Abstract
Surgical training has followed the master-apprentice model for centuries but is currently undergoing a paradigm shift. The traditional model is inefficient with no guarantee of case mix, quality, or quantity. There is a growing focus on competency-based medical education in response to restrictions on doctors’ working hours and the traditional mantra of “see one, do one, teach one” is being increasingly questioned. The medical profession is subject to more scrutiny than ever before and is facing mounting financial, clinical, and political pressures. Simulation may be a means of addressing these challenges. It provides a way for trainees to practice technical tasks in a protected environment without putting patients at risk and helps to shorten the learning curve. The evidence for simulation-based training in orthopedic surgery using synthetic models, cadavers, and virtual reality simulators is constantly developing, though further work is needed to ensure the transfer of skills to the operating theatre.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance
Nasca TJ, Day SH, Amis Jr ES. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363:e3.
Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA. 2002;288:1112–4.
Inaparthy PK, Sayana MK, Maffulli N. Evolving trauma and orthopedics training in the UK. J Surg Educ. 2013;70:104–8.
Chikwe J, de Souza AC, Pepper JR. No time to train the surgeons. BMJ. 2004;328:418–9.
Sonnadara RR, Van Vliet A, Safir O, Alman B, Ferguson P, Kraemer W, et al. Orthopedic boot camp: examining the effectiveness of an intensive surgical skills course. Surgery. 2011;149:745–9. Demonstrated that an intensive skills course can be highly effective at teaching key surgical skills in junior orthopedic trainees.
Bridges M, Diamond DL. The financial impact of teaching surgical residents in the operating room. Am J Surg. 1999;177:28–32.
De Cossart L, Fish D. Cultivating a thinking surgeon: New perspectives in teaching, learning and assessment. Shrewsbury: tfm Publishing Ltd; 2005.
Murphy JG, Torsher LC, Dunn WF. Simulation medicine in intensive care and coronary care education. J Crit Care. 2007;22:51–5.
Scott DJ, Cendan JC, Pugh CM, Minter RM, Dunnington GL, Kozar RA. The changing face of surgical education: simulation as the new paradigm. J Surg Res. 2008;147:189–93.
Scott DJ, Dunnington GL. The new ACS/APDS Skills Curriculum: moving the learning curve out of the operating room. J Gastroenterol. 2008;12:213–21.
Franzeck FM, Rosenthal R, Muller MK, Nocito A, Wittich F, Maurus C, et al. Prospective randomized controlled trial of simulator-based versus traditional in-surgery laparoscopic camera navigation training. Surg Endosc. 2012;26:235–41.
Aggarwal R, Tully A, Grantcharov T, Larsen CR, Miskry T, Farthing A, et al. Virtual reality simulation training can improve technical skills during laparoscopic salpingectomy for ectopic pregnancy. BJOG. 2006;113:1382–7.
Aggarwal R, Ward J, Balasundaram I, Sains P, Athanasiou T, Darzi A. Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery. Ann Surg. 2007;246:771–9.
Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Bansal VK, Andersen DK, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002;236:458–63. discussion 63–4.
Ahlberg G, Enochsson L, Gallagher AG, Hedman L, Hogman C, McClusky III DA, et al. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg. 2007;193:797–804.
Palter VN, Grantcharov T, Harvey A, Macrae HM. Ex vivo technical skills training transfers to the operating room and enhances cognitive learning: a randomized controlled trial. Ann Surg. 2011;253:886–9. Found that technical skills training using a low-fidelity simulator resulted in improved technical performance in the operating room and enhanced the ability of trainees to focus on the cognitive components of surgical expertise.
Zendejas B, Cook DA, Bingener J, Huebner M, Dunn WF, Sarr MG, et al. Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair: a randomized controlled trial. Ann Surg. 2011;254:502–9. discussion 9–11. Demonstrated that simulation based learning results in improved performance in the operating room and improved clinical outcomes.
Darzi A, Smith S, Taffinder N. Assessing operative skill. Needs to become more objective. BMJ. 1999;318:887–8.
