It is well established, practical and virtual simulation has become a mainstay in surgical training with transferability of acquired surgical skills to the medical setting (1). Surgeons in training have been finding a number of difficulties in learning the needed surgical skills, and confidence to be able to integrate in the operating theater during their junior years with very minimal exposure, and expertise This may be due to many circumstances including but not restricted to the stressful environment where the surgical team is trying to finish a massive workload in such a constricted time frame or at times where senior residents and fellows would take more advantage of the learning opportunities during the operating theater time. Nevertheless, with the aid of laparoscopic, virtual and basic surgical simulation, they have been able to overcome the many obstacles linked with the aforementioned deficiencies. There are benefits and limitations associated with training by simulation. This paper will address the role of simulation in surgical training and how its implementation benefits beat the drawbacks.
The role of simulation in surgical training has been acclaimed to be fundamental to the development and integration of the present-day surgical trainee by the medical community as a whole. Surgical simulation is a mock or a pretend medical model prototype which are available in various types, where a trainee can practice and master a defined technical surgical skill or procedure. One of the primary roles of simulation in surgical training is to better integrate the novice surgical trainee into the operating theater giving them more confidence to enact their acquired surgical skills to the real operative setting. By doing so has shown to reduce the technical learning curve thereby preparing their bimanual surgical skills for safer and more efficient surgeries in real practice (Milburn et al., 2012). Box training, virtual reality, tissue based, and mannequin-based simulations are some of the widely used forms of surgical simulation tools. The main core skills that are targeted to be improved in laparoscopy are ambidexterity, hand eye coordination developing better accuracy in suturing and instrumentation, and triangulation aiding to assimilate better depth perception and proprioceptive skills. By acquiring such skill through simulation, will ease the core/1st year surgical trainee’s transition to the traditional surgical training in the teaching hospital setting. Traditional surgical training also known as apprenticeship training is the standard surgical training which all certified surgeons experienced under the supervision of senior surgeons over their surgical training years with variable levels of exposure to practice depending on the hospital they are training in that is not standardized throughout all hospitals and lacks formal assessment. This brings us to the point that simulation may be used as a tool to train and assess surgical trainees throughout all phases of their medical training. Another important role that simulation can assimilate for working surgeons is to help introduce them to surgical novelties and instrumental innovations to modernize their current practice.
Advantages
There is a plethora of advantages of simulation are numerous. In apprenticeship surgical trainees may think that they have mastered quality laparoscopic surgical skills by repeating the procedure under the supervision of different surgeons many times, but quantity doesn’t necessarily mean quality. One of the most important gains of simulation in surgical training its ability to allow the surgical trainee to develop quality surgical skills, operative efficiency, proficiency and knowledge of the chronological sequence of the intended surgical procedures without jeopardizing or compromising patient safety. Patient safety is paramount in the surgical setting a minor slip may cause devastating life-threatening consequences. Being able to able to learn in an environment where mistakes are permissible relieves the stress and hesitation from the novice trainee to build the confidence to stand in the frontline, without reluctance to assist and be able to actively participate in the surgery without the excessive fear to disappoint senior surgeons or committing a critical error compromising their future as a surgeon.
Surgical virtual reality simulation may also help better initiate and familiarize to better acquaint surgical fellows with innovations in surgical procedures and advances in novel cutting-edge surgical instruments in the clinical practice. Additionally, operating theater multidisciplinary simulation has also shown its valuable potential in helping the surgical team as a whole acquire faster response time to surgical emergencies by conducting record time OR pre-operative preparation (Milburn et al., 2012). Furthermore, it may allow trainees to expand their nontechnical skills to be able to optimize their clinical integration in the practice. These include but aren’t limited to enhancing their ability to lead a clinical team to a collective target, work cohesively as part of a team, to make right decisions in tense and critical conditions, and workplace conflict resolution. Simulation may standardize surgical technique with objective assessment. The Royal Colleges of Surgeons have developed many simulation surgical skills courses, aiding progression in various ST levels
Disadvantages:
A selective number of trainees argue that simulation does not fully assimilate the real life tangible and raw operating room experience, the fact that some simulators are of low quality and the lack of standardization of simulation. The latter being problematic in the way that there would be fluctuation and inconsistencies in the trainee’s ability to adhere to the correct benchmarks in the clinical practice. Although simulation is a valuable adjunct that will aid the surgical trainee integrate the operative field, it will never replace traditional operative training. This doesn’t take away the fact that it is a very valuable tool that has to be taken advantage of. Certain simulation platforms are costly and not affordable to a majority of hospitals whose budgets are already tight as is. The majority of hospitals globally lack simulation centers however a UK survey shows that as much as it is accessible in certain hospitals surgical simulation is not open to all surgical trainees (See Table 3). Having your hands on such cutting-edge technology as a surgical trainee is a luxury.
(Milburn et al., 2012)
Conclusion
Simulation is an essential unequivocal training tool providing an opportunity for trainees to mold their surgical skills to better perform in their operative training. The advantages it accommodates for the trainees, practitioners, and patients outweigh the cons. The lack of access and exposure of simulation in surgical training nationally and globally should be addressed and tended to, easing accessibility of simulation centers within teaching hospitals. Objective worldwide surgical simulation training should be implemented to benefit the future generations of practitioners and patient to set a standard of training and assessment to strive towards prime universal patient care.
