Chirurgen fallen nicht vom Himmel, sondern müssen hart trainieren...

Using virtual reality simulators to train surgeons improves performance and reduces operating time, finds a study published on bmj.com today.

Surgery is traditionally learnt by repeated practice on patients but, in recent years, targets and reductions in working time have cut training opportunities for young doctors, while ethical factors sometimes make it unacceptable for novices to learn on patients.

Although simulation based training has been explored since the 1970s, high quality evidence to support its widespread adoption is still sparse. So a team of researchers based in Denmark set out to assess the effect of virtual reality training on surgical performance within the training curriculum.

The study took place from September 2006 to August 2007 and involved 24 junior registrars training in obstetrics and gynaecology with no clinical experience of laparoscopic (keyhole) surgery.

Participants were randomly allocated to either virtual reality simulator training or to traditional clinical training. The simulator group received seven hours of training. After training, the registrars performed their first laparoscopic operation on a patient (under senior supervision) and were scored according to their technical performance by two independent assessors. Their operation time was also recorded.

The simulator trained group scored an average of 33 points, equivalent to the experience gained in 20-50 laparoscopic procedures (intermediate level performance). The control group scored an average of 23 points, equivalent to the experience gained in less than five procedures (novice level performance).

Operating time was 12 minutes in the simulator group compared with 24 minutes in the control group.

The authors stress that surgical performance also involves non-technical skills, such as communication, teamwork and decision-making and therefore simulator training should only be considered as a supplement to real operations.

However, these findings clearly show that skills in laparoscopic surgery can be increased in a clinically relevant manner by virtual reality simulator training, they say. The performance level of novices was increased to the level of intermediately experienced laparoscopists and the operation time was reduced by half.

Simulator training should be incorporated into the curriculum for all surgical trainees before they embark on patient procedures, they conclude. This can potentially improve patient safety and improve operation room efficiency.

This study makes an important contribution to our understanding, but the strength of simulation is as an adjunct rather than an alternative to clinical experience, suggest two surgeons from Imperial College London in an accompanying editorial.

A key challenge is to integrate simulation within existing curricular structures to ensure that practice takes place within a robust educational framework, they say. Simulation is costly in terms of equipment and teaching facilities. However, the establishment of simulation centres at key sites can enable trainees to participate in regular practice sessions which align with and reinforce their clinical training, they conclude.

Impact of virtual reality training in laparoscopic surgery: randomised controlled trial http://www.bmj.com/cgi/doi/10.1136/bmj.b1802
Editorial: Surgical training using simulation http://www.bmj.com/cgi/doi/10.1136/bmj.b1001

Contacts: Research: Christian Rifbjerg Larsen, Clinical Research Fellow, Department of Gynaecology, The Juliane Marie Centre (for Children, Women and Reproduction), Copenhagen University Hospital, DenmarkEmail: mailto:crl@rh.regionh.dk
Editorial: Roger Kneebone, Reader in Surgical Education, Department of Biosurgery and Surgical Technology, Imperial college London, UK