- Email: [email protected]
A cost-effective approach to establishing a surgical skills laboratory
A cost-effective approach to establishing a surgical skills laboratory David A. Berg, MD, Richard E. Milner, BS, Carol A. Fisher, BA, Amy J. Goldberg, MD, Daniel T. Dempsey, MD, and Harsh Grewal, MD, Philadelphia, Penn
Background. Recent studies comparing inexpensive low-fidelity box trainers to expensive computerbased virtual reality systems demonstrate similar acquisition of surgical skills and transferability to the clinical setting. With new mandates emerging that all surgical residency programs have access to a surgical skills laboratory, we describe our cost-effective approach to teaching basic and advanced open and laparoscopic skills utilizing inexpensive bench models, box trainers, and animate models. Methods. Open models (basic skills, bowel anastomosis, vascular anastomosis, trauma skills) and laparoscopic models (basic skills, cholecystectomy, Nissen fundoplication, suturing and knot tying, advanced in vivo skills) are constructed using a combination of materials found in our surgical research laboratories, retail stores, or donated by industry. Expired surgical materials are obtained from our hospital operating room and animal organs from food-processing plants. In vivo models are performed in an approved research facility. Operation, maintenance, and administration of the surgical skills laboratory are coordinated by a salaried manager, and instruction is the responsibility of all surgical faculty from our institution. Results. Overall, the cost analyses of our initial startup costs and operational expenditures over a 3-year period revealed a progressive decrease in yearly cost per resident (2002-2003, $1,151; 20032004, $1,049; and 2004-2005, $982). Conclusions. Our approach to surgical skills education can serve as a template for any surgery program with limited financial resources. (Surgery 2007;142:712-21.) From The Department of Surgery and the Institute for Clinical Simulation and Patient Safety, Temple University School of Medicine, Philadelphia, Penn
The surgical training environment is currently experiencing a marked evolution. The opportunity for learning in the operating room is shrinking, mainly owing to pressure on time and costs.1 The traditional Halstedian apprenticeship model of “see one, do one, teach one” can no longer keep pace with these challenges that face surgical educators. Recent changes to the limited number of work hours, along with the rapid advancement of surgical technology and development of innovative minimally invasive techniques, have raised concerns regarding patient safety and underscore the need to supplement training outside the traditional
Industry product donations accepted from Ethicon, United States Surgical, Karl Storz, and Stryker. Accepted for publication May 17, 2007. Reprint requests: Harsh Grewal, MD, Pediatric Surgery, 5 East, TUCMC, 3509 N Broad Street, Philadelphia, PA 19140. E-mail: [email protected] 0039-6060/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.05.011
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clinical setting. Computer-based virtual reality systems have recently been developed and incorporated into some surgery residency training programs2-10 for this purpose. These models have been shown to be valid and effective for both skills acquisition and transferability to the operating room3,5,6,8,10,11; however, their high costs limit their applicability to many programs faced with budgetary constraints. In addition, recent studies have shown that low-fidelity box trainers are just as effective as virtual reality systems for improving psychomotor skills.5,12,13 The Residency Review Committee for Surgery of the Accreditation Council for Graduate Medical Education stated that, by July, 2008, all surgery residency programs will be required to have access to a surgical skills laboratory. A recent survey14 of surgery residency program directors revealed that 55% of surgery training programs have dedicated laparoscopic skills laboratories. These findings emphasize that many surgery programs need to reassess their current curricula and make adjustments to be in compliance with these future changes in surgical education. Program directors and chair-
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persons of surgery residency programs currently without access to skills laboratories need to evaluate their administrative and financial resources to determine whether establishing a surgical skills laboratory is a practical option for their particular training program. We describe our method of developing a costeffective surgery skills laboratory curriculum to train surgical residents in basic and advanced open and laparoscopic surgical skills utilizing inexpensive bench models, box trainers, and animate models in the setting of limited financial resources. MATERIALS AND METHODS The Surgical Skills Laboratory of the Temple University School of Medicine was established by the Department of Surgery during the 2002-2003 academic year. Each year, the Temple University Department of Surgery employs approximately 50 residents, both designated and nondesignated preliminary residents (PGY 1 and 2) and general surgery categorical residents (PGY 1-5). The total number of residents participating in the surgical skills laboratory during the 2002-2003, 2003-2004, and 2004-2005 academic years was 48, 49, and 49, respectively. Training exercises utilized in our skills laboratory are either based on variations of established models15,16 or have been designed in our laboratory. Models are constructed using a combination of materials found in our surgery research laboratories, items purchased at low-cost from retail stores, or industry-sponsored equipment donations. Expired surgical materials are acquired from the hospital operating room and a local food-processing plant serves as an inexpensive source of animal organs. Animate teaching exercises are conducted in an animal facility approved by the Institutional Animal Care and Use Committee of Temple University. A salaried laboratory manager is responsible for maintaining the laboratory schedule, setting up and administering all skill modules, and keeping records of laboratory expenditures. The manager, however, has other responsibilities within the Department of Surgery, including managing the animal care and research; he devotes approximately 0.5 full time equivalents (FTE) to the skills laboratory. This percentage of FTE was used in our cost analysis. When beginning the residency program, all residents are provided with a syllabus that utilizes diagrams, photographs, and text to outline the methods and objectives of each training module. This information is also accessible via our online web-based curriculum. The skills laboratory is scheduled for a
