Current status of simulation training in plastic surgery residency programs: A review <s> Virtual simulations <s> UNLABELLED ::: The objective of this project was to develop a computer-based surgical simulation system for planning and performing cleft lip repair. This system allows the user to interact with a virtual patient to perform the traditional steps of cleft-lip repair (rotation-advancement technique). ::: ::: ::: MATERIALS AND METHODS ::: The system interfaces to force-feedback (haptic) devices to track the user's motion and provide feedback during the procedure, while performing real-time soft-tissue simulation. An 11-day-old unilateral cleft lip, alveolus and palate patient was previously CT scanned for ancillary diagnostic purposes using standard imaging protocols and 1mm slices. High-resolution 3D meshes were automatically generated from this data using the ROVE software developed in-house. The resulting 3D meshes of bone and soft tissue were instilled with physical properties of soft tissues for purposes of simulation. Once these preprocessing steps were completed, the patient's bone and soft tissue data are presented on the computer screen in stereo and the user can freely view, rotate, and otherwise interact with the patient's data in real time. The user is prompted to select anatomical landmarks on the patient's data for preoperative planning purposes, then their locations are compared against that of a 'gold standard' and a score, derived from their deviation from that standard and time required, is generated. The user can then move a haptic stylus and guide the motion of the virtual cutting tool. The soft tissues can thus be incised using this virtual cutting tool, moved using virtual forceps, and fused in order to perform any of the major procedures for cleft lip repair. Real-time soft tissue deformation of the mesh realistically simulates normal tissues and haptic-rate (>1 kHz) force-feedback is provided. The surgical result of the procedure can then be immediately visualized and the entire training process can be repeated at will. A short evaluation study was also performed. Two groups (non-medical and plastic surgery residents) of six persons each performed the anatomical marking task of the simulator four times. ::: ::: ::: RESULTS ::: Results showed that the plastic surgery residents scored consistently better than the persons without medical background. Every person's score increased with practice, and the length of time needed to complete the 11 markings decreased. The data was compiled and showed which specific markers consistently took users the longest to identify as well as which locations were hardest to accurately mark. ::: ::: ::: CONCLUSION ::: These findings suggest that the simulator is a valuable training tool, giving residents a way to practice anatomical identification for cleft lip surgery without the risks associated with training on a live patient. Educators can also use the simulator to examine which markers are consistently problematic, and modify their training to address these needs. <s> BIB001 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Virtual simulations <s> BioDigital Systems, LLC in collaboration with New York University Langone Medical Center Department of Reconstructive Plastic Surgery has created an interactive, step-based latissimus musculocutaneous flap simulator. Preliminary testing of fourteen residents (PGY1-6) demonstrates that simulator training results in significant improvement in an objective assessment of surgical knowledge (p < 0.0006, pre-training score: 81.0%, post-training score 92.7%). This study is the first in the field of plastic and reconstructive surgery to demonstrate objective improvement in surgical knowledge as a result of simulator training, suggesting the potential effectiveness of simulators for a panopoly of breast reconstruction options. <s> BIB002 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Virtual simulations <s> BioDigital Systems, LLC in collaboration with New York University Langone Medical Center Department of Reconstructive Plastic Surgery has created a complex, real-time, step-based simulation platform for plastic surgery education. These simulators combine live surgical footage, interactive 3D visualization, text labels, and voiceover as well as a high-yield, expert-approved testing mode to create a comprehensive virtual educational environment for the plastic surgery resident or physician. <s> BIB003 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Virtual simulations <s> SummAry Surgery on the temporal bone is technically challenging due to its complex anatomy. Precise anatomical dissection of the human temporal bone is essential and is fundamental for middle ear surgery. We assessed the possible application of a virtual reality temporal bone surgery simulator to the education of ear surgeons. Seventeen EnT physicians with different levels of surgical training and 20 medical students performed an antrotomy with a computer-based virtual temporal bone surgery simulator. The ease, accuracy and timing of the simulated temporal bone surgery were assessed using the automatic assessment software provided by the simulator device and additionally with a modified Final Product Analysis Scale. Trained EnT surgeons, physicians without temporal bone surgical training and medical students were all able to perform