The best training model for residents is to perform different parts of the operation under supervision of a qualified surgeon, and then when every step is performed several times the entire operation. The procedure is cheked as learned when the operation is done by a resident and another resident to assist. This model worked with me. 

I think each has its advantages and they complement each other. Virtual reality simulators provide greater potential scope for repetitive training tasks, and also a basis for continuous assessment & feedback, allowing correction of deficiencies, perhaps even appropriate redirection of training streams. On the other hand, animal models provide a biological system, with greater potential for "reality" simulation. However, costs & practicalities may well limit access & numbers of repetitions. Also, probably needs greater involvement of qualified supervisors/instructors - whereas VR simulators can have built in instruction/self directed progress.

In my training (to a small extent) and now in the training that I deliver & supervise, the main focus has been on animal models, but to fairly limited extent. I believe the future of surgical training will lie in VR simulation - as the technology evolves & becomes more high fidelity & affordable

In my experiencia teaching residents vascular surgery, core basic skills are an absolute necessity, and a combination of VR simulation, plastic models, and assisted learning in the OR is probably the most feasible way in the future. The problem we face is, what defines a good surgeon, how do we , our colleagues and even the scrub nurse know wether the surgeon is good or not? I believe we all know the stories about other surgeons who just don´t have ¨the right stuff ¨ and have high complication rates. There lies the question, what is this ¨right stuff ¨ and how can we reproduce this in a safe environment.

Further research into who the surgeons brain works is needed to be able to better define these ambiguous terms.

The simulation in the surgical training has always been important,  through the use of biological simulators (corpses or animals), but has become an unavoidable subject in the acquisition of laparoscopic skills and abilities with the use of inanimate simulators, both with physical reality as with virtual reality (1).

A recent publication by Benjamin Zendejas et al, entitled "State of the Evidence on Simulation-Based Training for Laparoscopic Surgery", (2), through a systematic review and rigorous analysis of more than 200 studies, allows to position the skills laboratory as the most appropriate environment for laparoscopic skills acquisition, even more so if it takes into account other premises of paramount importance with regard to the safety of the patient (3,4)

The aforementioned paper consists of a meta-analysis carried out according to the PRISMA methodology (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) which ensures the quality of the reports of systematic reviews of randomized controlled trials and its statistical treatment, for what it constitutes a scientific paper of high level of validity and reliability.

This publication is considered by Selzer and Dunnington (6), as a breakthrough in the 25 year old debate about the need to formally incorporate the simulation-based training to educational programs in general surgery and in other specialties. At the same time, these latter authors infer that from the mentioned work, that there will be a shift in the approach to the problem: of: is it effective?, to a discussion of "How can do it more effective?

In the light of its analysis, Zendejas et al, reach three critical conclusions:

First, the authors confirm the superiority of simulation-based training in laparoscopic skills acquisition, when compared with the simple intraoperative experience.

Second, the authors found that a computer simulation of high cost, not always resulted in better training. The systematic analysis of 21 studies that compare box simulators with virtual reality simulators, failed to demonstrate the superiority of virtual reality simulators with haptic feedback. Furthermore, even with virtual environments of great similarity with the human anatomy, the simple box devices, with mirrors or web cameras, were as effective as complex systems. This advantage of lower-cost simple devices, also implies a greater affordability, portability and ease of use.

Third, the authors also found that the opportunity of feedback during the training cycle, is essential to the success of the process, in terms of the acquisition of skills. It became evident, that  feedback in general, promoted better results and increased student satisfaction; However, when the feedback is immediate and continuous, you get greater benefits in the process of skills learning.

1. Quirarte-Cataño C, Muñoz-Hinojosa JD. La revolución pedagógica en la cirugía, Parte III. Metodología de la enseñanza de destrezas psicomotoras: los simuladores. Cir Endoscópica. 2013;14 Suppl 1:S37-51.

2. Zendejas B, Brydges R, Hamstra SJ, Cook DA. State of the evidence on simulation-based training for laparoscopic surgery: a systematic review. Ann Surg. 2013;257(4):586-93.

3. Salas E, Wilson KA, Burke CS, Priest HA. Using simulation-based training to improve patient safety: what does it take? Jt Comm J Qual Patient Saf. 2005;31(7):363-71.

4. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative. Acad Med. 2003;78(8):783-8.

5. Selzer DJ, Dunnington GL. Surgical Skills Simulation: A Shift in the Conversation.

Ann Surg 2013;257(4):594-5.

At current stage, computer-based simulation can not fully supply with visual and hapitc realities for a resident to build sufficient surgical skills. Therefore, animal model still plays an important role for training basic surgical skills. However, cost in using whole animal model can be an issue. One way worth to try is the hybrid model that combines animal parts with bench-top model, as placing the pig liver and gall bladder inside lap training box for teaching lap chole surgery. An innovative approach to the hybrid model is to merge animal model with virtual reality. We can develop patient-specific 3D anatomy from CT scans and superimpose images on top a piece of pig livers for training skills of liver resection.  Hybrid models that combine clinical images with real haptic sensation from animal model  is a feasible way to improve simulation training outcome of residents.