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3-hour time block and begins after our weekly educational conferences. The time during which residents are either attending conferences or scheduled for the skills laboratory is considered “protected time” (i.e., residents are free from clinical duties). Each skills session is attended by up to 6 residents and one attending surgeon. The entire skills laboratory program is directed by one of the authors (HG); the skills lab director spends approximately 0.1 FTE in these activities for the time periods described in this report, and this time allocation was used in our cost calculations. Before the start of each module, the attending surgeon leads a didactic session that covers the material relevant to the particular skill session, and is present for the entire skills session to provide instruction and immediate feedback (the attending staff spend approximately 2.5 hours for each session they are instructing). The faculty participating are full-time academic faculty and are not compensated separately for their time and effort; in addition, each section is responsible for staffing the modules, for example, the trauma section staffs the trauma critical care modules. The skills laboratory curriculum is composed of 4 open modules (basic skills, bowel anastomosis, vascular anastomosis, and trauma skills) and 5 laparoscopic modules (basic skills, cholecystectomy, Nissen fundoplication, suturing and knot tying, and advanced in vivo skills). During the first year of the skills laboratory (2002-2003), most training modules were administered to residents of all PGY levels. Before the second year (2003-2004) of the skills laboratory, the curriculum was evaluated and residents were surveyed, resulting in the current skills laboratory curriculum in which modules are geared toward appropriate skills and tasks for their PGY level (Table I). Open skills. Basic open skills: All PGY 1 residents participate in the basic open skills module when they learn the identification of basic instruments, the classification and uses of different types of sutures, methods of knot tying and wound closure, and the use of electrocautery and ultrasonic dissector. No-cost materials include pig bowel harvested from prior in vivo skills sessions. Purchased materials include pig feet, chicken thighs, and industry-manufactured skin pad trainers. Bowel anastomosis: The bowel anastomosis module is administered to all PGY 2 residents and teaches the skills of both hand-sewn (1 and 2 layers) and stapled anastomoses. With the exception of a trial of an industry-manufactured bowel model (Limbs and Things, Inc., Bristol, United Kingdom), all supplies are either harvested from prior
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Table I. Surgical skills laboratory curriculum (X denotes postgraduate year in which module provided) Postgraduate Year 1 Open skills Basic open skills Bowel anastomosis Vascular anastomosis Trauma skills Laparoscopic skills Basic laparoscopic skills Laparoscopic cholecystectomy Laparoscopic Nissen fundoplication Laparoscopic suturing/ knot tying Advanced in vivo laparoscopic skills
2
3
4
5
X
X
X
X
X
X
X
X
X
X X X X X X
in vivo laboratories (pig bowel), fabricated in the laboratory (latex bowel model), or donated (staplers and reloads). Vascular anastomosis: PGY 2 residents are introduced to vascular instruments and instructed on the anastomosis of a donated synthetic graft to a harvested pig aorta in an end-to-side fashion. Vascular instruments were purchased during the first year and have been reused for subsequent laboratory sessions. Trauma skills: The trauma skills module utilizes a live porcine model to teach PGY 1 residents various skills essential to the treatment of the injured patient (tracheostomy, peripheral venous cutdown, chest tube placement, diagnostic peritoneal lavage, and thoracotomy). Purchased materials include a live animal, central venous catheter kits, peritoneal lavage kits, and ultrasound supplies (battery and charger). Donated items include chest tubes and an ultrasound machine. Laparoscopic skills. Basic laparoscopic skills: In the basic laparoscopic skills module, first-year residents are instructed on abdominal access, proper trocar placement, and various fundamental skills sets including pegboard, cup drop, rope pass, pattern cutting, and endoscopic clip and loop application.15,16 Outcomes were measured using a time and error system to obtain a composite score. Laparoscopic cholecystectomy: PGY 2 residents participate in the ex vivo laparoscopic cholecystectomy module using a laparoscopic box trainer. They are instructed on the proper methods of exposure, dissection, identification of the cystic artery, cystic
duct, and common bile duct, application of laparoscopically placed clips, and removal of the gallbladder from the liver bed using electrocautery or ultrasonic dissector. Pig livers are purchased from a local food-processing plant. Laparoscopic clips are either purchased or donated. Outcomes were measured using a checklist system. Laparoscopic Nissen fundoplication: Using an ex vivo porcine stomach model in a laparoscopic box trainer, PGY 3, 4, and 5 residents are instructed on performing key steps of a laparoscopic Nissen fundoplication, including esophageal dissection, fundoplication, and proper suture placement.17 Pig stomachs are purchased from a local food processing plant. Laparoscopic suturing and knot tying: This module is offered to PGY 3, 4, and 5 residents and covers the skills of extracorporeal and intracorporeal knot tying and both interrupted and continuous suturing. Cloth suspended from alligator clips serves as a medium on which to suture and is available in the laboratory. Purchased items include chicken thighs and endoscopic suturing devices. Advanced in vivo laparoscopic skills: Utilizing a live porcine model, PGY 3, 4, and 5 residents perform various laparoscopic procedures, such as cholecystectomy, Nissen fundoplication, splenectomy, and colectomy. Costs are incurred for a live animal, endoscopic clips, and insufflation supplies. Endoscopic staplers and reloads are donated. Cost calculations. For every skills module administered in the surgical skills laboratory, the laboratory manager maintained a database of all materials purchased with department funds, provided by our operating room, or donated by industry. Resident attendance was mandatory and recorded for each laboratory session. Therefore, total expenditures were available on a per resident/per session basis. The laboratory manager’s salary was also factored into the costs for each module. The total time to schedule, set up, and administer each skills laboratory module was estimated at 6 hours per module per session (3 hours scheduling and setup, 3 hours administration and clean up). The compensation to the laboratory manager was factored as $40/ hour (we utilized the equivalent of 0.5 FTE in our calculations). At the beginning of each academic year, certain items not considered a specific aspect of any particular skills module but deemed necessary to administer the skills laboratory were factored into the total annual expenditures. For the 2002-2003 skills laboratory, television monitors, VCRs, portable video carts, a camera lens, and printed laboratory manuals were purchased. For the 2003-2004 academic year, in addition to laboratory manual re-
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Table II. Itemized costs of open skills Module Basic open skills
Bowel anastomosis
Vascular anastomosis
Trauma skills
Items
Cost per item ($)
Pig bowel Suture Silk ties Pig feet Chicken thighs Skin pad trainer Pig bowel Latex bowel model Stapler Stapler reload Suture Commercial latex bowel Vascular surgery needle holders Potts scissors Pig aorta Gore-tex graft Suture Pig, delivery, room/board Trauma central line kit DPL catheter kit Ultrasound battery Ultrasound charger Operating room light bulbs Ultrasound machine Chest tubes Suture
0 (harvested) 0 (donated) 0 (donated) 0.5 1 14.88 0 (harvested) 0 (made in lab) 0 (donated) 0 (donated) 0 (donated) 45.50 40.80 89.29 0 (harvested) 0 (donated) 0 (donated) 400 20 29 215 200 141 0 (donated) 0 (donated) 0 (donated)
Estimated list price (each) of donated items ($) 4.00* 1.50†
3.00‡ 343.80§ 180.35¶ 4.00储
15.00/cm** 5.83††
8,000‡‡ 8.76§§ 4.00§
DPL, diagnostic peritoneal lavage. *Ten sutures per resident. †One pack of 12 ties per resident. ‡Based on $50.00 for 1 gallon of latex mold (makes approximately 20 bowel segments); 2 bowel segments per resident. §One per resident. ¶Two per resident. 储Four per resident. **Based on $1,200 for 8 mm ⫻ 80 cm graft, cut to 5-cm length per resident. ††Two polypropylene sutures per resident. ‡‡List price for refurbished Site-rite IV. §§One chest tube per resident.
