Time for a new training model in cardiac surgery

Traditionally, technical skills in surgery are taught by the “apprentice model”: trainee surgeons learn under supervision in the operating room, by performing portions of or complete real operations on real patients.

Today, however teaching in the operating room is limited by several factors:

  • legal restrictions in working hours and respect of off duty time limit exposure to suitable interesting but rare cases, which result in insufficient time to teach technical skills and does not ensure exposure to rare but important adverse events.
  • contemporary quality requirements, as well as referral and public scrutiny put significant pressure to hospitals and individual surgeons, a fact that has an impact on tolerance and time needed for training in especially exposed operations.
  • the progress of minimally invasive procedures, which require additional and sometimes controintuitive skills on top of the “normally” required skills needed for a specific open operation.

 All the above elements complicate the task to safely train sovereign and skilled surgeons.

 An alternative training model emerges: the use of surgical simulators.

Surgical simulators enable the trainee surgeon to gain a solid base of technical and behavioural skills under scenarios of increasing complexity.

Surgical simulators are not intended for trainee surgeons only; in fact, also established and experience surgeons can learn and / or experiment new techniques in this safe environment. You can see the author of this blog training minimal – invasive techniques on two “low fidelity” (but highly difficult) simulators, one of which has been self-invented for the purpose (Figure 1). The commonly used distinction between “low” and “high” fidelity of a given simulator is misleading. It refers to the simplicity or complexity of the simulator, as well as to the materials used. Simulators as shown in Figure 1 are obviously of “low” fidelity due to the material and their technical simplicity; however, their true biological fidelity is high! They are thought out to train specific skills, their grade of technical and situational fidelity is high.

Figure 1: On the left-hand side low fidelity simulation training for the proximal anastomosis in minimally invasive coronary bypass surgery (MICS-CABG). On the right-hand side training on a commercially available low fidelity simulator for minimally invasive mitral valve repair surgery.

Figure 1: On the left-hand side low fidelity simulation training for the proximal anastomosis in minimally invasive coronary bypass surgery (MICS-CABG). On the right-hand side training on a commercially available low fidelity simulator for minimally invasive mitral valve repair surgery.

In cardiac surgery there are many objectives and aims that can be achieved by using surgical simulators. Let us go briefly through them:

  • Surgical accesses to the heart: median sternotomy, mini-upper sternotomy, lower hemi-sternotomy, right and left mini-thoracotomy
  • Preparation and connection to the cardiopulmonary bypass circuit
  • Instrument handling / suturing / knot tying under odd conditions in minimally invasive cardiac surgery
  • Techniques of cardiac valve replacement
  • Techniques of cardiac valve repair
  • Wire skills as basis for transcatheter valve and endovascular interventions

No single simulator can cover all these interventions and requirements. For some, realistic tissue feeling is crucial (preparation and connection to CPB, valve repair), for others, a similar feeling but correct anatomy and anatomical relationships between the heart and intrathoracic structures and thoracic wall are preferable (surgical access training).  An array of simulation devices is needed to cover each specific need. Pure simulator instruction on mannequins or appropriate segments of the human body is, however, not sufficient. Instructional video lessons either on dedicated platforms or more recently in combination with virtual reality visors can increase the benefit of this kind of training.

Despite what we could think using common sense, there is limited evidence on the efficacy of a simulator-based training preceding operating on real patients compared to the classical “apprentice” training model. The results, however, are encouraging and point towards the need for an increased engagement of the surgical community in this direction. Not only in terms of pure technical skills, but also in terms of the ability to handle significant complications and adverse events (clinical scenarios).

The time is now ripe for a new training model in cardiac surgery (and in surgery in general): hybrid training. A new revised curriculum (the inclusion of systematic and structured training in wire skills is in my opinion mandatory!) should foresee a staged approach to practical training: first extensive training on simulators, then supervised and segmented training in the operating room. There is already a brilliant paradigm: aviation. Safety in aviation has already served as leading paradigm regarding safety of procedures and introduction of checklists. Flight simulator hours are an integral part in pilot training. And it makes absolutely sense. In my opinion, the same applies to surgery.