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Ann Thorac Surg 2009;87:1546-1551. doi:10.1016/j.athoracsur.2009.02.022
© 2009 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Open Lobectomy Simulator Is an Effective Tool for Teaching Thoracic Surgical Skills

Yvonne M. Carter, MD*, M. Blair Marshall, MD

Division of Thoracic Surgery, Georgetown University Medical Center, Washington, DC

Accepted for publication February 9, 2008.

* Address correspondence to Dr Carter, Georgetown University Medical Center, Division of Thoracic Surgery, 3800 Reservoir Rd NW, 4PHC, Washington, DC 20007 (Email: ymc01{at}gunet.georgetown.edu).

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
Background: Simulation has long been appreciated and used in professional industry training. The effectiveness of high-fidelity, low-cost simulators in such settings has led to its integration into surgical education for skill development. Simulation may possibly have a role in surgical specialty training.

Methods: Replicas of a human torso with a posterolateral thoracotomy incision were constructed from poultry netting and casting fiberglass, and used to house a previously prepared bovine lung. After reviewing computerized instructional material, student volunteers were asked to perform a lobectomy with the assistance of a thoracic surgeon, who also evaluated the subjects. Objective data were collected from knowledge-based examinations and technical skills evaluation scales. Statistical analysis was performed with the Student's t test.

Results: The initial success rate was 88.9% (16 of 18). Significant improvements were appreciated in both subjective and objective measures by the third week with weekly repetition. The average operative time was reduced to 34.8 ± 5 minutes from 48.5 ± 4.9 minutes (p = 0.01). The average task-specific score was 7.8 ± 0.8 (versus 5.6 ± 2.1; p = 0.05), and students achieved an average global performance score of 28.6 ± 3.8 (p = 0.01). Scores on knowledge-based examinations also significantly improved.

Conclusions: This open lobectomy simulation can be used to effectively teach thoracic surgery techniques. Our results prove the effectiveness of simulation training in thoracic surgery. Additional studies will determine whether simulation is effective for different training levels in thoracic surgery.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
The traditional apprenticeship model in surgical training is currently being challenged by mandated resident duty hour restrictions. As our health-care system evolves, concerns for patient safety, service, and outcome data have taken precedence over training. It has been estimated that a trainee needs to perform a surgical procedure 15 to 100 times before having the ability to do so with minimal complications [1–3]. Whether the current restrictions on resident work hours have negatively impacted on the trainees' operative experience is debatable [4, 5]; however, there are no data on the impact of reduced work hours on cardiothoracic surgery training. The practice of cardiothoracic surgery during the past two decades has seen an increase in both procedure complexity and diversity. Routine open lobectomy for early staged disease has essentially been replaced by video-assisted thoracic surgery lobectomy. Thoracic surgeons' adaptation to video-assisted thoracic surgery lobectomy has resulted in procedures of greater complexity being approached minimally invasively. In cardiac surgery, the routine three-vessel coronary revascularization has waned, and has been replaced by repeat combined complex procedures in higher risk patients. These are not easily turned over to the trainee as "teaching cases."

Simulation has the potential to be a successful educational tool in surgery, as it has been in other professional industries, with the added benefit of enhancing patient safety. As educational tools, surgical simulators allow for repetitive practice of fine technical skills and assessments based on direct observations [6]. The experienced surgeon can also use effective simulators to rapidly develop new procedures, to practice safe skill development, and to assist in introducing new technology into clinical practice.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Discussion
 Acknowledgments
 References
 
Skill Course Curriculum
The study was conducted at Georgetown University School of Medicine either once (n = 13) or weekly (n = 5) for 1 month. Each study participant was provided with computerized instructional modules for knot tying, suturing, anatomy of the thorax, and pulmonary resection 3 weeks before the study.

Simulation Model
Models of the human torso with a retracted posterolateral thoracotomy incision were constructed from poultry netting (Home Depot, Atlanta, GA) and Technoform II fiberglass casting (Royce Medical Co, Camarillo, CA; Fig 1). Bovine lungs obtained from a local slaughterhouse were prepared from an en bloc sample, and refrigerated until ready for use. A single lung was placed within the torso model to simulate the appearance of a deflated lung through a posterolateral thoracotomy incision (Fig 2).


Figure 1
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  		Fig 1. The human torso replica was constructed from poultry netting (A), which was then covered with a fiberglass plaster (B). The hole was modeled to replicate a retracted posterolateral thoracotomy wound.

 

Figure 2
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  		Fig 2. A bovine lung was placed within the torso model, replicating the view a thoracic surgeon has after retracting a posterolateral thoracotomy incision in a human.

