Learning gynecologic surgery from a simulator

We may no longer have the luxury of acquiring surgical skills through traditional residency training programs in which students learn by observation, practice at the tableside, and spend a final year of independent, supervised work both in the operating room and the lecture halls. The "See one, do one, teach one" approach based on Dr. William Halsted's principles of teaching surgery has been the norm for surgical education for decades. But limitations in resident work hours and declining surgical caseloads have thrust the problem of adequate training and appropriate evaluation to the forefront of medical education.

Surgical simulators have been available for many years, and in many formats. For more than a decade, our group has been involved with teaching via surgical simulators, including pelvic trainers (simple box-tools to enhance eye-hand coordination), animal labs (teaching proficiency in tissue handling), and cadaver labs (providing anatomically correct models). Each has its strengths and weaknesses, but all provide an opportunity to practice surgical skills in a safe environment, risk-free to a patient.

Recently developed virtual reality (VR) platforms can now replace or enhance some of these simulators. Virtual environments that simulate hysteroscopic or laparoscopic surgical scenarios can be equipped with software that's capable of assessing competence, identifying errors, and teaching specific surgical skills and procedures. As these new technologies advance, they likely represent the future of surgical teaching, testing, and competency evaluation. Our goal here is to review a few of the latest tools on the market, as well as some of the current issues surrounding the development of VR and other simulators.

Validating improved surgical skills Simulators continue to evolve in their ability to visually approximate real tissue, to provide haptic (tactile) feedback (that is, feel like the real thing), and to simulate increasingly complex tasks and procedures. As their use in surgical training becomes more common, it is important to demonstrate that these exercises actually improve the operative skills of the trainee. Many studies suggest that simulators improve surgical performance when used as part of a structured training program. For example, a recent study presented at the Society of American Gastrointestinal Endoscopic Surgeons using LapSim and MIST VR showed that students who underwent simulator training for 10 weeks increased their intracorporeal knot-tying speed by 66%.¹ Data exist for many other simulators-both VR based and box trainers-and although much of the work of validating trainers has been done in the field of general surgery, some data exist for ob/gyn trainees as well.^2,3