Surgical simulation and training for ENT surgery

Introduction

Many people wonder whether surgical simulation really is just a gadget: some think it is an important educational tool, while others see it as an aid to surgical strategy. There is, in fact, sufficient hard evidence to show that simulation improves knowledge and skill acquisition, although this obviously means that the simulation has to target the knowledge or skill in question.

Why bother about simulation?

Technological and social changes over the last two decades have revolutionized the traditional “see one, do one, teach one” model of surgical training. In Canada, factors that have had direct impact on surgery-room teaching include the following:

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  regulations on residents’ working hours, to ensure patient safety and residents’ well-being [ , ]. The shortened working week has impacted patient care and medical teaching. The risk is that graduates may end up lacking certain skills that are essential to their specialty. For example, ENT specialists may not be at ease performing emergency cricothyroidectomy if they have never encountered the procedure during training;

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  a culture of responsibility, with an expectation on the part of society that the population’s needs should be met, with quality standards and particular attention to patient safety. What kind of parent would happily agree to their child being the guinea-pig for a junior trainee trying out his or her first mastoid surgery?

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  the development of new technologies and procedures, some of which come with a long learning-curve: robotic surgery, sialendoscopy, middle-ear endoscopic surgery, skull base surgery.

Simulation provides an interesting response to these three challenges that have catalyzed change in our training system. It is also an important tool in the revolution that the Royal College of Physicians and Surgeons of Canada set off in the medical education system, with the “competence by design” approach whereby medical training throughout the country is founded on “competences” to be included in the training and assessment of residents and physicians. This model, supporting continuous training and skill enhancement, is structured around competence and productivity rather than on duration of training alone.

Simulation is an excellent means of ensuring patient safety, while allowing trainees to learn from their mistakes in mastering skills and achieving excellence in surgical techniques and procedures. Graber et al. demonstrated that patients were more likely to agree to be operated on by a trainee who has acquired the appropriate skill on simulation [ ].

Traditional surgical simulation

Many simulations of surgical techniques are carried out on human cadavers or animal models. Examples from McGill University include temporal bone dissection laboratories, human cadaver sinus and skull base endoscopic surgery laboratories, head and neck dissection workshops on cadavers embalmed by a method that conserves tissue texture, airway reconstruction and foreign-body ablation workshops in anesthetized pig, and cochlea ablation in chinchilla. The advantages of such models include anatomic precision, tissue quality and tactile and haptic feedback. A recent review of temporal bone dissection simulation platforms reported that cadaver dissection was the optimal teaching platform for this procedure [ ].

For reasons of access, cost and logistics, certain workshops now use 3D-printed models of the temporal bone, which provide almost comparable experience.

“Low-fidelity” models

These models are inexpensive and portable, with the advantage for the trainee of being able to progress by repetition and for the surgeon of being able to acquire psychomotor skills.

One of our simulation research projects compared residents’ performance and skill after learning by observation and assisting in the operating room versus structured learning on a simple model comprising a small metal box with a latex membrane, in which tube insertion under microscopic control could be practiced: the simulation group performed better in terms of speed, ergonomy, precision and tissue preservation.

Integrating virtual reality simulation in clinical practice

It will revolutionize training for the upcoming generation. It provides immediate feedback and often includes objective assessment measurements such as time and motion analysis. One disadvantage is cost, which can be exorbitant. A recent meta-analysis by Nagendran et al. demonstrated the interest of integrating virtual reality simulation in surgical training programs [ ].

Advantages of surgery simulation

As well as giving the trainee plenteous opportunity to practice a skill or procedure, simulation provides immediate feedback in a safe setting. In a randomized study, Moulton et al. showed that residents maintained skills acquired by simulation better when practice was spread out rather than concentrated, for example in a single day [ ].

Several studies reported improved surgical performance and reduced complications rates with simulation [ , ]. Simulation also allows preparation for a given procedure or clinical situation, and can compensate for lack of turnover for certain clinical procedures.

Simulation can also serve as a proxy, for objective assessment of residents’ and physicians’ surgical skills. For example, the Quebec College of Physicians requires anesthetists at the end of their career to take a structured examination in a simulation center.

Simulation can also be used to assess mastery beyond the question of procedural skill: e.g. the surgeon’s communication skills, interaction with the rest of the team, speed of decision-making, and clinical reasoning in front of particular situations.

Limitations

Some surgeons have lingering doubts as to how skills acquired in simulation are transferred to the actual operating room, although this has in fact been the focus of several studies [ ]. Others speak of skill decontextualization in simulation.