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Simulation in surgery: A review

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 SMJ-11-098

E D U C AT I O N A L A R T I C L E

Simulation in surgery: a review

Shaun Shi Yan Tan* and Sudip K Sarker†
*Medical Student, School of Medicine, University of Glasgow, Wolfson Medical School Building, Glasgow G128QQ, UK;
†
Consultant Surgeon, Colorectal Surgical Unit, Whittington Hospital, London N195NF, UK
E-mail: shaunnietan@hotmail.com

Abstract
The ability to acquire surgical skills requires consistent practice, and evidence suggests that many of these
technical skills can be learnt away from the operating theatre. The aim of this review article is to discuss
the importance of surgical simulation today and its various types, exploring the effectiveness of
simulation in the clinical setting and its challenges for the future. Surgical simulation offers the oppor-
tunity for trainees to practise their surgical skills prior to entering the operating theatre, allowing detailed
feedback and objective assessment of their performance. This enables better patient safety and standards
of care. Surgical simulators can be divided into organic or inorganic simulators. Organic simulators,
consisting of live animal and fresh human cadaver models, are considered to be of high-fidelity. Inorganic
simulators comprise virtual reality simulators and synthetic bench models. Current evidence suggests that
skills acquired through training with simulators positively transfers to the clinical setting and improves
operative outcome. The major challenge for the future revolves around understanding the value of this
new technology and developing an educational curriculum that can incorporate surgical simulators.
Keywords: assessment, skills, simulation, surgery, training

Introduction complications rather than refining technical skills during

Rising demands on current surgical programmes have led
to investigations into new approaches to training.1 The
ability to acquire surgical skills requires consistent practice,
and evidence suggests that many of these technical skills
can be learnt away from the operating theatre.2 Surgical
simulation is one of the methods through which surgical
education has focused on in the last few years. It offers
the opportunity for trainees to practise their surgical tech-
nical skills prior to entering the operating theatre, allowing
detailed feedback and objective assessment of their
performance.1
Simulation can be defined as the reproduction of the
essential features of a real-life situation.3 The aim of simu-
lation is to represent reality as close as possible such that
the trainee is convinced the simulated encounter replicates
what would happen in a real-life situation.3 Surgical simu-
lation has evolved considerably over the past two decades
and is now a mainstay in training, playing a major role in
the acquisition of new skills and knowledge out with the
clinical environment.4 It is considered particularly valu-
able in the surgical discipline because it avoids the use of
patients for skills practice, ensuring that surgical trainees
have had sufficient practice before permitted to treat
humans.1,5 Gallagher et al. suggest that simulation-based
surgical training allows an individual to acquire technical
skills to the point where many psychomotor and spatial
judgement skills become ingrained and automated. This
places the trainee in better stead to manage intraoperative
real-life scenarios.1,6
The aim of this review article is to discuss the impor-
tance of surgical simulation today and its various types,
exploring the effectiveness of simulation in the clinical
setting and its challenges.
The need for surgical simulation
Surgical training consists of developing cognitive, clinical
and technical skills, where the latter is traditionally
acquired through mentoring.7 Apprenticeship models
were developed over a century ago, originally championed
by Dr William Halsted in 1904.4 The Halstedian model
describes gaining progressive experience through super-
vised training on patients, but this depends on an opportu-
nistic flow of patients in the operating theatre and
precludes any organized curriculum.8,9 There is a need to
adopt a more formal skills-based training programme.
Surgical simulation provides the opportunity for self-
directed learning through continuous evaluation and feed-
back, permitting the trainee to correct deficiencies in
training and performance.1,10
With the implementation of the new European
Working Time Directive (EWTD) in the National
Health Service (NHS), trainees are beset with restrictions
in working and training hours. Before the EWTD, a trainee
could expect to work over 30,000 hours between becoming
a basic surgical trainee and becoming a Consultant