prints for new residents, 2 computer systems were purchased at the start of the academic year for administrative purposes. For the 2004-2005 academic year, the only items that were purchased in addition to items needed for each skills module were laboratory manual reprints for incoming residents. In addition, because donated equipment and supplies may not be readily available, we have estimated the costs if these supplies needed to be purchased using manufacturers list prices where available; however, most health systems in bulk purchasing arrangements pay less than list price. RESULTS An itemized list of all necessary materials and costs to administer each open and laparoscopic skills module is shown in Tables II (open) and III
(laparoscopic). Table IV gives a breakdown of actual costs and estimated costs for donations for all open and laparoscopic skills modules, the academic years each module was administered, the total number of sessions, and the total number of residents participating in each module per year. Table IV also depicts the total annual cost for each skills module and the annual cost per module per resident (based on the number of residents employed by the department each year). The total annual cost per resident for administering and maintaining the entire skills laboratory, considering total initial expenditures each year, total number of sessions administered for all modules, and the total number of residents in our residency program each year decreased progressively ($1,151 for 2002-2003 [total cost for 48 residents ⫽ $55,234],
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Table III. Itemized costs of laparoscopic skills Module Basic laparoscopic skills
Laparoscopic cholecystectomy
Laparoscopic suturing/knot tying
Laparoscopic Nissen fundoplication Advanced laparoscopic in vivo skills
Items
Cost per item ($)
Video trainers Pegboard Cupdrop Rope pass Endoscopic clip appliers Endoscopic loop appliers Electrocautery Harmonic scalpel Pig liver Endoscopic clip applier Cloth Suture Endoscopic stitch device Endoscopic stitch reloads Pig stomach Suture Pig (delivery, housing) Endoscopic clip applier Endoscopic stapler Endoscopic stapler reloads Insufflator supplies
0 0 0 0
0 0
0 0
0
0 0
(donated) (made in lab) (made in lab) (made in lab) 108 15.58 (donated) (donated) 3 108 (made in lab) (donated) 186.38 35.89 4 (donated) 400 108 (donated) (donated) 217
Estimated list price (each) of donated items ($) 28,680*
1,700 20,902
4.00†
4.00‡
700§ 217.64¶
*List price for 1 trainer (quoted February 2007; includes trainer cart, training module, skin pads, flat panel display). †Ten per resident. ‡Six per resident. §One per session. ¶Six per session.
$1,049 for 2003-2004 [total cost for 49 residents ⫽ $51,377], and $982 for 2004-2005 [total cost for 49 residents ⫽ $48,120]). We also calculated estimated costs per resident including donated services: $3,702 for 2002-2003, 1,462 for 2003-2004, and $1,066 for 2004-2005 (Table V). The total cost for our skills laboratory over a 3-year period ($154,732 for academic years 2002-2005; $146,884 is the estimated costs of donated equipment and supplies) are not comparable to the purchase price of various commercially available computerbased simulators. To contrast the cost of a single virtual reality laparoscopic simulator, estimates were obtained from vendors in February, 2005, and do not include service contracts, which can approach $3,000 per year. Company A’s laparoscopic virtual reality system was quoted at $49,475. Company B’s laparoscopic virtual reality system was quoted at $61,155. Company B’s endoscopic virtual reality system was quoted at $86,985. These estimates are the up-front purchase costs, do not include service contracts or down time, and have not been depreciated. DISCUSSION The traditional system of educating surgery residents is facing many challenges of time efficiency,
costs, and patient safety.11 These issues have led to the emergence of surgical skills laboratories as important components of curricula for surgery residents in many training programs. Surgical skills laboratories provide residents with the opportunity to acquire technical skills in a low-stress, simulated environment, while focusing on learning and repeating key steps of procedures in a setting where they are able to reduce their learning curve with the goal of decreasing potential harm to patients. Currently, various media, both organic and inorganic, exist for surgical simulation outside of the operating room.5 Organic models include human cadavers, live animals, or animate cadavers. Human cadavers provide the benefit of high fidelity and anatomy identical to the simulated procedure; however, they are costly, not readily available, and owing to individual variability, cannot provide standardized assessments.5 Live animate models are high fidelity with bleeding tissue, but their use is limited by cost, variations from human anatomy, or laws banning their use in some countries.5 We developed in vivo animate models for trauma skills,18 cholecystectomy, Nissen fundoplication, splenectomy, and colectomy. Animal cadaver models are inexpensive, readily available, and provide good
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Table IV. Three-year breakdown of costs incurred for administration of a surgical skills laboratory*
Skill module Open skills Basic skills
Bowel anastomosis Vascular anastomosis Trauma skills
Laparoscopic skills Basic skills
Cholecystectomy
Suturing and knot tying Nissen fundoplication Advanced in vivo skills
Total cost without donations ($)
No. of residents participating
Cost per resident with donations ($)
Cost per resident without donations ($)
Academic year
No. of sessions
Total cost with donations ($)
2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005
None 8 3 None 5 3 9 8 4 None 3 4
— 428.56 137.88 — 0 91.00 423.38 0 0 — 2,352.00 1,796.00
— 1,341.56 1,050.88 — 6,046.30 1,585.30 7,983.38 1,733.00 867.00 — 10,633.00 2,077.00
— 22 22 — 16 10 48 20 10 — 22 22
— 19.48 6.27 — 0 9.10 8.82 0 0 — 106.91 81.64
— 60.98 47.77 — 377.89 158.53 166.32 86.65 86.70 — 483.32 94.41
2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005
9 3 8 8 None 3 13 None 3 8 None 1 2 2 None
4,087.68 1,333.52 1,333.52 1,440.00 — 482.00 2,281.86 — 800.58 192.00 — 40.00 1,233.00 1,016.00 —
90,127.68 1,333.52 1,333.52 24,042.00 — 482.20 4,101.86 — 1,240.58 1,344.00 — 160.00 4,544.00 4,327.00 —
48 22 22 48 — 10 48 — 11 48 — 5 8 8 —
85.16 60.61 60.61 30.00 — 48.20 47.54 — 72.78 4.00 — 8.00 154.13 127.00 —
1,877.66 60.61 60.61 500.88 — 48.20 85.46 — 112.78 28.00 — 32.00 568.00 540.88 —
*Does not include skills laboratory manager and faculty director salary costs. These costs are reflected in total annual costs (see Table V).
