Traditionally, surgeons have been trained and evaluated on the basis of their performance of surgical procedures in live patients. This article in the Medical Education series explores the use of mechanical devices for the teaching and evaluation of surgical skills.

Teaching Surgical Skills — Changes in the Wind

Background: Virtual reality (VR) training has been shown previously to improve intraoperative performance during part of a laparoscopic cholecystectomy. The aim of this study was to assess the effect of proficiency-based VR training on the outcome of the first 10 entire cholecystectomies performed by novices.

Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies.

Objective: To determine whether skills acquired by simulationbased training transfer to the operative setting. Summary Background Data: The fundamental assumption of simulation-based training is that skills acquired in simulated settings are directly transferable to the operating room, yet little evidence has focused on correlating simulated performance with actual surgical performance. Methods: A systematic search strategy was used to retrieve relevant studies. Inclusion of articles was determined using a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Only studies that reported on the use of simulationbased training for surgical skills training, and the transferability of these skills to the operative setting, were included. Results: Ten randomized controlled trials and 1 nonrandomized comparative study were included in this review. In most cases, simulation-based training was in addition to normal training programs. Only 1 study compared simulation-based training with patient-based training. For laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy, participants who received simulation-based training before undergoing patient-based assessment performed better than their counterparts who did not receive previous simulation training, but improvement was not demonstrated for all measured parameters. Conclusions: Skills acquired by simulation-based training seem to be transferable to the operative setting. The studies included in this review were of variable quality and did not use comparable simulation-based training methodologies, which limited the strength of the conclusions. More studies are required to strengthen the evidence base and to provide the evidence needed to determine the extent to which simulation should become a part of surgical training programs. (Ann Surg 2008;248: 166‐179)

A systematic review of skills transfer after surgical simulation training.

Changes in the surgical training curriculum, precipitated by limitations to resident work hours,1,2 concerns over patient safety,3,4 and budgetary constraints in the operating room5,6 have compelled surgical educators to search for more effective and creative means of teaching surgical skills. Emerging technologies have also created a need for strategies to deliver technical education to surgeons already in practice. Consequently, laboratories dedicated to teaching technical aspects of surgical skill have become increasingly popular worldwide. These laboratories deploy an increasing array of training models, both low and high fidelity, many of which have been validated as effective teaching tools.7,8 Much work has been done on the development of performance metrics of assessment that can chart the progress through training regimens, demonstrate effects of intervention, and differentiate between varying levels of experience.9,10 Recently, there has been an important focus on ensuring that skills taught in laboratory environments can translate to the real world of human operations.11,12

Despite the important work on model development, simulators, and assessment methodologies, there is needed effort in the realm of curricular development.13 The ways in which the training is delivered (how, what, when, and how often) are equally important. For example, in many programs, junior residents learn a particular skill 1 week and return the next week to learn a different skill, with very little opportunity structured within the curriculum to rehearse what has previously been taught. Likewise, many CME programs offer courses that are short and intensive (1-day or weekend), not allowing for rehearsal of skills after a period of rest (and forgetting) has elapsed. Commonly, there is a delay between the time the skill is learned in the laboratory and the time the skill is needed in the operating room. Performance may be adequate immediately following training, but how much is retained is uncertain. The ultimate value of skills courses should be measured not by performance immediately after training, but by performance after a time delay, preferably in a realistic setting.

Drawing upon the motor skill learning principle of massed versus distributed practice found in the domains of psychology and athletics, there is good evidence that practice interspersed with periods of rest (distributed practice), leads to better acquisition and retention of skill compared with practice delivered in continuous blocks with little or no rest in between (massed practice).14–16 How these principles transfer to the domain of surgical skill acquisition have yet to be demonstrated. This randomized controlled trial was designed to assess the impact that scheduling of practice (massed versus distributed) has on surgical skill acquisition. The study was designed to have maximal relevance to current residents' surgical skills courses and curricula. Using previously validated outcome measures and microsurgery as the technical skill domain, this study evaluates not only the immediate impact of each training schedule, but more importantly, the durability of skill acquisition (“retention” testing 1 month later) and the clinical transferability of the skill to a more realistic setting (testing on live anesthetized rats).

Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial.

Objective:
To evaluate the effectiveness of surgical simulation compared with other methods of surgical training.

Surgical simulation: a systematic review.

Background:
This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy.

Methods:
Sixteen surgical trainees performed a laparoscopic cholecystectomy on patients in the operating room (OR). The participants were then randomized to receive VR training (ten repetitions of all six tasks on the Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR)) or no training. Subsequently, all subjects performed a further laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotape, and assessed by two independent and blinded observers using predefined objective criteria. Time to complete the procedure, error score and economy of movement score were assessed during the laparoscopic procedure in the OR.

Results:
No differences in baseline variables were found between the two groups. Surgeons who received VR training performed laparoscopic cholecystectomy significantly faster than the control group (P = 0·021). Furthermore, those who had VR training showed significantly greater improvement in error (P = 0·003) and economy of movement (P = 0·003) scores.

Conclusion:
Surgeons who received VR simulator training showed significantly greater improvement in performance in the OR than those in the control group. VR surgical simulation is therefore a valid tool for training of laparoscopic psychomotor skills and could be incorporated into surgical training programmes. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

J Bendix

Papers

Randomized clinical trial of virtual reality simulation for laparoscopic skills training.