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 Table of Contents  
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 84-89

The importance of laparoscopic simulation in the continuing medical education of community surgeons

The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA

Date of Web Publication7-Jul-2017

Correspondence Address:
Thomas J Papadimos
College of Medicine and Life Sciences, University of Toledo, Toledo, OH
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_37_17

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One well-established challenge for medical educators and surgeons is maintaining patient safety during a period of widespread surgical skill acquisition. The incongruity between evidence-based recommendations and real-world practice highlights the inadequacy of our current continuing medical education (CME) tradition, which consists of short courses and preceptored practice. The effectiveness of short courses for surgical skill training has been questioned many times since the beginning of the laparoscopic revolution. Laparoscopic simulation trainers also offer pedagogical advantages over other CME formats because they are learner centric, allowing for skill acquisition and improvement without the responsibility of patient care. Ongoing research is providing new evidence that simulation is of paramount importance to continuing professional development as it has been in graduate medical education. After briefly outlining the limitations of our current surgical CME paradigm, this paper will suggest that medical simulation using laparoscopic simulation trainers is a powerful yet underutilized adjunct to the current methods of surgical training for the practicing community surgeon.
The following core competencies are addressed in this article: Patient care, Medical knowledge, Practice-based learning and improvement.

Keywords: Continuing medical education, laparoscopy, medical simulation, surgery

How to cite this article:
Vanderbilt AA, Baugh RF, Muscaro MK, Papadimos TJ. The importance of laparoscopic simulation in the continuing medical education of community surgeons. Int J Acad Med 2017;3:84-9

How to cite this URL:
Vanderbilt AA, Baugh RF, Muscaro MK, Papadimos TJ. The importance of laparoscopic simulation in the continuing medical education of community surgeons. Int J Acad Med [serial online] 2017 [cited 2022 Jan 25];3:84-9. Available from: https://www.ijam-web.org/text.asp?2017/3/1/84/209841

  Introduction Top

One well-established challenge for medical educators and surgeons is maintaining patient safety during a period of widespread surgical skill acquisition.[1],[2] Historically, patient care has suffered as new surgical procedures are implemented.[3] The global adoption of laparoscopic cholecystectomy was rapid but resulted in a temporary increase in adverse surgical events, particularly bile duct injuries.[4],[5] The increased surgical complication rate was attributed to the surgical learning curve or the period during which surgeons continue to improve their newly acquired skills through practice.[5],[6],[7] The effect of the laparoscopic learning curve on patient safety seemed to be related to a lack of effective continuing medical education (CME) for the acquisition of the laparoscopic skills necessary to complete the new procedure.[3],[7]

Today, laparoscopic innovation persists, and CME in the field of surgical skill acquisition continues to underperform. The most recent example involves laparoscopic hysterectomy. A recent survey revealed that many gynecologists agree with guidelines endorsing minimally invasive approaches to hysterectomy but have not implemented these guidelines because of a perception of technical difficulty and a lack of training and experience with laparoscopic hysterectomy.[8] Of the nearly 600,000 hysterectomies performed annually in the United States, 66% are still performed as an open procedure.[9] Even though laparoscopic hysterectomy was first introduced in 1988, only 12% of American hysterectomies are conducted minimally invasively.[8],[10] The incongruity between evidence-based recommendations and real-world practice highlights the inadequacy of our current CME tradition, which consists of short courses and preceptored practice. The effectiveness of short courses for surgical skill training has been questioned many times since the beginning of the laparoscopic revolution.[1],[3],[4],[5],[7],[11],[12] While longer or mentorship-style training alternatives have been proposed, they have not been extensively implemented because of feasibility concerns.[3] After briefly outlining the limitations of our current surgical CME paradigm, this paper will suggest that medical simulation using laparoscopic simulation trainers is a powerful yet underutilized adjunct to current methods of surgical training for the practicing community surgeon.

