Surgical Skills Training
Surgical simulation provides deliberate practice, training, and assessment in a safe environment. Simulators range from simple task trainers to high-fidelity mock operating rooms. Suture repair on pigs’ feet or knot-tying to a post were early and enduring iterations of both organic and inorganic models. With the advent of laparoscopy came technical challenges – altered depth perception, reduced tactile feedback, and the fulcrum effect – requiring a sophisticated level of practice. The laparoscopic box trainer was an early spark in the proliferation of depth and breadth in surgical skills training, now driven by forces including work-hour restrictions, patient safety concerns, financial cost of training, and emerging technology.
Box Trainers and Partial Task Trainers
Laparoscopic box trainers display a basic design: a box with holes for trocars and a camera or mirror displaying an image from a closed space meant to simulate the insufflated abdominal cavity. Most manufactured laparoscopic trainers – regardless of the technology used – display this basic design. Partial task training is most epitomized by major systems developed for it – including the Yale Laparoscopic Skills and Suturing Program (Top Gun), the Guided Endoscopic Module (GEM) at University of Texas Southwestern Medical Center, and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), adapted into the Fundamentals of Laparoscopic Surgery (FLS) program. Featuring low-fidelity components, these programs were most prolific in demonstrating the reliability, validity, and learning curves for inanimate partial task training
While partial task trainers simulate specific, individual maneuvers required to perform an operation, procedure-specific trainers feature a set of tasks in the chronological order of an operation, or part of an operation. Procedural trainers tend to utilize rubber or plastic parts to simulate tissues and anatomic relationships. Early described models include laparoscopic preperitoneal hernia repair and common bile duct exploration. Common to these procedural trainers were advanced laparoscopic operations that, at least at the time of their development, were not widely practiced. As the demand for simulation increases, operational trainers are expected to increase, as evidenced by the 10 procedural modules of Phase II of the ACS/APDS National Skills Curriculum.
Virtual Reality Simulators
Virtual reality is a computer simulation that enables users to perform operations on the system and shows effects in real time. Computer simulators usually allow instant score reporting, feedback, and automated tutoring. Haptics may bridge the gap to mechanical trainers to some degree, decreasing cognitive load on the learner despite lower fidelity of the tactile feedback. Expense is a major downside. The Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) is the most vigorously studied system. More recent simulators feature higher levels of fidelity and haptic technology, but disparity remains between the degree of required financial investment and outcome data demonstrating value for training.
Hybrid trainers may have a computerized visual interface with inanimate components, or organic parts combined with a inanimate housing. Other combinations of current modes of simulation continue to emerge. The basic template of the laparoscopic box trainer remains an important milestone in the evolution of simulation and technical skills training in surgery