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Surgeons’ Skills Training
Boel A. Fransson, Heather A. Towle Millard, and Claude A. Ragle
Adding Minimally Invasive Surgery to the Surgical Repertoire
Since the introduction of laparoscopy and thoracoscopy in small animal surgery in the mid 1970s, the main focus has been on the development of surgical techniques and equipment. Not until recently has veterinary medicine recognized the importance of skills development for surgeons who want to incorporate minimally invasive surgery (MIS) in their clinical practice.
Even for surgeons with considerable expertise in traditional open surgery, it will be readily apparent when approaching MIS that some laparoscopic skills are distinctly different from those of open surgery. The challenges and differences include the use of long instruments, which magnifies any tremor and limits tactile sensation, often referred to as haptic feedback. When the instrument movement is limited by a portal into the body cavity, the surgeon needs to handle the resulting fulcrum effect and the loss of freedom to simply alter an approaching angle. But even more important, the normal binocular vision becomes monocular; as a result, the associated depth perception is lost. Other challenges include the loss of a readily accessible bird’s eye view of the entire body cavity. The advantage of magnification may be perceived as offset by a reduced field of view, and any instrument activity outside the view becomes a liability.
Understandably, a surgeon who has performed hundreds or more of any given procedure, with good success and minimal time expenditure, may initially be reluctant to take on the challenges of MIS. This may be especially conspicuous in small animal laparoscopy, in which the conventional surgical approach provides excellent and easy access to all intraabdominal organs. A budding small animal laparoscopic surgeon may meet resistance from referring veterinarians and even staff members when converting open procedures to laparoscopic because costs and surgery time, at least initially, tend to be higher. Educating the referral base, clients, and staff in the advantages of laparoscopy may alleviate but not remove the initial resistance.
The solution to minimizing the surgeon’s pains of transitioning from open to laparoscopic surgery consists of pretraining. The basic laparoscopic skills of ambidexterity, optimizing instrument interaction; observing cues for depth perception; and precise, deliberate movements need to be achieved early in the skills development for the benefit of patient safety and surgeon’s confidence in the operating room (OR).
Basic Laparoscopic Skills
The basic skills required for laparoscopic surgery include ambidexterity, hand–eye coordination, instrument targeting accuracy, and recognition of cues to provide a sense of depth.1,2
Although these skills are used, and therefore trained, in clinical practice, the surgeon should not rely on caseload for training. The Institute of Medicine reported in “To Err Is Human” that approximately 100,000 humans die each year as a result of medical errors and that approximately 57% of these deaths are secondary to surgical mistakes.3 Despite efforts to prevent surgery-related human deaths, the cost of training one surgical resident in an OR throughout the course of his or her residency is estimated to cost nearly $50,000.4,5 and this is becoming cost prohibitive for teaching institutions. In addition, medical surgery residents are now limited to working 80 hours per week,6 which further limits their exposure to clinical cases.
Although the number of surgical-related deaths in veterinary medicine in the United States is not known, they do occur. In addition, even though OR costs do not equal those of training a human surgical resident and we currently do not have limits on the work week of veterinary students or veterinary surgery residents, veterinary medicine has its own set of dilemmas. Veterinary training curricula are also faced with financial limitations, as well as increasing external and internal ethical concerns regarding the use of research animals for surgical training; increasing number of veterinary students being admitted to programs and subsequent decreased exposure to laboratory and clinical cases; lack of sustainability of cadavers because of problems with availability, storage, and limited usefulness because of decay; and the drive to reduce errors made by inexperienced surgeons on actual patients.7,8 For these reasons, both human and veterinary educators are being compelled to develop innovative teaching methods for surgical skill instruction.