Table V. Total annual costs for administration of a surgical skills laboratory* Academic year 2002-2003 2003-2004 2004-2005
Cost with donations ($)
Cost/resident with donations ($)
Estimated cost without donations ($)
Estimated cost/resident without donations ($)
55,234.32 51,377.19 48,120.14
1,150.72 1,048.51 982.04
177,719.32 71,661.49 52,235.34
3,702.49 1,462.48 1,066.03
*Costs include skills laboratory manager and faculty director salary as described in text.
tissue handling when fresh; however, anatomy differs from that of humans.5 In our skills laboratory, utilizing animate organs, we have employed ex vivo models of bowel anastomosis, vascular anastomosis, cholecystectomy, and Nissen fundoplication.17 Inorganic media are either based on synthetic models or virtual reality systems.5 Synthetic models are reproducible, standardized, and useful for assessing isolated skills. We have adopted various inexpensive synthetic simulation models, including
pegboard, cup drop, rope pass, pattern cutting, and endoscopic application of clips and loops,15,16 and have developed our own models for basic open surgical skills and laparoscopic suturing. Virtual reality systems allow one to perform an operation or individual tasks in real time with instant objective feedback.5 Computer-based technology also may be more effective in training residents in endoscopic and laparoscopic procedures because this technology ensures accurate accomplishment
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of tasks and evaluates trainees using several parameters in addition to speed.12 Currently, however, the cost and absence of virtual reality open surgical procedures limit their widespread use in most surgery residency training programs. As the adoption of surgical skills laboratories into residency training programs becomes more widespread, it is imperative that well-designed, randomized, controlled studies comparing different media and their effects on the acquisition, maintenance, and transferability to the clinical venue of skills attained in the laboratory continue to be conducted. Recently, such studies have investigated bench models, traditional box trainers, and virtual reality systems. These studies are summarized in Table VI. Simple, low-cost bench models are more effective than didactics alone for acquisition of surgical skills, as measured in the laboratory.19,20 Four studies21-24 have gone on to test the transferability of skills learned in the laboratory on laparoscopic box trainers or bench models to performance in an operating room setting. These studies have demonstrated that technical skills and operative performance are improved by formal training on laparoscopic box trainers or bench models when compared with either no training or didactics alone. The concept of virtual reality for surgical skills simulation was introduced in the early 1990s.25 Since then, various commercial virtual reality simulators have been developed for surgical skills training and have been incorporated into residency training programs. Only in the last 5 years, however, have randomized, controlled trials examining their efficacy been completed.3,5,8,10,12,13,26,27 As with box trainers and bench models, the majority of randomized, controlled studies have demonstrated that training on a virtual reality simulator is more effective for transfer of skills to the operating room than no training at all. Of 4 studies comparing virtual reality to no training, 3 studies demonstrated transferability to the operating room8,10,27; one suggested no difference in operative performance.26 With the emergence of virtual reality systems, residency program directors and surgery educators are now faced not only with the task of developing surgical skills laboratories, but must also decide with what to equip the laboratory and how much to spend. To date, 4 randomized, controlled trials have compared traditional box trainers with virtual reality simulators.3,5,12,13 Three of these studies demonstrated that both models were equally effective at improving psychomotor skills,5,12,13 whereas
Surgery November 2007 2 studies3,12 demonstrated better performance by subjects trained on the virtual reality simulators. Although only 2 studies have suggested benefit of virtual reality over box trainers,3,12 it is essential that more studies comparing the 2 modalities are conducted before one can conclude that the potential benefits to resident education gained from costly, virtual reality computer-based surgical simulation are superior to those provided by inexpensive, easily constructed box trainers. Until that time comes, and while programs are currently faced with important decisions regarding mandatory access to technical skills and simulation facilities, our model of a surgical skills laboratory that utilizes animate models, inexpensive bench models, and laparoscopic box trainers represents a costeffective means to provide an adjunct to surgical training outside of the operating room. In our laboratory, we are now able to provide surgical skills training for about $1,000 per resident per year, and for the last 3 years we have successfully provided our surgical residents PGY level-appropriate modules for basic and advanced open and laparoscopic skills. In addition to lower costs, our skills laboratory model provides other benefits over a surgical skills laboratory based entirely on virtual reality. First, current virtual reality technologies preclude simulation of open surgical procedures. Our model provides a means to instruct residents on the basic open surgical skills that will form the foundation of their surgical skill sets. Second, assuming a program has the financial resources to purchase a virtual reality simulator, a single simulator can only train one resident at a time, on a single task or procedure, whereas our model, equipped with multiple stations, affords the opportunity to train several residents simultaneously. Third, the haptics of the box trainers utilized by our skills laboratory are more realistic than those provided by a virtual reality simulator. In fact, in one study, when asked to compare virtual reality to video (box) trainers, residents preferred training on the video trainer, felt it was a more effective training tool, more realistic, and provided better tactile feedback and depth perception.12 Despite the proposed benefits of a skills laboratory model such as we have described, we acknowledge limitations of our cost analysis. As mentioned, we have estimated the cost of donated services, equipment, and supplies. In addition, our instructors were attending surgeons from our department and arranged their clinical schedules graciously to volunteer to lead skills laboratory sessions. They received no compensation in addition to their reg-
