Open Lobectomy Simulator Is an Effective Tool for Teaching Thoracic Surgical Skills

Use of Low-Cost Task Trainer for Emergency Department Thoracotomy Training in General Surgery Residency Program

OBJECTIVE

Emergency department thoracotomy (EDT) is an uncommon but potentially lifesaving procedure that warrants familiarity with anatomy, instruments, and indications necessary for completion. To address this need, we developed a low-cost EDT trainer. The primary objective of this study was to compare the effectiveness of a low-cost EDT trainer to teach emergency department thoracotomy with a discussion-based teaching session. Secondary objective was to study the face validity of the low-cost EDT trainer.

DESIGN

A prospective 2-phase randomized control study was conducted. Participants were randomly divided into two groups. In phase one, baseline medical knowledge for both groups was assessed using a multiple-choice question pretest. In Group 1, each participant was taught EDT using a one-on-one discussion with a trauma surgeon, whereas Group 2 used the EDT trainer and debriefing for training. In phase 2 (1 month later), all participants completed a knowledge retention test and performed a videoed EDT using our EDT trainer, the video recordings were later reviewed by content experts blinded to the study participants using a checklist with a maximum score of 22. The participants also completed a reaction survey at the end of phase 2 of the study.

SETTING

OhioHealth Riverside Methodist Hospital, an urban tertiary care academic hospital in Columbus, Ohio.

PARTICIPANTS

Nine senior surgery residents from training years 3 to 5.

RESULTS

The mean score for the performance of the procedure for the simulation-based (Group 2) was significantly higher than that of the discussion-based (Group 1) (Rater 1: 21.2 ± 0.8 vs. 19.0 ± 2.0, p = 0.05, Rater 2: 20.4 ± 1.5 vs. 18.3±1.0, p = 0.04). Group 2 also was quicker than Group 1 in deciding to start the procedure by approximately 56 seconds. When comparing the mean pretest knowledge score to the mean knowledge retention score 30 days after training, the discussion-based group improved from 58.33% to 81.25% (p = 0.01); the simulation-trained group's scores remained at 68.33%. All the participants agreed or strongly agreed that the simulator provided a realistic opportunity to perform EDT and improved their confidence.

CONCLUSIONS

The results of this pilot study support our hypothesis that using a low-cost EDT trainer effectively improves general surgery residents' confidence and procedural skills scores in a simulated environment. Further training with low-cost simulators may provide surgical residents with deliberate practice opportunities and improve performance when learning low-frequency procedures.

Current Status of Simulation in Thoracic Surgical Training

BACKGROUND

Simulation is playing an increasingly important role in surgical training but is not yet a mandatory part of most surgical curricula. A simulator must undergo rigorous validation to verify it as a reliable tool. The aim of this study was to review the literature to identify simulators that are currently available to augment thoracic surgical training and to analyze any evidence supporting or validating them.

METHODS

A literature search of the MEDLINE (1946 to November 2022) and Embase (1947 to November 2022) databases was performed to identify simulators for basic skills and procedures in thoracic surgery. A selection of keywords were used to perform the literature search. After identification of appropriate articles, data were extracted and analyzed.

RESULTS

Thirty-three simulators were found in 31 articles. Simulators for basic skills (n = 13) and thoracic lobectomy (n = 13) were most commonly described, followed by miscellaneous (n = 7). Most models were of a hybrid modality (n = 18). Evidence of validity was established in 48.5% (n = 16) of simulators. In total, 15.2% (n = 5) of simulators had 3 or more elements of validity demonstrated, and only 3.0% (n = 1) accomplished full validation.

CONCLUSIONS

Numerous simulators of varying modality and fidelity exist for a variety of thoracic surgical skills and procedures, although validation evidence is frequently inadequate. Simulation models may be able to provide training in basic surgical and procedural skills; however, further assessment of validity needs to be undertaken before consideration of their integration into training programs.

Simulation training for lobectomy: a review of current literature and future directions†

With growing work-time restrictions and public expectations, the Halstedian educational model of 'see one, do one, teach one' is unfit for the modern training of thoracic residents. With the cardiothoracic surgical workforce set to decline by 50% over the next 10 years, new models are desperately needed to help trainees bypass the early error-prone phase of the lobectomy learning curve. In this review, we detail the development and validation of numerous simulators designed to teach trainees an array of skills ranging from basic technical skills to more complex non-technical skills. Given the recent increases in minimally invasive lobectomies, we critique both open and thoracoscopic simulators. We elucidate that whilst there are a growing number of thoracic simulators of varying fidelity available, fundamentally, there is currently a significant lack of well-designed trials validating various simulators for teaching lobectomy despite an awareness of their potential to improve surgical education. Furthermore, there is a void in the simulation training of non-technical skills within thoracic surgery. Encouragingly, there is a definite awareness of the ability of simulation to aid with the training of future thoracic surgical trainees.

