Surgical Simulation Strategies

1. Optimizing Simulation Strategies for Safer
Operations
JOSE JESUS HERRERA MD
JOSE JESUS HERRERA MD
JOSE JESUS HERRERA MD
JOSE JESUS HERRERA MD
Gastrointestinal Surgery
Gastrointestinal Endoscopy
Gastrointestinal Endoscopy and Surgery Chairman
Hospital General “Dr. Manuel Gea González”
Hospital General “Dr. Manuel Gea González”
Hospital General “Dr. Manuel Gea González”
Hospital General “Dr. Manuel Gea González”
México City
México City
México City
México City
drherrerajj@gmail.com
drherrerajj@gmail.com
drherrerajj@gmail.com
drherrerajj@gmail.com

2. • JOSE JESUS HERRERA MD
JOSE JESUS HERRERA MD
JOSE JESUS HERRERA MD
JOSE JESUS HERRERA MD
• Gastrointestinal Surgery
• Gastrointestinal Endoscopy

3. Intro
Intro
Intro
Intro

4. Intro
Intro
Intro
Intro
1874 William Halsted
“See One-Do One-Teach One”
Stages of Skills Acquisition - Teaching Procedure Patient Risk
1.-Cognitive: How to perform the skill. Memorization of steps required
to perform the skill. NO actual understanding.
-Mistakes are frequently observed High
2.-Associative: The learner undertands how to associate indivudual
steps in performance with likely outcomes. Able to asses progress and
Make adjustements in performance.
-Mistakes are still frequent Moderate
3.-Automatic response: The trainee is capable to perform the skill without
mistakes, uninterrupted and clean.
-Minimum mistakes are observed Low
Sushruta (Hindu surgeon) 3rd century BC, first to use simulation in surgical training.
Unique opportunity to practice psychomotor skills and procedures
Dawe SR, Pena GN, Windsor JA, Broeders JA, Cregan PC, Hewett PJ, Maddern GJ. Systematic review of skills transfer after surgical simulation-based training. Br J Surg. 2014 Aug;101(9):1063-76.
doi: 10.1002/bjs.9482. Epub 2014 May 15. PMID: 24827930.

5. • Why should we use simulation training
Simulation for Safer Operations
How What
Process
Skills
Technique

6. Teaching surgery
Paradigm shift:
Reduction of the times in the duration of
the shifts in residences.
Lack of availability of mentors
Low availability of patients
Long time learning at the operating
room
Hand and eye coordination is
associated with a long learning
curve
More and better surgeons are demanded
Quality of healthcare required
Higher standards of care
Patient safety is priority
Dawe SR, Pena GN, Windsor JA, Broeders JA, Cregan PC, Hewett PJ, Maddern GJ. Systematic review of skills transfer after surgical simulation-based training. Br J Surg. 2014
Aug;101(9):1063-76. doi: 10.1002/bjs.9482. Epub 2014 May 15. PMID: 24827930.

7. Simulation and SARS-CoV-2 pandemic
SARS-CoV-2
Medical provider and health system is focused in dealing with the pandemic
Number of Surgical Procedures dramatically reduced during the pandemic
Will the total number of surgical procedures be enough to reach the needed number of
exposure in order to be skilled?
Gutierrez, et al.
Mexico City General Hospital
Prepandemic, elective surgery average number 380 procedures
First three months 2020, elective surgery average number 21 procedures
Gutiérrez OJA, Vidrio DR, Sánchez MJC, Solís RC, Vidrio DE, Sánchez SR, et al. Impacto de la pandemia por SARS-CoV-2 en la residencia de Cirugía General en el Hospital General
de México. Cir Gen. 2020; 42(2): 165-169. doi: 10.35366/95376

8. Types of surgical simulation
• Variety of simulation models and devices
• Substitutes for human anatomy: bench model simulators.
• Bench model simulators
• Organic simulators
• Inorganic simulators
• These models differ greatly with respect to their degree of fidelity or ‘realism’ to live
patients.

9. Types of surgical simulation
Organic simulators
Live animal and fresh human cadaver models
 Considered to be of high-fidelity
 Limited in terms of availability
 High costs
 Potential for transmission of infectious diseases
 Ethical concerns

10. Types of surgical simulation
Organic simulators
 Animal
 Very realistic haptic feedback
 High-fidelity environment to develop psychomotor and cognitive skills
 Team working environment on a live operation
Reinforces team relationships
Communications
Gradients of authority
 Most common animals: canine, porcine and baboon models
 High costs
 Perioperative animal care needed
 Ethical implications

11. Types of surgical simulation
Organic simulators.
 Cadaver
 Acquisition and detailed understanding of human anatomy
 Very useful in using developing new techniques
 Formalin preserved cadavers loose fidelity as a surgical
instructional model
 High cost and single use
 Ethical issues
 Hard to access

12. Types of surgical simulation
Inorganic simulators
 Synthetic simulators and virtual reality (VR) or computer-based simulation
 Portable
 Low cost
 Potential for repetitive use

13. Types of surgical simulation
Inorganic simulators
 Electronic
 High fidelity and haptic (touch and motion -feedback)
 Laparoscopy and endoscopy most developed focus in surgical
VR simulators
 VR simulators Attractive and useful but limited due to high
costs

14. Types of surgical simulation
Inorganic simulators
 Synthetic
 Made of plastic, rubber and latex
 Useful for teaching and learning basic surgical skills and
techniques
 The greatest benefits:
Development of hand–eye coordination and motor skills
Useful to get skills in specific tasks
- cutting, suturing, grasping or clipping

