Simulation Training in Surgical Education: Experience and Innovative Methods

Invited Commentary

Introduction
\nSimulation training is widely adopted in clinical medicine. Simulated environment provides a safe condition for participants to practice without any harm inflicted on patients. Within the spectrum of clinical anaesthesia, simulation mannequin was first developed in 1960. The first journal article with description about the use of simulator to teach intubation to anaesthesia residents occurred in 1969. The first report about simulated anaesthesia training was in 1988. Since then, there has been a flourishing trend of adopting this simulation training in clinical anaesthesia, across various subspecialties including obstetric anaesthesia, cardiac anaesthesia. For individual perspective, simulation training expanded beyond skill development into non technical skill training. 
\nThis article is to review the impact of simulation training for individual development for anaesthesia residents or trainees. The aim is to evaluate the evidence of simulation training on individual anaesthesia resident performance and improvement on patient outcome. As a result, more vigorous use of simulation is adopted in modular subspecialty anaesthesia and also non-technical skill training for residents.
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\nMethods
\nA search of literatures through search engines of Pubmed, Google Scholars, EMBASE, Cochrane library for ‘Simulation for training of clinical anaesthesia’ was done. After limit the search for English language and past 10 years, there are 223 articles. With appropriate exclusion criteria, 25 articles are selected for detail evaluation. 
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\nResults
\nSimulation has good effects in various aspects. For various anaesthesia subspecialties, simulation-based training can improve trainees’ confidence and capability in handling rare but life-threatening peri-operative crises. For assessments, simulation is an essential part of Israeli Board Examination in Anesthesia with good discriminating power. For technical skill development, simulation-based training can reduce residents’ time requirement to perform cricothyroidotomy and improve successful rate of central line insertion. The specific skill developed can retain for long period of time such as 12 months. For non-technical skills, there are conflicting results in behavioural scores. For patient safety and outcome perspective, there lacks the result from individual simulation-based training study. 
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\nConclusions
\nSimulation in anaesthesia residents training is a worldwide practice. These simulation training allow residents to have exposure in various anesthesia subspecialty including cardiac, obstetrics, liver transplant. There are specific technical and non-technical skill development. Individual performance particularly time to complete cricothyroidotomy and confidence, understanding of procedures and anatomy by residents are also enhanced. Thus, simulation should be allocated more proportion of anaesthesia resident training in Hong Kong. Although there remains no study showing better patient outcome after simulation-based individual training, future studies should be done to confirm such presence and degree of association with simulation training.

IntroductionEmpirical data on the effectiveness of BRM trainings is still sparse and as far as studies were published, not very encouraging. Both O’Connor (2011) and Rottger, Vetter & Kowalski (201...

Excellence in performance and stress reduction during two different full scale simulator training courses: A pilot study

The objective of this paper is to describe the current status, advantages, and disadvantages of Virtual Reality simulators as tools for training and assessment of laparoscopic skills. This is a review of publications about Virtual Reality simulators in laparoscopic training and assessment. Information was obtained through author’s experience and by search of MEDLINE using the keywords Virtual Reality simulation, training, assessment and laparoscopic surgery. The references cited in these studies were reviewed to find out whether any other trials fitted the selection criteria. There are several validated Virtual Reality systems that allow the transfer of skills from the virtual environment to the operating room and objective assessment of operative skills in laparoscopic surgery. In conclusion, Virtual Reality simulators are valid and objective tools in surgical education. Several systems are currently considered sufficiently validated and ready to be implemented in comprehensive educational curricula in minimally invasive surgery.

