Surgical Training

By Steven D. Schwaitzberg, MD

Thirty years ago, it seemed so simple to teach the art of surgery. There were a few basic tools: knife, clamps, forceps, retractor and the Bovie cautery. We would see one, then do one, then teach one. If you transported surgeons from that time to today via a time machine, they would hardly recognize their environment. Yes, we still use the basic tools occasionally, but the revolution of minimally invasive surgery has created an explosion of instruments, techniques, energy sources and novel approaches that would be inconceivable not that long ago.

This raises the issue of how to train the next generation of surgeons. Even a procedure as seemingly straightforward as an inguinal hernia has been transformed. Instead of making a four-inch incision on everybody, we can use laparoscopic approaches through the abdomen, minimally invasive approaches in the abdominal wall, and robotic approaches, using sutures, staples, tacks or even sticky mesh. How will we train residents to perform inguinal hernias four different ways? We used to treat simple colon tumors by organ removal and inpatient admission. Now, in some situations, these tumors can be removed with an endoscope and the patient discharged the same day.

There is not enough time or potentially even enough patients to garner that level of expertise for everyone upon graduation. Classic apprenticeship models of surgical training are no longer practical for a variety of reasons, including the value of operating room time, liability and reduced training/work hours. Furthermore, surgical curriculum in the 21st century has expanded to include an increasing number of topics outside of the operating room that must be covered. These include use of the electronic health records, HIPAA, cultural competency, the ethics of consent and the culture of safety, to name a few. As a result, it is no longer viable to comprehensively train surgeons in the operating room. Instead, we need to bring trainees into this highly complex environment after having already mastered the basic skills, which can then be refined.

Many of these basic skills, therefore, will be learned in simulation centers, where the building block training can be performed in a safe environment. The surgical community is developing toolsets for skills mastery such as SAGES’ Fundamentals of Laparoscopic Surgery, Fundamentals of Endoscopic Surgery, and the Fundamental Use of Surgical Energy. The latter program highlights the complex changes that surgical energy has gone through in the last three decades. It was relatively straightforward when electrosurgery could be used to make incisions or treat small bleeders, but now there are multiple modalities, ranging from advanced bipolar energy to ultrasonic coagulation to argon beam plasma coagulation and the like. These high-energy devices need to be mastered outside of the clinical milieu in order to be used safely in the operating room.

In the next 25 years we will see a proliferation of simulation techniques, applications of artificial intelligence, surgical robotics and virtual reality that will be central to training all future physicians as well as surgeons. We already see the value in the dual-console robotic systems, where teacher and trainee have the identical view and instrumentation during live patient cases, which in some ways is even more advanced than what is available in a pilot’s cockpit, where student and instructor instead work their hands in mirrored fashion.

At the Jacobs School of Medicine and Biomedical Sciences, the opportunities afforded by the Behling Simulation Center, UB RIS²E² and Tjota Advanced Procedure Suites will be critical to teaching these techniques. Advanced training with a wide variety of models, techniques and technologies has already begun there and will continue in the years to come.