Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> We describe the basic components of a surgery simulator prototype developed at INRIA. After a short presentation of the geometric modeling of anatomical structures from medical images, we insist on the physical modeling components which must allow realistic interaction with surgical instruments. We present three physical models which are well suited for surgery simulation. Those models are based on linear elasticity theory and finite element modeling. The first model pre-computes the deformations and forces applied on a finite element model, therefore allowing the deformation of large structures in real-time. Unfortunately, it does not allow any topology change of the mesh therefore forbids the simulation of cutting during surgery. The second physical model is based on a dynamic law of motion and allows to simulate cutting and tearing. We called this model "tensor-mass" since it is analogous to spring-mass models for linear elasticity. This model allows volumetric deformations and cuttings, but has to be applied to a limited number of nodes to run in real-time. Finally, we propose a method for combining those two approaches into a hybrid model which may allow real time deformations and cuttings of large enough anatomical structures. This model has been implemented in a simulation system and real-time experiments are described and illustrated. <s> BIB001 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> BACKGROUND ::: Developing technical skill is essential to surgical training, but using the operating room for basic skill acquisition may be inefficient and expensive, especially for laparoscopic operations. This study determines if laparoscopic skills training using simulated tasks on a video-trainer improves the operative performance of surgery residents. ::: ::: ::: STUDY DESIGN ::: Second- and third-year residents (n= 27) were prospectively randomized to receive formal laparoscopic skills training or to a control group. At baseline, residents had a validated global assessment of their ability to perform a laparoscopic cholecystectomy based on direct observation by three evaluators who were blinded to the residents' randomization status. Residents were also tested on five standardized video-trainer tasks. The training group practiced the video-trainer tasks as a group for 30 minutes daily for 10 days. The control group received no formal training. All residents repeated the video-trainer test and underwent a second global assessment by the same three blinded evaluators at the end of the 1-month rotation. Within-person improvement was determined; improvement was adjusted for differences in baseline performance. ::: ::: ::: RESULTS ::: Five residents were unable to participate because of scheduling problems; 9 residents in the training group and 13 residents in the control group completed the study. Baseline laparoscopic experience, video-trainer scores, and global assessments were not significantly different between the two groups. The training group on average practiced the video-trainer tasks 138 times (range 94 to 171 times); the control group did not practice any task. The trained group achieved significantly greater adjusted improvement in video-trainer scores (five of five tasks) and global assessments (four of eight criteria) over the course of the four-week curriculum, compared with controls. ::: ::: ::: CONCLUSIONS ::: Intense training improves video-eye-hand skills and translates into improved operative performance for junior surgery residents. Surgical curricula should contain laparoscopic skills training. <s> BIB002 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> BACKGROUND ::: Traditionally, the acquisition of surgical skill has occurred entirely in the operating room. To meet the expanding challenges of cost containment and patient safety, novel methods of surgical training utilizing ex-vivo workstations are being developed. The purpose of our study was to evaluate the impact of a laparoscopic training curriculum on surgical residents' operative performance. ::: ::: ::: METHODS ::: Twenty-one surgery residents completed baseline laparoscopic total extraperitoneal (TEP) hernia repairs. Operative performance was evaluated using a validated global assessment tool. Each resident was then randomized to a control group or a trained group. A CD ROM, video, and simulator were used for training. At the end of the study, each resident's operative performance was again evaluated. ::: ::: ::: RESULTS ::: Improvement was significantly greater in the trained group in five of the eight individual global assessment areas as well as the composite score (P <0.05). Questionnaire data suggested that training resulted in improved understanding of the TEP hernia repair (P = 0.01) and an increased willingness to offer the operation to patients with nonrecurrent unilateral hernias (P = 0.02). ::: ::: ::: CONCLUSIONS ::: A multimodality laparoscopic TEP hernia curriculum improves residents' knowledge of the TEP hernia repair and comfort in performing the procedure, and may also improve actual operative performance. <s> BIB003 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> Surgical education has dramatically changed in response to numerous