Simulation in General Surgery

  • Mark W. BowyerEmail author
  • Ryan B. Fransman
Part of the Comprehensive Healthcare Simulation book series (CHS)


The ability to train competent surgeons to perform open general surgical procedures remains a top priority that has been complicated by a number of changes in medical and technical progress and decreased opportunities for clinical exposure. The result is trainees who, upon completion of training, are increasingly not fully prepared to independently perform the entirety of open procedures expected of general surgeons. Simulation has been proposed as part of the potential solution for this current and growing problem. While simulation technology has made great strides in the fields of minimally invasive surgery, simulators which allow for the training of open general surgical skills using actual instruments have lagged significantly behind. The ability of virtual reality to replicate open surgical procedures in which the instruments and the tissue characteristics can be replicated in a realistic fashion providing transfer of training to the patient has been elusive and likely not obtainable in the near term. Cadavers and animals can be utilized but have a number of limitations as will be discussed. The likely near-term solution will be the use of human tissue realistic physical models designed to augment the clinical experience of trainees in a standardized fashion. While there are a number of physical models currently available or under development that have the potential to meet this need, the current expense has prevented widespread use or expansion. This chapter will outline the current challenges in general surgical training that necessitates the need for further development and incorporation of simulation technologies. The current state of the art will be presented with examples of current and near-term future physical models that have significant potential for improving the training of general surgeons to perform open procedures.


Open general surgery Simulation-based training Physical models Biofidelic emulation 



The views expressed herein are those of the authors and are not to be construed as official or reflecting the views of the Department of Defense, the Uniformed Services University, or the US government. The authors have nothing to disclose.


