Surgical simulation deserves a separate emphasis because it has a larger role than only in surgical education. Unquestionably, surgical simulation will continue to grow, developing newer, more sophisticated skills trainers that more closely approximate reality and that address abilities beyond basic skills such as simulating entire procedures. However, it must be kept in mind that a simulator is simply a tool—albeit a powerful tool—to supplement a total educational curriculum. It is essential to incorporate the didactic teaching of anatomy, steps of a procedure, and potential errors, along with expected outcomes of skills training and embed these into a curriculum that includes the simulator. Continuous feedback while training (an automatic function of any proper simulator) provides the methodology for a goal-oriented, criterion-based curriculum that permits the student to learn at his or her own pace, on his or her own time, and with automatic mentoring. In addition, an over-arching curriculum must be developed for each residency training year that describes all the surgical procedures for which the resident must obtain proficiency. No longer will it be acceptable to have exposure only to those diseases and surgical procedures that happen to occur when the resident is on a clinical rotation; it will be necessary to agree upon a fundamental curriculum of all the important procedures a resident must learn (and become proficient) and provide simulations of all these possibilities (a digital library of procedures) so every resident will perform to criterion each important surgical procedure before graduating—a very large challenge that will last decades to achieve. This same methodology will become the standard for experienced surgeons who wish to adopt a new surgical procedure in their practice. No longer will it be acceptable to take a weekend course and return to operate on patients; rather, a longer period of training to proficiency followed by a period of mentoring and/or proctoring will be required.
Simulation is also being used for preoperative planning and then surgical rehearsal of complicated surgical procedures. Some of these difficult cases can be included in the digital library to train future surgeons as well. A unique opportunity arises with surgical robotics: The same surgical console that is used to perform an operation can be used to do preoperative planning, surgical rehearsal of a specific patient, or for education and training. The robotic system can keep track of hand motions and continuously assess performance, whether for the assessment of skills or documentation of proficiency, both during residency training and throughout clinical practice career. Thus the surgical robot has a role well beyond enhancement of surgical performance; it can incorporate training and assessment as an integral part of daily practice and life-long learning.
Until surgical robotic systems become ubiquitous, separate systems for training, assessment, planning, and rehearsal will need to be used. The practicing clinician should foster the use of robotics with inclusion of simulation capabilities. As technology both advances in sophistication and also incorporates the above simulation capabilities, surgeons should adapt by seizing the opportunity to train on simulators as well as preplan and rehearse their more difficult elective surgical cases.
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