DOI: 10.1258/smj.2011.011098 Scottish Medical Journal 2011; 00: 1 –6

 SMJ-11-098
2 Tan and Sarker
Surgeon. Chikwe et al. 11 have reported that this will now
fall to a mere 6000– 8000 hours, based on calculations by
the Royal College of Surgeons. Coupled with an increasing
number of patients presenting with serious and complex
surgical problems, this translates to young surgeons
required to be more proficient albeit decreased mentoring
opportunities.12 The use of simulators alleviates the
burden placed on trainees for developing core skills in
light of shortened clinical and operative opportunities.
Continuous quality improvement is imperative to
health-care services. The use of surgical simulation
enables better patient safety and standards of care.13,14
Innovative state of the art simulation devices can train
both surgical tasks and skills without risk to patients.
This allows for the detection and analysis of errors and
‘near misses’ which are potentially avoidable.15 During
early training, surgical trainees should be closely super-
vised, but it is inevitable that preventable patient injuries
may occur due to inexperience. In the clinical setting, such
errors must be prevented or terminated immediately by
supervisors in order to protect patients.13,14 In a simulated
environment, however, training errors can be allowed to
progress in the face of error.14 This allows trainees to be
taught the implications of the error, and reactions to
rectify such deviations. The availability of video feedback
for many surgical simulators strengthens the impact of
learning and provides further incentives for behaviour
modification.13,14 A study by Fried et al. 15 has also
shown that the use of an Endoscopic Sinus Surgery
Simulator (ES3) for training surgical residents, when amal-
gamated with a rigorous formal curriculum, inculcates a
unique culture of safety into participating surgical training
programmes. They believe a structured curriculum incor-
porating surgical simulation will improve surgical efficacy,
reduce errors and ultimately improve standards of safety in
surgical departments.15
Additionally, the operating theatre no longer serves as
the ideal atmosphere for the training of novice surgeons.16
Ethical concerns about teaching and learning surgical
skills on live human patients have been voiced.17 With
simulation, trainees have their first encounters with real
patients when they are at higher levels of technical and
clinical proficiency. Existing practitioners can also use sur-
gical simulation to improve proficiency when learning new
procedures or when honing existing skills.14
Types of surgical simulation
A wide host of simulation models and devices now exist for
the benefit of trainees.1 Many academic medical centres
and University hospitals have developed skills laboratories
to accommodate learners through a range of surgical spe-
cialties, allowing them to practise their skills.18 Surgical
simulation enables repetitive performance of a single task
to allow a trainee to develop essential hand – eye coordi-
nation and motor skills prior to entering a real-patient
setting.1 Through surgical simulation, the development
of speed, efficiency and precision are honed through
Scottish Medical Journal 2011 Volume 00 Number 0
continual practice. Eventual automaticity and proficiency
in the skill can thus be achieved.19
As surrogates for human anatomy, surgical simulation
laboratories rely on a variety of bench model simulators.
These models differ greatly with respect to their degree
of fidelity or ‘realism’ to live patients.16 They can be
divided into organic or inorganic simulators. Organic
simulators, consisting of live animal and fresh human
cadaver models, are considered to be of high-fidelity.
Unfortunately, studies have shown that they are limited
in terms of availability, high costs, potential for trans-
mission of infectious disease and possible ethical con-
cerns.16,20,21 Lower-fidelity inorganic bench models, on
the other hand, often sacrifice realism for the convenience
of portability, lower costs and the potential for repetitive
use.16,20,21
Inorganic – synthetic
Synthetic simulators are models made of plastic, rubber
and latex. They are particularly useful in teaching and
learning basic surgical and technical skills, and have
been incorporated into courses such as the Basic Surgical
Skills Course in line with the Royal College of
Surgeons.10 Lower-fidelity simulators usually compose of
simple devices used for knot tying and suturing techniques.
A box trainer is often used in tandem with such simulators,
where actual instruments and optical systems used clini-