Anesthesiologists and otolaryngologists are specialists who share overlapping patient considerations because of the proximity of the surgical field and airway. Although many surgical environments benefit from a collegial team dynamic, the interdisciplinary otolaryngologic environment mandates collaboration from anesthesiologists and otolaryngologists for optimal patient outcomes1. Patients undergoing head and neck surgery are at high risk of potentially devastating events if the airway anatomy is distorted secondary to pathologic conditions or previous surgeries. Although many ENT Anesthesia fellowship programs provide exposure to a wide array of clinical cases and development of airway technical skills, the current simulation literature suggests that training programs focus on improvement of procedural skills in silo2–4. However, this is not optimal for prevention or management of high stress situations where crises resource management (CRM) and interdisciplinary team dynamics can affect patient outcome. We would like to encourage every ENT Anesthesia and Surgical training program to consider introducing a comprehensive simulation-based educational component to ensure proficiency in CRM, communication skills, and leadership skills to better manage the rare and critical cases. The use of simulation for interdisciplinary training amongst anesthesiologists, surgeons, and nurses offers flexibility, preserves realism, and enhances patient safety, which makes it ideal for education and assessment of practitioners, regardless of level of training. A wide variety of simulation technology exists with differing degrees of complexity and fidelity that can be used to advance technical skills. Two major classes are part-task trainers and whole-task trainers. Part-task trainers include simple models designed for a specific task. They vary from animal models and mannequins, to more advanced screen-based computer interface. Examples of airway trainers such as the Laerdal adult airway mannequin are capable of mask ventilation, supraglottic airway placement, fiberoptic intubation, as well more invasive procedures of cricothyrotomy and tracheostomy. Slightly more advanced part-task trainers include bronchoscopy devices such as GI-BRONCH Mentor (3D Systems, Littleton, CO) which provide screen-based simulation coupled with tactical psychomotor mechanics. Part-task trainers are important for clinicians to build fundamental skills that can be translated into proficiency in clinical practice. For example, studies have shown a faster acquisition of direct laryngoscopy and improved psychomotor skills on fiberoptic intubations when practiced initially on part-task trainers5,6. In contrast, whole-task trainers (Laerdal SimMan 3G, CAE HPS) are full-scale patient simulators with advanced computer-driven technology and human-modeled physiology that can be altered for desired clinical scenarios. When whole-task trainers are combined with standardized patients and part-task trainers, a hybrid learning environment can be created to incorporate high-fidelity simulation scenarios involving technical as well as nontechnical skills. Team training in the form of interprofessional education (IPE) and interprofessional learning (IPL) is critical for patient safety in the operating room in general, but more so in head and neck cases due to the shared working environment between otolaryngologists and anesthesiologists1. IPE refers to 2 or more professions learning with, from and about each other to improve collaboration and the quality of care, whereas IPL is learning that arises from interaction between members of 2 or more professions7. Rare and potentially disastrous ENT scenarios can be created and implemented, requiring interdisciplinary teamwork and communication for proper patient care. For instance, an in situ simulation course (one that uses actual clinical resources and equipment) at Boston Children’s Hospital teaches teamwork, CRM, and decision-making of high-risk, low frequency airway emergencies to a team of otolaryngology residents, anesthesia trainees, and operating room nurses8. Scenarios such as foreign body aspiration, the bleeding airway, or airway obstruction requiring a surgical airway can be simulated using a hybrid approach with mannequins and standardized patients. These complex educational modules can enhance the learning process and joint coordination of care for both specialists9,10. A rarer emergency includes the airway fire scenario, which not only tests the nontechnical skills and treatment, but also introduces the “fire triad” (oxidizer, ignition source, and fuel), and creates heightened awareness of anesthetic and surgical management to avoid such a disaster11–13. In situ simulations can also be conducted before implementation of new protocols to assess efficiency, to identify disruptions to workflow, and to evaluate various aspects of patient care such as systems-based errors and integration errors. At Johns Hopkins, an interdisciplinary difficult airway response team was created to manage hospital wide airway emergencies and incorporation of in situ simulations proved to be an invaluable tool to probe the system and to identify defects in resources14. A comprehensive, high-fidelity simulation curriculum incorporated into the ENT anesthesia fellowship allows the refinement of psychomotor skills for advanced airway as well as development of nontechnical management skills. Furthermore, when deliberate stressors are added to a fully immersive simulation involving participants in anesthesiology, otolaryngology and nursing, an opportunity is provided to enhance IPE and to facilitate multidisciplinary collaboration. A study conducted on advanced cardiac life support skills showed that adding extreme emotional stressors to a simulated scenario demonstrated an increased retention of skills and knowledge, as well as better performance of advanced cardiac life support15. Another study revealed that a negative outcome to the patient during simulated independent practice led to better retention of clinical skills upon retesting as compared with those who performed in a simulated supervised practice (where a superior helped intervene to prevent the negative outcome)16. The debriefing period that follows allowed the participants to reflect on individual practice and teamwork to identify weak links and areas of improvement for patient safety and care. Simulation has been used successfully as an assessment tool for medical students, residents, nurse anesthetists and practicing anesthesiologists17–20, as well those deemed incompetent21,22 or those retraining to reestablish competence23. Simulation is an ideal technique for fellowship training, education, and assessment of technical and nontechnical skills, especially in the subspecialty of ENT Anesthesia where unfamiliarity of rare ENT emergencies and crisis situations can have catastrophic implications. We urge that every ENT Anesthesia fellowship consider developing and incorporating simulation as part of the fellowship curriculum. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report.

