The role of simulation technology for skills acquisition in image guided surgery

Technical proficiency is an essential ingredient in surgical competence, which has hitherto been poorly evaluated. The introduction of disruptive technology into the Operating Room (OR) with respect to operative procedures requires an equally disruptive paradigm shift in surgical training that matches the development in OR technology. Automation and overcoming difficulties in navigating these technologies, is probably best achieved outside the OR and, therefore, the conventional apprenticeship model does not fit well with the development of such skills.

Simulators have been a part of the aviation training curriculum for over 70 years and this technology has now confronted surgical education. In all fields where simulators have been implemented, error reduction has been the major driving force and the surgical discipline is no exception. In fact, medical errors have become a significant source of patient risk, and increasing complexity, as in surgical care, implies increasing error proneness. The effect of simulator training with respect to transfer of skills from the simulated environment to the OR is of crucial interest if this technology is to reach compulsory status in surgical education.

The general aim of this study was to investigate the possible role of simulation technology as an integral component in future educational programs in image guided surgery.

Paper I describes a randomised, controlled study where laparoscopic skills were assessed for a group of novices performing, under supervision of an experienced laparoscopic surgeon, in a porcine model in the OR. All procedures were videotaped and reviewed. Performance in the simulator was demonstrated to correlate with performance in the operating room. In a prospective study design.

Paper II deals with the learning curve for laparoscopic fundoplication in a group of surgical trainees during the performance of their first 20 supervised procedures. Three independent observers assessed the operations, giving scores for essential parts of the procedure. The shape of the individual's learning curve varied immensely and the level of the teaching surgeon seemed to limit the pupil's possibility to reach a high grade.

Papers III and IV were randomised, controlled trials where skills transfer from Virtual Reality (VR) to OR was studied. Simulator-trained subjects performed significantly better during their first 10 colonoscopies (Paper III) and in their first 10 laparoscopic cholecystectomies (Paper IV), as compared to the respective control groups.

In conclusion, we have demonstrated that novice performance measured in a VR-simulator seems to predict the ultimate performance in the OR. Moreover, proficiency-based training facilitated skills transfer to the actual clinical environment, thereby, constituting a training curriculum that greatly improves the initial learning curve in endoscopic procedures. Thus, as a result of these studies the AccuTouch® and the LapSim® systems can now be considered as clinically validated for this purpose. In addition, the performance level of the teaching surgeon seemed to greatly influence the proficiency level attainable by the surgeon in training.

We believe that the objective methods for assessing technical skills in the OR developed in this study, and by others, will provide the possibility to explore the link between technical performance and patient outcome. Furthermore, the results in this study strongly support the ongoing implementation of simulation technology for skills acquisition and assessment in image-guided surgery.

List of scientific papers

I. Ahlberg G, Heikkinen T, Iselius L, Leijonmarck CE, Rutqvist J, Arvidsson D (2002). Does training in a virtual reality simulator improve surgical performance? Surg Endosc. 16(1): 126-9.
https://doi.org/10.1007/s00464-001-9025-6

II. Ahlberg G, Kruuna O, Leijonmarck CE, Ovaska J, Rosseland A, Sandbu R, Stromberg C, Arvidsson D (2005). Is the learning curve for laparoscopic fundoplication determined by the teacher or the pupil? Am J Surg. 189(2): 184-9.
https://doi.org/10.1016/j.amjsurg.2004.06.043

III. Ahlberg G, Hultcrantz R, Jaramillo E, Lindblom A, Arvidsson D (2005). Virtual reality colonoscopy simulation: A compulsory practice for the future colonoscopist? Endoscopy. [Accepted]
https://doi.org/10.1055/s-921049

IV. Ahlberg G, Enochsson L, Gallagher A, Hedman L, Hogman C, McClusky D, Ramel S, Smith D, Arvidsson D (2005). Compulsory simulator training for residents prior to performing laparoscopic cholecystectomy? [Submitted]