Beside the ethical and cost issues, it is likely that a training program built on practice in live patients becomes limited and inconsistent. Interestingly, we have noticed in our work that even experienced veterinary laparoscopic surgeons tend to lag in efficient use of their nondominant hands, something easily rectified by simulation training.9 In fact, the basic skills are most efficiently trained through simulation training.10 This has been recognized for more than a decade among medical doctors, and since 2008, laparoscopic simulation training curricula have been a requirement for surgery residency programs in the United States.11 Robust evidence has been presented to demonstrate that skills developed by simulation indeed transfer into improved OR performance.12-16
Simulation Training Models
A number of simulation models have been presented and can currently be divided into three main categories: physical; virtual reality (VR); and hybrid, or augmented reality (AR), models.
Physical Simulation Models: Box Trainers
Box trainers have in common that tasks are performed using regular laparoscopic instruments in a box containing a camera, which projects onto a computer or TV screen. A number of box trainers are commercially available (Figure 1.1) and carry the advantages of being portable and highly versatile. As web cam technology has improved within recent years, homemade trainers can be a very cost-effective alternative if portability is not a requirement. An example of a homemade trainer used in the author’s Veterinary Applied Laparoscopic Training (VALT) laboratory is presented in Figures 1.2 to 1.4. Homemade versions are used solely for practice and not for skills assessments.
Figure 1.1 A number of laparoscopic skills training boxes are commercially available. Most are portable, and many have cameras that connect to a computer by USB connections. Some, including the official box for Fundamentals of Laparoscopic Surgery, require a TV screen. (Photo courtesy of Henry Moore, Jr., Washington State University, College of Veterinary Medicine.)
Figure 1.2 Commonly used dimensions in laparoscopic training boxes.
Figure 1.3 An example of a homemade training box.
Figure 1.4 Recent advances in web cameras enable real-time imaging to a low cost.
Box training can be considered low-fidelity simulation (i.e., less lifelike but nonetheless highly efficient training tools). A number of practice drills have been developed and validated. In the 1990s, several structured training tasks were described, including the Dr. Rosser’s station tasks developed at Yale University, which are part of the popular “Top-Gun Shoot-Out” competition at national meetings for physicians. The physical training task system with the most solid validation to date is the McGill Inanimate Simulator for Training and Evaluation of Laparoscopic Skills (MISTELS).10,17-19 At present, MISTELS includes peg transfer, pattern cutting, ligature loop placement, and intra- and extracorporeal suturing. An additional cannulation task is currently being incorporated.20
We have considerable experience of MISTELS-type training of veterinarians in our simulation training facility, the VALT laboratory (Figure 1.5) at Washington State University. The adaptation of MISTELS for the VALT laboratory has been described in detail elsewhere,9,21 and currently, the tasks we use include:
- Pegboard transfer: Laparoscopic grasping forceps in the nondominant hand is used to lift each of six pegs from a pegboard, transfer them to a grasper in the dominant hand, place them on a second pegboard, and finally reverse the exercise (Figure 1.6).
- Pattern cutting: This task involves cutting a 4-cm diameter circular pattern out of a 10 × 15-cm piece of instrument wrapping material or a gauze suspended between alligator clips (Figure 1.7).
- Ligature loop placement: The task involves placing a ligature loop pretied with a laparoscopic slip knot over a mark placed on a foam appendix and cinching it down with a disposable-type knot pusher (Figure 1.8).
- Extracorporeal suturing: A simple interrupted suture using long (90-cm) suture on a taper point needle is placed through marked needle entry and exit points in a slitted Penrose drain segment. The first throw in the knot is tied extracorporeally with a slip knot and cinched down by use of a knot pusher. Thereafter, three single square throws are placed by use of laparoscopic needle holders and the suture is cut (Figure 1.9).
- Intracorporeal suturing: A simple interrupted suture is placed using short (12- to 15-cm-long) suture on a taper point needle through marked needle entry and exit points in a slitted Penrose drain segment. Three throws are placed, the first being a surgeon’s (double) throw, by use of laparoscopic needle holders. The exercise is completed when the suture is cut (Figure 1.10).
Figure 1.5 Logotype for the Veterinary Applied Laparoscopic Training laboratory at Washington State University.
