Echtgenoot Lps Stassen

Clinical outcome of patients treated

Fig. 7.3 Cuschieri's model of proficiency

Fig. 7.3 Cuschieri's model of proficiency when reliable simulation will elevate a surgeon's skill, increasing the patients' safety.

Simulation and attitudinal evaluation, at a lower level, could be used as well for medical schools students' selection, using the same productivity criteria applied to simpler tasks for novices.

Finally, another field of application for the satisfactory VR simulator of the future is the possibility of testing and evaluating new instruments: New tools and innovative technologies can be tested while still in a computer-animated design (CAD) configuration, increasing safety and significantly reducing costs. Following the same guidelines, new surgical techniques will be safely introduced and mastered on virtual patients before being introduced in clinical practice.

Now, the question introduced in the title can be slightly but significantly modified: Is there a "holy grail" in the described simulation systems? Is it possible, at the state-of-the-art point where we are now, to say when a multifunctional system will be able to cover satisfactorily all needs of a comprehensive program for trainees?

Current experience is negative, but future developments, although challenging, can bridge the gap, giving us the chance to change today's negative answer in a future's positive one.

Apart from the already-described and well-known pitfalls of simulation systems, there are more general consideration to be introduced:

• Development of simulators is currently devoted almost completely to laparoscopic surgery and minimally invasive techniques, such as endovascular procedures. It is evident that medical treatments will be increasingly performed with a less invasive approach; nevertheless, it is equally clear that, at least in the future of current generations, a large amount of procedures will be still completed with a traditional techniques, especially in the fields of emergency or major procedures. Moreover, some of these complex operations will not be planned, but will represent the rescue treatment of complications occurred during minimally invasive surgery. As a third important aspect, the surgeon generation trained after the 1980 is brilliantly skilled in laparo-scopic complex procedures, performed daily, while the chance of working with the open approach is less frequent, sometimes occasional, for the majority of them. When facing a complication or a complex patient, the multifactorial attitude that includes not only technical skills, but also experience, team coordination, and decision making is of utmost importance for a positive result. The introduction of simulators devoted to acquiring skills in open and emergency surgery will be then a key point of a complete curriculum for in-training surgeons. Un fortunately, simulating open techniques is still more challenging and complex than is mimicking laparoscopic procedures, and will require a comprehensive, immersive environment with advanced navigation systems. Tracking of hand movement, already available, should be expanded to the whole field of operation. The use of a robotic console, as the one currently available, could be helpful in mimicking the hand movement in traditional techniques. It is important to mention that such a console, as a part of a surgical robot devoted to open surgery, is already available for clinical experimental use, being not so far from widespread applications.

• As repeatedly stated, technical skill is one of the many components of surgery. Daily clinical experience brings a considerable amount of stress, and clinical outcome can be influenced by this. Surgical simulation can greatly help in reducing this influence, with a less stressing approach to the operating theater, considering that the real procedure can be repeatedly simulated and pretested in a safe environment. Consequently, stress control should also be taught and learned virtually. Although measures are not always completely reliable, integrating biohumoral data of the trainees (collected by noninvasive methods) in a comprehensive evaluation system of the simulator could help each trainee and tutor to better identify the key points of the procedures and to understand and manage challenging situations.

• As previously briefly introduced, critical and unexpected situations (e.g., power failure, instrument breakdown) are critical part of procedures that are dependent on complex and integrated technology. Future classes of simulators should introduce randomly these accidents in their simulated procedures, in order to stimulate the creative component and the quick decisionism that have always been components of surgeons' background.

• Integrating the last concept, it is evident that group working is also a part of surgery: While introducing robotic assistants, camera holders, circulating and scrub nurses in daily practice, future simulation developers should enhance the already existing possibility to change tools, positions, etc., creating a more realistic integration with the OR environment.

Which other fields will be explored by surgery in the future? Electronics, robotics, and information technology have transformed the growth of science from linear to exponential. In the next few years, we will see many new treatments made possible by miniaturization of surgical components, such as smart materials and microrobots. The role of surgeons in a near future will be to not only eradicate, modify, or replace organs macro-scopically, but also to downscale their effect on the human body at a cellular level. While simulation brands are working to reproduce codified procedures, new techniques and approach philosophies are continuously developed, more and more of them requiring an integrated, multicompetent, highly qualified team. In this field, the growth of endoluminal therapies is a typical example. The future challenges for scientist, engineers, and educators are then composed of several aspects:

• Continuing the current line of development, solving today unresolved issues through technological solutions and clearly defining the real utility of different class of simulators.

• Enhancing educational opportunities and developing training and assessment methods, with standardized, objective, criterion-based evaluation.

• Giving a consistent demonstration of transfer of skills to the operating room, with a linear relation to the improvement of the surgical performance.

• Achieving a consistent reduction of the training time, thus reducing residency length and, more important, the learning curve for new techniques.

How can we train new surgeons for new surgery, and more efficient surgeons for the old surgery? As illustrated, the burdening of knowledge of new ideas and procedures is dramatically quick, while consensus on guidelines and validation studies are mostly time-consuming and never fast enough. These considerations demonstrate that we will never be allowed to reach a static gold standard, an immutable holy grail, a dogmatic statement to define surgical simulation goals and to award the best VR simulators. Certainly, minimal requirements, efficacy, and many other aspects must be pointed out and standardized, but we must be aware that future simulators will be a component of an ongoing dynamic process, with continuous modification of surgical environment, trainees' attitude, and standards of care. The adventure has just begun.

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The Medical Informatics Challenge in Surgery

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