the antrotomy. however, the highly trained EnT surgeons were able to complete the surgery in approximately half the time, with better handling and accuracy as assessed by the significant reduction in injury to important middle ear structures. Trained EnT surgeons achieved significantly higher scores using both dissection analysis methods. Surprisingly, there were no significant differ ences in the results between medical students and physicians without experience in ear surgery. The virtual temporal bone training system can stratify users of known levels of experience. This system can be used not only to improve the surgical skills of trained EnT surgeons for more successful and injury-free surgeries, but also to train inexperienced physicians/medical students in developing their surgical skills for the ear. <s> BIB004 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Virtual simulations <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> BIB005 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Virtual simulations <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> BIB006 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Virtual simulations <s> In the last three decades, simulation has become a key tool in the training of doctors and the maintenance of patient safety. Simulation offers an immersive, realistic way of learning technical skills. Recent changes to the training schemes in many surgical specialities mean that the hours spent working between senior house officer and consultant have been reduced. This, combined with other pressures (such as reduced operating hours), means that surgery has moved away from its traditional apprenticeship model and toward a competency-based one. Simulation can be a standardized and safe method for training and assessing surgeons. Use of simulation for training has become significant alongside the development of laparoscopic techniques, and evidence suggests that skills obtained in simulation are applicable in real clinical scenarios. Simulation allows trainees to make mistakes, to ask the "what if?" questions, and to learn and reflect on such situations without risking patient safety. Virtual reality simulators have been used to allow experts to plan complicated operations and assess perioperative risks. Most recently, fully immersive simulations, such as those with whole theater teams involved, and patient-centered simulations allow development of other key skills aside from purely technical ones. Use of simulation in isolation from traditional teaching methods will furnish the surgeon in training with skills, but the best time and place to use such skills comes only with experience. In this article we examine the role of simulation in surgical training and its impact in the context of reduced training time. <s> BIB007 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Virtual simulations <s> Background While other surgical specialties have embraced virtual reality simulation for training and recertification, microsurgery has lagged. This study aims to assess the opinions of microsurgeons on the role of simulation in microsurgery assessment and training. Methods We surveyed faculty members of the American Society of Reconstructive Microsurgery to ascertain opinions on their use of simulation in training and opinions about the utility of simulation for skills acquisition, teaching, and skills assessment. The 21-question survey was disseminated online to 675 members. Results Eighty-nine members completed the survey for a 13.2% response rate. Few microsurgeons have experience with high-fidelity simulation, and opinions on its utility are internally inconsistent. Although 84% of respondents could not identify a reason why simulation would not be useful, only 24% believed simulation is a useful measure of clinical performance. Nearly three-fourths of respondents were skeptical that simulation would improve their skills. Ninety-four percent had no experience with simulator-based assessment. Conclusion Simulation has been shown to improve skills acquisition in microsurgery, but our survey suggests that unfamiliarity may foster bias against the technology. Failure to incorporate simulation may adversely affect training and may put surgeons at a disadvantage should these technologies be adopted for recertification by regulatory agencies. <s> BIB008 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Virtual simulations <s> BACKGROUND ::: This article presents a real-time surgical simulator for teaching three- dimensional local flap concepts. Mass-spring based simulators are interactive, but they compromise accuracy and realism. Accurate finite element approaches have traditionally been too slow to permit development of a real-time simulator. ::: ::: ::: METHODS ::: A new computational formulation of the finite element method has been applied to a simulated surgical environment. The surgical operators of retraction, incision, excision, and suturing are provided for three-dimensional operation on skin sheets and scalp flaps. A history mechanism records a user's surgical sequence. Numerical simulation was accomplished by a single small-form-factor computer attached to eight inexpensive Web-based terminals at a total cost of $2100. A local flaps workshop was held for the plastic surgery residents at the University of Wisconsin hospitals. ::: ::: ::: RESULTS ::: Various