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S. O. Cawich et al.
The cardiac surgical simulator was developed
as a collaborative project between the University
of the West Indies and the University of
Technology in Jamaica, demonstrating that fruitful collaboration between academic institutions
in LMICs was possible and could be very productive. The Cardiac Surgery Simulator was
designed to provide a safe, anatomically accurate,
and clinically challenging simulated operative
environment to facilitate the teaching and acquisition of essential surgical skills. It facilitates
trainees learning skills such as cannulation
(Fig.16.8) and cardiopulmonary bypass management and coronary and aortic anastomoses. As a
full task simulator, the Cardiac Surgery Simulator
also provides simulated clinical challenges and
dilemmas that require the trainee to make decisions and take actions such as those that would be
necessary in a real surgical procedure.
The entire functionality of the cardiac simulator with all its complexities is controlled by a laptop computer using proprietary software. The
overall effect is to enable the trainer to take the
trainee through parts of or a complete standard
open-heart surgical operation, with the option of
presenting the trainee with most of the possible
adverse events that could arise during the conduct
of such surgical procedures. The Cardiac Surgery
Simulator has been described as a “ight simulator” for cardiac surgery, referring to the way pilots
are trained to y safely in optimal and adverse
conditions and which has become standard training practice for airline pilots worldwide [20].
The Cardiac Surgery Simulator became one of
the centerpieces of the Thoracic Surgical
Director’s Association Annual Boot Camp event
spanning the period 2008 to 2022. It has been
estimated that a minimum of one third of all US
cardiothoracic surgical trainees were exposed to
this simulator during the decade spanning from
2009 to 2019. A major point of note is that this
demonstrated that innovations in surgical education can originate in LMICs, and these innovations can be equally applicable in HICs based on
the intrinsic merits of the ideas as they are formulated and implemented.
Simulation for Laparoscopic Surgery
After laparoscopic cholecystectomy was demonstrated to be feasible and safe in the 1990s,
there was rapid adoption of the minimally invasive approach. Laparoscopy almost became the
standard of care for many abdominal operations.
There was great emphasis on training and preventing complications [21]. Many surgeons
pointed out that laparoscopy did not allow surgeons to have tactile feedback and depth perception and required new skill sets to operate
instruments mounted on a long stick. Simulation
seemed to be a natural t to teach minimally
invasive surgery. It allowed surgical residents to
Fig. 16.8 Cannulation
of the Cardiac Surgical
Simulator for simulated
cardiopulmonary bypass
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163
become accustomed to these nuances and learn
laparoscopic techniques in a safe environment
outside of the operating room. Therefore, surgical residents would have already amassed signicant skill by the time they are exposed to patients
in the operating room [22].
Laparoscopic Trainers
Laparoscopic trainers may range from simple
box trainers with feedback monitors to highresolution virtual reality simulators. Virtual reality simulators provide realistic experiences that
closely mimic the operative environment, but they
are not affordable in many LMICs. Even when
donated, they are difcult to maintain. For example, the Hawassa University in Ethiopia was gifted
a virtual reality simulator but was no longer able
to use it due to need for software upkeep. There
are full-task or procedure-specic very expensive
simulators that are dedicated to teaching entire
operations. Virtual reality trainers use computer
software to analyze tasks, and so they eliminate
the need for a dedicated human proctor. They also
have the advantage of comparing scores and/or
allowing analyses of records. However, these
advantages have not been shown to make virtual
reality trainers superior to other simulators.
Most LMICs will have access to low-delity
box trainers, which are portable and unlimited in
availability. These are often partial task trainers
that allow the resident to practice simple repetitive tasks such as object transfers, suturing, knot
tying, clipping, and stapling. Other tasks, such as
cutting a shape from a surgical glove or removing
objects from the ngers of a glove, can also be
taught as is done at the University of West Indies.
These are basic skills that are used in every laparoscopic operation and are readily transferrable.
