The role of simulation in developing surgical skills

  • K. S. N. AkhtarEmail author
  • Alvin Chen
  • N. J. Standfield
  • C. M. Gupte
Resident Education (P Achan, Section Editor)


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.


Arthroscopy Assessment Boot camp Cadaver Competency Education Feedback Patient safety Phantom Proficiency Psychomotor Simulation Skills Surgical training Task performance Training Virtual reality 


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.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    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.PubMedCrossRefGoogle Scholar
  2. 2.
    Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA. 2002;288:1112–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Inaparthy PK, Sayana MK, Maffulli N. Evolving trauma and orthopedics training in the UK. J Surg Educ. 2013;70:104–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Chikwe J, de Souza AC, Pepper JR. No time to train the surgeons. BMJ. 2004;328:418–9.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.•
    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.PubMedCrossRefGoogle Scholar
  6. 6.
    Bridges M, Diamond DL. The financial impact of teaching surgical residents in the operating room. Am J Surg. 1999;177:28–32.PubMedCrossRefGoogle Scholar
  7. 7.
    De Cossart L, Fish D. Cultivating a thinking surgeon: New perspectives in teaching, learning and assessment. Shrewsbury: tfm Publishing Ltd; 2005.Google Scholar
  8. 8.
    Murphy JG, Torsher LC, Dunn WF. Simulation medicine in intensive care and coronary care education. J Crit Care. 2007;22:51–5.PubMedCrossRefGoogle Scholar
  9. 9.
    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.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    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.Google Scholar
  11. 11.
    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.PubMedCrossRefGoogle Scholar
  12. 12.
    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.PubMedCrossRefGoogle Scholar
  13. 13.
    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.PubMedCrossRefGoogle Scholar
  14. 14.
    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.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    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.PubMedCrossRefGoogle Scholar
  16. 16.•
    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.PubMedCrossRefGoogle Scholar
  17. 17.•
    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.PubMedCrossRefGoogle Scholar
  18. 18.
    Darzi A, Smith S, Taffinder N. Assessing operative skill. Needs to become more objective. BMJ. 1999;318:887–8.PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    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.PubMedCrossRefGoogle Scholar
  20. 20.
    Overby DW, Watson RA. Hand motion patterns of Fundamentals of Laparoscopic Surgery certified and noncertified surgeons. Am J Surg. 2014;207:226–30.PubMedCrossRefGoogle Scholar
  21. 21.
    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.PubMedCrossRefGoogle Scholar
  22. 22.
    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.PubMedCrossRefGoogle Scholar
  23. 23.
    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.Google Scholar
  24. 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.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.•
    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.PubMedCrossRefGoogle Scholar
  26. 26.•
    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.CrossRefGoogle Scholar
  27. 27.•
    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.PubMedCrossRefGoogle Scholar
  28. 28.
    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.PubMedCrossRefGoogle Scholar
  29. 29.
    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.PubMedGoogle Scholar
  30. 30.
    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.PubMedCrossRefGoogle Scholar
  31. 31.
    Jaung R, Cook P, Blyth P. A comparison of embalming fluids for use in surgical workshops. Clin Anat. 2011;24:155–61.Google Scholar
  32. 32.
    Grechenig W, Fellinger M, Fankhauser F, Weiglein AH. The Graz learning and training model for arthroscopic surgery. Surg Radiol Anat. 1999;21:347–50.PubMedCrossRefGoogle Scholar
  33. 33.
    Blyth P, Stott NS, Anderson IA. Virtual reality assessment of technical skill using the Bonedoc DHS simulator. Injury. 2008;39:1127–33.PubMedCrossRefGoogle Scholar
  34. 34.
    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.PubMedCrossRefGoogle Scholar
  35. 35.•
    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.PubMedCrossRefGoogle Scholar
  36. 36.
    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.PubMedCrossRefGoogle Scholar
  37. 37.
    Michelson JD. Simulation in orthopaedic education: an overview of theory and practice. J Bone Joint Surg Am. 2006;88:1405–11.PubMedCrossRefGoogle Scholar
  38. 38.
    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.PubMedCrossRefGoogle Scholar
  39. 39.•
    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. Google Scholar
  40. 40.•
    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.PubMedCrossRefGoogle Scholar
  41. 41.•
    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.PubMedCrossRefGoogle Scholar
  42. 42.
    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.PubMedCrossRefGoogle Scholar
  43. 43.
    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.PubMedCrossRefGoogle Scholar
  44. 44.
    Pedowitz RA, Esch J, Snyder S. Evaluation of a virtual reality simulator for arthroscopy skills development. Arthroscopy. 2002;18:E29.PubMedCrossRefGoogle Scholar
  45. 45.
    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.PubMedGoogle Scholar
  46. 46.
    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.PubMedCrossRefGoogle Scholar
  47. 47.
    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.Google Scholar
  48. 48.
    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.Google Scholar
  49. 49.
    Andersen C, Winding TN, Vesterby MS. Development of simulated arthroscopic skills. Acta Orthop. 2011;82:90–5.Google Scholar
  50. 50.
    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.PubMedGoogle Scholar
  51. 51.
    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.PubMedGoogle Scholar
  52. 52.
    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.PubMedCrossRefGoogle Scholar
  53. 53.
    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.PubMedCrossRefGoogle Scholar
  54. 54.
    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.PubMedCrossRefGoogle Scholar
  55. 55.
    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.PubMedCrossRefGoogle Scholar
  56. 56.•
    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.PubMedCrossRefGoogle Scholar
  57. 57.
    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.PubMedCrossRefGoogle Scholar
  58. 58.
    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.Google Scholar
  59. 59.•
    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. Google Scholar
  60. 60.•
    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.PubMedCrossRefGoogle Scholar
  61. 61.•
    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.PubMedCrossRefGoogle Scholar
  62. 62.
    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.PubMedCrossRefGoogle Scholar
  63. 63.
    Bollen S. Epidemiology of knee injuries: diagnosis and triage. Br J Sports Med. 2000;34:227–8.PubMedCentralPubMedCrossRefGoogle Scholar
  64. 64.
    Bollen S. Ligament injuries of the knee—limping forward? Br J Sports Med. 1998;32:82–4.PubMedCentralPubMedCrossRefGoogle Scholar
  65. 65.
    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.PubMedCrossRefGoogle Scholar
  66. 66.
    Committee FP. Fundamentals of Arthroscopic Surgery Training. Available at: Accessed 31 Jan 2014.
  67. 67.
    Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15:988–94.PubMedCrossRefGoogle Scholar
  68. 68.
    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.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • K. S. N. Akhtar
    • 1
    Email author
  • Alvin Chen
    • 1
  • N. J. Standfield
    • 1
  • C. M. Gupte
    • 1
  1. 1.Orthopaedic Surgery, Msk lab, Imperial CollegeCharing Cross HospitalLondonUK

Personalised recommendations