flap designs of Z-plasty, rotation, rhomboid flaps, S-plasty, and related techniques were demonstrated in three dimensions. Angle and incision segment length alteration advantages were demonstrated (e.g., opening the angle of a Z-plasty in a three-dimensional web contracture). These principles were then combined in a scalp flap model demonstrating rotation flaps, dual S-plasty, and the Dufourmentel Mouly quad rhomboid flap procedure to demonstrate optimal distribution of secondary defect closure stresses. ::: ::: ::: CONCLUSIONS ::: A preliminary skin flap simulator has been demonstrated to be an effective teaching platform for the real-time elucidation of local flap principles. Future work will involve adaptation of the system to facial flaps, breast surgery, cleft lip, and other problems in plastic surgery as well as surgery in general. <s> BIB009
Unique to virtual simulators is the capacity to replicate rare clinical cases that surgeons would not otherwise encountered BIB007 . Furthermore, although the initial cost of program set up can be high-approximately $2,000 per simulator-they facilitate repetition without replacement of materials, which is cost-effective in the long run BIB008 BIB006 . The potential for repetition has led opponents of virtual based learning modules to critique the potential for memorization as opposed to the active learning of new skill sets. Similarly, others maintain that the anatomical variation observable across patient populations cannot be adequately represented through simulators, and that the experience of physical resistance or recoil encountered in live surgery is impossible to accurately recreate BIB001 BIB004 . Research conducted by Stern et al. BIB002 utilized virtual simulations to assess resident competency in the identification of complex anatomical landmarks and sequential latissimus dorsi flap reconstruction procedural steps. Residents were evaluated for their ability to correctly identify anatomy and answer a series of interactive questions. Subsequently, residents received an objective assessment of his or her cognitive competency-in terms of anatomy, procedural knowledge, indications, and complications. The scores of each participant were later stratified to indicate relative levels of surgical experience and knowledge of the test material. Pre-test versus post-test evaluation indicated that simulators had effectively improved competency; however, comparison to other simulation models has yet to be investigated BIB002 . Similarly, Oliker et al. BIB003 utilized three-dimensional (3D) virtual models to evaluate procedural knowledge for monobloc, Le Fort III, fronto-orbital advancement, and latissimus dorsi flap reconstruction. The interactive questions where designed to gauge resident knowledge of anatomical models, soft tissue deformities, surgical tool motions, chapter divisions, live surgical videos, voiceover audio, and animated transparencies. Although the simulation activity was shown to be beneficial in terms of acquiring and evaluating cognitive surgical knowledge, degree of skill transfer to the OR was not examined BIB003 . Spring-mass virtual simulators have been developed in an attempt to mimic recoil and tension encountered during surgery. In 2016, Mitchell et al. BIB009 conducted a local flaps workshop to test the efficacy of mass-spring based simulators for teaching flap designs (e.g., Z-plasty, rhomboid flaps, S-plasty, etc.), allowing participants to perform techniques through a web-based platform. Feedback regarding the simulator was positive for its ability to facilitate step-by-step practice for a given procedure, but the development of a more detailed assessment of resident skill improvement to evaluate its use is needed BIB005 . The benefits of high resolution meshes resemble those of spring mass models, with the former emulating the physical properties of bone and soft tissue. Schendel et al. BIB001 combined high resolution meshes with a spring-mass model for resident training on unilateral cleft lip repair. 3D scans of an 11-day-old patient were translated to a spring model to simulate the effects of recoiling upon incision, as well as meshes, to mimic the physical properties of the anatomical structure involved in the procedure. Six laypersons and six residents were able to rotate and interact in real time, while identifying landmarks for assessment. Each participant interacted four times, with scores improving after each interaction. While participants experienced the simulator as a useful teaching tool, it was incapable of fully mimicking the physical aspects of surgery. The authors note that while improvement in layperson performance was attributable to memorization, the residents were more likely to reflect on their mistakes and to learn new skills with each additional use BIB001 . Virtual simulation offers the benefit of learning through repetition, at the cost of memorizing material due to lack of variation rather than actively learning as is accomplished from apprentice based training. Applications that require the identification of surgical landmarks or sequential steps can offer residency programs the ability to gauge baseline knowledge prior to clinical application. Notable pitfalls of virtual simulation include the high cost of initial acquisition and the inability to fully simulate the experience of live surgery in an OR setting.