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Surgical skills simulation: a shift in the conversation.

W ith the publication of the article “State of the Evidence on Simulation-Based Training for Laparoscopic Surgery: A Systematic Review,” Zendejas et al1 have allowed the conversation regarding the skills laboratory and laparoscopic skill acquisition to shift from a discussion of “Is it effective?” to a discussion of “How can it be most effective?” Importantly, this shift in the conversation allows a vigorous focus on critical issues such as the timing to initiate simulation, how best to coordinate the skills laboratory with clinical experience, what type of simulators should be purchased, how to use the skills laboratory to assess proficiency, and how to avoid deterioration of laparoscopic skills. Before these questions are answered, it is necessary to understand why simulation-based training in laparoscopic surgery was inevitable. During the 1990s, a series of events significantly impacted surgical training. In many ways, these changes had a greater impact on surgical training than the often-blamed 80-hour workweek. First, in an attempt to avoid another well-publicized federal lawsuit, medical schools mandated attending surgeon participation in all operative procedures to avoid fraudulent billing activities. Second, the medico-legal environment gave attending surgeons pause as they considered the potential for morbidity associated with autonomous activity of surgical residents. Third, the addition of specialty fellowships reduced the opportunity for surgical residents to participate in new and innovative laparoscopic and endoscopic procedures.2 Fourth, adoption of minimally invasive surgical techniques caused practicing surgeons to reenter the learning curve for operations they had mastered in the traditional open technique. This was most evident as the bile duct injury rate skyrocketed in the early era of laparoscopic cholecystectomy.3 Finally, compared with open surgery, laparoscopic procedures commonly relegate an attending surgeon to camera control and provision of adequate exposure. Consequently, attending surgeons challenged with this less active teaching model limited resident participation in surgical cases further reducing surgical skill acquisition. This combination of stressors caused the responsibility of patient care, surgical decision making, documentation, and performance of surgery to shift to senior residents, fellows, or faculty members. Subsequently, attending surgeons were present for all surgical procedures from start to finish, thus decreasing autonomy and independent learning. Instead, graduating residents were provided with a limited laparoscopic experience and reduced confidence in their ability to enter surgical practice.4,5 In the end, it was clear that a structured curriculum and a better environment for practice were needed to teach these laparoscopic techniques.6 With this publication, Zendejas et al1 have identified the skills laboratory as the appropriate environment for laparoscopic skills acquisition and silenced those who doubt the benefit of simulation-based laparoscopic training.7 Specifically, upon rigorous examination of this pool of more than 200 comparative studies, Zendejas et al1 formulated 3 critical conclusions. First, the authors confirm the superiority of simulation-based laparoscopic training for skill acquisition when compared to intraoperative experience. Even the addition of watching videos of operative procedures prior to operative participation failed to impart laparoscopic skills such as simulation-based training. Second, the authors found that a high price tag did not always result in better training. Systemic analysis of the 21 studies comparing virtual reality (VR) simulators with box trainers failed to demonstrate the superiority of complex virtual reality simulators with haptic feedback. Moreover, as long as the training scenarios resembled the human body, simple box trainers with a webcam or a mirror were as effective as the complex systems. This preference for simpler training devices may also reflect their easier availability, portability, and ease of use. Third, commonly cited as lacking within surgical residencies, Zendejas et al1 found that the opportunity for feedback during the training process was important to overall success with regard to skill acquisition. It seemed clear that feedback of some type generated better outcomes and learner satisfaction, but the best time