  1. 1.
    Pickersgill T. The European working time directive for doctors in training. BMJ. 2001;323:1266.CrossRefGoogle Scholar
  2. 2.
    Lamont PM, Scott DJ. The impact of shortened training times on the discipline of vascular surgery in the United Kingdom. Am J Surg. 2005;190:269–72.CrossRefGoogle Scholar
  3. 3.
    Pellegrini CA, Warshaw AL, Debas HT. Residency training in surgery in the 21st century: a new paradigm. Surgery. 2004;136:953–65.CrossRefGoogle Scholar
  4. 4.
    Bell RH Jr, Banker MB, Rhodes RS, Biester TW, Lewis FR. Graduate medical education in surgery in the United States. Surg Clin North Am. 2007;87:811–23.CrossRefGoogle Scholar
  5. 5.
    Barden CB, Specht MC, McCarter MD, Daly JM, Fahey TJ 3rd. Effects of limited work hours on surgical training. J Am Coll Surg. 2002;195(4):531–8.CrossRefGoogle Scholar
  6. 6.
    Benes V. The European working time directive and the effects on training of surgical specialists (doctors in training): a position paper of the surgical disciplines of the countries of the EU. Acta Neurochir. 2006;148(11):1227–33.CrossRefGoogle Scholar
  7. 7.
    Ferguson C, Kellog K, Hutter M, Warshaw A. Effect of work-hour reforms on operative case volume of surgical residents. Curr Surg. 2005;62:535–8.CrossRefGoogle Scholar
  8. 8.
    Ferguson CM. The arguments against fellowship training and early specialization in general surgery. Arch Surg. 2003;138:915–6.CrossRefGoogle Scholar
  9. 9.
    Leach DC. A model for GME: shifting from process to outcomes. A progress report from the accreditation council for graduate medical education. Med Educ. 2004;38:12–4.CrossRefGoogle Scholar
  10. 10.
    Reznick RK, MacRae H. Teaching surgical skills— changes in the wind. N Engl J Med. 2006;355:2664–9.CrossRefGoogle Scholar
  11. 11.
    Valentine RJ, Rhodes RS, Jones A, Biester TW. Members of the Vascular Surgery Board of the American Board of Surgery evolving patterns of vascular surgery care in the United States: a report from the American Board of Surgery. J Am Coll Surg. 2013;216:886–93.CrossRefGoogle Scholar
  12. 12.
    Erkert M, Cuadrado D, Steele S, et al. The changing face of the general surgeon: national and local trends in resident operative experience. Am J Surg. 2010;199:652–6.CrossRefGoogle Scholar
  13. 13.
    Bulinski P, Bachulis B, Naylor DF Jr, Kam D, Carey M, Dean RE. The changing face of trauma management and its impact on surgical resident training. J Trauma. 2003;54(1):161–3.CrossRefGoogle Scholar
  14. 14.
    Gaarder C, Skaga NO, Eken T, Pillgram-Larsen J, Buanes T, Naess PA. The impact of patient volume on surgical trauma training in a scandinavian trauma centre. Injury. 2005;36:1288–92.CrossRefGoogle Scholar
  15. 15.
    Jennings GR, Poole GV, Yates NL, Johnson RK, Brock M. Has nonoperative management of solid visceral injuries adversely affected resident operative experience? Am Surg. 2001;67:597–600.PubMedGoogle Scholar
  16. 16.
    McCoy AC, Gasevic E, Szlabick RE, Sahmoun AE, Sticca RP. Are open abdominal procedures a thing of the past? An analysis of graduating general surgery residents’ case logs from 2000 to 2011. J Surg Educ. 2013;70(6):683–9.CrossRefGoogle Scholar
  17. 17.
    Bell RH Jr, Biester TW, Tabuenca A, et al. Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg. 2009;249:719–24.CrossRefGoogle Scholar
  18. 18.
    Lewis FR, Klingensmith ME. Issues in general surgery residency training-2012. Ann Surg. 2012;256:553–9.CrossRefGoogle Scholar
  19. 19.
    Bell RH Jr. Why Johnny cannot operate. Surgery. 2009;146:533–42.CrossRefGoogle Scholar
  20. 20.
    Malangoni MA, Biester TW, Jones AT, Klingensmith ME, Lewis FR. Operative experience of surgery residents: trends and challenges. J Surg Educ. 2013;70:783–8.CrossRefGoogle Scholar
  21. 21.
    Mattar S, Minter RM, Alseidi A, et al. General surgery residency inadequately prepares trainees for fellowship: results of a North American survey of program directors. Presented at the American Surgical Association annual meeting, Indianapolis, IN. 5 Apr 2013.Google Scholar
  22. 22.
    Fonseca AL, Evans LV, Gusberg RJ. Open surgical simulation in residency training: a review of its status and a case for its incorporation. J Surg Educ. 2013;70(1):129–37.CrossRefGoogle Scholar
  23. 23.
    Leblanc F, Zeinali F, Marks J, et al. Stepwise assessment tool of operative skills (SATOS): validity testing on a porcine training model of open gastrectomy. J Am Coll Surg. 2010;211:672–6.CrossRefGoogle Scholar
  24. 24.
    Lipman JM, Marderstein EL, Zeinali F, et al. Objective evaluation of the performance of surgical trainees on a porcine model of open colectomy. Br J Surg. 2010;97:391–5.CrossRefGoogle Scholar
  25. 25.
    Olson TP, Becker YT, McDonald R, Gould J. A simulation based curriculum can be used to teach open intestinal anastomosis. J Surg Res. 2012;172:53–8.CrossRefGoogle Scholar
  26. 26.
    Jensen AR, Wright AS, McIntyre LK, et al. Laboratory based instruction for skin closure and bowel anastomosis for surgical residents. Arch Surg. 2008;143:852–9.CrossRefGoogle Scholar
  27. 27.
    Gröne J, Lauscher JC, Buhr HJ, Ritz JP. Face, content and construct validity of a new realistic trainer for conventional techniques in digestive surgery. Langenbeck’s Arch Surg. 2010;395:581–8.CrossRefGoogle Scholar