 
Second-year medical students volunteered to participate in the study. At least 1 week before the initial session each participant received instructional material by means of electronic transmission for individual review. Instruction on the use of the surgical instruments and the simulator was provided individually at the beginning of the study. Although it was mandatory for the student to perform all of the surgical dissection, the participant was allowed to request assistance with knot tying. At the end of each session, immediate feedback was provided to each individual. The feedback was noted and repeated at the beginning of the next session for the 5 participants of the month-long study.

Evaluation
Study subjects were evaluated with a knowledge-based examination, which was administered at the beginning and end of the study. The same test was administered at the end of the simulation session, but was labeled "posttest." The 5 students who participated in the month-long study retook the posttest. Ninety minutes was allotted to complete the simulation, and operative times were collected. Surgical technique was evaluated with two Objective Structured Assessment of Technical Skills–based scales [7–11]. One scale focused on task-specific skills, assigning a score of 1 for correctly done tasks (ie, dissects bronchus without injury), and 0 for tasks either done incorrectly or not at all. A global 5-point assessment of surgical performance was completed with the use of a predetermined scoring system (range, 1 to 5). This scale subjectively assessed performance in seven different areas required to perform a surgical procedure (ie, time and motion, knowledge of the specific procedure). This scale also allowed for conclusive "pass" or "fail" grading. Following the Objective Structured Assessment of Technical Skills model, these scales were designed specifically for an anatomic pulmonary resection.

Statistics
The collected data were descriptively analyzed with the Student's t test. A probability value of 0.05 or less was considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Discussion
 Acknowledgments
 References
 
Subjects' Characteristics
The study group consisted of 18 second-year medical student volunteers. There was no difference in surgical experience among the study participants, as none had previous hands-on experience. Five students participated in the month-long study, during which they repeated the simulation on a weekly basis. All students were recruited from a surgery interest group at the medical school.

Comparison of Performance With Repetition
In total 16 (88.9%) students were able to complete the simulated lobectomy on the initial attempt. Statistical comparison of the students in the two groups did not demonstrate a significant difference in any of the measured variables (Table 1). Scores on the knowledge-base pretest were similar, with an overall average score of 7.9 ± 1.6 (range, 4 to 10; maximum, 10). Although the posttest scores after the simulation were slightly higher, the difference was not statistically significant. However, the posttest scores did significantly improve after the fourth simulation week (9.6 ± 0.9 versus 8 ± 0.7; p = 0.01) in the cohort who participated in the four-session study (Fig 3).


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  		Table 1 Group Comparison After Single Simulation Session a
 

Figure 3
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  		Fig 3. There was no difference in the knowledge-based test scores after a single simulation session. Scores significantly improved when students repeated the examination after the fourth simulation session. (*p < 0.05.)

 
Only 2 students—one from each study group—were unable to complete the simulated lobectomy within the allotted 90 minutes during the first simulation session. The average time necessary to complete the procedure was 52.4 ± 11.9 minutes: 56.2 ± 13.6 minutes for the single-session group and 48.5 ± 4.9 minutes for the four-session group. This difference was not statistically significant. All 5 students completed the simulation within the allotted time during the second session; however, the average time was not significantly different. An improvement in operative times was appreciated in the third week, with an average time of 34.8 ± 5 minutes (range, 30 to 42 minutes; p = 0.005; Fig 4). Although the times continued to improve in the fourth week, they were not significantly lower than the third week.


Figure 4
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  		Fig 4. The average time to complete the simulated lobectomy significantly decreased during the third week of the study. This improvement in operative times was sustained into the fourth week. (*{dagger}p < 0.05.)

 
Similar to operative times, the subjective analysis of surgical skills was not significantly different between the two study groups. The overall task-specific grading score was 5.6 ± 1.6 (maximum, 9), and the global score was 17 ± 4.2 (maximum, 35). Weekly repetition resulted in progressive improvement in evaluation scores. As with the operative times, the subjective scoring significantly improved in the third week of the study. The task-specific score improved to 7.8 ± 0.8 (p = 0.05; Fig 5), and continued to improve in the fourth week (p = 0.03). The global assessment scores improved to an average of 28.6 ± 3.8 (p = 0.01; Fig 6).


Figure 5
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  		Fig 5. Task-specific operative skills improved during the third week of the study, with significantly higher Objective Structured Assessment of Technical Skills evaluation scores. Skills continued to improve in the final week of the simulation. (*{dagger}p < 0.05.)

 

Figure 6
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  		Fig 6. Improvements in the global performance scores were similar to the trend for the task-specific skills. The average scores on this Objective Structured Assessment of Technical Skills scale significantly improved in the third week, and continued to improve in the fourth session. (*{dagger}p < 0.05.)

