Since the Middle Ages and until today, the education of surgeons has always consisted of "learning on the job." In the daily practice of surgical residency all over the world, a large part of surgical skills is still learned in the operating room while working on patients. However, learning on human beings is not always the best way, not for the patient nor for the surgical trainee. All residency programs are reducing working hours for trainees; the introduction of new technologies and the minimally invasive revolution have certainly increased the number and sometimes the complexity of procedures; ethical considerations have led us to nearly abandon the use of cadavers for enhancing surgical experience, while animal labs are strongly contrasted in most Western countries. These issues elicit the need to develop alternative training methods using physical models, box trainers, or electronic simulators.

While thinking that we are living in a very advanced and technological era, we must keep in mind that iat-rogenic pathology is nowadays the seventh cause of death. Therefore, recognition of the importance of errors is an essential component of the practice of surgery, and new methods and technologies are being used to identify, avoid, and reduce errors. The medical community in general has ascribed errors to the system; however, during a surgical procedure, surgeons are the only actors of an error, and the consequences are more and more relevant, considering that litigation is a main issue as well.

The possibility of reducing medical errors (surgical acts account for 50% of them) could then dramatically influence the healthcare systems, and socioeconomic advantages could be at least as relevant as they were 30 years ago, when flight simulators introduced as a standardized part of the curriculum of in-training pilot brought a 30% reduction in civil aviation accidents.

Many new methods to train surgeons have become available as education, training, and accurate assessment of skill and performance represent the most important challenge of the new century for medical schools, scientific societies, academic and clinical environments.

Two main examples are mentioned:

1. In his presidential address at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2002 Meeting, William L. Traverso said that the three missions of SAGES for the 3rd millennium are "Education, education, and ... education!" Before and after this statement, SAGES has dedicated major resources and efforts to this goal.

2. At the same time, the European Association for En-doscopic Surgery (EAES) created in 2004 the Work Group for Evaluation and Implementation of Simulators and Skills Training programs, thus devoting intellectual and financial resources to these new educational opportunities.

Medical education, a field where tradition has always played a main role, is now introducing a "bits-and-bytes" system with the use of information technology, thus undergoing significant changes. Simulators have achieved widespread acceptance in the field of anesthesia, intensive care, flexible endoscopy, and recently in surgery, especially for minimally invasive surgery. The fast introduction of minimally invasive skills has speeded up the development of new training methods to train residents through these new technologies.

Some simulators are based on phantoms (physical models, e.g., plastic structures) others are virtual reality (VR) computer-based simulators. A third group is represented by the hybrid simulators, where the two components are integrated (Fig. 7.1).

Although phantoms may provide realism concerning tissue behavior, computer-based simulators will increasingly become more eligible as a training aid, especially because of their extensive range of educational features. Several systems are on the market, and producers are continuously enhancing their products, covering the field of more popular procedures with virtual reconstructions. In some recent studies, although evidence-based validation is not yet achieved, it has been shown that they can improve surgeons' performance, predicting a significant contribution to patient care.


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