Figure 1.6 Peg transfer task. Six objects are lifted from the left-sided pegs with nondominant grasper, transferred midair to the dominant hand grasper, and then placed on a right-sided peg. The exercise is then reversed.
Figure 1.7 Pattern cut task. A 4-cm circle is cut, with a penalty applied if the cut is outside the mark.
Figure 1.8 Ligature loop application task.
Figure 1.9 Extracorporeal suture task.
Figure 1.10 Intracorporeal suture task.
In addition to the MISTELS exercises, we have found important benefits in the VALT laboratory of a variety of exercises, which have been presented.9 We find that exercises performed in a simulated canine abdomen (Mayo Endoscopy Simulated Image, Sawbones, Vashon, WA; Figure 1.11) can be helpful in practicing camera manipulation and mirroring situations (i.e., camera facing surgeon) and can help prepare the surgeon for the confines of a canine abdomen.
Figure 1.11 The Mayo Endoscopic Simulated Image (MESI) canine model (Sawbones, Vashon, WA) for laparoscopic and endoscopic practice.
The one major disadvantage with box training is the lack of instant feedback. Without automated feedback, an experienced surgeon needs to be available to critique the performance of the trainee, which becomes an important limitation because of the busy schedules of most surgeons. However, proficiency goals have been defined for MISTELS such that the trainee can monitor his or her progress by simple metrics such as time and errors.22 With these goals in mind, the trainee can practice independently for the basic tasks of peg transfer, pattern cutting, and ligature loop placement. Laparoscopic suturing requires instructive sessions with an experienced surgeon. When suturing technique has been learned, the trainee can continue to practice independently to reach an expert level of performance, as defined by the proficiency goals.
Another disadvantage of box training is the current lack of veterinary high-fidelity surgery procedural models. Physical models for cholecystectomy, appendectomy, and so on are commercially available, but they are all fairly expensive. In addition, they are all based on human anatomy and physiology and thus are less relevant for veterinary surgeons. A physical model, which can often be used only once, may not be feasible for most residency training programs if the cost is more than $100/each. Research into construction of low-cost yet higher fidelity physical models is ongoing at our institution, which may provide increased access to veterinary procedure models in the future.
Virtual Reality Simulation
Highly realistic VR simulation (Figure 1.12) is commercially available for both basic skills as well as entire simulated surgical procedures. In fact, one of the main advantages with VR training is realistic simulation of surgical procedures, which is hard to achieve to a reasonable cost in box training. For veterinarians, this advantage is somewhat limited, though, because anatomy and surgical procedures are all based on human anatomy.
Figure 1.12 The ProMis augmented reality trainer is a combination of a physical box trainer and a virtual reality overlay used in many surgical exercises. (Photo courtesy of CAE Healthcare, © 2014 CAE Healthcare.)
Basic task simulations give the trainee opportunity to experience a variety of surgical complications, such as bleeding, dropping clips, and repercussion from rough tissue handling while benefiting from instant feedback and suggestions on how to proceed. Other advantages of VR simulation are that modules contain detailed instruction for performance of all tasks and summative feedback comparing the overall performance with an expert level. The summative performance is also broken down into a number of performance metrics, such as time, instrument path length for the dominant and nondominant hands, and errors, giving objective information about the performance. Therefore, the provided feedback of VR gives the trainee opportunity to practice without the need for an instructor. We have found that this instant feedback also serves as motivation because most surgeons and residents have competitive personalities and enjoy the comparison with expert level.
At present, a number of VR simulators are commercially available, but they all carry the disadvantage of being expensive. For example, a haptic LapSim (Surgical Science, Minneapolis, MN) unit currently cost a little over $90,000 (personal communication, Tony Rubin, VP, Surgical Science, Inc., September 2013), and software updates are also expensive. Another disadvantage is that, as mentioned, all VR simulation is based on human anatomy, and developing software for veterinary simulation is expensive; such models may not become available, at least not in the near future.
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