  The Limitations of Short Courses Top

In an attempt to maintain quality control in the early days of laparoscopy, the Society for American Gastrointestinal and Endoscopic Surgeons (SAGES) published training guidelines recommending that surgeons complete an accredited skills course and preceptor with an experienced laparoscopic surgeon before performing laparoscopic cholecystectomy alone.[5] The popularity of accredited “short courses” soared as surgeons saw these intensive, 1–3-day surgical training courses as time-efficient and financially feasible ways to comply with the guidelines. Two decades later, short courses are the basic unit of CME for the acquisition of new surgical skills, with or without the practical supervision originally recommended by SAGES.[3],[5]

While many short courses demonstrate effective skill acquisition, few collect data regarding skill retention in the months follow course completion.[11] It has been established that short bursts of multifaceted instruction over weeks promote long-term skill retention more effectively than a single long session, so the brief, intensive nature of short courses may inhibit long-term skill retention.[5],[11] Skill retention is an important consideration because surgeons often wait for the ideal surgical candidate to start their new surgical experience, sometimes causing a significant delay between instruction and implementation.[12]

Furthermore, while surgeons already practicing advanced laparoscopy might find a short course adequate for their needs, surgeons with a more basic exposure to laparoscopy often consider short courses, a mere introduction.[3],[7],[12] In the early days of laparoscopic cholecystectomy, one survey revealed that surgeons did not feel comfortable performing the procedure after attending a 2-day workshop.[13] Later, another survey showed that surgeons tended not to perform laparoscopic splenectomies on their own patients despite successfully completing a skills course. The surgeons who hesitated cited “high stakes” and “low tolerance for mistakes” as their chief concerns.[12] Just as the original SAGES guidelines recommended, many surgeons may require additional supervised practice beyond the short course, particularly if the laparoscopic procedure falls too far above their comfort level.[5],[7],[12]

  Preceptored Practice Top

Learning under the supervision of more experienced colleagues was a cornerstone of medical education long before it was a component of the SAGES guidelines for the acquisition of laparoscopic skills. There is evidence that proctoring, specifically in the learner's own operating room, is a strong adjuvant to short course training.[2],[5],[7] In a need of assessments regarding CME, 73% of surgeons preferred proctoring to short courses for the acquisition of surgical skills.[3] Together, these two studies suggest that surgeons feel confident in the skills; they attain through a proctoring format. Unlike a short course, proctoring allows for an extended period of individualized practice, remediation, and immediate expert feedback within the surgeon's operating room. The length of instruction, moreover, can be tailored to the individual's learning curve and almost always involves more than one episode, increasing the potential for long-term skill retention even if a delay in further practice occurs.[11] In addition, it has the practical benefit of helping the surgeon fulfill hospital privileging requirements, which frequently requires the surgeon to log a certain number of cases with a preceptor before operating unassisted.[14]

While postcourse proctoring ameliorates many of the shortcomings of the short course, it has logistical drawbacks. When the Rural Physician Action Plan of Alberta Canada recognized that many rural physicians had no access to new skill development because of their geographic isolation, “skills brokers” were hired to travel the region proctoring rural physicians until their individual needs were met.[15] While this was an effective model, expert proctors are not always available to surgeons who practice in rural communities or under low-volume conditions.[14] While gynecologists in large US academic centers describe a successful transition from abdominal hysterectomy to laparoscopic hysterectomy,[16] in the United States community gynecologists claim training barriers to the procedure.[8]

Proctor availability notwithstanding, supervised practice creates ethical concerns in light of modern-day quality control and patient safety initiatives.[4] In England, some medical organizations are openly declaring that patients should not be exposed to surgeons operating during the early phase of their learning curves.[6] In the United States, patient advocates are demanding that informed consent routinely includes full disclosure of the surgeon's case-specific experience and outcomes.[17],[18] If these recommendations are adopted, proctored training may become more difficult when surgeons are compelled to disclose to patients that they are still in the learning process.