  28. 28.
    Lauscher JC, Ritz JP, Stroux A, Buhr HJ, Gröne J. A new surgical trainer (BOPT) improves skill transfer for anastomotic techniques in gastrointestinal surgery into the operating room: a prospective randomized trial. World J Surg. 2010;34:2017–25.CrossRefGoogle Scholar
  29. 29.
    Davies J, Khatib M, Bello F. Open surgical simulation--a review. J Surg Educ. 2013;70(5):618–27.CrossRefGoogle Scholar
  30. 30.
    Garrett HE. A human cadaveric circulation model. J Vasc Surg. 2001;33(6):1128–30.CrossRefGoogle Scholar
  31. 31.
    Aboud E, Al-Mefty O, Yaşargil MG. New laboratory model for neurosurgical training that simulates live surgery. J Neurosurg. 2002;97(6):1367–72.CrossRefGoogle Scholar
  32. 32.
    Aboud ET, Krisht AF, O’Keeffe T, Nader R, Hassan M, Stevens CM, Ali F, Luchette FA. Novel simulation for training trauma surgeons. J Trauma. 2011;71(6):1484–90.PubMedGoogle Scholar
  33. 33.
    Reihsen TE, Alberti L, Speich J, Poniatowski LH, Hart D, Sweet RM. Feasibility of a perfused and ventilated cadaveric model for assessment of lifesaving traumatic hemorrhage and airway management skills. J Trauma Acute Care Surg. 2016;80(5):799–804.CrossRefGoogle Scholar
  34. 34.
    Carey JN, Rommer E, Sheckter C, Minneti M, Talving P, Wong AK, Garner W, Urata MM. Simulation of plastic surgery and microvascular procedures using perfused fresh human cadavers. J Plast Reconstr Aesthet Surg. 2014;67(2):e42–8.CrossRefGoogle Scholar
  35. 35.
    Carey JN, Minneti M, Leland HA, Demetriades D, Talving P. Perfused fresh cadavers: method for application to surgical simulation. Am J Surg. 2015;210(1):179–87.CrossRefGoogle Scholar
  36. 36.
    Delpech PO, Danion J, Oriot D, Richer JP, Breque C, Faure JP. SimLife a new model of simulation using a pulsated revascularized and reventilated cadaver for surgical education. J Visc Surg. 2017;154(1):15–20.CrossRefGoogle Scholar
  37. 37.
    Kuhls DA, Risucci DA, Bowyer MW, Luchette FA. Advanced surgical skills for exposure in trauma: a new surgical skills cadaver course for surgery residents and fellows. J Trauma Acute Care Surg. 2013;74(2):664–70.CrossRefGoogle Scholar
  38. 38.
    Bowyer MW, Kuhls DA, Haskin D, Sallee RA, Henry SM, Garcia GD, Luchette FA. Advanced surgical skills for exposure in trauma (ASSET): the first 25 courses. J Surg Res. 2013;183(2):553–8.CrossRefGoogle Scholar
  39. 39.
    Sidhu RS, Park J, Brydges R, MacRae HM, Dubrowski A. Laboratory-based vascular anastomosis training: a randomized controlled trial evaluating the effects of bench model fidelity and level of training on skill acquisition. J Vasc Surg. 2007;45:343–9.CrossRefGoogle Scholar
  40. 40.
  41. 41.
  42. 42.
    Loveluck J, Copeland T, Hill J, Hunt A, Martin R. Biomechanical modeling of the forces applied to closed incisions during single-use negative pressure wound therapy. Eplasty. 2016;16:e20.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Sawyer T, Strandjord TP, Johnson K, Low D. Neonatal airway simulators, how good are they? A comparative study of physical and functional fidelity. J Perinatol. 2016;36(2):151–6.CrossRefGoogle Scholar
  44. 44.
  45. 45.
  46. 46.
    Kirkpatrick AW, Tien H, LaPorta AT, Lavell K, Keillor J, Wright Beatty HE, McKee JL, Brien S, Roberts DJ, Wong J, Ball CG, Beckett A. The marriage of surgical simulation and telementoring for damage-control surgical training of operational first responders: a pilot study. J Trauma Acute Care Surg. 2015;79(5):741–7.CrossRefGoogle Scholar
  47. 47.
    Hoang TN, Kang J, Siriratsivawong K, LaPorta A, Heck A, Ferraro J, Robinson D, Walsh J. Hyper-realistic, team-centered fleet surgical team training provides sustained improvements in performance. J Surg Educ. 2016;73(4):668–74.CrossRefGoogle Scholar
  48. 48.
    Hoang TN, Kang J, Laporta AJ, Makler VI, Chalut C. Filling in the gaps of predeployment fleet surgical team training using a team-centered approach. J Spec Oper Med. 2013;13(4):22–33.PubMedGoogle Scholar
  49. 49.
  50. 50.
    Moorthy K, Munz Y, Sarker SK, Drazi A. Objective assessment of technical skills in surgery. BMJ. 2003;327(7422):1032–7.CrossRefGoogle Scholar
  51. 51.
    Scott DJ, Valentine RJ, Bergen PC, Rege RV, Laycock R, Tesfay ST, et al. Evaluating surgical competency with the American board of surgery in-training examination, skill testing, and intraoperative assessment. Surgery. 2000;128:613–22.CrossRefGoogle Scholar
  52. 52.
    Reznick RK. Teaching and testing technical skills. Am J Surg. 1993;165:358–61.CrossRefGoogle Scholar
  53. 53.
    Martin JA, Regehr G, Reznick R, MacRae H, Murnaghan J, Hutchison C, et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg. 1997;84:273–8.CrossRefGoogle Scholar
  54. 54.
    Sultana CJ. The objective structured assessment of technical skills and the ACGME competencies. 2006; Department of Obstetrics and Gynecology Faculty Papers. Paper 1.

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Division Trauma and Combat SurgeryVal G. Hemming Medical Simulation CenterSilver SpringUSA
  2. 2.Department of SurgeryThe Uniformed Services University and Walter Reed National Military Medical CenterBethesdaUSA
  3. 3.Department of SurgeryJohns Hopkins HospitalBaltimoreUSA

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