Laparoscopic Box Trainers
Laparoscopic box trainers are relatively inexpensive and consist of a closed box, camera,
visual feedback monitor, and light source. A few
authors have also described the use of homemade
trainers from readily available and inexpensive
materials [22, 23]. Several groups have invented
programs to augment the use of trainers. Examples
of these include the Royal College of Surgeons.
Laparoscopic Training course [24], the
Fundamentals of Laparoscopy course from
SAGES [25], and Curacao Laparoscopic Course
[9], among others. The basic tenet is that residents are given standardized tasks to complete
and are graded on accuracy and time to complete
them. There has been sufcient evidence collected to show that structured programs are benecial in training, resulting in improved
performance metrics in the operating room [26].
Robotic Trainers
There has been signicant progress in the
adoption of robotics in surgery. The surgical
robot has been widely adopted across the globe,
especially the DaVinci robot (Intuitive Surgical
Inc., Sunnyvale, California, USA), which has
dominated the robotic landscape over the past
two decades. While there is good evidence to
validate these sophisticated, full-task robotic
simulators, they are expensive and may be out of
reach of many LMICs.
Live Non-survival Porcine Models
A common criticism of surgical simulators is
that normal anatomic relationships are missing
and tissue handling is unrealistic. For this reason,
live animal tissue was thought to be more representative of the operating room experience
because there is bleeding, movement with breathing, and more realistic tissue handling [27]. The
two most common animals used are canine and
porcine models, but many countries have existing
laws against their use as surgical training models
[27]. The non-survival porcine model is probably
most common where the animals are anesthetized during the procedure and euthanized postprocedure; the porcine models have been shown
to be effective for teaching a variety of operative
procedures, but their use is limited by differences
in legislation in each nation.
Cadaveric Models
Cadaver models are used commonly for surgical teaching because trainees can work with normal anatomic relationships and more realistic
tissue characteristics [28, 29]. Many countries
have existing legislation permitting cadaver use
for surgical training [29]. Although cadavers are
limited in supply, costly to procure, and difcult
to store, they may be used by residents demonstrating to medical students in medical school
anatomy laboratories.
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S. O. Cawich et al.
Cadaveric models are reserved for complex
procedures that require realistic tissue handling
and anatomic integrity, such as surgical exposure
in limbs for joint replacements, ber-optic airway intubation, and endoscopic sinus surgery.
(5) Guidance in the OR
In LMICs, most general surgeons perform a wide
repertoire of operations, each at low volumes.
Although most surgeons are highly competent,
they may not possess the necessary skill sets to
complete advanced procedures. Surgical mentoring may be utilized as a method for development
in this scenario. Formal mentorship is commonly
used in fellowships following residency training,
while in informal mentorship, one surgeon seeks
out their own local or visiting mentors to increase
their skillset for complex special operations, such
as liver or pancreas resections. They also benet
from better networking while able to provide services that may not be normally available. This will
reduce the need for outbound patient transfers,
improve workplace satisfaction, retain healthcare
staff, and increase access to essential surgical services within the healthcare system [30, 31].
The ideal mentor should be well trained, have
signicant operating experience, and must be a
well-respected authority in their eld. Good leadership qualities, interpersonal communication skills,
patience, and professional integrity are other essential qualities. It is important for mentors to be emotionally mature so that they are not threatened by
the potential success of their mentees.
Potential disadvantages from mentorship
include gender, race or religious discrimination,
trainee disenchantment, and abuse of authority
[32, 33]. Unfortunately, it has been documented
that many of these attitudes still exist and serve as
barriers to development in LMICs, as well as in
HICs.
A signicant obstacle to mentorship in LMICs
is that the mentor would have to travel for mentorship in the operating room. The cost to the
mentor has been borne either by the mentee’s
institution or by public–private partnership with
professional bodies or with industry [31]. To
overcome such costs and inconvenience is to
explore the concept of distance mentoring.
(6) Distance Mentoring
Distance mentoring differs from the traditional
concept of physical mentoring by the fact that the
mentor is not physically in the operating room,
and this was triggered by the 2020 pandemic
[34]. It involves a surgical mentor using videotelephony to guide a less experienced colleague to
complete an operation. A carefully planned and
effectively administered program of distance
mentoring can be effective in stimulating progress in surgery in LMICs.