Simulation-based surgical education in cardiothoracic training

Simulation has emerged as a feasible adjunct to surgical education and training for most specialties. It provides trainees with an immersive, realistic way to learn a variety of skills in a safe environment with the end goal of improving patient safety. There are three broad types of simulators: full mannequin simulators, part-task trainers or bench models and virtual reality systems. This review aims to describe the current use of simulation in cardiothoracic surgical education and training. We identified multiple procedures that can be simulated in cardiothoracic surgery using a combination of the above simulators, three-dimensional printing and computer-based simulation. All studies that assessed the efficacy of simulators showed that simulation enhances learning and trainee performance allowing for repetitive training until the acquisition of competence but further research into how it translates into the operating theatre is required. In Australia, cardiac surgery simulation is not yet part of the training curricula, but simulators are available for certain tasks and procedures.

Cadaveric simulation: a review of reviews

BACKGROUND

Traditional surgical training, largely based on the Halstedian model "see one, do one, teach one" is not as effective in the era of working time restrictions and elaborate shift-patterns. As a result, contemporary surgeons turned to educational methods outside the operating theatre such as simulation. Cadavers are high fidelity models but their use has ethical and cost implications and their availability may be limited. In this review, we explore the role of cadaveric simulation in modern surgical education.

METHODS

All the Evidence-Based Medicine databases were searched for relevant reviews. The resulting studies were assessed for inclusion to this review, according to pre-determined criteria. Data extraction was performed using a custom-made spreadsheet, and the quality of included reviews was assessed using a validated scoring system (AMSTAR).

RESULTS

The literature review yielded 33 systematic reviews; five of which matched the inclusion criteria and were included in this review of reviews. Cadaveric simulation was found to have good face (subjective assessment of usefulness) and content validity (whether a specific element adds or retracts to the educational value) while trainees improved their surgical skills after practicing on cadavers. However, concerns have been raised about ethical issues, high cost and availability.

CONCLUSION

Cadavers are an effective medium for surgical teaching, and it may be appropriate for them to be used whenever surrounding conditions such cost and availability allow. Further research is required to provide evidence on whether there is equivalence between cadavers and other educational media which may not bear the same shortcomings.

The MAVID heart holder: a demonstration device to anchor cadaver hearts for surgical simulation and practical education

Performing open heart surgery involves learning challenging techniques and a need for realistic training models to achieve and maintain a high level of surgical skills. The MAVID heart holder is an organ holder primarily designed to hold the heart in its anatomic position for the purpose of surgical simulation and education, thereby closing the gap between surgical performance in the laboratory and in the operating room. The device is simple to use, can be adjusted to organ size, and has the necessary instrumentation to be used with any solid organ. The MAVID heart holder also provides a platform for presentation and assists in advancing the research sphere. The advantage over other existing models is that the MAVID heart holder uses real tissue and does not distort the organ at the attachment sites. Further, it offers superior stability as well as the ability to manipulate the organ during presentation and dissection. Training with the MAVID heart holder has the potential to shorten training time to acquire surgical skills and proficiency before performing these techniques in the operating room and in so doing enhance patient safety.

Resuscitative thoracotomy in penetrating trauma

The resuscitative thoracotomy (RT) is an important procedure in the management of penetrating trauma. As it is performed only in patients with peri-arrest physiology or overt cardiac arrest, survival is low. Experience is also quite variable depending on volume of penetrating trauma in a particular region. Survival ranges from 0% to as high as 89% depending on patient selection, available resources, and location of RT (operating or emergency rooms). In this article, published guidelines are reviewed as well as outcomes. Technical considerations of RT and well as proper training, personnel, and location are also discussed.

Simulation in cardiothoracic surgical training: where do we stand?

OBJECTIVES

Simulation may reduce the risks associated with the complex operations of cardiothoracic surgery and help create a more efficient, thorough, and uniform curriculum for cardiothoracic surgery fellowship. Here, we review the current status of simulation in cardiothoracic surgical training and provide an overview of all simulation models applicable to cardiothoracic surgery that have been published to date.

METHODS

We completed a comprehensive search of all publications pertaining to simulation of cardiothoracic surgical procedures by using PubMed.

RESULTS

Numerous cardiothoracic surgical simulators at various stages of development, assessment, and commercial manufacturing have been published to date. There is currently a predominance of models simulating coronary artery bypass grafting and bronchoscopy and a relative paucity of simulators of open pulmonary and esophageal procedures. Despite the wide range of simulators available, few models have been formally assessed for validity and educational value.

CONCLUSIONS

Surgical simulation is becoming an increasingly important educational tool in training cardiothoracic surgeons. Our next steps forward will be to develop an objective, standardized way to assess surgical simulation training compared with the current apprenticeship model.