BackgroundSurgical education necessitates hands-on training, which poses ethical challenges when practicing on real patients. Simulation training emerges as a pivotal solution, offering a safe and effective environment for skill acquisition. However, existing simulation models often overlook common surgical conditions like superficial skin abscesses. The National Medical Commission advocates for simulation-based training in basic surgical skills, highlighting the need for accessible and cost-effective models. Thus, this study aimed to develop and evaluate a novel Indigenous Cost-effective model for Incision & Drainage (NICA) of subcutaneous abscesses, addressing the gap in surgical education.MethodologyFollowing institutional ethics clearance, the study employed Kern’s Six-step approach for curriculum development. The NICA model was conceptualized and crafted using locally available, low-cost materials, validated by expert opinion, and implemented in a simulation lab setting. A total of 155 surgical interns underwent training, consisting of didactic video sessions, hands-on practice with the NICA model, and structured assessments. Pre- and post-training evaluations were conducted to measure interns’ performance and feedback.ResultsExpert validation confirmed NICA model’s fidelity and usefulness. Training 155 surgical interns resulted in significant skill improvements. Pre-training, 33% correctly performed pre-procedural requisites, 46% executed procedural techniques, and 48% performed post-procedural steps accurately. Post-training, these percentages surged to 95%, 97%, and 98%, respectively. Post test score showed significant skill enhancements across all domains (p < 0.05). Intern feedback highlighted increased confidence, satisfaction, and interest in learning, affirming NICA model’s effectiveness.ConclusionThe development and implementation of the NICA model offer a scalable and cost-effective solution for surgical training in resource-limited settings. The model’s effectiveness in enhancing interns’ skills and confidence underscores its potential to address training needs effectively. The study highlights the significance of simulation-based training in surgical education and advocates for the widespread adoption of indigenous low-cost models to improve surgical skills acquisition.

Aim Cross-specialty exposure within the training and education of surgical trainees has been suggested as a way to address the needs of increasingly complex patients driven by an aging population. As training pathways diverge early, enhancing cross-specialty understanding fosters improved teamwork, a core component of surgical practice. The aim of this study was to review current and emerging practices in cross-specialty exposure within surgical training and their benefits, as well as challenges, for trainees. Method For this review, PubMed, EMBASE, Medline, Google Scholar, Cochrane Central, and Web of Science were searched, from 2004 to 2024, for English articles pertaining to “cross-disciplinary” or “cross-specialty” and “surgical training” or “surgical education.” Results Several structured approaches, including attachments, rotations, team training, and simulation methods have demonstrated the potential to integrate technical and non-technical skills effectively for surgical trainees. Adaptations for emergency and rural general practitioners also highlight versatility in application. Importantly, these opportunities are usually received positively by both trainees and training providers. Key benefits include enhanced exposure to diverse practices, expanded knowledge bases, strengthened teamwork, and potential cost efficiencies. However, challenges remain, such as increasing already lengthy training periods, risks of burnout, and limited operative opportunities in certain specialties, particularly exacerbated post-COVID. Addressing compatibility with international training standards is complex given already significant global variability in surgical training. Conclusions Despite challenges, the demonstrated benefits of cross-specialty training suggest its inclusion in more surgical programs merits exploration to better prepare surgeons for collaborative, multidisciplinary care environments and complex patient care.