In the model originally published, readily
available and inexpensive equipment was utilized
[34]. A surgical resident was in command of the
patient in the operating room and used two
devices equipped with FaceTime (Apple Inc.,
Cupertino, California, USA) to live stream to the
attending surgeon [34]. In the operating room,
the rst device was xed onto the operating light
or behind the surgeon to capture the surgeon’s
view, and another was placed on the ventilator
stack facing backward to observe instrument handling in the operating eld (Fig.16.9). When necessary, the latter device was handled by circulating
theatre staff to obtain closer views of the operating eld while maintaining strict aseptic technique [34]. The attending surgeon was isolated in
a separate room with two devices to observe both
feeds and instruct residents during the live operation. The virtual mentor was available throughout
the entire operation and instructed the mentee on
steps to complete the operation.
This technique utilizes videotelephony to
transmit audio-video signals in real time [35] and
requires a high-resolution, uninterrupted power
and Internet supply. Most modern personal computers and smartphones have built-in codec software to compress audio-video streams and
transmit them as labeled digitalized packets on
high-bandwidth connections using Internet
Protocols [36]. The technology has become relatively cheap and transmits images with high resolution over the Internet at a low cost.
Apart from distance mentoring, videotelephony has found applications in distance education [36], virtual medical consultations [37],
diagnostics [37], and transmission of medical
images [34, 35]. The possibilities are endless,
Surgeon
ub
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16 How to Establish Surgical Teaching, Guidance, and Simulation Practices in Low- and Middle-Income…
connection. It is important to ensure system com-
T
patibility. In the Caribbean model, free proprietary software such as FaceTime (Apple Inc.,
Cupertine, CA, USA) was used to establish communication between supported devices.
Procedure Related
Eye contact is an important way to communicate
nonverbal cues [35]. It is important to be aware of
S
Scr
nurse
this; otherwise, there is the potential to transmit
visual cues that may be confusing or misinterpreted [38]. It is important to appreciate the
occurrence of appearance consciousness, the
knowledge that one is on camera [35]; that adds a
psychologic burden to the mentee to present an
Camera
person
acceptable on-camera appearance, and this can
potentially distract from concentrating on operative tasks.
Fig. 16.9 Setup of operating room for distance mentoring. One smartphone (T) is positioned on the laparoscopic
stack and records the operating eld. The second smartphone (S) is positioned behind the surgeon’s shoulder and
captures images from the laparoscopic monitor. Both
feeds are transmitted to the remote mentor who observes
the instructions on two receiving devices. In this image,
the operating room is set up to facilitate laparoscopic
drainage of a giant left hepatic cyst
Finally, for the mentor, there is the absence of
stereopsis. Stereopsis is the act carried out by the
brain exploiting parallax from differing views in
each eye. It allows us to perceive depth and estimate distance. These are not possible in distance
mentoring, as there is a single device camera
recording the operating eld and the surgeon, not
allowing stereopsis. Therefore, the mentor is seeing the operative eld in two dimensions, similar
and the advantages are obvious, but there are also
inherent drawbacks when using this technique,
to the comparison between open and laparoscopic
surgery.
which can be grouped into three categories: (1)
technology related, (2) procedure related, and (3)
medicolegal.
Patient Safety/Medicolegal Issues
In any operative procedure, patient safety is paramount. There must be full disclosure to the
Technology Related
These issues include signal latency, data transfer
speed, system complexity, and compatibility.
Signal latency refers to the time taken to transmit
large digitalized data packages across the
Internet. It becomes noticeable at >200 milliseconds and will appear as a lagged image on the
receiving end of the transmission. It is affected
by the data size, connection quality, and Internet
bandwidth speed and can produce frustration and
contribute to fatigue when using this technique.
