RCSI leads the way on surgical simulators

Technology has enhanced medical training immensely, helping future surgeons to hone their skills on virtual patients, practising common procedures and operations repeatedly in the classroom before performing the real thing.

Trainee surgeons can master procedures such as laparoscopic cholecystectomies (keyhole removal of the gallbladder) through the use of surgical simulators. Mistakes result in poor feedback from a lecturer as opposed to the nightmarish side effects that come with botched surgery on a live patient.

Thanks to the vision of consultant surgeon and National Surgical Training Centre director Prof Oscar Traynor, the Royal College of Surgeons in Ireland (RCSI) is leading the way when it comes to surgical simulators, having adopted the technology in its infancy in 2003, and helping advance it further.

The college has made a significant investment in surgical simulators over the last decade spending more than €1 million on the technology in the last year alone, according to Kieran Tangney, associate director of clinical programmes.

The RCSI is also in the advanced stages of the planning process for a new €80 million medical education training facility in Dublin city centre, which will include new state-of-the-art surgical simulators and a mock operating room with an adjacent control room.

The mock operating theatre will allow multidisciplinary teams of anaesthetists, nurses and surgeons to come together and rehearse complex operations on a “virtual patient”. The lecturers meanwhile can put the team into crisis mode and test their ability to remain calm and collected under pressure, by lowering the blood pressure or raising the heart rate of the virtual patient from the control room, even causing it to go into cardiac arrest.

"There is no question that technology and surgical simulators have made a huge impact on medical training and the RCSI has been at the forefront in developing a simulation-based surgical training curriculum," Mr Tangney said.

Practice makes perfect
He said trainee surgeons at the college are using simulators to practise specific types of procedures such as a colonoscopy without the use of cadavers or even live patients. The trainee can improve their hand-eye coordination, develop technical skills and master their ability to perform three dimensional actions using a two-dimensional screen as a guide.

“Medicine and surgery is not just about knowledge. There is a huge skills element and you have to hone those skills over time. The simulators give the trainee the opportunity to practice their craft.”

After all, practice makes perfect and hundreds of trainee surgeons at the RCSI are receiving the repeated practice they need to excel in an operating theatre, thanks to these surgical simulators, where they can practice everything from suturing to removing a skin mole.

However, more often than not, the trainees spend their time practising common operations and laparoscopic procedures, which are performed in Irish hospitals on a daily basis. These include procedures to remove the appendix, colon or gall bladder and hernia repair. Trainees can also simulate gastric bypass, hysterectomy and nephrectomy operations.

“The virtual patient can be pre-programmed with different conditions. For example, it might have a tumour.”

The simulator has a computer screen which displays three-dimensional graphics of the organs being operated on. Various surgical tools are linked to motion sensors and tracking devices so the user’s performance of the operation can be monitored.

The devices have become more and more advanced over the years, and the latest ones now have haptic feedback technology, which allows trainee surgeons not only see and hear the virtual patient, but also feel the sensation of drilling through bone or pressing a scalpel against muscle.

For the purpose of this article, a laparoscopic cholecystectomy was demonstrated using the surgical simulator.

A screen above the virtual patient displayed 3D graphics of the gall bladder and the surrounding organs, ducts and arteries. The demonstrator (RCSI learning and development manager Donncha Ryan) used hand-held instruments which were entered into the “virtual abdomen” via two tiny holes, to simulate keyhole surgery.

He then used these hand-held instruments to safely remove all the fat around the cystic duct and cystic artery. Next, the artery and duct were clipped with staples to close and seal them. The connective tissue between the gallbladder and liver is then cut, before the gall bladder can be taken out.

All the while the surgical simulator monitored the procedure tracking the handheld instruments through sensors, noting how long the operation was taking, how steady the “surgeon’s” hands were, how smoothly they performed the procedure and whether they nicked any other organs with the laparoscopic instruments, causing bleeding. In this case, there were lots of nicked organs, due to “minor complications” in the words of the demonstrator, which resulted in the patient losing lots of blood. Thankfully the patient was a virtual one!

However, Mr Tangney is quick to point out that the simulated surgery will not replace the traditional apprenticeship model, whereby a trainee watches a consultant, learns from them, and gets increasing responsibility to do things over time.

Games background
While he may not be the best at removing virtual gallbladders, Mr Ryan was the architect behind the ProMIS simulators used at the college.

"I used to develop games for the PlayStation, Xbox and PC. Then I moved to Haptica, a company on Baggot Street which has since been taken over by CAE, a Canadian manufacturer of simulation technologies. At Haptica, I worked to develop the ProMIS surgery simulator which is built on video game technology."

Mr Ryan said experts and leading consultants performed mock procedures on the simulator so a benchmark standard could be set, by which students can measure their performance.

The simulator tracks the trainee’s use of the instruments and prowess in carrying out the procedure, letting them know how close they are to the expert standard.

One person who used the RCSI simulators in his surgical training is Dara Kavanagh, a consultant colorectal surgeon at Tallaght Hospital.

“Practising procedures on a simulator means you are not fumbling with instruments you’ve never handled before when it comes to helping in actual hospital operations,” he said.

Mr Kavanagh said the simulator also helps trainee surgeons monitor their hand dominance in surgery. “When you start training, your right hand will most likely do more work than the left hand. You need to be able to use both hands equally though. The more practice you get the better you become at using both hands.”

He believes the technology is very helpful in familiarising students with particular surgical tools and procedures.

“From a laparoscopic point of view, I was very comfortable with the instruments when I performed my first real life laproscopic appendectomy (removal of the appendix).”