Rooney DM, Santos BF, Hungness ES. Fundamentals of laparoscopic surgery (FLS) manual skills assessment: surgeon vs nonsurgeon raters. J Surg Educ. 2012;69:588–92.
Overby DW, Watson RA. Hand motion patterns of Fundamentals of Laparoscopic Surgery certified and noncertified surgeons. Am J Surg. 2014;207:226–30.
Leong JJ, Leff DR, Das A, Aggarwal R, Reilly P, Atkinson HD, et al. Validation of orthopaedic bench models for trauma surgery. J Bone Joint Surg Br. 2008;90:958–65.
Howells NR, Brinsden MD, Gill RS, Carr AJ, Rees JL. Motion analysis: a validated method for showing skill levels in arthroscopy. Arthroscopy. 2008;24:335–42.
Tuijthof GJ, van Sterkenburg MN, Sierevelt IN, van Oldenrijk J, Van Dijk CN, Kerkhoffs GM. First validation of the PASSPORT training environment for arthroscopic skills. Knee Surg Sports Traumatol Arthrosc. 2010;18:218–24.
Tashiro Y, Miura H, Nakanishi Y, Okazaki K, Iwamoto Y. Evaluation of skills in arthroscopic training based on trajectory and force data. Clin Orthop Relat Res. 2009;467:546–52.
Jackson WF, Khan T, Alvand A, Al-Ali S, Gill HS, Price AJ, et al. Learning and retaining simulated arthroscopic meniscal repair skills. J Bone Joint Surg Am. 2012;94:e132. Illustrated learning curves for meniscal repair in synthetic models and confirmed the value of repetition in learning and retaining this skill.
Butler A, Olson T, Koehler R, Nicandri G. Do the skills acquired by novice surgeons using anatomic dry models transfer effectively to the task of diagnostic knee arthroscopy performed on cadaveric specimens? J Bone Joint Surg Am. 2013;95:e15(1–8). Showed that practicing knee arthroscopy on synthetic models can be a useful adjunct to cadaveric training.
Howells NR, Gill HS, Carr AJ, Price AJ, Rees JL. Transferring simulated arthroscopic skills to the operating theatre: a randomized blinded study. J Bone Joint Surg Br. 2008;90:494–9. The only reference of note showing that skills learned on a simulator can transfer to the operating room.
Holland JP, Waugh L, Horgan A, Paleri V, Deehan DJ. Cadaveric hands-on training for surgical specialties: is this back to the future for surgical skills development? J Surg Educ. 2011;68:110–6.
Tortolani PJ, Moatz BW, Parks BG, Cunningham BW, Sefter J, Kretzer RM. Cadaver training module for teaching thoracic pedicle screw placement to residents. Orthopedics. 2013;36:e1128–33.
Gomoll AH, O’Toole RV, Czarnecki J, Warner JJ. Surgical experience correlates with performance on a virtual reality simulator for shoulder arthroscopy. Am J Sports Med. 2007;35:883–8.
Jaung R, Cook P, Blyth P. A comparison of embalming fluids for use in surgical workshops. Clin Anat. 2011;24:155–61.
Grechenig W, Fellinger M, Fankhauser F, Weiglein AH. The Graz learning and training model for arthroscopic surgery. Surg Radiol Anat. 1999;21:347–50.
Blyth P, Stott NS, Anderson IA. Virtual reality assessment of technical skill using the Bonedoc DHS simulator. Injury. 2008;39:1127–33.
Blyth P, Stott NS, Anderson IA. A simulation-based training system for hip fracture fixation for use within the hospital environment. Injury. 2007;38:1197–203.
Froelich JM, Milbrandt JC, Novicoff WM, Saleh KJ, Allan DG. Surgical simulators and hip fractures: a role in residency training? J Surg Educ. 2011;68:298–302. The only reference of note assessing construct validity of a haptic VR trauma simulator.