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Discussion
 Acknowledgments
 References
 
The traditional apprenticeship model used in surgical training is archaic in comparison with training in other professional industries. In addition, with current work-hour limitations and anticipated further limitations, concerns for patient safety and outcomes may take precedence over resident training. Some training programs may not have an adequate patient census to provide optimal training of residents on certain procedures. A recent review of a single teaching institution's 4-year experience with video-assisted thoracic surgery lobectomy revealed an increase in the number of procedures performed by the thoracic surgery resident. However, the resident was only cited as the operating surgeon in 35% of the cases. Either the thoracic surgery resident or junior faculty surgeon conducted 75% of the cases performed in the last year of the study [12]. Although the resident experience improved with time—the exact extent is uncertain—the overall 35% leads one to question whether the training experience is adequate preparation for one's individual career. The number of thoracic surgery residents and the length of the training program in this study are unknown.

Leaders in thoracic surgery are anticipating the integration of simulation for proficiency demonstration, specialty certification, and introduction of new surgical techniques [13, 14]. Passing a K-type question examination should no longer be the standard for assessing field proficiency. Such ideas are not without support, as others have previously considered integrating simulation into surgical specialty training [15–18]. Challenging stressors to medical education have motivated some to reevaluate how surgical training is obtained. The success of simulation in other industries suggests its potential in surgical skills training. The development and integration of adequate simulation models into medical training will result in a relocation of the learning curve from the operating room to the skills laboratory. This will likely, in turn, have a positive impact on patient safety, cost of medical care, and development of surgeon confidence.

The aim of this study was to demonstrate the ability of a thoracic surgery simulator for skills development performing a common thoracic surgery procedure. Objective skills assessment is a necessary adjunct to evaluate the utility of proposed simulation models in medical education. In our study, a single surgeon was the evaluator. Although we recognize the inherent bias associated with only one evaluator, limited resources did not allow for multiple thoracic surgeons to serve as evaluators for the study. The assessment method is based on the validated Objective Structured Assessment of Technical Skills method. This evaluation method can be applied to both live animal and bench models, uses two types of scoring systems, and has been shown to be valid and reliable in multiple scenarios [7–11]. We found faster operating times, better accuracy, and improved economy of motion among our participants who repeated the study weekly. These students were able to recognize the three-dimensional thoracic anatomy, and had familiarized themselves with the pattern of the lobectomy operation by the end of the study. Our results parallel those of Hassan and colleagues [19], who had surgical residents complete a 3-day laparoscopic skill course. These investigators concluded that the advanced resident participants benefited most from the course, as opposed to novice participants. Repetition was the most likely factor for the positive results in our study. These data suggest that minimally invasive models may be better suited for senior level trainees, as opposed to open simulators for novices. Such a conclusion is supported by the study by Iwasaki and associates [16], who tested an economical thoracoscopic trainer on experienced surgeons. These investigators thought their model was best suited for the trained surgeon, provided perfect simulation, and minimized both surgical errors and animal experimentation.

As our study introduced students to thoracic surgery, new surgical techniques can be introduced and practiced in simulated settings and the developed skills transferred to the human subject. von Segesser and colleagues [20] introduced a minimally invasive aortic valve procedure, in which cardiothoracic surgeons were able to practice and hone skills on porcine hearts within realistic thoracic models. Such "suspension of disbelief" simulation models allow the surgeon to feel as if the procedure is being performed on a live patient, resulting in increased surgeon confidence [20, 21], a benefit of simulation in skill set acquisition and new technology introduction. Proposed high-fidelity, low-cost simulation models for cardiothoracic surgical training would encompass the major challenges a thoracic surgeon faces in the progression from a posterolateral thoracotomy incision, to an anterolateral thoracotomy incision, and ultimately a minimally invasive (video-assisted thoracic surgery) approach. The models would allow one to experience the natural transition involved in using smaller surgical incisions and viewing the entire procedure from a video monitor.

The current study demonstrates the use of a simulation to educate students in thoracic surgery. Such a model can be used for trainees to practice the procedural steps before applying their surgical skills to the human patient, as well as for building self-confidence associated with the comfort level of being familiar with a surgical procedure. With models such as these, input from attending surgeons is essential while students and residents perform on the simulator. Other studies in simulation have remarked on the development of poor surgical technique, learned errors, and a sense of inadequate training when simulation training is carried out in an unproctored setting [22–25]. Albeit optimal for educational settings, an arrangement using fully proctored simulation is extremely time-consuming. Even our study is limited by the inclusion of a single thoracic surgeon evaluator. Repeated endoscopic simulation without a proctor has been proven to be adequate in the attainment of manual and technical skills [26–28]. It may be that a proctored setting is necessary for more complex procedures, whereas repetition alone is adequate for the simpler, less-invasive skill sets. Standardized curricula are necessary to compare different courses (ie, open versus video-assisted thoracic surgery) in thoracic surgery; however, sufficient simulators must first be developed. Regardless, at this time, there is no indication that simulation can completely replace proctored, bedside teaching. Its role in surgical education, we believe, is as an adjunct to traditional teaching methods.