Changes to Training Practices during a Pandemic - The Experience of the Irish National Trauma & Orthopaedic Training Scheme

Background: The safety of patients and improvement in medical care to minimize the occurrence of adverse events is a widely discussed topic. In neurological emergencies, stroke stands out as a major concern. The time from recognition of the event to the initiation of treatment is crucial for outcomes, considering morbidity and mortality. Due to the emergency environment, there is a higher propensity for adverse events. Therefore, continuous education for team training is of utmost importance. For adults, the learning process differs from children, as they need to understand the reasons for their learning, motivated by problem-solving and active involvement in the learning process; in this aspect, realistic simulation becomes relevant. Objective: To evaluate the effectiveness of Realistic Simulation as a teaching and training method for stroke care teams. Methods: For the conduction of this review, the methodology proposed by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was used. Experimental studies of the type Clinical Trial, Quasi-Experimental, Cohort Studies and Case-Control studies were included; the study population was health professionals and the intervention was the use of Realistic Simulation as a training method in acute stroke care. The databases used were MEDLINE (PubMed), LILACS and Cochrane. The search was carried out in October 2023, by two independent evaluators, using the following search strategy: ("Realistic Simulation" OR "Simulation Training") AND ("Acute Stroke" OR Stroke). Results: A total of 159 studies were identified, of which 90 were selected and 17 included. Among the 17 studies evaluated, seven had the primary outcome of Door-to-Needle Time before and after team training through realistic simulation. All studies observed a reduction in Door-to-Needle Time, with some findings being statistically significant. Two studies assessed knowledge on the topic through pre and post-testing, both demonstrating an increase in score on the evaluation after training with Realistic Simulation. Another important concept addressed was Patient Safety, improvement in non-technical skills such as Leadership and Team Communication, which were also proven. Additionally, there was an improvement in personal perception of training capacity, greater learning of the topic, increased confidence in decision-making, and indication for thrombolysis. One of the limitations of this review was that, due to the diversity of study designs and primary outcomes, a meta-analysis was not performed. Conclusion: The results obtained through this systematic review allow us to conclude that training through Realistic Simulation for stroke patient care is associated with improved personal learning perception, acquisition of technical and non-technical skills, directly influencing important markers in acute stroke care, such as Door-to-Needle Time and higher thrombolysis rates.

Invited Commentary

WOCRM is based on the Crew Resource Management (CRM) training program developed in the aviation industry in the 1980's. It is an attitudinal and behavioural training methodology; used to continuously engage the crews in repetitive, hands on and interactive exercises and simulations, providing structured feedback to develop each crew members’ non-technical skills. The training was first developed for airline cockpit crews in the 1980's and has since flourished within commercial and military aviation, mining and medical industries. A review done for Qantas by David Hainsworth, (Briefing to Qantas safety management, 2000) indicated that 96% of their LTI's root causes were behavioural in nature. According to Edkins (2002), it follows that if we agree that the focus of CRM is to modify and reinforce effective safety Behaviour, it is reasonable then to assume that LTI's will be reduced. If LTI's are reduced, so too then is the costs associated with them, which in Oil and Gas can go into the billions and so a very good Return on Investment (ROI). Focusing on Oil and Gas, the IOGP reports clearly indicate that Well Operations Crew Resource Management (WOCRM) training is required and that it should be incorporated into the mandatory International Well Control Forum (IWCF) and International Association of Drilling Contractors (IADC) Well Control Training. This is all well and good, however, if anything is to be learned from Dr Graham Edkins, (The state of the nation: How mature are HF/NTS programs within the Australian Airline Industry?, 2012) training alone is not enough. From a psychological standpoint, to change or correct a Behaviour takes 66-270 days of repetition and constructive feedback. Therefore, the new Behaviour, process or procedure must be repeated for at least 3 months, to ensure that the Behaviour or procedure will in fact be applied when needed, especially in a stressful situation. This then implies the need to add coaching techniques to the methodology, which this paper will introduce. The major benefit to Oil and Gas, is that all of the techniques mentioned herein have already been created and developed, and our Industry simply has to apply the lessons learned from those that are more advanced, to create a continuous personal development methodology to reduce Lost Time Incidents (LTI's) caused by human error, which would have a potentially massive effect on the financial loss associated with these errors, concluding that this methodology could have a very impressive Return on Investment (ROI) for companies large and small.