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Table VI. Summary of randomized, controlled trials for surgical simulation Reference Bench model Matsumoto et al (2002)20
Grober et al (2004)19
Media tested
Skill tested
Comparison
Bench model
Ureteroscopy and stone extraction
Performance on highor low-fidelity model versus didactic only
Bench model
Microsurgical technique
Performance on highor low-fidelity model versus didactic only
Bench model/box trainer transferability to OR Fried et al (1999)22 Lap video box Technical skills in trainer vivo (animal)
Formal training versus no training of lap skill drills Formal training versus no training of lap skill drills
Scott et al (2000)24
Lap video box Technical skills trainer LC in OR
Naik et al (2001)23
Bench model
Orotracheal intubation in OR
Coleman et al (2002)21
Laparoscopic video box trainer
Technical skills Lap Formal training versus salpingectomy in no training of lap skill OR drills
VR simulator
Basic lap skills in vivo (animal)
VR training versus no training
Seymour et al (2002)10
VR simulator
LC in OR
Ahlberg et al (2002)26
VR simulator
Simulated lap appendectomy (animal)
VR training versus no training VR training versus no training
VR transferability to OR Hyltander et al (2002)27
Hamilton et al (2002)12 See VR versus box trainer Grantcharov et al VR simulator (2004)8
Youngblood et al (2005)3 Virtual reality versus box trainer Torkington et al (2001)13 Hamilton et al (2002)12
Fiberoptic intubation model versus didactic only
Significant findings Hands-on better than didactic; low better than high fidelity; low-fidelity more cost effective Hands-on better than didactics; low and high fidelity equally effective
Improved in vivo performance in formal training group Improved technical skills and operative performance in formal training group Bench model more effective in clinical setting than didactic only Improved technical skill and operative performance in formal training group VR performed basic lap skills better than untrained VR performed LC better than untrained No difference in performance
LC in OR
VR training versus no training
VR performed LC better than untrained VR had better improvement in error and economy of movement
Standardized lap skill tests
VR simulator versus box trainer versus no training VR simulator versus box trainer
Both equally effective at improving skills over control Both effective at improving psychomotor skills VR simulator performed better in OR
See VR versus box trainer
VR simulator and box trainer VR simulator and box trainer
Psychomotor skill development LC in OR
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Table VI. (Continued) Reference
Media tested 5
Munz et al (2004)
Youngblood et al (2005)3
VR simulator and box trainer VR simulator and box trainer
Skill tested Basic lap psychomotor skills Lap tasks, global assessment in vivo (animal)
Comparison
Significant findings
VR simulator versus box trainer versus no training VR simulator versus box trainer versus no training
Both equally effective at improving skills over control VR simulator performed better
lap, laparoscopic; LC, laparoscopic cholecystectomy; OR, operating room; VR, virtual reality.
ular salary. We did not provide an estimate of the cost of attending physician instructor time, which likely would have incurred substantive charges had instructors required compensation, a realistic situation for a smaller department whose limited faculty resources might require such arrangements. Last, our data did not include cost estimates for physical space and facilities, because this infrastructure already existed as part of the department at the time we began our skills laboratory. Our surgical skills laboratory utilized a portion of the Surgery Research laboratory; approximately 2,000 square feet were available for this activity (once a week during the academic year). In addition, we have not addressed components of training that are an essential part of surgery education, such as team training, interdisciplinary training, and communication skills. We have described the costs associated with specific task training and procedural training that are essential to start a successful surgical skills laboratory. We have expanded our laboratory and offer the above skills currently to our residents, but an analysis of the costs associated with training in these skills was not the intent of this paper. REFERENCES 1. Gawande AA. Creating the educated surgeon in the 21st century. Am J Surg 2001;181:551-6. 2. Lehmann KS, Ritz JP, Maass H, et al. A prospective randomized study to test the transfer of basic psychomotor skills from virtual reality to physical reality in a comparable training setting. Ann Surg 2005;241:442-9. 3. Youngblood PL, Srivastava S, Curet M, Heinrichs WL, Dev P, Wren SM. Comparison of training on two laparoscopic simulators and assessment of skills transfer to surgical performance. J Am Coll Surg 2005;200:546-51. 4. Villegas L, Schneider BE, Callery MP, Jones DB. Laparoscopic skills training. Surg Endosc 2003;17:1879-88. 5. Munz Y, Kumar BD, Moorthy K, Bann S, Darzi A. Laparoscopic virtual reality and box trainers: is one superior to the other? Surg Endosc 2004;18:485-94. 6. Conn J. The games doctors play. Physicians are turning to high-tech simulators to practice their clinical techniques. Even video-game skills prove valuable in the OR. Mod Healthc 2004;34:32-3. 7. Strom P, Kjellin A, Hedman L, Johnson E, Wredmark T,
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22.