cally are employed to manipulate the synthetic tissue.1,15
The greatest benefit of such synthetic simulators is the
development hand – eye coordination and motor skills
requisite for specific tasks such as cutting, suturing, grasp-
ing or clipping structures.10 Higher-fidelity synthetic
models (Figure 1) are more expensive, some of which repli-
cate an entire operation such as aneurysm repair, fracture
fixation or femoral-popliteal bypass.10
Inorganic – electronic
With the advent of technology, virtual reality (VR) or
computer-based simulation has become increasingly
popular due to the high fidelity and haptics (tactile feed-
back) of the models.10 VR is defined by Moorthy et al. as
a collection of technologies which allow people to interact
efficiently with three-dimensional deformable computer-
ized databases in realtime, using their natural senses and
skills.22,23 VR simulators (Figure 2) use computer-
generated images of organs or objects integrated with a
human – computer interface. This allows the trainee to
Figure 1 TraumaManw reproduced with permission from Simulab –
a life-like, high-fidelity model used to teach basic surgical skills
 SMJ-11-098
Simulation in surgery
Figure 2 Captured virtual reality endoscopic simulator pictures
manipulate the images and obtain objective feedback on
his performance from the computer.22
Currently, both laparoscopic and endoscopic surgeries,
as opposed to open surgery, have received most of the
development focus in surgical VR simulators.1,24,25 This
is mainly attributed to the fact that laparoscopic and endo-
scopic scenarios are more easily recreated by VR simulators
rather than open surgery as they comprise a two-
dimensional visual system without much haptic inter-
actions.1,26 Their increased emphasis also stems from
efforts to address complications and problems identified
in early clinical experience with laparoscopic cholecystect-
omy.27 Studies have shown that VR simulators are useful
and effective in the training of procedures such as upper
endoscopy, flexible sigmoidoscopy and colonoscopy.28 – 32
Within the last few years, there have been developments
in other VR simulators for minimizing invasive gastro-
intestinal surgery. These systems are of higher fidelity
and have improved haptics, examples of which include
the Reachinw, ProMisw and LapMentorw. VR simulators
are appealing but are often limited due to high costs.
Hybrid simulators combine both attributes of physical
simulators and VR simulators, often taking the form of a
mannequin linked to a sophisticated computer programme
which provides visual images or feedback.1,33 The compu-
ter programme can simulate physiological and physical
responses such as bleeding, as a reaction to a procedure.
These simulators allow the production of a realistic clinical
environment where team-working is reinforced, bridging
gaps in the operating theatre.1,34
Organic – animal
Anaesthetized, live animals provide a high-fidelity
environment which allows trainees to develop psychomo-
tor and cognitive skills necessary for the operative
setting.1,35 The advantage of animal models is that they
allow trainees to work together as a team on a live oper-
ation through reinforcing team relationships, communi-
cations and gradients of authority.1,34 They have been
used extensively in both open and laparoscopic surgical
training, the most common animals being canine,
porcine and baboon models.1,36,37 Examples include the
use of the dog in the coronary bypass model where it was
shown that vascular trainees improved their technical
3
complications rate.10 However, anatomy of animal
models differs from humans. The Calot’s triangle in pigs
varies from that in humans so laparoscopic cholecystect-
omy in these animal models should not be confused.10
Animal models are most commonly used in Europe and
America. Currently, the UK law forbids the use of live
animal tissues for practising of surgical techniques due to
ethical issues but allows the use of dead animal tissue.
Sheep and pig skin are commonly used for bowel anasto-
mosis in surgical courses.10 Although these animal
models provide very realistic haptic feedback, they are
limited by high costs and the need for more sophisticated
training such as perioperative monitoring and analgesia of
the animals.1
Organic – cadaver
The main advantage of cadaveric training is the acqui-
sition a detailed understanding of human anatomy and
its relations to diseases.1,38 Cadaveric procedures com-
monly practised on by trainees include laparoscopy, endo-
scopy and saphenous vein cutdown.39 – 41 Cadavers are used
commonly in America as well as in the UK for certain
courses such as the Definitive Trauma Skills Course.10