Part B
– Discuss the role of laparoscopy and how the surgical skills transfer to clinical practice.
Laparoscopy, an innovative novel minimally invasive surgical technique, that has changed the face of medicine after it was successfully introduced as an exploratory diagnostic, and a therapeutic method. In 1987 the first documented surgical laparoscopic procedure on a human was a cholecystectomy executed by Mouret in the city of Lyon, France (Polychronidis et al., 2008). Known as the futuristic least aggressive surgical technique, with the least post-operative complications and recovery periods it has become the most attractive surgical technique to patients. We will discuss the many roles this revolutionary surgical technique has yielded in the hospital setting within the last few decades and the transferability of the acquired laparoscopic surgical skills to the clinical practice.
The diagnostic and surgical roles in laparoscopic surgical technique have been well established in the majority of the surgical field in medicine. In general surgery, laparoscopic surgery has been implemented and became a gold standard approach for many surgeries including but not limited to cholecystectomy, appendectomy, esophagectomy, various types of cancer resections, gastric fundoplication, PU perforations, hernia repairs, and bowel obstruction surgeries. The most popular emergency laparoscopic surgeries being diagnostic stable trauma exploratory laparoscopies, perforated peptic ulcer repair, acute cholecystitis, and appendectomy (Warren et al., 2006). In trauma surgery, laparoscopy has a major role in vitally hemodynamically stable patients otherwise for such cases open surgery would be lifesaving. In bariatric surgery, laparoscopy has eased the anesthesia morbidity risks that would otherwise be inevitable in open surgery.
Similarly, in urology, the laparoscopic approach has become the notorious primary alternative to open surgery in the stable uncomplicated cases including but not limited to conducting simple/partial/radical/live donor nephrectomies, radical prostatectomy, radical cystectomy, adrenalectomy, nephroureterectomy, orchidopexy, uretero-lithotomy, pyelolithotomy, pyelolithotomy, ureterolysis, ureteric reimplantation, augmentation cystoplasty and lymph node dissections (Sharma and Varshney, 2011).
Laparoscopic surgery has become a core pillar in diagnosing and treating gynecologic pathologies in emergency and elective cases. Some important etiologies that are worth mentioning that may manifest in patients with acute or chronic pelvic pain include; ectopic pregnancy, acute pelvic inflammatory disease, pyosalpinx, hydrosalpinx, endometriosis, ovarian cyst, and benign or malignant masses. In the management of pediatric and neonatal emergency and elective surgeries, diagnostic laparoscopy has shown to be a vital go-to surgical method that avoids unnecessary physiological stress to neonates and infants. The emergency diagnostic laparoscopic approach has been used to diagnose and treat cases of midgut atresia, necrotizing enterocolitis, volvulus and sepsis in neonates without conversion to open surgery (Burgmeier and Schier, 2016). However therapeutic laparoscopy was shown to be helpful in localizing and descending impalpable testes and in emergency acute appendicitis in the pediatric population.
Some patients may push the surgeon to conduct a minimally invasive approach where in their case the outcomes may not be in their favor. Although Laparoscopy is the gold standard for many cases, open surgery may be deemed to be the more appropriate method to be conducted in their case instead of directing towards a laparoscopic approach. This would be the case in patients who are vitally hemodynamically unstable, or with a history of multiple previous open or laparoscopic surgeries, peritonitis, pelvic inflammatory disease, currently pregnant or in cases of bowel obstruction. In these well-defined circumstances it is preferable to divert to open surgery.
Surgical skills acquired through the multiple simulation platforms transfer to clinical practice by various means. One of the ways simulation integrates into the hospital setting is by mastering operative skills by learning to become ambidextrous, attain positive behaviors and not give up and being temperamental. This would improve the surgeon’s intraoperative reflexes when handling instruments. The prevention of the acquisition of negative reflexes which would include keeping instruments open or deviating the instruments out of the camera view field of vision, would prevent injury to the tissue. Being able to plan ahead and prepare and rehearse using simulation tools to be able to better perform during the surgical procedure. These skills will help the surgical trainee into the operating theater giving them more confidence to enact their acquired surgical skills to the real operative setting. Doing this has been shown to reduce the technical learning curve (Milburn et al., 2012). An important skill that is to be learned and become a reflex is the way surgical instruments are to be used. Catching the instruments correctly with the tips of the fingers and not being rough on the tissues when instrumenting the surgical tools. The main core skills that are targeted to be improved in laparoscopy are ambidexterity, hand eye coordination by keeping a good posture which will help them develop better accuracy in suturing and instrumentation, by using the triangulation method to aid adapt better depth perception and proprioceptive skills. Keeping in mind that respectful communication is the best way to communicate in the operative field.
In conclusion the minimally invasive surgical approach has multiple roles in the hospital setting transferability of the acquired laparoscopic surgical skills to the clinical practice. Future areas of study implication (lines of enquiry)