Point of Focus Debate

The Role of Simulation in Surgical Training: An Analysis of Controversies

By: Ettore Di Trapani a b and Bertrand Guillonneau a

EU Focus, Volume 2 Issue 1, April 2016, Pages 65-66

Published online: 01 April 2016

Abstract Full Text Full Text PDF (158 KB)

The technologies applied to surgery cause urologists to use modified anatomic approaches, different surgical steps, and new instruments. In parallel, patients themselves require novel techniques and expect improved outcomes.

It has been suggested that the introduction of new surgical techniques, even in high-volume centers with experienced surgeons, leads to impaired outcomes, at least initially, compared with the standard [1]. In contrast, the traditional volume-based apprenticeship is associated with higher rates of complications until the initial part of the learning curve is reached [2].

Performing surgery on animal models and on human fresh cadavers has historically been the only available option. Animals provide a system with living tissues and reactions to tissue damage (eg, active bleeding), but they have different anatomy, even if somehow close, and do not represent a realistic pathologic model. Alternatively, cadavers offer the best anatomic experience, but the tissues are passive and generally healthy. Finally, both are limited by ethics and costs.

For all of these reasons, surgical simulators are now considered possible learning tools for trainees to better perform surgery.

Beyond these reasonable considerations, some questions should be raised. First, we must definitively distinguish basic tasks (eg, suturing, knot tying, cutting, tissue handling and manipulation, or dissection) from surgery, that is, a much more complex process that combines understanding of the disease and a permanent technical adaptation to local conditions. The ideal patient, if one exists, is certainly not representative of the daily, yearly, or even career experience of the surgeon.

1. Simulation is not reality

Virtual simulation software, even when supervised by expert surgeons, far from replicates the intraoperative conditions we all encounter in real life. In this sense, this kind of preparation gives trainee a false sense of the complexities of a given procedure. In addition, some nontechnical skills have to be considered during surgery. Simulation cannot push the trainee to the same stress level that will be reached in the operating room.

No simulator can improve the decision-making process and communication abilities that significantly affect surgical performance in a group [3].

2. Standardization

Although several simulation platforms are on the market, there are still no criteria by which to evaluate them or comparative studies assessing whether one simulator might be better than another. We still lack a commonly agreed definition of difficulties and standard proficiency to define the completion of the training that characterizes an apprentice as “fully trained” in a specific technique. To standardize difficulties, a consensus from the European Association of Urology should define precise directives addressed to specific end points. Who will declare that a given surgeon, based on certain number of hours of simulation, is trained enough to operate on a patient?

3. Costs

As noted, technology progressively enters our daily surgical practice, and direct costs increase accordingly. This explains why small centers cannot afford new technologies and their related simulators. In this context, it is interesting to read the review and meta-analysis by Nguyen and colleagues of the available literature, concluding that commercial video laparoscopic trainers are equally proficient for learning skills compared with “homemade” trainers [4].

4. Final considerations

Only a few studies have demonstrated the effectiveness of training and its transferred technical skills to the operation theater [5] and [6]. Historically, the surgical experience has been led by mentors teaching young urologists the different steps of the operations and their integration within the complex environment of the human bodies of our patients, with their personal medical histories. This training has been done for several decades in the conventional surgery era, and it is even easier to imagine that endoscopic, laparoscopic, or robotic assisted techniques will follow the same historical path, supported by improved vision of the operating field.

Although the literature on this topic is extremely heterogeneous, several studies have suggested that training, even for residents, fellows, or trainees with no previous experience, does not affect patients’ outcomes for both small procedures and more complex surgeries [7], [8], [9], and [10]. One of the methods suggested is to divide the most difficult operations into different segments, allowing the trainees to learn step by step according to the complexity of the surgery and under the tutor's supervision [10] and [11].

Even if mentoring is, by definition, time consuming and often poorly considered by the patient, it is still the only method by which to demonstrate to trainees all of the possible scenarios that can occur during a given procedure and how to manage the difficulties for the sake of our patients.

Conflicts of interest

The authors have nothing to disclose.


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a Department of Urology, Diaconesses-Croix Saint-Simon Hospital, Paris, France

b Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy

Corresponding author. Department of Urology, Diaconesses-Croix Saint-Simon Hospital, 18, rue du Sergent Bauchat, Paris, 75012, France.

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