Most modern smartphones utilize MPEG4 codecs
that can transmit high-denition audio-video signals at 2 megabytes per second, but they can still
be limited by the quality and speed of the Internet
patient, including the inherent drawbacks and
incurred risks; this should also be documented as
a part of the informed consent process. The most
obvious concern is that the surgical mentor has
no ability to physically intervene at the operation,
whether it is to “take over the operation” or just
to “demonstrate tips and tricks.” It means that the
mentor must be an experienced teacher with good
communication skills. It is also important for the
operating surgeon and mentor to build a bond of
condence in each other that will develop as the
working relationship progresses. All contingency
plans for potential complication during the operation must be discussed. Obviously, the operating
surgeon should have sufcient skill to complete
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S. O. Cawich et al.
the operation and handle any complications that
may arise. Predetermined thresholds that may
trigger specic actions must be established prior
to the operation, such as threshold for blood loss
or for conversion to an open operation.
The mentor should know the operating surgeon sufciently to determine whether they are
within their capacity before embarking on telesurgery. This is clearly not something that will
work with all surgeons and/or operations.
It is paramount that there is careful selection
of straightforward cases following a planning
meeting where all surgeons discuss detailed clinical information and plans for contingencies.
Telemedicine is a rapidly developing eld,
and so there are many potential medicolegal
issues that will need to be addressed and are
beyond the scope of this chapter.
Conclusions
Currently, there is rapid change occurring in
healthcare delivery, with many new opportunities
becoming available for surgical teaching. It is
clear that simulation is becoming the new normal, but LMICs must adapt their teaching techniques to do so. There are also many other models
used by LMICs that are valuable for other settings, including live animal models, cadaveric
models, and innovative models such as distance
mentoring techniques.
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How toTeach Technical
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andJudgment Skills Eectively
fromOutside theOperating Room
(Including Virtually)
ElijahW.Riddle andCarlE.Haisch
The supreme surgeon uses his supreme judgment to avoid situations that would test his
supreme abilities.
– Unattributed aphorism (published in collection by Dr. Moshe Shein)
17
Abbreviations
ABS American Board of Surgery
ACGME Accreditation Council for
Graduate Medical Education
BID Brieng-Intraoperative Teaching-
Debrieng
CME Continuing medical education
COSECSA College of Surgeons of East,
Central and Southern Africa
FLS Fundamentals of Laparoscopic
Surgery
LMICs Low- and middle-income countries
E. W. Riddle (*)
College of Health Sciences, VinUniversity,
Hanoi, Vietnam
Department of Surgery, Rutgers New Jersey Medical
School, Newark, NJ, USA
C. E. Haisch
Division of Surgical Immunology and
Transplantation, Faculty Development,
Greenville, NC, USA
e-mail: haischc@ecu.edu
OPRS Operative Performance Rating
SCORE Surgical Council on Resident
SiS Step into Surgery
Introduction
The central goal of surgical training is progressive development of a trainee’s surgical skill and
judgment, culminating in the graduation of a
safe, independent surgeon. Certainly, other competencies of an effective physician must be developed during training, including medical
knowledge applicable to perioperative and multidisciplinary care, professionalism, interpersonal
skills and communication, navigation of the
healthcare system, personal and practice quality
improvement, and lifelong learning. Yet the key
ability differentiating a surgeon from other
physicians is the ability to complete an operation
safely and effectively.
and judgment through an apprenticeship model
with high volume of operative experience and pro-
System
Education
Traditionally, trainees acquired surgical skills
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_17
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E. W. Riddle and C. E. Haisch
gressive autonomy in the operating room. However,
in the United States and Europe, various changes—
including resident duty hour restrictions, increasing demands for operative throughput, and
accreditation and legal restrictions on resident
supervision—have cut into residents’ volume and
autonomy of experience during training. In
response, many successful approaches to teaching
technical skills and judgment outside the operating
room have been developed. Visiting surgeons may
nd it challenging to teach in the operating room
for many reasons in low- and middle-income countries (LMICs), including licensing limitations,
legal restrictions, language barriers, and the imperative to avoid interrupting the practice of local surgeons or educational experience of local trainees.
Beyond the individual surgeon, international partnering institutions may seek to maintain ongoing
educational activities even when visiting surgeons
are not physically present at the partner site. Thus,
optimization of opportunities to teach technical
skills and judgment outside of the operating room
will be high yield for any training program.