The operating room is a suboptimal educational environment in other ways as well. Studies suggest that when physicians learn in the workplace, most of their education is incidental to the task itself.[19] Practice sessions in the operating room are by their very nature “patient centric” rather than “learner centric.”[19],[20] In other words, a surgeon performing a procedure on a living person has little time for real-time reflection, skill repetition, or remediation.[19],[20]

  Laparoscopic Simulation Trainers Top

Laparoscopic simulation trainers have been available since the early 1990s when the transition from open to laparoscopic procedures began [Figure 1].[21] The technology, used primarily for training residents, has evolved from simplistic box trainers to high-fidelity virtual reality trainers [Figure 1]. Investigators have confirmed skill transferability of laparoscopic simulation and found evidence that the trainers improve knowledge, reduce the risk of adverse surgical events, reduce operating times, and improve efficiency of surgical movements, all while circumventing the concerns of patient advocacy groups regarding the ethics of practicing on living patients.[4],[21],[22] Given the growing body of literature validating its efficacy, some authors believe that laparoscopic simulation training will become a compulsory component of graduate medical education [4],[23] and undergraduate medical education.
Figure 1: Traditional laparoscopic box trainer

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Laparoscopic simulation trainer use in CME has been limited to short courses for which they have been found effective.[24] Prior researchers found that experienced and novice surgeons learn new surgical skills in a similar fashion.[5] In fact, Boza et al. have presented evidence that simulation-trained junior residents were better than graduated general surgeons on advanced procedures.[25] In ten junior residents, twelve general surgeons, and five bariatric surgeons, there was a demonstration of the transference of advanced laparoscopic surgical skills through simulation. The authors correctly comment that quality, efficiency, and patient safety can be substantially impacted in a positive fashion.

Further, Shore et al. designed a standard laparoscopy curriculum for gynecology residents which established benchmarks for identification of virtual reality tasks at the basic, intermediate, and advanced levels.[26] Such an addition to a training program would be part of a competency-based medical education (CBME) while CBME has its critics such as decreases motivation, creates minimal acceptable standards, increases administrative work, and reduces educational content.[27] In an accompanying editorial, Geoffrey Cundiff instructs us that “these concerns are largely related to how CBME is implemented rather to inherent shortcomings on the model itself.”[28] Again, a positive view of laparoscopy through simulation, regardless of its CBME relationship. De Win et al. have presented evidence that a laparoscopic simulation curriculum can shorten clinical learning and contribute to patient safety through reduction of adverse events during surgical education/residency.[29]

Laparoscopic simulation trainers also offer pedagogical advantages over other CME formats because they are learner centric, allowing for skill acquisition and improvement without the responsibility of patient care [Figure 2].[20] Unlike short courses or proctoring with live patients, a laparoscopic simulation trainer allows surgeons to practice skills on their own schedules with less risk of a lapse between practice and execution. Laparoscopic simulation trainers also allow the surgeon to practice a skill repetitively while providing immediate and objective feedback against a previous performance or a set benchmark.[4],[23],[30]
Figure 2: The advantages of learner-centric skill acquisition and improvement through laparoscopic medical simulation

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While further investigation is needed, the consistent access to objective feedback provided by the laparoscopic simulation trainer may also improve the accuracy of a surgeon's self-assessment. This is important because self-assessment has been identified as a central component for professional self-regulation.[31] Historically, self-assessment has been difficult for surgeons because of a lack of objective evaluation in the medical field.[19] The traditional benchmark, patient outcomes, has so many confounding variables that one study suggests that physicians spend little time reflecting on their performance because job performance is so difficult to assess.[19] Laparoscopic simulator trainers provide feedback specific to surgical skill,[30] and access to this dependable objective feedback may encourage surgeons to exercise their own self-assessment ability.

As previously established, geographically isolated surgeons encounter more barriers to continuing professional development than surgeons practicing near academic centers.[8],[14],[15] Laparoscopic simulation trainers may offer practical solutions for these surgeons. According to one study, preceptors are not needed to assist learners with the laparoscopic simulation trainers. In fact, giving the learner a self-study resource and time to practice until they achieve established proficiency, benchmarks may be more efficient than providing a proctor to guide the learner through the simulation exercises.[23] Because laparoscopic simulator trainers are portable, shipping easily between affiliated hospitals and into rural areas, they may be a potent educational adjunct for geographically isolated surgeons.