There are many works reporting how the surgical training should be targeted in a stepwise chart. Simulation and vitual realty is the first step, than the dry-lab, the animal model and lastly the humans. All these issues are best demonstrated when dealing with robotic surgery, where the virtual simulation is very adherent to clinical practice. However, I am strongly convinced that all these training models are appliable to both open surgery and laparoscopy.

Example:

Virtual reality robotic surgery warm-up improves task performance in a dry laboratory environment: a prospective randomized controlled study. Lendvay TS, Brand TC, White L, Kowalewski T, Jonnadula S, Mercer LD, Khorsand D, Andros J, Hannaford B, Satava RM. J Am Coll Surg. 2013 Jun;216(6):1181-92. doi: 10.1016/j.jamcollsurg.2013.02.012. Epub 2013 Apr 11

Dear Eleftherios, dear all,

an excellent new tool for surgical education in surgery is the dual console of the da Vinci robot. It enables not only to instruct by showing surgical steps in 3D/HD quality but also to assist or to take over certain steps of the surgery according to the experience of the resident. To prepare for the first surgeries "dry training" and the Simulator are useful tools to support to get familiar with the system but cannot replace  concrete surgery. All colleagues who are lucky to be allowed to do robotic surgery with dual console may experience a complete new dimension of teaching surgery and training surgery step by step.

Dear Eleftherios, this truly is one of the critical questions in simulation-based education. The topic not only interests educators but naturally product designers alike. In my opinion there really is no "right" answer as the optimum modality will vary depending on surgical discipline, surgical training level, as well as the nature of the course structure in which the simulation is imbedded.

The benefit of simulation has been recently been supported by several publications by Cook and colleagues that have conducted several systematic reviews with meta-analyses on related topics (as discussed in a prior post).

Furthermore, the relevance of the trainees' perceptions of the models needs to be acknowledged, as this may well effect motivation for any planned simulation training (Perceptions, training experiences, and preferences of surgical residents toward laparoscopic simulation training: a resident survey. Shetty S, Zevin B, Grantcharov TP, Roberts KE, Duffy AJ. J Surg Educ. 2014 Sep-Oct;71(5):727-33).

Last, the simulator does not preclude the need for educational or surgical staff being present during training, neither does it preclude appropriate course structure and modern instructional approaches such as feedback and debriefing.

Therefore, in my opinion the question should not be which modality, rather it should be how to ensure sound instructional design in simulation curricula, standardize training settings, and how to ensure successful local program implementation. 

Dear Esther,

I completely agree to your comment. For my experience there are different skills which have to be taught. One is surgical technique which may be trained first in simulators or animal models. Second however is surgical strategy, handling of tissue compartments and borders, rescue strategies in case of complications. This can only be learned by real performed surgeries and should be accompanied by an experienced surgeon not only for advice but also for patients safety; this cannot be replaced by any training tools to get the final education before beeing allowed to perform surgery independently. As already mentioned, a new dimension of educational quality in real surgery is opened by the possibility to act like a "driving instructor" in dual console robotic surgery.

Rainer

As an orthopaedic surgeon, I perfer the virtual reality.

With the development of virtual reality, force-feedback technology, the advantages of animal procedure is diminishing. 

Virtual reality will be money-saving, simple and convenient.

Ideal way of surgical training would be to start with simulation and progress to the next level depending on the local access to animal models.

For the basic suturing skills, practice on a animal tissue is invaluable. In the initial stages, tying knots can be practiced on a cardboard / tissue simulator. As the trainee is confident of the initial steps, the advanced stage of suturing skill can be reinforced. Vascular anastomosis, bowel anastomosis are some of the examples where the surgical trainee can get a good hands on and be satisfied with the experience.

A well equipped skills centre with wet & dry lab facilities will go a long way for establishing successful surgical training.

I think the choices are as follows:surgery simulation using high-end virtual reality software (first) AND SECOND, animal models as part of licensed live-tissue research protocols.

If you don't have local access to animal models you have to go to a Centre with animal models to get a good trainee programm

I think for the first step, using simulators sense good. By using this way you can anatomically learn your students well, then you can switch to the animal case or also to the real surgeries. 

Efficacy of virtual reality versus wet-lab training is indeed a topic of interest in medical education. As a learner, I feel that wetlab using animal model has the advantage of increased realism and use of the actual surgical instruments, whereas virtual reality simulator provide automated feedback which helps identifying potential weak points/ area for improvement.

From my recent Simulation based learning workshop, I came to aware that on top of modality and/ or fidelity of the simulator, effective simulation exercise should be integrated into curriculum (not as standalone) with well planned briefing, instructional design, debriefing and feedback. I find this a good read- Simulation in Medical Education by Ker et al- http://onlinelibrary.wiley.com/doi/10.1002/9781444320282.ch12/summary