surgery (MAS), simulator; simulation, 3R principle, skill training, technique, procedure, BeetleVideoscopie Endo Trainer

More than a hundred years of surgical resi-dency training programmes have used theoperating room to teach basic surgical skillsto residents. However, considering the accel-erating changes in our health care system,this strategy may no longer be feasible.Several forces are making it difficult for theoperating room to be the predominant venuefor acquiring technical skills. There istremendous pressure on our surgeons to bemore efficient and competent in the operat-ing room due to increasing financial con-straints within our teaching institutes, whichresults in a lack of time, even in the operat-ing room. Ethical issues conceming teachingor learning basic surgical skills on patients orusing animal models are restricting thelearning process.

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Every skill involving life-threateningactions, such as aircraft navigation, marineoperations, battlefield training and alsosurgery on a patient, requires simulations forlearning. Simulation demonstrates physical,technical, biologieal, psychological or eco-nomical processes or systems using a math-ematical or physical model. A simulator is adevice used especially in training to repro-duce the conditions of the working situation,enabling tasks to be learned and practicedsafely and economically to build safety anda predictable outcome.

Simulator-based surgical training over-comes all these problems and enables learn-ers to practice the tasks in a stress- freeatmosphere outside the operating theatre,similar to the airline industry where pilotslearn flying techniques on flight simulators.If we carry out the process of mapping

surgery, we can divide the events into twoseparate parts i.e. surgical technique and sur-gical procedure.

Surgical technique is the proficiency andrefinement of a particular skill which can beput into practice while conducting a surgicalprocedure, e.g. making a tissue incision, dis-secting a tissue or suturing in depth. This canbe learnt very well on a scientificallydesigned and validated simulator, and weneed not use animal tissue or take the life ofan innocent animal. In case of conducting asurgical procedure, for example removing apathology or reconstructing a vital organ, weneed to use knowledge and wisdom to selectan appropriate training model. Learning onsimulators helps to collapse the learningcurve and also helps to convert inherentskills into tricks in case of emergency.

Economic and social factors are driving

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Tab. 1: Comparison of learning models

Inanimate Animate Cadaver Simulation (computer)

Realism (anatomy, tactile) low to medium medium high medium to high

Bleeding, moving no yes no yes

Variations limited limited limited yes

Complication seenarios impossible limited limited possible

InvestJinfrastructure requirement low high high low to medium

Public perception low tech questionable questionable high tech

Running costs medium to low high high medium to low

the change towards new forms of medicaleducation and methods. There is a skill andtechnique component, which must be trans-mitted along with a knowledge component.The adoption of new technology andadvanced surgical techniques is slow inmedical education and is usually constrainedby budgets and the needs of the teachers.Adoption spreads from one department toanother, encouraged by the enthusiasm ofstudents and teachers. For example,although the animal model used to be con-sidered a requirement for acquiring basicskills in laparoscopic surgery, advances insimulator development have replaced suchkinds oftraining models slowly, by applying3R principles such as replacement, reductionand refinement. The change has not just hap-pened ovemight, but people who care foranimal life have promoted such simulatorsaggressively by convincing the surgicalcommunity of the convenience and power ofthese learning tools. It is interesting to knowthat extensive use of animal models hasnever been reported in the past while learn-ing open surgery.

Medical college teachers are the mostvaluable community who can encourage thedevelopment of clinically eloser simulatorsto avoid or replace animal use in surgical

Fig. 1: This Beetle Videoscopic EndoTrainer (design paten ted) has beendeveloped by Ulhas S. Gadgil.

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training. It is a need of the time that suchelinically eloser and scientifically validatedsimulators should become part of the medi-cal education curriculum. The medical uni-versities should deelare scholarships forinventing simulators to propagate 3R princi-ples as part of education and cultural devel-opment. The simulator manufacturingindustry and medical colleges should worktogether elosely to develop scientifically val-idated simulators to transfer the techniquesleamt in the operating room.

The medical device and pharmaceuticalindustry should also actively encourage andsupport simulator- manufacturing compa-nies to develop innovative and cost effectivesimnlators as an alternative to animal mod-els. This will help the surgical as weil asmedical community to use and adopt newtechnology products much faster in thiscompetitive world and extend the benefit topatients more safely.

As the technology is changing rapidly, thelearning process needs to be made muchsimpler, faster, more economical and safer.Therefore innovations in the computer simu-lation or simple simulators should be usedextensively in medical colleges. This willdefinitely bring down costs and the use ofanimal models while improving the qualityof learning and teaching in the dry labs.

With the advances in the development ofoptics, Minimal Access Surgery (MAS) hasgiven a new direction to surgical science,which requires new surgical approaches andtechniques. This is a great challenge forsenior as weil as young surgeons. When per-forming MAS, the surgeon needs to adaptfrom the 3-dimensional approach of opensurgery to the 2-dimensional magnified viewof the internal organs, which needs to betackled acquiring depth perceptions. Toacquire these new challenging techniques,the surgeon has to undergo extensive train-

ing to develop the required hand-eye co-ordination. Such skills can only be learnt onelinically elose, scientifically developedsimnlators, e.g. the very cost effective andclinically elose Beetle Videoscopic EndoTrainer (Fig. 1). It is to be emphasised that toleam basic techniques in MAS, use of ani-mal models is not at all necessary, and thesurgeon can acquire such skills by definingthe task while converting it into an exercisewhich can be majorable.

ReferencesDi Lorenzo, N. and Dankelman, J. (2005).

Surgical Training and Simulation.Business Briefing Global Surgery -Future Directions.

Keysar, E. 1., Derossis, A. M. Antoniuk, M.et al, ( ..... ). A Simplified simulator for thetraining and evalutation of Laparoscopicskills. Surg. Endose. 14, 149-153.

Moorthy, K., Munz, Y., Sarkar, S. K andDarzi, A. (2004). Objective assessment oftechnical skills in surgery. Selection fromBM], Volume 19.

Reznick, R. K. (2005). Surgical Simnlation aVital Part of Our Future. Annals ofSurgery, Volume 242, Number 5.

Scott, D. J., Valentine, R. J., Bergen, P. C. etal. ( .... ) Evaluating surgical competencywith the American Board Of Surgery InTraining Examination, skill testing andintraoperative assessment. Tex. Surgery,Volume 128, Number 4, 613-622.

Correspondence toDr. Ulhas S. Gadgil, M.V.Sc., Ph.D.Rekha BI, Kores Tower,Flat 303, Vartak Nagar,Pokharan Road No.1,Thane(W)-400606Indiaemail: ugadgil@jnjin.jnj.com andulhasgadgil@yahoo.com

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