15. Simulation
Systematic Review
Azzam et al.
2012
Students Simulation No use of simulators
Surgical Skills ++++ ++
Tissue management. ++++ +
Surgical performance time ++ ++++
Surgical mistakes in real surgery. + +++
Surgical complications + +++
Azzam S, Donnon T, Oddone E, Mitchel P, Debru E, Church N. The effect of simulation in improving students performance in laparoscopic surgery: a meta-analysis. Surg Endosc. 2012.
DOI: 10.1007/s00464-012-2327-z
Spiliotis A, Spiliotis P, Palios I. Transferability of simulation – based training in Laparoscopic Surgeries: A systematic Review. Hindawi. Minimally Invasive Surgery. Vol 2020. Aticle
ID: 5879485. DOI: /doi.org/10.1155/2020/5879485

16. Simulation
1998
Derossi et al.
Quebec- Canada
Laparoscopic Surgery Evualuation Method
“MISTELS” (McGill Inanimate System for training and Evaluation of Laparoscopic
Skills )
1) Object transfer
1) Circular patern cut
2) Titanium clip application
3) Preformed extracorporeal knot ligation
4) Polypropylen mesh placement
5) Extracorporal knot suturing
6) Intracorporeal knot suturing
Vasiliou M, Ghitulesco G, Feldman L, Stanbridge D, Leffondré K, Fried G. The MISTELS program to measure technical skill in laparoscopic surgery. Sur Endosc 2006. 20: 744-747.
DOI: 10.1007/s00464-005-3008-y

17. Simulation
2004
SAGES (Society of American Gastrointestinal and Endoscopic Surgeons)
&
ACS (American College of Surgeons)
FLS (Fundamentals of Laparoscopic Surgery).
Teaching surgical tool, basic laparoscopic procedures.
Didactic modules
Hands-on
Evaluation
Required prior to Achieve Board Certification
Zheng B, Chun H, Johnson S, Swanstöm L. Validity of using fundamentals of laparoscopic Surgery program to asses laparoscopic competence for gynecologists. Surg Endosc. 2010
Jan;24(1):152-60. doi: 10.1007/s00464-009-0539-7.
Zendejas B, Ruparel R, Cook D. Validity evidence for fundamentals of Laparoscopic Surgery (FLS) program as an assessment tool: a systematic review. Springer, Surg Endosc 2015
DOI: DOI 10.1007/s00464-015-4233-7

18. Simulation
2007 Scott, et al.
FLS High-level skill development
Laparoscopy board certification
21 Trainees from 2 Hospitals
2 month period
Trained 9,7± 2,4 h (6-14 hours)
119 ± 31 repetitions (66-161 repetitions)
0/21 trainees (0%) passed de initial evaluation test 126±75 points
21/21 trainees (100%) passed the final evaluation test 468±24 points. P<0.001
Self assessment
How confident does the trainee feel in laparoscopic surgery: 4.8%. vs 89.4. p<0.001
How comfortable does the trainee feel with the skills 1.2±0.5 vs 3.6±0.3 p<0.001
Scott D, Matt E, Tesfay S, Pimentel E, Nagji A, Fried G. Certification pass rate of 100% for fundamental of laparoscopic surgery skills after proficiency-based training. Surg Endosc
2008. 22: 1887-1893. DOI: 10.1007/s00464-008-9745

19. GEA General Hospital
Laparoscopic Basic skills training program. -Simplified MISTEL-
McGill Inanimate Sytem for training and Evaluation of Laparoscopic Skills
1.- Object transfer
2.- Precision Cut
3.- Preformed extracorporeal knot ligation
4.- Extracorporeal knot suturing
5.- Intracorporeal knot suturing

21. Simulation highlights
Augmented Reality (AR): Combine physical simulation & VR overlay simulation
Truly immersive experience.
Helps to understand spatial relationships and concept conditions
Increase in self-reported confidence and comfort with technical skills and knowledge
Disadvantages
• High-cost
• No improved cost–benefit comparing the virtual reality training model & apprenticeship
model.

22. No evidence of improved patient safety
Reduced operation time
Enhanced instrument and tissue handling technique
Diminished errors.
A supplement to surgical training, not a substitute.
Simulation highlights

23. Simulation summary
- Safe and efficient way to learn needed skills in order to perform a safe procedure
Should be:
*Controlled scenario
*Similar Surgical expected conditions
*Patient Risk free
*Unlimited exposure capability
*Low cost Could be in:
*Cadaver
*Laboratory –Live animals-
*Laboratory –Ex Vivo tissue
*Simulation Boxes
*Virtual reality (Expensive)
Larsen CR, Soerensen JL, Grantcharov TP, et al. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ 2009;338:b1802

24. Must be:
*Cheap
*Portable
*Unlimited Access
Expected gain:
*Psychomotor ability
*2D and 3D familiarity
*Coordination Improvement –Visual-Hand-
*Tissue sensibility- tissue management
*Get used to surgical instruments
*Get used to work in confined spaces
Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med 2008;15(11):988–94.
Simulation summary

25. Optimizing Simulation Strategies for Safer
Operations
JOSE JESUS HERRERA MD
JOSE JESUS HERRERA MD
JOSE JESUS HERRERA MD
JOSE JESUS HERRERA MD
Gastrointestinal Surgery
Gastrointestinal Endoscopy
Gastroinestinal Endoscopy and Surgery Chairman
Hospital General “Dr. Manuel Gea González”
Hospital General “Dr. Manuel Gea González”
Hospital General “Dr. Manuel Gea González”
Hospital General “Dr. Manuel Gea González”
México City
México City
México City
México City
drherrerajj@gmail.com
drherrerajj@gmail.com
drherrerajj@gmail.com
drherrerajj@gmail.com