Teaching video-assisted thoracic surgery (VATS) lobectomy

Video-assisted thoracic surgery (VATS) lobectomy has become the standard of care for early stage lung cancer throughout the world. Teaching this complex procedure requires adequate case volume, adequate instrumentation, a committed operating room team and baseline experience with open lobectomy. We outline what key maneuvers and steps are required to teach and learn VATS lobectomy. This is most easily performed as part of a thoracic surgery training program, but with adequate commitment and proctoring, there is no reason experienced open surgeons cannot become proficient VATS surgeons. We provide videos showing the key portions of a subcarinal lymph node dissection, posterior hilar dissection of the right upper lobe, fissureless right middle lobectomy, and fissureless left lower lobectomy. These videos highlight what we feel are important principals in VATS lobectomy, i.e., N2 and N1 lymph node dissection, fissureless techniques, and progressive responsibility of the learner. Current literature in simulation of VATS lobectomy is also outlined as this will be the future of teaching in VATS lobectomy.

Open surgical simulation--a review

BACKGROUND

Surgical simulation has benefited from a surge in interest over the last decade as a result of the increasing need for a change in the traditional apprentice model of teaching surgery. However, despite the recent interest in surgical simulation as an adjunct to surgical training, most of the literature focuses on laparoscopic, endovascular, and endoscopic surgical simulation with very few studies scrutinizing open surgical simulation and its benefit to surgical trainees. The aim of this review is to summarize the current standard of available open surgical simulators and to review the literature on the benefits of open surgical simulation.

CURRENT STATE OF OPEN SURGICAL SIMULATION

Open surgical simulators currently used include live animals, cadavers, bench models, virtual reality, and software-based computer simulators. In the current literature, there are 18 different studies (including 6 randomized controlled trials and 12 cohort studies) investigating the efficacy of open surgical simulation using live animal, bench, and cadaveric models in many surgical specialties including general, cardiac, trauma, vascular, urologic, and gynecologic surgery. The current open surgical simulation studies show, in general, a significant benefit of open surgical simulation in developing the surgical skills of surgical trainees. However, these studies have their limitations including a low number of participants, variable assessment standards, and a focus on short-term results often with no follow-up assessment.

FUTURE OF OPEN SURGICAL SIMULATION

The skills needed for open surgical procedures are the essential basis that a surgical trainee needs to grasp before attempting more technical procedures such as laparoscopic procedures. In this current climate of medical practice with reduced hours of surgical exposure for trainees and where the patient's safety and outcome is key, open surgical simulation is a promising adjunct to modern surgical training, filling the void between surgeons being trained in a technique and a surgeon achieving fluency in that open surgical procedure. Better quality research is needed into the benefits of open surgical simulation, and this would hopefully stimulate further development of simulators with more accurate and objective assessment tools.

Simulation-based postcardiotomy extracorporeal membrane oxygenation crisis training for thoracic surgery residents

BACKGROUND

We developed and tested a clinical simulation program in the principles and conduct of postcardiotomy extracorporeal membrane oxygenation (ECMO) with the aim of improving confidence, proficiency, and crisis management.

METHODS

Twenty-three thoracic surgery residents from unique residency programs participated in an ECMO course involving didactic lectures and hands-on simulation. A current postcardiotomy ECMO circuit was used in a simulation center to give residents training with basic operations and crisis management. Pretraining and posttraining assessments concerning confidence and knowledge were administered. Before and after the training, residents were asked to identify components of the ECMO circuit and manage crisis scenarios, including venous line collapse, arterial hypertension, and arterial desaturation.

RESULTS

In the hands-on portion, residents had difficulty identifying the gas source and flow rate, centrifugal pump head inlet, and oxygenator outflow line. Timely and accurate ECMO component identification improved significantly after training. The arterial desaturation crisis scenario gave the residents difficulty, with only 22% providing the appropriate treatment recommendations in a timely and accurate fashion. At the end of the simulation training, most residents were able to manage the crises correctly in a timely manner. Posttraining confidence-related scores increased significantly. Most of the residents strongly recommended the course to their peers and reported simulation-based training was helpful in their postcardiotomy ECMO education.

CONCLUSIONS

We developed a simulation-based postcardiotomy ECMO training program that resulted in improved ECMO confidence in thoracic surgery residents. Crisis management in a simulated environment enabled residents to acquire technical and behavioral skills that are important in managing critical ECMO-related problems.