constraints placed on residency programs, but a substantial gap in uniform practices exist, especially in the area of skills laboratory availability and usage. Simulation-based training has gained significant momentum and will be a requirement for residencies in the near future. In response, the American College of Surgeons and the Association of Program Directors in Surgery have formed a Surgical Skills Curriculum Task Force with the aim of establishing a National Skills Curriculum. The first of three phases will undergo implementation in 2007, with subsequent phases scheduled for launch in 2008. The curriculum has been carefully structured and designed by content experts to enhance resident training through reproducible simulations, with verification of proficiency before operative experience. Free-of-charge distribution is planned through a web-based platform, and widespread adoption is encouraged. In the future, these simulation-based strategies may be useful in assuring the competency of practicing surgeons and for credentialing purposes. <s> BIB004 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> OBJECTIVE ::: To determine whether skills acquired by simulation-based training transfer to the operative setting. ::: ::: ::: SUMMARY BACKGROUND DATA ::: The fundamental assumption of simulation-based training is that skills acquired in simulated settings are directly transferable to the operating room, yet little evidence has focused on correlating simulated performance with actual surgical performance. ::: ::: ::: METHODS ::: A systematic search strategy was used to retrieve relevant studies. Inclusion of articles was determined using a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Only studies that reported on the use of simulation-based training for surgical skills training, and the transferability of these skills to the operative setting, were included. ::: ::: ::: RESULTS ::: Ten randomized controlled trials and 1 nonrandomized comparative study were included in this review. In most cases, simulation-based training was in addition to normal training programs. Only 1 study compared simulation-based training with patient-based training. For laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy, participants who received simulation-based training before undergoing patient-based assessment performed better than their counterparts who did not receive previous simulation training, but improvement was not demonstrated for all measured parameters. ::: ::: ::: CONCLUSIONS ::: Skills acquired by simulation-based training seem to be transferable to the operative setting. The studies included in this review were of variable quality and did not use comparable simulation-based training methodologies, which limited the strength of the conclusions. More studies are required to strengthen the evidence base and to provide the evidence needed to determine the extent to which simulation should become a part of surgical training programs. <s> BIB005 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> SUMMARY ::: Computer-based training simulators have been used extensively, most notably in flight simulation. Over the past 20 years, surgical simulators have been developed, initially for training of minimally invasive surgery and more recently for open surgical simulation. The key effort in today's surgical simulation field is to develop metrics to evaluate how well the skills learned in a simulator translate to improvement in real surgical skills, execution of procedures, and team cooperation in the operating room. The American College of Surgeons has begun implementing a phased approach to introduce simulation in training and education for general surgery. The authors believe that a similar training plan should be mandated for plastic surgery, to take advantage of the use of computers, virtual reality, and simulation in the training of plastic surgery residents and to explore the value of this technology for continuing medical education and maintenance of certification. This article gives a brief background and history of surgical simulation and its technology, followed by a detailed description of the three phases of the American College of Surgeons' plan and how the authors propose that each phase be implemented, with modifications as applicable for trainees in plastic surgery. <s> BIB006 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> Many medical schools and hospitals throughout the world are equipped with a simulation center for the purpose of training anesthesiologists to perform both technical and non-technical skills. Because induction, maintenance, and emergence of general anesthesia are critical to patient welfare, various simulation mannequins and tools are utilized for the purpose of training anesthesiologists for safer patient care. Traditionally, anesthesia residency training mostly consisted of didactic lectures and observations. After completion of "traditional" training, anesthesia residents were allowed to perform procedures on patients under supervision. However, simulation would be a more effective training tool for which to teach anesthesiologists the skills necessary to perform invasive procedures, such as endotracheal intubation, central venous catheter insertion, and