How computer-based surgical simulation can supplement textbooks, videos and wet-lab experience in surgical training.

The modernisation of junior doctor training programmes and implementation of the European Working Time Directive (EWTD) have diminished surgical training time.13 Ophthalmic surgical trainees must acquire, within a limited time, sufficient experience and proficiency in cataract surgery before qualifying as consultants. Before they embark on a career in ophthalmology, the vast majority of first-year trainees have never performed in vivo intraocular surgery. Evidence has shown that trainees have the highest complication rates at the start of their training, which emphasises the importance of adequate and appropriate surgical training and supervision.4,5

The paradigm of surgical training has evolved from laboratory practice to operating on cadaveric and animal tissue in wet labs and, more recently, synthetic eye models.6 Although simulation has been long-standing practice in other industries such as the aviation industry and computer gaming world, it is a relatively novel concept that has revolutionised surgical training in the 21st century. The VRmagic Eyesi Ophthalmic Surgical Simulator is unique, as it provides a realistic and appropriate platform to acquire psychomotor skills and develop micro-surgical spatial awareness, which can be applied to real-life cataract and vitreoretinal surgery (Figure 1).7 This aids in building the confidence of beginner surgeons by allaying unnecessary stress in the operating theatre and carrying out an objective assessment of surgical performance in a safe environment.

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Figure 1 VRmagic Eyesi Ophthalmic Surgical Simulator

Cataract surgery is fascinating because each step that is carried out determines the next. It takes much practice, experience and skill for the surgeon to perfect each step, ensuring a seamless surgery with minimal complications. As a first-year ophthalmology trainee in the North Thames deanery, I had the exclusive opportunity of completing a recently validated cataract simulation programme at Moorfields Eye Hospital, London. As part of the deanery’s annual review of competence progression (ARCP) requirement, my peers and I were given a year to complete the structured and supervised course, which involved approximately 10 hours of individual training time – including 6 hours of consultant-supervised sessions.

The Eyesi bridges the gap between textbook surgery and real-life theatre experience, and allows one to contextualise the precise nature of intraocular surgery. It also provides tactile feedback, an appreciation of depth perception, and safe instrument-handling.8 The surgeon must handle ophthalmic instruments inside a human eye model that is attached to a human head model, while sitting as he or she would in theatre – on a stool, looking down a microscope while operating two foot pedals. This set-up allows the surgeon to understand the ergonomic dimensions and challenges that operating presents and to develop muscle memory for intraocular surgery.

The programme tests four of the seven steps of cataract surgery and begins with four ‘entry’ tasks that encompass a mixture of single-handed, bimanual, static and dynamic tasks that are either generic three-dimensional or cataract-specific (Figure 2).9 Many junior trainees report that the most difficult step of cataract surgery is the ‘capsulorhexis’ – where a 5mm continuous curvilinear hole is cut in the anterior capsule to gain access to the lens.10 I personally found the anti-tremor and capsulorhexis tasks challenging.

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Figure 2 Various tasks on the Eyesi simulator:(a, b) capsulorhexis; (c) cracking and chopping; (d) navigation; (e) bimanual training; (f) anti-tremor

Using the Eyesi improved my confidence in certain areas of cataract surgery. Two elements helped greatly: the repetition of tasks (each task must be passed three times to progress) and the consultant-supervised sessions. It provided a safe environment in which to operate on complex cases, allowing me to modulate cognitive factors that can affect one’s performance during surgery.11 Despite some of the steps of cataract surgery not being included in the tasks and differences between operating on a real patient’s ocular tissues in a theatre setting, the Eyesi simulator is a useful way of initiating and familiarising ophthalmic surgeons with the safe handling of a patient’s eye.

The call upon virtual reality to serve as a platform for surgical training and a higher-order level of microsurgical skills training came after the significant reform of postgraduate medical training in the UK following the introduction of Modernising Medical Careers programme in 2007 and the aim of the NHS to achieve 100% compliance with the EWTD by 2009.13 Applying the computer gaming world of virtual reality to medicine places the user at the forefront of the operating theatre, orchestrating a series of tasks in the face of unpredictable events in a controlled manner without exposing patients to preventable harm. Inbuilt are parameters for evaluating progression towards proficiency goals in addition to providing real-time feedback and objective assessment along a stepwise technical skills pathway.10,12,13 Although far from seamless, the transferable skills of this simulation to the real environment have been proven through scientific methods to demonstrate construct validity – a phenomenon whereby the simulator can differentiate the varying skills between novice and experienced surgeons.14,15

The application of tracking methodology to cataract surgery and other microsurgical procedures with the purpose of recording and analysing perioperative fine-finger and instrument movement has been coined ‘motion analysis’. This is another validated tool providing a numerical score of trajectories that instruments make throughout the procedure.16 Akin to computer video gaming, the more advanced ‘player’ will exhibit quick and accurate movements, demonstrating economy of movements as they retain muscle memory-improving precision. Again drawing parallels with the accession through computer gaming levels, motion analysis uses metrics of time of procedure, number of movements, trajectory instrument movement and path length to discriminate between the junior and experienced surgeon.16

Surgical training is traditionally taught in an apprenticeship model, producing the adage ‘see one, do one, teach one’. Owing to limitations in surgical training and the need to gain skills without operating on patients, the need for wet-lab exposure or access to computer-based simulation is a growing necessity.

Surgical simulators have been produced to provide high-fidelity feedback and training for a variety of laparoscopic, cardiac and ophthalmological surgeries, all of which are gaining an evidence base producing safer and faster surgeons.11 These have increased in complexity and some simulators, including the Eyesi, are beginning to provide basic tactile feedback – often the flaw of computer-based simulation. The instruments are not representative of reality (with the Eyesi, a generic ‘probe’ is programmed to be a needle, syringe, lens dialler or a second instrument). The properties of virtual tissue are not identical to reality either, although these aspects are constantly improving.

The role of immersive technologies has already been applied in medical schools across the US via the use of Google Glass technology.17 More recently, Shafi Ahmed, cancer surgeon at Barts NHS Health Trust, showcased the use of augmented reality to teach medical students. Here, students were immersed via a 360-degree virtual reality headset in the operating theatre, visualising the entire surgical procedure in real-time through the eyes of the assisting surgeon.18 The Microsoft HoloLens, a mixed reality headset that projects hovering three-dimensional holograms as an overlay on the real environment, has sparked interest among surgeons operating in the macroscopic world.19 These technologies potentially have a place in the operating theatre, reshaping the future and format in which junior surgeons learn new surgical techniques.

In summary, computer-based surgical simulation is a useful arrow in the quiver of the trainee surgeon, which acts to supplement – but not replace – surgical textbooks, videos and wet-lab experience.

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