In this chapter, we describe several practical
approaches to teaching technical skills and judgment, with a focus on modalities that can be
effectively employed outside the operating room.
We will outline frameworks for the development
of a surgeon that provide context for the teaching
modalities and that may be useful for faculty
development and intraoperative guidance. We
will describe opportunities for integrating teaching of technical skills and judgment into existing
structures and outline development of new teaching forums that may be in-person, virtual, or via
independent study by trainees.
Needs Assessment andFaculty
Development
A training needs assessment may be a valuable
early step in determining the gaps and capabilities for teaching technical skills and judgment at
a partner site. Chapter 6 describes a surgical
needs assessment, which may overlap in many
areas with a training needs assessment. In addition to understanding the local burden of surgical
disease, the potential educator will want to inves-
tigate the local training program objectives, funding, teaching capacity, conference structure, and
educational facilities. Published approaches to
educational needs assessment in international
settings include structured interviews [1], surveys of faculty and residents [2], and focus
groups [3]. Close collaboration with a faculty
partner from the host institution is critical to
ensure proposed new educational activities or
changes to existing activities will be appropriately received in the local cultural, regulatory,
and training environment.
Ideally, teaching activities from visiting or
remote partner surgeons would incorporate an
element of “training the trainer,” with a goal of
developing local capacity to sustain the training
long term. To that end, it can be helpful to deliver
faculty development materials alongside the
rollout of any new training activities. Local faculty or potential faculty surgeons should be
invited to any training activities by a visiting surgeon and encouraged to participate or lead sessions once they have observed a few sessions.
Visiting surgeons should encourage local surgeons to suggest changes or additions that may
better adapt the activities to the local context.
Trainees should also be empowered to take ownership of their educational activities. Explicitly
outlining the objectives and format of any new
training activity may improve local acceptance
and provide critical background at sites without
a long history of surgical training where the
goals and objectives are not implicit. The ultimate faculty development strategy is to continuously train future surgical faculty from the
current trainees by using teaching methods that
the trainees buy into and want to carry forward
for future generations. The bidirectional nature
of communication between visiting or remote
faculty and local faculty has been addressed in
Chap. 4. This communication is crucial if training is to be successful.
Technical Skill
Most surgeons are familiar with the progressive
acquisition of technical skills through consistent
practice over time, both inside and outside of the
17 How to Teach Technical and Judgment Skills Eectively from Outside the Operating Room (Including…
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Fig. 17.1 A six-step process for skill development (from Sawyer, T, etal.—2015 Academic Medicine, 90(8))
171
operating room. Various groups have outlined
this process using frameworks that may be helpful for directing educational efforts. Sawyer etal.
described a six-step process for skill development, starting with a cognitive phase and then
moving to a psychomotor phase before the nal
maintenance phase [4]. The six steps of their pedagogical framework include Learn, See, Practice,
Prove, Do, and Maintain, as illustrated in the diagram below (Fig. 17.1). For simple skills and
procedures, this entire six-step process may be
accomplished in series. However, most surgical
procedures are an accumulation of multiple technical skills that are acquired over time via repetitive cycling through the cognitive and
psychomotor phases. The cognitive phase
involves learning about the procedure through
reading, didactic teaching, and multimedia modules, followed by seeing the procedure and hearing the steps described by an instructor. The
psychomotor phase involves acquisition of manual skills through practice, ideally in a simulated
setting rst, and then performing the procedure in
the clinical setting with supervision and feedback. It is important to note that many surgical
procedures do not have high-delity simulation
models, though core components such as knot
tying, suturing, and laparoscopic maneuvering
may be developed even with low-delity practice
as described in Chap. 15. Overall, this framework
shows clear opportunities for educational return
outside the operating room in the cognitive phase,
through curated reading or listening, lectures,
surgical planning conferences, and video review,
and in the psychomotor phase through simulation
and feedback.