Open surgical simulation in residency training: a review of its status and a case for its incorporation

BACKGROUND

With the increase in minimally invasive approaches to surgical disease and nonoperative management for solid organ injury, the open operative experience of current surgical residents has decreased significantly. This deficit poses a potentially adverse impact on both surgical training and surgical care. Simulation technology, with the potential to foster the development of technical skills in a safe, nonclinical environment, could be used to remedy this problem. In this study, we systematically review the current status of simulation technology in the training of open surgical skills with the aim of clarifying its role and promise in the education of surgical residents.

METHODS

A systematic search of the PubMed database was performed with keywords: "surgical simulation," "skill," "simulat," "surgery," "surgery training," "validity," "surgical trainer," "technical skill," "surgery teach," "skill assessment," and "operative skill." The retrieved studies were screened, and additional studies identified by a manual search of the reference lists of included studies.

RESULTS

Thirty-one studies were identified. Most studies used low fidelity bench models designed to train junior residents in more basic surgical skills. Six studies used complex open models to train senior residents in more advanced surgical techniques. "Boot camp" and workshops have been used by some authors for short periods of intense training in a specialized area, with good results.

CONCLUSIONS

Despite the increasing use of simulation in the technical training of surgical residents, few studies have focused on the use of simulation in the training of open surgical skills. This is particularly true with regard to skills required to competently perform technically challenging open maneuvers under urgent, life-threatening circumstances. In an era marked by a decline in open operative experience, there is a need for simulation-based studies that not only promote and evaluate the acquisition of such less commonly performed techniques but also determine the efficacy with which they can be transferred from a simulated environment to a patient in an operating room.

A simulator model for sacroiliac screw placement

OBJECTIVE

Fixation with percutaneously placed sacroiliac screws has become a well-established technique for fixation of the posterior pelvic ring in the proper clinical setting. This technique, however, carries with it the risk of iatrogenic injury to neurovascular structures with aberrant screw placement. Given the potential risks involved with this technique, a model whereby the psychomotor skills involved could be refined before entering the operating room may be of benefit. The purpose of the current study is (1) to describe a simulator model for SI screw placement that can be assembled from readily available equipment and (2) to attempt to demonstrate the construct validity of such a simulator.

DESIGN

A simulator was assembled using readily available equipment found in the hospital and at a hardware store, and the cost of set up is less than $50. Orthopedic surgeons and novice operators were then observed using the simulator and results were recorded.

SETTING

Tertiary referral teaching hospital.

PARTICIPANTS

Orthopedic surgery residents, resident faculty, x-ray technicians.

RESULTS

This simulator has been found to be a safe and effective model for teaching junior residents the technique of sacroiliac (SI) screw placement. An added benefit to this module is that it helps train new C-arm technicians to learn how to obtain the necessary views for this procedure.

CONCLUSIONS

This model can be a valuable component of orthopedic training programs whereby technical and psychomotor skills necessary for percutaneous SI screw placement can be developed in a controlled setting.

An integrated simulator for endolaryngeal surgery

The acquisition and maintenance of skills in transoral microlaryngeal surgery requires extended practice. Effective mentoring of such single-operator procedures is not possible, making it important for trainee surgeons to acquire basic skills outside of the operating room before participating in procedures on patients. Currently available training simulators use either synthetic materials or human tissue, both of which have limitations. We have designed a hybrid simulator that incorporates a porcine larynx in to an airway training manikin, providing both accurate airway anatomy and natural tissue handling characteristics. This model allows training in the skills required for suspension laryngoscopy and the resection of laryngeal lesions. Further applications could include development of surgical techniques and instruments, and use in accreditation of training and revalidation of trained surgeons.

Can image-based virtual reality help teach anatomy?

OBJECTIVE

To assess the utilization of a novel virtual reality robotic surgical simulator (RoSS) in surgical anatomy training and pattern recognition.

STUDY DESIGN

Ten surgical trainees (medical students and residents) were recruited to participate in a study that evaluated the efficacy of a robotic simulator in anatomy training. The subjects were divided into two groups of five individuals each. Each participant received a syllabus consisting of line diagrams and color pictures of the human anatomy. All participants were later tested on identifying the same five anatomical landmarks from photographs from actual laparoscopic procedures. Group I studied the syllabus and took the test. Group II similarly studied the syllabus, but were trained on the RoSS system using cognitive skill sets and then took the same test. Group II were asked to complete a posttest survey.

RESULTS

Mean time to complete the test was 142.8 seconds for group I and 118.4 seconds for group II. Mean number of errors committed by the group trained on RoSS was 0.4 out of 5, whereas the group that did not undergo training on RoSS committed 1.7 out of 5. The mean number of correct answers given by group I was 2.9 out of 5, whereas group II answered 4.2 out 5 correctly. All results were statistically significant. The subjects rated the anatomy module helpful, with a mean rating of 3.6 out of 5.

CONCLUSIONS

RoSS is an effective tool in anatomy training. Further testing is underway to illustrate its important role in medical education and robotic surgical training.