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: A competent urologist should not only have effective technical skills, but also other attributes that would make him/her a complete surgeon. These include team-working, communication and decision-making skills. Although evidence for effectiveness of simulation exists for individual simulators, there is a paucity of evidence for utility and effectiveness of these simulators in training programmes that aims to combine technical and non-technical skills training. This article explains the process of development and validation of a centrally coordinated simulation program (Participants - South-East Region Specialist Registrars) under the umbrella of the British Association for Urological Surgeons (BAUS) and the London Deanery. This program incorporated training of both technical (synthetic, animal and virtual reality models) and non-technical skills (simulated operating theatres). To establish the feasibility and acceptability of a centralized, simulation-based training-programme. Simulation is increasingly establishing its role in urological training, with two areas that are relevant to urologists: (i) technical skills and (ii) non-technical skills. For this London Deanery supported pilot Simulation and Technology enhanced Learning Initiative (STeLI) project, we developed a structured multimodal simulation training programme. The programme incorporated: (i) technical skills training using virtual-reality simulators (Uro-mentor and Perc-mentor [Symbionix, Cleveland, OH, USA], Procedicus MIST-Nephrectomy [Mentice, Gothenburg, Sweden] and SEP Robotic simulator [Sim Surgery, Oslo, Norway]); bench-top models (synthetic models for cystocopy, transurethral resection of the prostate, transurethral resection of bladder tumour, ureteroscopy); and a European (Aalborg, Denmark) wet-lab training facility; as well as (ii) non-technical skills/crisis resource management (CRM), using SimMan (Laerdal Medical Ltd, Orpington, UK) to teach team-working, decision-making and communication skills. The feasibility, acceptability and construct validity of these training modules were assessed using validated questionnaires, as well as global and procedure/task-specific rating scales. In total 33, three specialist registrars of different grades and five urological nurses participated in the present study. Construct-validity between junior and senior trainees was significant. Of the participants, 90% rated the training models as being realistic and easy to use. In total 95% of the participants recommended the use of simulation during surgical training, 95% approved the format of the teaching by the faculty and 90% rated the sessions as well organized. A significant number of trainees (60%) would like to have easy access to a simulation facility to allow more practice and enhancement of their skills. A centralized simulation programme that provides training in both technical and non-technical skills is feasible. It is expected to improve the performance of future surgeons in a simulated environment and thus improve patient safety.

The efficacy of simulation-based training in surgical education is well known. However, the development of training programs should start with problem identification and a general needs assessment to ensure that the content is aligned with current surgical trainee needs. The objective of the present study is to identify the technical skills and clinical procedures that should be included in a simulation-based curriculum in general surgery. A national, three-round Delphi process was conducted to achieve consensus on which technical skills and clinical procedures should be included in a simulation-based curriculum in general surgery. In total, 87 key opinion leaders were identified and invited to the study. Round 1 of the Delphi process had a response rate of 64% (56/87) and a total of 245 suggestions. Based on these suggestions, a consolidated list of 51 technical skills or clinical procedures was made. The response rate in Delphi round 2 was 62% (54/87) resulting in a pre-prioritized order of procedures for round 3. The response rate in Delphi round 3 was 65% (35/54). The final list included 13 technical skills and clinical procedures. Training was predominantly requested within general open surgical skills, laparoscopic skills, and endoscopic skills, and a few specific procedures such as appendectomy and cholecystectomy were included in the final prioritized list. Based on the Delphi process 13 technical skills and clinical procedures were included in the final prioritized list, which can serve as a point of departure when developing simulation-based training in surgery.

Mental Training in Surgical Education