Creation of a High Fidelity, Cost Effective, Real World Surgical Simulation for Surgical Education
Authors: Stewart Lygia , De La Rosa Elizabeth 
Published: July 2021

Background How do surgical residents learn to operate? What is a surgical plane? How does one learn to see and dissect the plane? How do surgical residents learn tissue handling and suturing (sewing)? One method to learn and practice performing surgery is through the use of simulation training. Surgical training models include laparoscopic box trainers (a plastic box with holes for instruments) with synthetic materials inside to simulate tissues, or computer-based virtual reality simulation for laparoscopic, endoscopic, and robotic techniques. These methods, however, do not use real tissues. They lack the haptic and kinesthetic feedback of real tissue. These simulations fail to recreate the fidelity of soft tissues, do not foster the ability to accurately see surgical planes, do not accurately mimic the act of dissecting surgical planes, do not allow for complex surgical procedures, and do not provide accurate experience to learn tissue handling and suturing. Despite their poor performance, these plastic and virtual trainers are extremely costly to purchase, maintain, and keep up to date - with prices starting at $700 for basic plastic training boxes to thousands of dollars for virtual simulation. Also, there are additional costs of maintenance and software curriculum. Despite the cost of software, virtual simulators do not include a simulation for every surgery. Our aim was to create a life-like surgical simulation as close to real world as possible that allows trainees to learn how to see and dissect surgical planes, learn how soft tissues move, and learn the dynamics of soft tissue manipulation. We created a laparoscopic simulator using porcine tissues for gallbladder removal, acid reflux surgery, and surgery to treat swallowing difficulties (cholecystectomy, Nissen fundoplication, and Heller myotomy, respectively). Second year general surgery residents were able to practice these procedures on real tissues, enabling them to learn the steps of each procedure, increase manual dexterity, improve use of laparoscopic equipment, all while maintaining life-like haptic, soft-tissue feedback and enabling them to develop the ability to see real surgical planes. Methods The abdomen was recreated by purchasing intact porcine liver, gallbladder, (Cholecystectomy simulation) and intact esophagus, stomach, and diaphragm (Nissen and Heller simulation) from a packing supplier. Each organ system was placed into a laparoscopic trainer box with the ability to re-create laparoscopic ports. Surgical residents were then able to perform the procedures using real laparoscopic instruments, laparoscopic camera/video imaging, and real-time electrocautery. The simulation included all critical steps of each procedure such as obtaining the critical view of safety and removing the gallbladder from the liver bed (cholecystectomy), wrapping the stomach around the esophagus and laparoscopic suturing (Nissen fundoplication), and dissecting the muscular portion of the esophageal wall (Heller myotomy). Because these porcine tissues were readily available, several stations were set-up to teach multiple residents during each session (10-12 residents / session). Discussion Surgeons develop haptic perception of soft tissues by cutaneous or tactile feedback and kinesthetic feedback (Okamura, 2009). Kinesthetic feedback is the force and pressure transmitted by the soft tissues along the shaft of the laparoscopic instruments (Okamura, 2009). This soft tissue simulation re-creates the ability to experience what soft tissue feedback feels like, outside a normal operative environment. Real tissue learning allows trainees to learn how to see surgical planes, learn how soft tissues feel and move, develop proficiency in surgical dissection, and learn how to suture laparoscopically. This is the only model that recreates the movement of soft tissues and visualization of dissection planes outside the operative environment. Because this model utilizes the laparoscopic instruments used in the operating room, residents also develop familiarity with laparoscopic instruments, thus, flattening another learning curve. A literature review found that this is the only real tissue simulation being performed for foregut procedures used specifically for resident training. By building a realistic, anatomical model with inherent accurate soft tissue surgical planes, surgical trainees can have a more realistic surgical experience and develop skills in a safe, low pressure environment without sacrificing the hepatic learning and surgical visualization that is critical to performing safe laparoscopic surgery. All residents that participated in the stimulation reported positive feedback and felt that is contributed to their surgical education.