Unfortunately, cadavers preserved by formalin lose some
fidelity as a surgical instructional model. Its high cost
and single use have also limited its supply to many
medical schools, decreasing opportunities for dissection.38
Assessment of competency
Simulation holds a strong common-sense appeal.
Nevertheless, attractive programmes are not inherently suf-
ficient.42 We need to know if they can work, and if they
can assess true surgical competency.42 Ideally, assessment
should produce reliable and valid results which are both
affordable and practical for the trainee and institution.43
Assessment results should also correlate with the trainee’s
actual operative experience and must be shown to improve
with surgical training, distinguishing between experienced
and novice surgeons. Discussed below are some of the
objective methods currently used to assess competency
with surgical simulation.43
Scottish Medical Journal 2011 Volume 00 Number 0
 SMJ-11-098
4 Tan and Sarker
Motion analysis systems
The Imperial College Surgical Assessment Device
(ICSAD) was developed at Imperial College,
London.43,44 The system consists of a commercially avail-
able electromagnetic tracking system connected to a porta-
ble computer.10 The device’s electromagnetic trackers and
two sensors are affixed to the dorsum of the trainee’s hand
and bespoke software is used for the retrieval of data and
analysis.10 ICSAD gauges positional data to produce dex-
terity measures of the trainee, such as distance travelled,
number and speed of hand movements and time taken to
Q1 complete the task.44 Recently, Dosis et al. have developed
a new software known as ROVIMAS – Robotic Video
Motion Analysis Software.45 This enables video inte-
gration on the ICSAD where the user can concentrate
on video frames exhibiting kinematic properties which
can result in operative errors.10,45 Other studies have vali-
dated the construct of ICSAD with respect to a range of
laparoscopic tasks.10 Experienced and skilled laparoscopic
surgeons exhibit more economical movements, hence use
significantly lower path lengths which is a determinant
of accuracy.10
Virtual reality
The minimally invasive surgical trainer-virtual reality
system was one of the first commercially available VR
laparoscopic simulators.10 The system was developed in
collaboration with surgeons and psychologists who
designed a task analysis of laparoscopic cholecystectomy.
A particularly attractive feature of VR simulation is its
ability to generate output data, or what is known as
metrics. This allows objective and repeated measurements
of the activity performed, such as the time taken to com-
plete a task, the errors made in the process and also the
economy of movements in the accomplishment of the
task.1 Realtime feedback can be provided, and results com-
pared with validated data. The use of metrics also allows
the opportunity for assessment of competency without
the need for an observer to be present. VR trainers can
allow trainees to practise independently in their free
time, and this can be incorporated into a structured curri-
culum.1,34 A large proportion of surgical VR systems func-
tion as part-task trainers, which focus on the training of a
particular task within the surgery, that aims to improve the
quality of surgery by shaping certain skills required to
perform the surgery.1
Task-based analysis assessment
This type of assessment of technical skills is derived from
human error and reliability analysis. It breaks down an
operation into fundamental\key steps and these key steps
are then broken down into mini steps. The key steps are
very important in the quality of the operation while the
mini steps incorporate more generic technical skills, e.g.
knot tying, haemostasis, etc. Sarker’s group10,46 – 49 has
demonstrated the construct validity and reliability of this
method of assessment over the past few years in
Scottish Medical Journal 2011 Volume 00 Number 0
endoscopic, open and intermediate and advanced laparo-
scopic surgery.
Effectiveness of simulation
To establish a benefit in using simulated environments to
teach surgical skills, it must be shown that skills acquired
through training with simulators can positively transfer
to clinical practice, translating into better patient
outcome.1 Recent evidence does suggest an improved per-
formance in clinical setting after the use of simulation.
Scott et al. 16,50 demonstrated that surgical residents who
underwent laparoscopic skills training with a simulated
video trainer exhibited significantly improved perform-
ances on laparoscopic tasks in the operating room, as com-
pared with the control group who was not exposed to any