epidural catheter insertion. Recently, non-technical skills, such as the Anesthesia Non-Technical Skills developed by anesthesiologists from Aberdeen University, have been emphasized as an important training resource. Technical skills and non-technical skills can be learned by anesthesiology residents through a standardized and organized simulation program. Such programs would be beneficial in training anesthesia residents to work efficiently as a team in the operation room. <s> BIB007 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> Currently, plastic surgery occupies a negligible component of many undergraduate curricula, and its recognition as a specialty is poorly understood by both medical students and primary care physicians.1,2 One important reason for this is that medical students are seldom exposed to plastic surgery.1,2 Because it is difficult to change the undergraduate curriculum, alternative solutions are required for increased exposure to plastic surgery at the undergraduate level.1,2 ::: ::: To meet that need, we propose training in basic surgical skills pertinent to plastic surgery on an alternative low-fidelity synthetic bench model, prepared with 2.5-mm-thick laminated plates composed of rubber (flattened pure polyvinyl chloride) reinforced with mesh (polyester and cotton) (Emborrachado or Rubberised Line; Kelson's Industria e Comercio S.A., Rio de Janeiro, Brazil). Generally, these plates are used in the manufacture of decorative objects such as handpainted rugs and are readily purchased at craft stores (eg, Sonalk Representacoes Ltda, Sa Paulo, Brazil, and ANMAG Representacoes Ltda, Rio de Janeiro, Brazil). This synthetic material can also be purchased and shipped anywhere in the world through … <s> BIB008 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> The widespread use of microsurgery in numerous surgical fields has increased the need for basic microsurgical training outside of the operating room. The traditional start of microsurgical training has been in undertaking a 5-day basic microsurgery course. In an era characterised by financial constraints in academic and healthcare institutions as well as increasing emphasis on patient safety, there has been a shift in microsurgery training to simulation environments. This paper reviews the stepwise framework of microsurgical skill acquisition providing a cost analysis of basic microsurgery courses in order to aid planning and dissemination of microsurgical training worldwide. <s> BIB009 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> BackgroundElectronic health records (EHR) are becoming increasingly integrated into the clinical environment. With the rapid proliferation of EHRs, a number of studies document an increase in adverse patient safety issues due to the EHR-user interface. Because of these issues, greater attention has been placed on novel educational activities which incorporate use of the EHR. The ICU environment presents many challenges to integrating an EHR given the vast amounts of data recorded each day, which must be interpreted to deliver safe and effective care. We have used a novel EHR based simulation exercise to demonstrate that everyday users fail to recognize a majority of patient safety issues in the ICU. We now sought to determine whether participation in the simulation improves recognition of said issues.MethodsTwo ICU cases were created in our EHR simulation environment. Each case contained 14 safety issues, which differed in content but shared common themes. Residents were given 10 minutes to review a case followed by a presentation of management changes. Participants were given an immediate debriefing regarding missed issues and strategies for data gathering in the EHR. Repeated testing was performed in a cohort of subjects with the other case at least 1 week later.Results116 subjects have been enrolled with 25 subjects undergoing repeat testing. There was no difference between cases in recognition of patient safety issues (39.5% vs. 39.4%). Baseline performance for subjects who participated in repeat testing was no different than the cohort as a whole. For both cases, recognition of safety issues was significantly higher among repeat participants compared to first time participants. Further, individual performance improved from 39.9% to 63.6% (p = 0.0002), a result independent of the order in which the cases were employed. The degree of improvement was inversely related to baseline performance. Further, repeat participants demonstrated a higher rate of recognition of changes in vitals, misdosing of antibiotics and oversedation compared to first time participants.ConclusionParticipation in EHR simulation improves EHR use and identification of patient safety issues. <s> BIB010 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> Techniques of virtual simulation have been used to teach junior surgeons how to do a cheiloplasty, but still do not meet the trainees' demands. We describe a CAD/CAM silicone simulator, which we made using several maxillofacial prosthetic techniques. An optical scanning system was used to collect the data about the cleft lip. Reverse engineering software was then used to build the virtual model, and this was processed in wax by machine. The definitive simulator