Surgical Judgment
Surgical judgment is considered an essential
capability of a safe surgeon. However, surgical
judgment cuts across many cognitive and perceptual domains, resulting in a wide range of
denitions and a major challenge to develop and
assess the attainment of this capability in trainees. Moulton and colleagues have proposed a
framework for evaluating and teaching surgical
judgment centered around the concept of “slowing-down moments” in surgery [5]. These are the
critical moments of each operation when a surgeon must consciously or unconsciously slow
down and make decisions. Slowing-down
moments may be pre-planned, for patientspecic or procedure-related reasons, or situationally responsive when unexpected challenges
arise. Within this framework, the authors note
that three cognitive domains facilitate good
judgment and distinguish levels of expertise—
attention capacity, situational awareness, and
automaticity. Targeting improvement in these
domains outside the operating room can improve
a trainee’s judgment and facilitate improved
opportunities for learning and exercising judg-
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E. W. Riddle and C. E. Haisch
ment in the operating room. For example,
improving technical skills in simulation allows
the trainee to devote less attention to these
maneuvers in the operating room and provides
more attention capacity for surveying the surgical eld for cues to planned or unplanned slowing-down moments. Video review can augment
actual operative experience in helping a resident
discern operative anatomy, procedural steps, and
cues for impending misadventures, improving
their situational awareness and automaticity.
Even more explicitly, faculty surgeons may push
trainees to commit to planned slowing-down
moments in preoperative surgical planning conferences or brieng discussions. They may
assess and develop appropriate judgment in
unplanned slowing-down moments by taking the
trainees through boards-style scenarios or
curated video review. This framework highlights
the potential educational impact of a wide range
of teaching activities.
Implementing Progressive
Autonomy
Progressive autonomy, culminating in independence, is the foundation of surgical training.
Introducing the concept of progressive autonomy may be challenging at sites without a history of surgical training, but shared mental
frameworks and consistent language may help
inculcate this critical idea. The “Zwisch Scale”
has been proposed as a simple framework for
categorizing trainee autonomy in a procedure or
portion of a procedure [6]. Originally developed
by Dr. Zwischenberger over years of use in his
thoracic surgery fellowship, the scale includes
four levels of faculty involvement that reect
progressive degrees of trainee autonomy—
Show and Tell, Active Help, Passive Help, and
Supervision Only (Table 17.1). The Zwisch
scale provides a shared language and vision for
development of trainee autonomy and can promote more granular goal setting and specic
formative feedback for trainees.
Achieving progressive autonomy requires a
concerted effort by faculty and trainees. Much of
this effort occurs in the operating room, but key
opportunities exist outside the operating room to
set the stage for progressive autonomy, develop
clear goals for development of technical skills
and judgment, and coalesce the intraoperative
teaching from each case to prepare the trainee to
improve in the future. Roberts and colleagues
have proposed the Brieng-Intraoperative
Teaching-Debrieng (BID) model, which advocates optimizing three critical time points in the
perioperative period [7].
During the preoperative brieng, the faculty
surgeon should assess the experience and needs
of the trainee and establish shared learning objectives for the case. The authors note that this interaction may occur even in the 2–3minutes that are
shared at the scrub sink or during the timeout
prior to the start of the procedure. The learning
objectives may include an explicit discussion of
expected autonomy levels for all or part of the
operation. The intraoperative teaching includes
all guidance and instruction that the faculty surgeon provides the trainee during the case but ideally will be focused on the shared learning
objectives developed in the preoperative brieng.
If the circumstances of the case require the surgeon to take more control than anticipated, they
may use the Zwisch scale to signal the transition
to the trainee and to restore autonomy to the
trainee when it is safe to do so. Finally, the postoperative debrieng includes a discussion of the
learning objectives and signposted feedback
regarding the key take-home points from the
case. The debrieng may be accomplished during
closing at the end of the case, if this portion is
relatively automatic for surgeon and trainee, or
may be reserved for a private setting after the
case, particularly when more severe or potentially
embarrassing feedback is necessary. This model
emphasizes the critical educational importance of
preoperative preparation and postoperative feedback, two time points where a visiting or remote
partner surgeon may engage to teach technical
skills and judgment.
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