Finally, routine access to laparoscopic simulator trainers may allow surgeons to maintain or continually improve the surgical skills that they have acquired previously.[21] Research has shown that when highly experienced professionals are motivated, they can continue to advance their objective performance by purposefully targeting skills that can be improved.[32] Laparoscopic simulator trainers, with their learner-centric opportunities for repetition and immediate feedback, provide a framework for this deliberate practice.[32] Furthermore, surgeons operating under low-volume conditions could use additional time logged on a laparoscopic simulation trainer as a supplement for skill maintenance. This is particularly important given that high surgical volume is positively correlated with better patient outcomes, even after controlling for hospital volume.[32]

  Laparoscopic Simulation “plus” Top

While we have emphasized laparoscopic simulation training as effective method of CME for surgeons, we also encourage “scenario work” (i.e., the “plus”) in conjunction with laparoscopic training. By “scenario work,” we mean to highlight simulated high-fidelity scenarios in the setting of a simulation center operating theater, where laparoscopic complications may be mimicked using a full body manikin that actually hemorrhages (or has other complications) that necessitates an increased cognitive stress for the surgeon in the presence of anesthesiology and nursing teams that are assisting with the procedure [Figure 3]. The surgeon must not only solve the surgical predicament but also use the anesthesiology and nursing staff to assist her or him, thereby leading a team solution to assist the surgeon to ensure a safe patient outcome. A further extension of such scenarios includes the use of unembalmed cadavers, which, if refrigerated properly, can be used multiple times by learners. In this case, the cadaveric anatomy and difficulty in dissection is very close to reality [Figure 4].
Figure 3: High-fidelity team simulation scenario

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Figure 4: Cadaveric laparoscopy

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  Potential Areas of Research Top

We are suggesting that the acknowledged limitations of recent CME tradition, combined with the need for large-scale professional development in advanced laparoscopic skills and the success of laparoscopic simulation trainers in residency training, are a sound argument for an investigation into the broader use of laparoscopic simulation trainers in CME. Additional information is needed concerning practicing surgeons' attitudes toward using simulators as a means of improving current laparoscopic skills or as an adjunct to other traditional methods of surgical skill acquisition. The usefulness of routine access to laparoscopic simulation trainers needs to be confirmed in this population. Furthermore, the prevalence of the substitution of simulation for live surgical cases for the purposes of hospital privileging and whether substitution is appropriate needs to be assessed. Simulators may be most useful for geographically isolated surgeons, particularly those who practice under low surgical volume conditions. Further study is required to assess the validity of this assumption and to address the cost-effectiveness of using laparoscopic simulation trainers in this setting, especially as it may relate to those surgeons in less advanced/economically and/or technologically disadvantaged areas of the world.

  Conclusion Top

Short courses for the acquisition of new surgical skills have the advantage of accessibility and efficiency, but if the skills are too dissimilar from the surgeon's current skillset or the hospital has case log requirement for procedure privileging, then practice beyond the short course is necessary. Proctoring has traditionally fulfilled this need, but proctoring can present logistical and now ethical dilemmas. Access to proctoring has proven to be a barrier in the adoption of laparoscopic surgical procedures in isolated areas, which often lag years behind large urban academic centers in the implementation of beneficial surgical techniques. Laparoscopic simulation has the potential to augment proctoring, if not replace it altogether under certain circumstances. Laparoscopic simulation training has pedagogical and ethical advantages over practicing on live patients and could potentially mitigate some of the disadvantages regarding continuing professional development experienced by surgeons practicing under low-volume conditions or in geographically isolated areas. Ongoing research is providing new evidence that simulation is of paramount importance to continuing professional development as it has been in graduate medical education.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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