Fellander-Tsai L. Validation and learning in the Procedicus KSA virtual reality surgical simulator. Surg Endosc 2003; 17:227-31. Grantcharov TP, Kristiansen VB, Bendix J, Bardram L, Rosenberg J, Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004;91:146-50. Gallagher AG, Ritter EM, Champion H, et al. Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Ann Surg 2005;241:364-72. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 2002;236:45863; discussion 463-4. Haluck RS, Krummel TM. Computers and virtual reality for surgical education in the 21st century. Arch Surg 2000; 135:786-92. Hamilton EC, Scott DJ, Fleming JB, et al. Comparison of video trainer and virtual reality training systems on acquisition of laparoscopic skills. Surg Endosc 2002;16:406-11. Torkington J, Smith SG, Rees BI, Darzi A. Skill transfer from virtual reality to a real laparoscopic task. Surg Endosc 2001;15:1076-9. Korndorffer JR Jr, Stefanidis D, Scott DJ. Laparoscopic skills laboratories: current assessment and a call for resident training standards. Am J Surg 2006;191:17-22. Derossis AM, Fried GM, Abrahamowicz M, Sigman HH, Barkun JS, Meakins JL. Development of a model for training and evaluation of laparoscopic skills. Am J Surg 1998;175: 482-7. Rosser JC, Rosser LE, Savalgi RS. Skill acquisition and assessment for laparoscopic surgery. Arch Surg 1997;132:200-4. Jensen AR, Milner R, Gaughan J, Grewal H. An inexpensive ex-vivo porcine laparoscopic Nissen fundoplication training model. JSLS 2005;9:322-7. Berg DA, Milner RE, Demangone D, et al. Successful collaborative model for trauma skills training of surgical and emergency medicine residents in a laboratory setting. Curr Surg 2005;62:657-62; discussion 663. Grober ED, Hamstra SJ, Wanzel KR, et al. The educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures. Ann Surg 2004;240:374-81. Matsumoto ED, Hamstra SJ, Radomski SB, Cusimano MD. The effect of bench model fidelity on endourological skills: a randomized controlled study. J Urol 2002;167:1243-7. Coleman RL, Muller CY. Effects of a laboratory-based skills curriculum on laparoscopic proficiency: a randomized trial. Am J Obstet Gynecol 2002;186:836-42. Fried GM, Derossis AM, Bothwell J, Sigman HH. Comparison of laparoscopic performance in vivo with performance
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measured in a laparoscopic simulator. Surg Endosc 1999;13:1077-81; discussion 1082. 23. Naik VN, Matsumoto ED, Houston PL, et al. Fiberoptic orotracheal intubation on anesthetized patients: do manipulation skills learned on a simple model transfer into the operating room? Anesthesiology 2001;95:343-8. 24. Scott DJ, Bergen PC, Rege RV, et al. Laparoscopic training on bench models: better and more cost effective than operating room experience? J Am Coll Surg 2000;191:272-83.
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25. Satava RM. Virtual reality surgical simulator. The first steps. Surg Endosc 1993;7:203-5. 26. Ahlberg G, Heikkinen T, Iselius L, Leijonmarck CE, Rutqvist J, Arvidsson D. Does training in a virtual reality simulator improve surgical performance? Surg Endosc 2002;16:126-9. 27. Hyltander A, Liljegren E, Rhodin PH, Lonroth H. The transfer of basic skills learned in a laparoscopic simulator to the operating room. Surg Endosc 2002;16:1324-8.
Background. Recent studies comparing inexpensive low-fidelity box trainers to expensive computerbased virtual reality systems demonstrate similar acquisition of surgical skills and transferability to the clinical setting. With new mandates emerging that all surgical residency programs have access to a surgical skills laboratory, we describe our cost-effective approach to teaching basic and advanced open and laparoscopic skills utilizing inexpensive bench models, box trainers, and animate models. Methods. Open models (basic skills, bowel anastomosis, vascular anastomosis, trauma skills) and laparoscopic models (basic skills, cholecystectomy, Nissen fundoplication, suturing and knot tying, advanced in vivo skills) are constructed using a combination of materials found in our surgical research laboratories, retail stores, or donated by industry. Expired surgical materials are obtained from our hospital operating room and animal organs from food-processing plants. In vivo models are performed in an approved research facility. Operation, maintenance, and administration of the surgical skills laboratory are coordinated by a salaried manager, and instruction is the responsibility of all surgical faculty from our institution. Results. Overall, the cost analyses of our initial startup costs and operational expenditures over a 3-year period revealed a progressive decrease in yearly cost per resident (2002-2003, $1,151; 20032004, $1,049; and 2004-2005, $982). Conclusions. Our approach to surgical skills education can serve as a template for any surgery program with limited financial resources. (Surgery 2007;142:712-21.) From The Department of Surgery and the Institute for Clinical Simulation and Patient Safety, Temple University School of Medicine, Philadelphia, Penn
The surgical training environment is currently experiencing a marked evolution. The opportunity for learning in the operating room is shrinking, mainly owing to pressure on time and costs.1 The traditional Halstedian apprenticeship model of “see one, do one, teach one” can no longer keep pace with these challenges that face surgical educators. Recent changes to the limited number of work hours, along with the rapid advancement of surgical technology and development of innovative minimally invasive techniques, have raised concerns regarding patient safety and underscore the need to supplement training outside the traditional
Industry product donations accepted from Ethicon, United States Surgical, Karl Storz, and Stryker. Accepted for publication May 17, 2007. Reprint requests: Harsh Grewal, MD, Pediatric Surgery, 5 East, TUCMC, 3509 N Broad Street, Philadelphia, PA 19140. E-mail: [email protected] 0039-6060/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.05.011
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clinical setting. Computer-based virtual reality systems have recently been developed and incorporated into some surgery residency training programs2-10 for this purpose. These models have been shown to be valid and effective for both skills acquisition and transferability to the operating room3,5,6,8,10,11; however, their high costs limit their applicability to many programs faced with budgetary constraints. In addition, recent studies have shown that low-fidelity box trainers are just as effective as virtual reality systems for improving psychomotor skills.5,12,13 The Residency Review Committee for Surgery of the Accreditation Council for Graduate Medical Education stated that, by July, 2008, all surgery residency programs will be required to have access to a surgical skills laboratory. A recent survey14 of surgery residency program directors revealed that 55% of surgery training programs have dedicated laparoscopic skills laboratories. These findings emphasize that many surgery programs need to reassess their current curricula and make adjustments to be in compliance with these future changes in surgical education. Program directors and chair-