Tonetti J, Vadcard L, Girard P, Dubois M, Merloz P, Troccaz J. Assessment of a percutaneous iliosacral screw insertion simulator. Orthop Traumatol Surg Res. 2009;95:471–7.
Michelson JD. Simulation in orthopaedic education: an overview of theory and practice. J Bone Joint Surg Am. 2006;88:1405–11.
Datta V, Mackay S, Mandalia M, Darzi A. The use of electromagnetic motion tracking analysis to objectively measure open surgical skill in the laboratory-based model. J Am Coll Surg. 2001;193:479–85.
Martin KD, Belmont PJ, Schoenfeld AJ, Todd M, Cameron KL, Owens BD. Arthroscopic basic task performance in shoulder simulator model correlates with similar task performance in cadavers. J Bone Joint Surg Am. 2011;93:e1271–5. Demonstrated a strong correlation between the performance of basic arthroscopic tasks on a VR shoulder arthroscopy simulator and performance of the same tasks in cadavers.
Martin KD, Cameron K, Belmont PJ, Schoenfeld A, Owens BD. Shoulder arthroscopy simulator performance correlates with resident and shoulder arthroscopy experience. J Bone Joint Surg Am. 2012;94:e160. Confirmed that performance on a VR shoulder arthroscopy simulator correlates with clinical experience.
Henn III RF, Shah N, Warner JJ, Gomoll AH. Shoulder arthroscopy simulator training improves shoulder arthroscopy performance in a cadaveric model. Arthroscopy. 2013;29:982–5. Found that training on a VR shoulder arthroscopy simulator results in improved clinical performance in cadaveric shoulder arthroscopy.
Gomoll AH, Pappas G, Forsythe B, Warner JJ. Individual skill progression on a virtual reality simulator for shoulder arthroscopy: a 3-year follow-up study. Am J Sports Med. 2008;36:1139–42.
McCarthy AD, Moody L, Waterworth AR, Bickerstaff DR. Passive haptics in a knee arthroscopy simulator: is it valid for core skills training? Clin Orthop Relat Res. 2006;442:13–20.
Pedowitz RA, Esch J, Snyder S. Evaluation of a virtual reality simulator for arthroscopy skills development. Arthroscopy. 2002;18:E29.
Smith S, Wan A, Taffinder N, Read S, Emery R, Darzi A. Early experience and validation work with Procedicus VA—the Prosolvia virtual reality shoulder arthroscopy trainer. Stud Health Technol Inform. 1999;62:337–43.
Srivastava S, Youngblood PL, Rawn C, Hariri S, Heinrichs WL, Ladd AL. Initial evaluation of a shoulder arthroscopy simulator: establishing construct validity. J Shoulder Elbow Surg. 2004;13:196–205.
Tuijthof GJ, Visser P, Sierevelt IN, Van Dijk CN, Kerkhoffs GM. Does perception of usefulness of arthroscopic simulators differ with levels of experience? Clin Orthop Relat Res. 2011;469:1701–8.
LeBlanc J, Hutchison C, Hu Y, Donnon T. A comparison of orthopaedic resident performance on surgical fixation of an ulnar fracture using virtual reality and synthetic models. J Bone Joint Surg Am. 2013;95(e601–6):S1–5.
Andersen C, Winding TN, Vesterby MS. Development of simulated arthroscopic skills. Acta Orthop. 2011;82:90–5.
Bliss JP, Hanner-Bailey HS, Scerbo MW. Determining the efficacy of an immersive trainer for arthroscopy skills. Stud Health Technol Inform. 2005;111:54–6.
Mabrey JD, Cannon WD, Gillogly SD, Kasser JR, Sweeney HJ, Zarins B, et al. Development of a virtual reality arthroscopic knee simulator. Stud Health Technol Inform. 2000;70:192–4.
Fernandez GL, Page DW, Coe NP, Lee PC, Patterson LA, Skylizard L, et al. Boot camp: educational outcomes after 4 successive years of preparatory simulation-based training at onset of internship. J Surg Educ. 2012;69:242–8.