was made with prosthetic silicone and extrinsic colourants. The surgical trainees practised the basic skills of cheiloplasty on the simulator, and proved its worth. <s> BIB011 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Synthetic models <s> Since the introduction of competency-based education and the restriction of residents’ working hours, simulator-aided training has obtained increasing attention for its role in teaching and assessing resident surgical skills. Within plastic surgery training, such simulators would be particularly useful for aesthetic surgery procedures such as augmentation mammoplasty where residents have fewer opportunities for hands-on experience. The aims of this study were to develop a part-task trainer that allows plastic surgery trainees to acquire skills necessary for augmentation mammoplasty and to assess its potential value as a training tool. ::: The mammoplasty part-task trainer (MPT) was designed to have a reusable and rigid thorax base and “soft” disposable layers to mimic the skin and subcutaneous tissues. A mock unilateral subglandular breast augmentation was performed by 4 board-certified plastic surgeons using standard instruments and scored using a 0 to 5 Likert scale where a score of 5 was considered the most satisfactory. ::: Four board-certified plastic surgeons participated in the survey. On a scale of 0 to 5, the MPT’s “value” as a training tool, “relevance to practice,” and “physical attributes” scored highest, with mean values of 4.5, 4.3, and 4.1, respectively. “Realism of experience,” “ability to perform tasks,” and “realism of material” scored 3.9, 3.8, and 3.7, respectively. The observed average of the “global assessment” of the MPT was 4.3. The cost of fabrication of the MPT was estimated at approximately Can $113. ::: This study describes a preliminary novel mammoplasty task trainer that was highly valued by experts as a potential training tool. <s> BIB012
The use of synthetic material to simulate tissues and vessels can offer residents an opportunity to practice procedural steps and simultaneously gain experience in the handling and manipulation of surgical tools (Fig. 1)  . Common materials, such as silicone and wax, are more affordable than virtual reality BIB009 . Although the cost of materials is significantly lower than in virtual simulation, synthetic materials must be replaced after each use, and the cost of frequent replacements can add up. Utilization of synthetic materials ranges from practicing sutures to performing full procedures; junior residents are able to learn at their own pace in a safe environment, and subsequently receive objective feedback on their performance BIB007 BIB010 BIB008 . A major obstacle in synthetic materials is synthesizing materials that feel and behave as closely as possible to human anatomy. Careful attention to texture, recoil, and anatomy must be present in order for competency to be deemed transferable to the OR BIB003 BIB002 BIB004 BIB005 . In an effort to simulate resident training in mammoplasty, Kazan et al. BIB012 developed a synthetic Mammoplasty Part-Task Trainer (MPT). Various layers were created to mimic natural anatomy, including skin, subcutaneous fat, breast tissue, and ribs. Evaluations by four board-certified plastic surgeons were scored on a scale of 0 to 5 and included physical attributes, realism of materials, realism of experience, ability to perform tasks, value, relevance to practice, and overall rating. Although the MPT was able to successfully mimic physical attributes, the realism of materials, especially the subcutaneous fat, was not deemed close enough to live versions BIB008 . While the model can certainly be used to facilitate procedural learning, its value in terms of transferrable competency remains in question, and realism is lacking. Synthetic models have been widely used in craniofacial practice BIB006 BIB011 BIB008 BIB001  for both implants and surgical training in complex anatomy. Zheng et al. BIB011 created a model to aid in the development of psychomotor and manual skills involved in cheiloplasty. Wax was utilized followed by silicone to give lifelike texture, hardness, and elasticity BIB011 . Additionally, a multicomponent cleft palate simulator replicating a 6-month-old's mouth was created by Vadodaria et al  . The model included components to replicate the various anatomical aspects involved in the surgery, including mouth, hard palate, and soft palate. Similar to other studies, the models proved helpful in training on surgical techniques but lacked the ability to fully replicate physical tissue BIB011  . Competency in the use of surgical tools is a vital milestone in residency training, with synthetic models allowing for repeated practice. Current models allow for anatomical representation but still lack the ability to fully replicate physical attributes BIB011 BIB001  . As a training model, most synthetic materials are far more affordable than virtual simulators, at the price of needing to constantly replace after use BIB009 . To date, the models made are on a smaller scale and resemble specific anatomical areas. Much research into development of life-like materials is needed, for the closer to real a surgical training is, the more transferable competency will be.