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persons of surgery residency programs currently without access to skills laboratories need to evaluate their administrative and financial resources to determine whether establishing a surgical skills laboratory is a practical option for their particular training program. We describe our method of developing a costeffective surgery skills laboratory curriculum to train surgical residents in basic and advanced open and laparoscopic surgical skills utilizing inexpensive bench models, box trainers, and animate models in the setting of limited financial resources. MATERIALS AND METHODS The Surgical Skills Laboratory of the Temple University School of Medicine was established by the Department of Surgery during the 2002-2003 academic year. Each year, the Temple University Department of Surgery employs approximately 50 residents, both designated and nondesignated preliminary residents (PGY 1 and 2) and general surgery categorical residents (PGY 1-5). The total number of residents participating in the surgical skills laboratory during the 2002-2003, 2003-2004, and 2004-2005 academic years was 48, 49, and 49, respectively. Training exercises utilized in our skills laboratory are either based on variations of established models15,16 or have been designed in our laboratory. Models are constructed using a combination of materials found in our surgery research laboratories, items purchased at low-cost from retail stores, or industry-sponsored equipment donations. Expired surgical materials are acquired from the hospital operating room and a local food-processing plant serves as an inexpensive source of animal organs. Animate teaching exercises are conducted in an animal facility approved by the Institutional Animal Care and Use Committee of Temple University. A salaried laboratory manager is responsible for maintaining the laboratory schedule, setting up and administering all skill modules, and keeping records of laboratory expenditures. The manager, however, has other responsibilities within the Department of Surgery, including managing the animal care and research; he devotes approximately 0.5 full time equivalents (FTE) to the skills laboratory. This percentage of FTE was used in our cost analysis. When beginning the residency program, all residents are provided with a syllabus that utilizes diagrams, photographs, and text to outline the methods and objectives of each training module. This information is also accessible via our online web-based curriculum. The skills laboratory is scheduled for a
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3-hour time block and begins after our weekly educational conferences. The time during which residents are either attending conferences or scheduled for the skills laboratory is considered “protected time” (i.e., residents are free from clinical duties). Each skills session is attended by up to 6 residents and one attending surgeon. The entire skills laboratory program is directed by one of the authors (HG); the skills lab director spends approximately 0.1 FTE in these activities for the time periods described in this report, and this time allocation was used in our cost calculations. Before the start of each module, the attending surgeon leads a didactic session that covers the material relevant to the particular skill session, and is present for the entire skills session to provide instruction and immediate feedback (the attending staff spend approximately 2.5 hours for each session they are instructing). The faculty participating are full-time academic faculty and are not compensated separately for their time and effort; in addition, each section is responsible for staffing the modules, for example, the trauma section staffs the trauma critical care modules. The skills laboratory curriculum is composed of 4 open modules (basic skills, bowel anastomosis, vascular anastomosis, and trauma skills) and 5 laparoscopic modules (basic skills, cholecystectomy, Nissen fundoplication, suturing and knot tying, and advanced in vivo skills). During the first year of the skills laboratory (2002-2003), most training modules were administered to residents of all PGY levels. Before the second year (2003-2004) of the skills laboratory, the curriculum was evaluated and residents were surveyed, resulting in the current skills laboratory curriculum in which modules are geared toward appropriate skills and tasks for their PGY level (Table I). Open skills. Basic open skills: All PGY 1 residents participate in the basic open skills module when they learn the identification of basic instruments, the classification and uses of different types of sutures, methods of knot tying and wound closure, and the use of electrocautery and ultrasonic dissector. No-cost materials include pig bowel harvested from prior in vivo skills sessions. Purchased materials include pig feet, chicken thighs, and industry-manufactured skin pad trainers. Bowel anastomosis: The bowel anastomosis module is administered to all PGY 2 residents and teaches the skills of both hand-sewn (1 and 2 layers) and stapled anastomoses. With the exception of a trial of an industry-manufactured bowel model (Limbs and Things, Inc., Bristol, United Kingdom), all supplies are either harvested from prior
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Table I. Surgical skills laboratory curriculum (X denotes postgraduate year in which module provided) Postgraduate Year 1 Open skills Basic open skills Bowel anastomosis Vascular anastomosis Trauma skills Laparoscopic skills Basic laparoscopic skills Laparoscopic cholecystectomy Laparoscopic Nissen fundoplication Laparoscopic suturing/ knot tying Advanced in vivo laparoscopic skills
2
3
4
5
X
X
X
X
X
X
X
X
X
X X X X X X
in vivo laboratories (pig bowel), fabricated in the laboratory (latex bowel model), or donated (staplers and reloads). Vascular anastomosis: PGY 2 residents are introduced to vascular instruments and instructed on the anastomosis of a donated synthetic graft to a harvested pig aorta in an end-to-side fashion. Vascular instruments were purchased during the first year and have been reused for subsequent laboratory sessions. Trauma skills: The trauma skills module utilizes a live porcine model to teach PGY 1 residents various skills essential to the treatment of the injured patient (tracheostomy, peripheral venous cutdown, chest tube placement, diagnostic peritoneal lavage, and thoracotomy). Purchased materials include a live animal, central venous catheter kits, peritoneal lavage kits, and ultrasound supplies (battery and charger). Donated items include chest tubes and an ultrasound machine. Laparoscopic skills. Basic laparoscopic skills: In the basic laparoscopic skills module, first-year residents are instructed on abdominal access, proper trocar placement, and various fundamental skills sets including pegboard, cup drop, rope pass, pattern cutting, and endoscopic clip and loop application.15,16 Outcomes were measured using a time and error system to obtain a composite score. Laparoscopic cholecystectomy: PGY 2 residents participate in the ex vivo laparoscopic cholecystectomy module using a laparoscopic box trainer. They are instructed on the proper methods of exposure, dissection, identification of the cystic artery, cystic