Moazed F, Cohen ER, Furiasse N, Singer B, Corbridge TC, McGaghie WC, et al. Retention of critical care skills after simulation-based mastery learning. J Grad Med Educ. 2013;5:458–63.
Cohen ER, Barsuk JH, Moazed F, Caprio T, Didwania A, McGaghie WC, et al. Making July safer: simulation-based mastery learning during intern boot camp. Acad Med. 2013;88:233–9.
Krajewski A, Filippa D, Staff I, Singh R, Kirton OC. Implementation of an intern boot camp curriculum to address clinical competencies under the new Accreditation Council for Graduate Medical Education supervision requirements and duty hour restrictions. JAMA Surg. 2013;148:727–32.
Sonnadara RR, Garbedian S, Safir O, Nousiainen M, Alman B, Ferguson P, et al. Orthopaedic Boot Camp II: examining the retention rates of an intensive surgical skills course. Surgery. 2012;151:803–7. Found that surgical skills taught through an intensive skills-training course at the beginning of residency can have excellent retention rates.
Sonnadara RR, Garbedian S, Safir O, Mui C, Mironova P, Nousiainen M, et al. Toronto orthopaedic boot camp III: examining the efficacy of student-regulated learning during an intensive, laboratory-based surgical skills course. Surgery. 2013;154:29–33.
Alvand A, Auplish S, Gill H, Rees J. Innate arthroscopic skills in medical students and variation in learning curves. J Bone Joint Surg Am. 2011;93:e115.
Alvand A, Auplish S, Khan T, Gill HS, Rees JL. Identifying orthopaedic surgeons of the future: the inability of some medical students to achieve competence in basic arthroscopic tasks despite training: a randomized study. J Bone Joint Surg Br. 2011;93:1586–91. Showed that some individuals are unable to achieve competency in basic arthroscopic tasks despite focused training.
Koehler RJ, Amsdell S, Arendt EA, Bisson LJ, Braman JP, Butler A, et al. The Arthroscopic Surgical Skill Evaluation Tool (ASSET). Am J Sports Med. 2013;41:1229–37. Described the development and validation of a useful and reliable method of assessing diagnostic knee arthroscopy in cadavers.
Koehler RJ, Nicandri GT. Using the arthroscopic surgery skill evaluation tool as a pass-fail examination. J Bone Joint Surg Am. 2013;95:e1871–6. Demonstrated the use of a novel assessment tool as a pass-fail examination in the simulation laboratory.
Van Sickle KR, Ritter EM, McClusky III DA, Lederman A, Baghai M, Gallagher AG, et al. Attempted establishment of proficiency levels for laparoscopic performance on a national scale using simulation: the results from the 2004 SAGES Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) learning center study. Surg Endosc. 2007;21:5–10.
Bollen S. Epidemiology of knee injuries: diagnosis and triage. Br J Sports Med. 2000;34:227–8.
Bollen S. Ligament injuries of the knee—limping forward? Br J Sports Med. 1998;32:82–4.
O’Neill PJ, Cosgarea AJ, Freedman JA, Queale WS, McFarland EG. Arthroscopic proficiency: a survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs. Arthroscopy. 2002;18:795–800.
Committee FP. Fundamentals of Arthroscopic Surgery Training. Available at: https://abos.org/media/7665/preamble_to_fast_modules_for_abos_curriculum_project.pdf Accessed 31 Jan 2014.
Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15:988–94.
Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T, Schouenborg L, Ottosen C, et al. Effect of virtual reality training on laparoscopic surgery: randomized controlled trial. BMJ. 2009;338:b1802.
Compliance with Ethics Guidelines
Conflict of Interest
K. S. N. Akhtar, N. J. Standfield, and C. M. Gupte declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Akhtar, K.S.N., Chen, A., Standfield, N.J. et al. The role of simulation in developing surgical skills. Curr Rev Musculoskelet Med 7, 155–160 (2014). https://doi.org/10.1007/s12178-014-9209-z
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12178-014-9209-z