Simulation has the potential to benefit the field of cardiothoracic surgery in many ways. Trainees can be provided with a stress-free practice environment to hone technical skills and build confidence in preparation for the human patient. In an era in which the exposure to cardiothoracic surgery has either significantly diminished or completely disappeared, specialty-based simulation is an opportunity to expose students and residents to the field. Such exposure has the potential to increase interest in cardiothoracic surgery as a career choice for trainees. We anticipate simulation will have an increasingly greater role in surgical education at all levels, with an emphasis on teaching, reinforcing, and evaluating skill development, knowledge accrual, error prevention, and technical innovation.


   Discussion
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
Acknowledgments
 References
 
DR RICHARD H. FEINS (Chapel Hill, NC): Thank you very much, and I would like to thank the authors for giving me the manuscript ahead of time. The work of Dr Marshall and Dr Carter that has been presented this morning is unique in two ways. First, it utilized the first of what will hopefully be a generation of very realistic simulators that create the circumstance of suspension of disbelief for doing lung resections. Despite the paper that was presented yesterday, see one, do one, teach one is an outdated, unacceptable, and probably unsafe concept that must be replaced by learn to do one correctly first and then do one. It has always been the hope that simulators could be developed that would accomplish this goal and allow teaching in an environment that is safe and educationally sound. An advanced model of the lung resection simulator shown here was used very successfully at the Thoracic Surgery Directors Association resident boot camp 2008 held in Chapel Hill last summer. Further modifications are ongoing, and it is expected that more advanced models that incorporate not only a moving mediastinum and perfused blood vessels, as was used at the boot camp and by Drs Carter and Marshall, but also a beating heart and VATS (video-assisted thoracic surgery) capability will soon be readily available.

A second unique feature of their work was that the students were medical students. It appears that they were very successful at teaching people, even at this very early stage of medical training, the basics of how to do lung resections. As cardiothoracic surgery accepts the responsibility, as it must, for comprehensive training at an earlier stage, techniques for teaching and evaluation such as the ones described by Dr Marshall will be essential. I have two questions.

First, you started with 18 medical students and yet only 5 went on to do the full 4 weeks. What were the reasons that 13 dropped out and what might that teach us about recruitment of medical students to the specialty?

Second, most all of this work was done by a single cardiothoracic surgeon, including the preprocedure education, all of the teaching and supervision on the simulator, and the assessments all along the way. None of this work, of course, produced any income. If simulator training is to become a mainstay of cardiothoracic surgical education, who do you envision is going to have the time to do this work and how would they be funded?

I appreciate the opportunity to discuss this paper and I want to congratulate you on an outstanding piece of work and hopefully a vision into the future.

DR MARSHALL: Thank you very much. I think that other course requirements show it was only the most really dedicated students that could afford the time. Many students, you know, are busy, just as busy as we are, and so I think that that was the factor in why some didn't go on to complete more than 1 week of simulation. We still have a core group of students that are interested and keep coming back, and I have 1 student who is working on a take-home model of subcuticular suturing. We all spent our early years of training practicing knot-tying at home. Why not be able to take more home and be able to work on your technical skills, thus cooperating with the 80-hour workweek.

You mentioned the relative value units. Most of us think that useful virtual reality simulators are far in the future, but I can tell you that it is not as far off as you think. There is an immersion bronchoscopy unit that is based on virtual reality. It is very effective, very expensive, and teaches bronchoscopy, colonoscopy, and esophagoscopy. To purchase the entire unit, it is $160,000. Currently, I am working with a group that is collaborating with Microsoft. Xbox is the platform, and they have got a bronchoscopy simulator unit, very similar to that which is currently available, and the final bill is going to come out at around $5,000. So the explosion in technology is going to, I think, impact virtual reality development and cost.

You have advocated the senior tour of training for those senior cardiac and thoracic surgeons that want to still be involved. They can help us in teaching students and residents. But again, it is very labor intensive and there are no RVUs generated. In the future, I think that we are going to be able to get around that. Right now you can put on virtual reality gloves. One can have a master surgeon, such as Tom Spray, put on the gloves and perform an operation while it is being filmed, put it into virtual reality, have a student wear the gloves. With this technology, they can then recognize where their motions are not that of an expert and adjust through direct feedback, too, without an attending surgeon there showing how to do that operation. So I think that this is where we are headed and how we are going to get around the intense labor that is currently involved in simulation.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
References
 
We sincerely appreciate the generosity of Horst Meats (Hagerstown, MD) for providing the animal tissue used in the study. Special thanks to Melanie Sion and Megan Carroll, who were extremely helpful in the completion of this project.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 

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