Simulation has long been an important aspect of the aerospace industry, helping train pilots before they get on the actual aircraft. With time, this technique has found acceptance in an increasing number of industries, such as automotive and healthcare. Surgical simulation is a rapidly emerging subsegment of simulation, helping train surgical interns before they actually get to operate on someone. This has become essential because of a perpetually high risk of human error in the operating room, which can cause patients their life and hospitals millions in medical malpractice allegations.
Moreover, even seasoned surgeons are nowadays training on simulators to sharpen their skills. As the medical field witnesses non-stop evolution, so must all doctors. With time, new diseases emerge and the need for better treatments for those known over ages strengthens, which is why even those who have been practicing medicine for 20–30 years must refresh their knowledge and acquire newer skills. Moreover, any medical procedure, however short and seemingly simple, carries risk, which is why many surgeons are now practicing the procedure on a simulator before actually performing it on the living.
History of Surgical Simulation
Despite sounding really high-tech and almost like the stuff of sci-fi movies, surgical simulation is an ancient technique. The earliest recorded evidence of it is from 600 BC India, where clay and leaf models of the human face were used to practice rhinoplasty, the oldest cosmetic procedure known to man. In medieval times, Ambroise Paré, often credited with revolutionizing surgery, is known to have taken embalmed corpses home, to practice surgical procedures. Later came wooden benchtop models with vaguely realistic impressions and carvings of the insides of the human body.
Modern Simulators for Surgeons
Like almost all fields, the advent of computers and TVs has changed the way surgical simulation works. Corpses are being replaced by high-tech systems with AR and VR technologies. Both kinds of systems use anatomical models of various parts of the human body, to help trainees as well as seasoned doctors sharpen their skills. Some of the ridiculously high-tech surgical simulators even mimic the sounds, smells, and haptic sensations one would feel if working on a living being!
Moreover, the likely unfavorable events one may encounter during an actual procedure, such as respiratory distress, arrhythmia, heart attack, cardiac arrest, stroke, hemorrhage, throat collapse during laryngoscopy or intubation, lung collapse, and seizures, can be created by these systems. This gives users more-extensive training, helping them take the right decision during an actual procedure in quick time. Apart from the simulation of the workings of various organs, these systems also offer audio and visual cues to help people complete the task more efficiently and confidently. Additionally, their software generally comes packed with extensive training modules, which guide users as they train on the system.
Then, there are simpler surgical simulators, which are no different than a videogame, wherein the procedure is conducted in a purely virtual environment, with no anatomical model. These variants are ideal for the initial training process, wherein residents and students need to simply be acquainted with the human anatomy and basic procedures and their terminology. In this regard, the popular videogame Surgery Master can be considered a basic surgical simulator, allowing users to perform more than 10 different procedures. These variants can help acquaint trainees with the step-by-step process in a perfectly safe and fun way.
Additionally, some systems even allow users to practice robot-assisted laparoscopic surgery. Modern healthcare demands proficiency in such procedures as they are painless, shorter, and leave less scarring. Moreover, they are cost-effective and demand a shorter stay at the hospital than open surgeries. As a result, they are becoming rapidly popular among people, especially the elderly and those conscious of their physical appearance. As per an article of January 2020, a study on 169,404 patients in 73 hospitals showed that compared to 1.8% in 2012, over 15% of the surgeries conducted in 2018 were robotic ones.
Moreover, the study showed an 8.8% rise in the volume of such procedures within four years of their introduction by hospitals. Additionally, in 2018, over 35% of the surgeons at the hospitals studied performed robot-assisted surgeries, compared to 8.7% in 2012. Similarly, as per an article published on NCBI, some of the commonest surgical procedures being conducted via robots are hysterectomy, colectomy, and prostatectomy. Since working with robots cannot be taught via traditional live-organism-based methods, modern simulators are essential for this purpose.
Patient-Specific VR Simulators and 3D Rapid Prototyping: Latest Advances in Surgical Simulation
Taking surgical simulation one step further into the future are systems that combine patient data on the disease and specific body response to therapy, to virtually create an environment that surgeons would encounter in reality. This allows healthcare professionals to plan the surgery better and improve patient outcomes. With 3D rapid prototyping, MRI and CT scans are used to create 3D-printed models of the patient anatomy, simulating the actual disease, for the doctor to practice the procedure.
Similarly, patient-specific VR simulation creates a virtual model of the disease or tissue as it functions within the patient’s body, which not only allows doctors to practice the procedure but also for effective information sharing among team members, which can ultimately reduce human error in the OR and improve the overall patient outcome. As claimed by the companies offering these simulators, their accuracy in using CT and MRI images to virtually create the patient anatomy ranges between 95% and 100%.
Impact of Surgical Simulation on Patients and Hospitals
The key aims of using simulations (low- or high-fidelity) for surgical training are to quicken the actual procedure, reduce human error, and enhance collaboration and communication in the OR, to ultimately improve patient outcomes. In this regard, 14 studies done on clinical trials were analyzed and assessed and the results published on NCBI. The assessment showed significant improvements in clinical outcomes for patients on whom the surgery was conducted after proper simulation-based training over those on whom the surgery was conducted without any prior surgical training, in four of the studies.
Similarly, as per an article published on the website of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), randomized VR simulation trials on junior surgical residents showed a 29% decrease in laparoscopic cholecystectomy duration and that residents who received the training were nine times less likely to stall during the procedure and five times less likely to injure the gallbladder or cauterize unintended tissue. This is confirmed by a study published in the Journal of Neurosurgery of the American Association of Neurological Surgeons in March 2021 that showed that post-simulation-based training, surgeons achieved an over 90% efficiency in treating internal carotid artery injury (ICAI), with the time to hemostasis and estimated blood loss reducing by 38 and 37%, respectively.
As per another study done at a community hospital in the U.S., the addition of a third-year resident to the OR can increase the surgery time by around 44 minutes, as the procedure needs to be slowed to train the resident. Moreover, simulation-based surgical training can reduce the per-minute OR expense, which is usually around $20 for the hospital and up to $60 for the patient. One study showed a decrease of over $700,000 in annual hospital expenses by imparting better and quicker training to residents and reducing the incidence of catheter-related bloodstream infections in the ICU.
Hence, with the multitude of benefits of surgical simulation for patients and hospitals, the popularity of this technique continues to grow, spurred by the increasing concerns related to medical malpractice and widening lack of OR space to train residents. Additionally, the advent of newer surgical techniques mandates even experienced surgeons to add to their repertoire of skills, with the ultimate aim to improve patient outcomes and reduce costs.
