Fig. 7.2 The Rasmussen model taxonomy and metrics. The Virtual Reality Turing Test, Objective Structured Clinical Exam (OSCE), Objective Structured Assessment of Technical Skills (OSATS), McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), and Minimally Invasive Surgical Training - Virtual Reality (MIST-VR) are examples of evaluation modalities based on these parameters.

In this regard, it is of utmost importance the work of the aforementioned Work Group for Evaluation and Implementation of Simulators and Skills Training programs of EAES, based on following a systematic process to establish minimal requirements and get to a standardized model for simulator's validation, using literature meta-analysis, testing, and guidelines creation.

Summarizing the above-depicted characteristics and potentials of simulators, one could imagine that no major obstacle blocks the road of wide diffusion as the main revolution in surgical education of the modern era. This is not true, as these tools belong to a newborn market, and producers are facing major problems in terms of fidelity and realism, reproducibility of true procedures, technological limitations, and clear validation of their effectiveness in transfer the acquired skills to clinical practice.

The use of effective virtual models means to interact with them, in a VR environment, exerting on them traction and forces. This interaction requires perceptive interfaces (visual, acoustical, tactile), in order to make immersive virtual environments suitable for human senses.

The main limits of simulators for general surgery in the current state-of-the-art can be summarized as follows:

• Realistic interaction with a virtual model

• Complex anatomy

• Organs variability

• Several conditions of pathology and development of that for surgical therapy

• Movement variability

• Thickness of organs and tissues

• External forces

From this list, two main critical points are addressed:

1. There is still a lot of effort needed to implement these VR systems with a better realistic haptics and tactile feedback: They are currently mediated by complex devices, or they reproduced by smart but simpler technologies that mimic them through frictions or other physical methods. The results are not yet very satisfactory, as they are not for robots used for telesurgery in clinical practice.

2. Lack of realism in simulation of tissue properties is another important limit, as changes induced by pathological conditions (inflammation, scarring, sclerosis, vascularization, etc.) bring to an enormous variability. Several complex mathematical models have been introduced, not yet with a satisfactory result. Probably, the solution will come with the enhanced computational ability of computers that is exponentially growing up since their introduction.

The recognition of the potential of electronic devices brings the argument of the utility of introducing robotic technology in the simulation devices. Currently, as Satava has stated, surgical robots are nothing other than computers with arms, as a Tc-scan is a computer with eyes, etc. Integrating them into an intelligent OR is a main goal of clinical application of technology. The same integration will bring to 3D VR for learning and practice, with the opportunity to have flexible models, representing the anatomic variations of each single patient and looking at anatomic organs from perspectives that would be impossible during surgery. This will dramatically enhance the educational capacities of simulation, amplifying the surgeon's dexterity through the use of suitable haptic and robotic interfaces. In facts, they will become more and more useful in repeating and electronically comparing training programs, remote teaching, and preoperative planning on virtual patients, and in performing specific diagnostic and therapeutic procedures.

7.1 Curriculum

Learning through VR simulation modalities is not yet being systematically introduced in the curricula of the residency programs in European countries (actually, the Royal College of Surgeons has a defined program, and the Royal College of Surgeons of Ireland is planning a selection of candidates for residency programs including attitudinal evaluation through simulation, but nothing has been standardized, i.e., in Italy and Germany), while a rational approach in the field has started in Unite States (American Council of Graduate Medical Education and the American Board of Medical Specialties).

The creation of reliable predictive tests, based on VR simulation, to assess candidate's attitude to surgery will represent an additional criterion to be integrated with other attitudinal evaluations for the access to the residency programs. Although still under debate, the prediction of proficiency based on Cuschieri's model (Fig. 7.3) could save relevant resources and increase health care safety, contemporarily addressing unsuitable candidates to nonsurgical specialties.

Scientific society must play the main role in managing, standardizing, and correctly addressing this evolution, quickly understanding that the change in surgical teaching needs to be driven by independent and noncommercial authorities. It is then necessary in the near future to establish an international consensus for an integrated curriculum, not only for surgeon training, but also to assess periodically the skill maintenance of surgeons in clinical activity. It must be remembered that, without the introduction of minimally invasive procedures, most surgeons have not had the chance to receive complete training before applying the laparoscopic technique to their patients, and this is very evident by the increased percentage of lesions (e.g., of the biliary tree) present in the learning curve of a generation. This will not be acceptable in the future,


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