As a part of updating and extending education methods in our Department of Surgery, a simulation laboratory for the teaching of technical skills to residents, medical students, and attendings has been established. The lab will demonstrate and allow hands on practice of motor skills from simple knot tying up through virtual reality clinical scenarios in laparoscopic or endoscopic settings. The use of an effective curriculum with pre-instruction, feedback during learning, adequate practice time in a safe environment, debriefing, and measurement of competency will accelerate learning. Effort will be effectively focused on needed areas of improvement; the range and level of skills obtainable should be extended for every level of user. Our goals, simply stated, are to exploit technology to enhance the learning of surgical motor skills and their integration into effective clinical practice.

The 700 sq. ft. laboratory is conveniently located in the Surgery Department offices in the Harper Professional Building. The space is divided into the hands on simulation room and an adjacent 2 work station desktop area.

Aside from dedicated computer workstations present equipment includes:

1. various materials to support teaching basic knot tying and suturing (along with surgical instrument demonstration sets)

2. two periscope tower trainers which optically demonstrate displaced display of the workspace and familiarize the student with the use of laparoscopic instruments (great for teaching fulcrum effects and for upgrading non-dominant hand skills)

3. two box trainers complete with lap video displays allowing integration of instrument use with actual camera views on training devices or organ models placed within the box which simulates the abdominal cavity. Performance can be recorded for review.

The lab is being physically reconditioned to accommodate 4 new pieces of equipment to support a multistage teaching curriculum:

1. Endotower: This is a mock laparoscopic camera mounted in a fulcrum port that transmits positional input to a virtual reality view generator. The user “drives” the camera and explores virtual models displayed on a standard video CRT, accomplishing tasks. There is only visual feedback; striking a surface is not felt but is signaled visually and awards performance demerits. The device can simulate end-view and angled cameras. It records performance metrics.

2. Surgical Sim (by METI): a “learning system” displaying a virtual reality fixed camera view. The user controls left and right hand instrument handles to input position that controls virtual instruments in the video view. There is only visual feedback from a fairly sophisticated anatomic simulation; no “haptic” mechanical sensation is fed back to the instruments. Training exercises are provided for all levels of tasks and all levels of users: simple grasping and passing, anatomy dissection, knot tying, and complete procedures (laparoscopic cholecystectomy). User performance is measured and problem areas identified. This device teaches operating skills and procedure steps. It can be used for assessment.

3. ProMis LapSim: this augmented “box trainer” uses 3 internal, orthogonally placed digital video cameras to record instrument and lap camera usage providing precise performance metrics. Visual input to the operator viewed CRT can be fixed virtual reality views allowing solo skills practice or real lap camera views for team exercises requiring a camera operator. Actual instruments are used for manipulations of real models or the tracked instruments interact with virtual reality views. This device could accommodate animal organs to generate realistic haptic feedback. Modules for assessing basic skills are provided.

4. Accutouch Endoscopy Simulator: This device is equipped with mock gastroscopes, colonoscopes, and bronchoscopes with active controls but no view channel or active tip motion. The scopes, when inserted into the device, initiate a simulated intraluminal view where manipulation of the scope controls alters the view realistically simulating a clinical exam. In addition the device grips the scope providing realistic resistance. The user negotiates the entire upper GI tract, or colon, or bronchial tree. Measurements of the percentage of the mucosa viewed, time taken, and pressure exerted are recorded. Scenarios featuring varied levels of difficulty with various pathological conditions are provided. Biopsies can be performed, polypectomies, papillotomies, and ERCPs. In addition “cheat views” showing the true position of the scope and its orientation can be toggled on as insets overlaying the intraluminal view.

Curricula including didactics covering appropriate knowledge domains, steps of conducting procedures, teaching exercises on the simulators, practice time, and assessment of competency are being proposed. When complete a graded experience by level of training will be instituted covering laparoscopic and endoscopic procedures.

Finally, simulations of whole patient scenarios on digitally controlled instrumented manikins will be used to teach and practice non-operative interventions for critical and common events in the OR, ER, and ICU. These devices are now available in our school of pharmacy and will be included in the new facilities of the educational commons of the school of medicine. The final degree of penetration of this technology is not yet known but will cover ACLS interventions, shock resuscitation, and other acute pathophysiologic events such as pulmonary embolism, drug reactions, etc.