**3. Simulation-based training**

Simulation training has quickly become a standard among surgical residents in the 21st century. The first roots of simulation training were set by the aviation industry in the early 1900s. With many accidents attributed to novice aviators and a high demand for pilots secondary to World War I, there was a push to develop better, cheaper, and safer approaches to training. The first wildly used flight simulator was created by Edwin Link in 1928 [12]. The medical community was slower

to utilize simulation and the first examples were not seen until the late 1950s where the Laerdal Company developed Resusi-Anne. This was a full-sized mannequin helped trainees practice a variety of clinical scenarios including management of obstructed airways and administration of chest compressions [12]. The field of anesthesia was one of the earliest adopters of simulation in the medical community; in the 1960s anesthesiologists utilized simulators that were able to replicate some basic human physiology and respond to medications [12]. From the basic models to teach CPR to sophisticated virtual reality simulators that can replicate the most complex human physiology, simulation training is now at the forefront of medical education.

Surgical training today has moved away from the traditional apprenticeship model where skills are developed solely in the operating room. In an era where minimizing healthcare expenditure is at the forefront; operating room time is too valuable for the development of basic surgical skills [13]. In a 2018 article published in JAMA, every minute in the operating room costs between \$36 to \$37 dollars [14]. Bridges et al. found that increased operative times related to resident training cost approximately \$53 million dollars per year [15]. Surgical simulation has provided opportunities for residents to develop competence with surgical skills, increase deftness, and become more comfortable using a variety of instruments [1]. Montbrun et al. argues the ethical basis for incorporating stimulation into surgical education. He states that it ensures that at least some practice has taken place prior to operating on a patient [13]. Lastly, simulators help combat the work hour restriction as simulators are always available to be used during a resident's free time. There are a variety of different simulators that residents use today.

Bench top models are an example of one of the oldest and most effective tools in surgical simulation. These models use synthetic or animal tissue to replicate a variety of surgical procedures. Different specialties have developed unique bench top models to replicate real life procedures. Montbrun et al. describe benchtop models in surgical education as inexpensive, allowing familiarity to equipment along with unlimited practice opportunities, which translates well to operative skills on live patients [13].

Skill acquisition is the goal of bench top models and has been supported by a variety of studies. Lauscher et al. performed a randomized control trial comparing the Berlin Operation Trainer (BOPT), a benchtop model, to conventional training methods. Results demonstrated significant improvements in speed and performance score among the BOPT group [16]. Anastakis et al. demonstrated improved performance among surgical interns in multiple open surgical procedures like fascial closure and bowel anastomosis [17]. Multiple studies have also demonstrated that the skills obtained from bench top models can be translated to improved performance on a live patient [13]. For example, Palter et al. demonstrated that learning abdominal fascial closure on a benchtop model correlated to improved operating room performance among surgical novices [18]. Furthermore, Datta et al. demonstrated that assessment of skills on a benchtop model correlates well to performance on a live patient. The authors argue that use of benchtop work can also be used in the assessment of surgical skills [19].

Laparoscopic surgery advanced quickly in all surgical specialties since the first laparoscopic cholecystectomy was performed in 1988 by J. Barry McKernan and William Sayer [20]. Because of the early learning curve, there was a push to introduce simulation into laparoscopic surgery [10]. Compared to open surgery, laparoscopy forced the surgeon to work in a two-dimensional space with minimal tactile feedback. The ABS noticed the effectiveness of simulation in assessing laparoscopic skills and developed the Fundamentals of Laparoscopic Surgery (FLS) and introduced it into their graduation curriculum in 2008 [9, 13].

#### *Surgical Education in the 21st Century DOI: http://dx.doi.org/10.5772/intechopen.99406*

There are a variety of laparoscopic trainers used today by surgical residents, but the most well-known is the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) [13]. The MISTELS trainer is used to evaluate precision and speed during FLS. This low fidelity system is a simple box trainer that uses a variety of laparoscopic instruments and a laparoscope [13]. This system evaluates basic laparoscopic skills including peg transfer, intra- and extracorporeal knot tying, pattern cutting, and ligating loop placement [13, 21]. The benefit of the MISTELS system has been demonstrated in multiple studies. McCluney et al. performed a prospective study which demonstrated that FLS simulator scores independently predicted intraoperative laparoscopic performance [22]. Sroka et al. established in a randomized control trial, residents who underwent FLS training with MISTELS had significant improvement in elective laparoscopic cholecystectomies [23]. In addition to the low fidelity trainers such as MISTELS, some surgical programs incorporate virtual reality laparoscopic trainers into surgical education. These virtual reality simulators include full procedure models in which a variety of different surgical procedures can be performed [13].

Robotic surgery has quickly developed a niche among the surgical community. Sheetz et al. demonstrated that robotic surgery accounted for 15.1% of all surgeries in 2018, up from 1.8% in 2012 [24]. The rapid implementation of robotic surgery has led to specific robotic curriculums among training programs. Just as with laparoscopic surgery, robotics offers the opportunity for the trainee to become proficient prior to use in the operating room. Current robotic curriculums follow a stepwise progression for trainees, starting with observation, then providing bedside assistance, then performing with supervision, and lastly practicing independently [24].

Robotic surgical curriculums first start with patient side training. During this phase, the trainee is not personally at the console performing the operation but aiding the surgeon at bedside. Besides the obvious benefit of observing and learning the steps to the operative procedure, the trainee also develops a variety of necessary skills, including patient positioning, robot docking, and port placement. While assisting at bedside the resident learns how to help the procedure run more efficiently [25].

The second phase of the robotic curriculum includes console training. The console is a distinct area where the surgeon gets a 3D image of the patient's anatomy and where the surgeon performs the operation. The robot converts the operator's hand and finger motion into simultaneous movement of the surgical instruments [26]. Console training begins with online computer modules which include basic information on the robot, the parts of the system, and trouble shooting. After obtaining this certification, training begins on the console [25]. Similar to laparoscopic training, there are variety of different tools with which the resident can become proficient prior to operating on patients. Current techniques used for console competency include virtual reality simulators along with dry and wet lab training [25].

Just as with laparoscopic surgery, virtual reality simulators are essential for robotic procedures. This often serves as the first step in developing basic to advanced robotic skills. There are variety of robotic simulators in use today which have been shown to be effective in the development of robotic skills. These simulators all enhance the trainee's skill set through task which incorporate needle control, suturing, clutching, energy use, and dissection. Dry skills lab is another area utilized in robotic surgical training. This is a cost-effective method in which the surgical trainee sits at the actual daVinci robot. Here utilizing the console, the trainee will use the actual robotic instruments on material mimicking human tissue. This allows development of advanced robotic skills in real time with no patient risk. The last form of console training is wet skills lab training. This method allows one to perform full surgical procedures utilizing the robot on both live animal as well as human cadaveric models [25].