training. In addition, other disciplines have also estab-
lished the value of simulation in the clinical setting.
Naik et al. report that fibreoptic orotracheal intubation
skills acquired by anaesthesiology trainees on a simulator
translated into better performance on real life-patients.
They were compared with trainees who received didactic
teaching only, and both groups were evaluated by
blinded anaesthesiologists who found that the simulation-
trained group significantly outperformed the control
group.51
A recent meta-analysis by Haque et al. analysed 16
prospective and randomized studies for the training effec-
tiveness of VR surgical simulators. Their results showed
VR simulation training was highly effective in the transfer-
ence of skills from the simulation environment to the
operating room, while being able to discriminate
between the experienced and inexperienced trainees.52
The VR trained group took significantly lesser time for
task completion compared with the control groups in the
process. These results are indeed promising, but further
prospective trials are required to explore the nature and
duration of simulation training required to deliver the
greatest clinical benefits.
Although simulation in surgery holds much promise
for the future and serves as an invaluable resource to the
education of young surgeons, it is not a one-stop solution
to our training needs. Becoming a competent surgeon
requires the amalgamation of good patient communi-
cation, team-work within a multidisciplinary setting, lea-
dership skills, decision-making and clinical acumen.
Technical skills are just one aspect of the myriads of com-
petencies required of a surgeon. We believe that apart from
VR systems, it will be prudent to engage as many members
in the operating theatre during simulation, to re-enact the
actual ‘live’ setting of operating. This will enable key
decision-making skills to be developed and foster team-
based environment which will improve effectiveness of
simulation.
The challenge
The discussion thus far has concentrated mainly on the
acquisition of skills through surgical simulation and the
 SMJ-11-098
Simulation in surgery
Figure 3 Proposed curriculum of assessment and feedback for the higher surgical trainee
pros and cons of each system.42 It is imperative to consider
how to assimilate simulation into training. Satava,33 a VR
pioneer has said, ‘simulators are only of value within the
context of a total educational curriculum, and technology
must support the training goals. New technology must con-
tinually seek to improve the quality of teaching and learn-
ing, and not simply to open up access to new information
and experiences.42 Managing simulator-based learning, as
described by Kneebone,42 should be an active process prop-
erly embedded in the learning context of the institution.
Simply providing sophisticated equipment will not guaran-
tee a successful learning outcome or translate into better
patient outcomes.33,42 At present in the UK, there is no
surgical programme that rigorously incorporates surgical
simulation into the assessment and training of surgeons.
The major challenge, therefore, revolves around under-
standing the value of this new technology, and developing
an educational curriculum (Figure 3) that can incorporate
surgical simulators.
Conclusion
With rapid advances in technology and the adoption of
more minimally invasive surgical interventions, there is a
demand for more simulators to complement and provide
training. Simulator-based learning commands an enor-
mous potential and seems poised to revolutionize surgical
training in future.42 For this to succeed, more studies will
need to validate the translational benefits from simulation
to the operating theatre and identify skills that are
5
developed the most with simulation. Currently in the
UK, only certain medical schools have a dedicated surgical
simulator centre. We believe that for simulation in surgery
to succeed, this will require academic directors in surgery
to embrace the potential of this technology and actively
promote it. A rigorous educational curriculum incorporat-
ing surgical simulation will augment the operative
exposure of surgical trainees, improving current training
standards and its research.
Conflict of interest
We declare that we have had no inappropriate influence in
our work, which includes avenues from employment, con-
sultancies, stock ownership, honoraria, paid expert testi-
mony, patent applications/registrations, grants or other
funding. We declare that these do not pose a conflict of
interest with regard to the submitted manuscript.
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