In Brief

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New technologies, more complex procedures, and a host of external constraints have changed where and how surgical skills are taught. Rather than learning through supervised patient care, residents are increasingly gaining required knowledge in nonclinical environments that focus on the acquisition of technical skills. Recently, the curriculum has expanded to include communication, teamwork, and crew resource management.

The advent of laparoscopy created a need to learn new surgical skills. Many surgeons had not kept pace with technology advances and were often ill prepared for laparoscopic procedures. Specifically, they lacked adequate expertise with 2-dimensional imaging, diminished tactile feedback, and required hand-eye coordination. Accordingly, the incidence of complications, including common bile duct injuries, skyrocketed 5-fold. Many of these skills could be taught effectively in laboratory settings, using either animate or inanimate models. In turn, the surgical community began to explore the use of models and simulators.

In the past decade, a plethora of surgical skill and simulation centers have emerged at academic medical centers across the United States. The American College of Surgeons (ACS) has instituted a process for accrediting such facilities as education centers, and has developed a detailed curriculum for their use in training residents. Currently, the ACS has accredited 27 education institutes in the United States and United Kingdom. This represents a large-scale investment in a relatively new approach that has yet to be proven unequivocally effective.

In designing surgical skills training and simulation centers, the goal is not only to bring together a host of procedural stations or tools, but also to develop authentic patient care sites that can be used to run real-life scenarios of patient care situations. Mock operating rooms, emergency departments, patient rooms, and intensive care units should be designed to run full codes, traumas, operations, and other simulated but instructional patient cases. These need to be sufficiently staffed with administrative personnel, educators, and clinical experts to ensure authenticity and provide necessary feedback to learners. The best centers currently provide feedback via direct expert supervision during procedures or by debriefing sessions following a simulation.

Simulation technology has quickly evolved from early box trainers to virtual reality operations. Early box trainers lacked integrated timers and error-tracking systems; a stopwatch was used to assess the speed at which an intracorporeal knot was tied, or beans dropped into a cup. Ideally, task trainers or simulators can record and analyze metrics in real-time to provide immediate feedback and the opportunity for graded improvement.

The advent of virtual reality simulators with computerized interfaces has led to several stand-alone systems that record metrics and create reports. These systems are automated and efficient. They provide a unique opportunity for self-directed practice that leads to proficiency. A centralized database of multiple users and their practice results may be ideal in a training environment or in the simulation and skills center.

In 1997, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) launched a computer-based certification program, the Fundamentals of Laparoscopic Skills (FLS), to assess the competence of surgeons to perform basic laparoscopy. The program, which evolved out of the task-based McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), tests learners with a peg transfer, pattern cutting, ligating loop, extracorporeal suturing, and intracorporeal suturing. It includes didactic components that cover the basic concepts of laparoscopy and skills tasks. It also provides a computer-based quiz of 75 multiple-choice questions. To become certified in FLS, surgeons complete a proctored examination that assesses 5 psychomotor skills in a standardized training box scored for time and errors. Since its inception, FLS has been adopted as a requirement by some surgical training programs. The success of the initiative has also led the way for the American Board of Surgery to require FLS certification for all general surgeons to qualify for board certification.

Lord Ara Darzi and colleagues at the Imperial College in London performed procedures in a simulated operating theater with a standardized surgical team. An unobtrusive clinical data recorder observed operating room events, and assessment of performance was facilitated by blinded rating of technical skills. A human factors expert and trained surgical research fellows reviewed a checklist with technical skills, communication, and a global rating of the team. Participants in the scenario underwent a debriefing session and rated the face validity of the simulated environment. The goal was to achieve a high level of realism in which to simulate team interactions and performance. An evaluation by a third party and a subsequent debriefing session were essential components of the simulation.

Inspired by the work of Darzi and colleagues, D.B. Jones built the first mock endosuite in 2006 at the Carl J. Shapiro Simulation and Skills Center (Beth Israel Deaconess Medical Center, Boston, MA). The endosuite includes multiple camera mountings, directional microphones, and sophisticated data management to record all communication and activity during a laparoscopic simulation. A separate control room with video monitors overlooks the simulation via a 1-way mirror. Laparoscopic equipment and the anesthesia machine are fully functional and integrated into the control room monitors. Powers and Rehrig and colleagues demonstrated face and construct validity of a mock operating endosuite with laparoscopic crisis scenarios. FLS-certified and non-FLS-certified surgeons were placed in a laparoscopic crisis scenario with an abdominal model integrated with a whole-body mannequin in a high-fidelity endosuite. Time to diagnose intraoperative bleeding following Veress needle entry was recorded, as well as time to inform the operating team for the need to convert to an open procedure, and the actual time to conversion. A validated team-based assessment was used to evaluate communication, followed by a debriefing session. This scenario was recreated at the SAGES 2007 annual meeting and is the basis for module 12 of the ACS/ASPDS National Skills Curriculum, Phase III.

The impact of clinical medicine and surgery go far beyond the operating room. Taking skills training and simulation beyond procedural-based curricula represents a revolution in traditional surgical education. Essentially, the concept of what is a “surgical skill” can be expanded to include all of the perioperative activities of a surgeon, from evaluating a patient to discussions with family members.