duct, and common bile duct, application of laparoscopically placed clips, and removal of the gallbladder from the liver bed using electrocautery or ultrasonic dissector. Pig livers are purchased from a local food-processing plant. Laparoscopic clips are either purchased or donated. Outcomes were measured using a checklist system. Laparoscopic Nissen fundoplication: Using an ex vivo porcine stomach model in a laparoscopic box trainer, PGY 3, 4, and 5 residents are instructed on performing key steps of a laparoscopic Nissen fundoplication, including esophageal dissection, fundoplication, and proper suture placement.17 Pig stomachs are purchased from a local food processing plant. Laparoscopic suturing and knot tying: This module is offered to PGY 3, 4, and 5 residents and covers the skills of extracorporeal and intracorporeal knot tying and both interrupted and continuous suturing. Cloth suspended from alligator clips serves as a medium on which to suture and is available in the laboratory. Purchased items include chicken thighs and endoscopic suturing devices. Advanced in vivo laparoscopic skills: Utilizing a live porcine model, PGY 3, 4, and 5 residents perform various laparoscopic procedures, such as cholecystectomy, Nissen fundoplication, splenectomy, and colectomy. Costs are incurred for a live animal, endoscopic clips, and insufflation supplies. Endoscopic staplers and reloads are donated. Cost calculations. For every skills module administered in the surgical skills laboratory, the laboratory manager maintained a database of all materials purchased with department funds, provided by our operating room, or donated by industry. Resident attendance was mandatory and recorded for each laboratory session. Therefore, total expenditures were available on a per resident/per session basis. The laboratory manager’s salary was also factored into the costs for each module. The total time to schedule, set up, and administer each skills laboratory module was estimated at 6 hours per module per session (3 hours scheduling and setup, 3 hours administration and clean up). The compensation to the laboratory manager was factored as $40/ hour (we utilized the equivalent of 0.5 FTE in our calculations). At the beginning of each academic year, certain items not considered a specific aspect of any particular skills module but deemed necessary to administer the skills laboratory were factored into the total annual expenditures. For the 2002-2003 skills laboratory, television monitors, VCRs, portable video carts, a camera lens, and printed laboratory manuals were purchased. For the 2003-2004 academic year, in addition to laboratory manual re-
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Table II. Itemized costs of open skills Module Basic open skills
Bowel anastomosis
Vascular anastomosis
Trauma skills
Items
Cost per item ($)
Pig bowel Suture Silk ties Pig feet Chicken thighs Skin pad trainer Pig bowel Latex bowel model Stapler Stapler reload Suture Commercial latex bowel Vascular surgery needle holders Potts scissors Pig aorta Gore-tex graft Suture Pig, delivery, room/board Trauma central line kit DPL catheter kit Ultrasound battery Ultrasound charger Operating room light bulbs Ultrasound machine Chest tubes Suture
0 (harvested) 0 (donated) 0 (donated) 0.5 1 14.88 0 (harvested) 0 (made in lab) 0 (donated) 0 (donated) 0 (donated) 45.50 40.80 89.29 0 (harvested) 0 (donated) 0 (donated) 400 20 29 215 200 141 0 (donated) 0 (donated) 0 (donated)
Estimated list price (each) of donated items ($) 4.00* 1.50†
3.00‡ 343.80§ 180.35¶ 4.00储
15.00/cm** 5.83††
8,000‡‡ 8.76§§ 4.00§
DPL, diagnostic peritoneal lavage. *Ten sutures per resident. †One pack of 12 ties per resident. ‡Based on $50.00 for 1 gallon of latex mold (makes approximately 20 bowel segments); 2 bowel segments per resident. §One per resident. ¶Two per resident. 储Four per resident. **Based on $1,200 for 8 mm ⫻ 80 cm graft, cut to 5-cm length per resident. ††Two polypropylene sutures per resident. ‡‡List price for refurbished Site-rite IV. §§One chest tube per resident.
prints for new residents, 2 computer systems were purchased at the start of the academic year for administrative purposes. For the 2004-2005 academic year, the only items that were purchased in addition to items needed for each skills module were laboratory manual reprints for incoming residents. In addition, because donated equipment and supplies may not be readily available, we have estimated the costs if these supplies needed to be purchased using manufacturers list prices where available; however, most health systems in bulk purchasing arrangements pay less than list price. RESULTS An itemized list of all necessary materials and costs to administer each open and laparoscopic skills module is shown in Tables II (open) and III
(laparoscopic). Table IV gives a breakdown of actual costs and estimated costs for donations for all open and laparoscopic skills modules, the academic years each module was administered, the total number of sessions, and the total number of residents participating in each module per year. Table IV also depicts the total annual cost for each skills module and the annual cost per module per resident (based on the number of residents employed by the department each year). The total annual cost per resident for administering and maintaining the entire skills laboratory, considering total initial expenditures each year, total number of sessions administered for all modules, and the total number of residents in our residency program each year decreased progressively ($1,151 for 2002-2003 [total cost for 48 residents ⫽ $55,234],
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Table III. Itemized costs of laparoscopic skills Module Basic laparoscopic skills
Laparoscopic cholecystectomy
Laparoscopic suturing/knot tying
Laparoscopic Nissen fundoplication Advanced laparoscopic in vivo skills
Items
Cost per item ($)
Video trainers Pegboard Cupdrop Rope pass Endoscopic clip appliers Endoscopic loop appliers Electrocautery Harmonic scalpel Pig liver Endoscopic clip applier Cloth Suture Endoscopic stitch device Endoscopic stitch reloads Pig stomach Suture Pig (delivery, housing) Endoscopic clip applier Endoscopic stapler Endoscopic stapler reloads Insufflator supplies
0 0 0 0
0 0
0 0
0
0 0
(donated) (made in lab) (made in lab) (made in lab) 108 15.58 (donated) (donated) 3 108 (made in lab) (donated) 186.38 35.89 4 (donated) 400 108 (donated) (donated) 217
Estimated list price (each) of donated items ($) 28,680*
1,700 20,902
4.00†
4.00‡
700§ 217.64¶
*List price for 1 trainer (quoted February 2007; includes trainer cart, training module, skin pads, flat panel display). †Ten per resident. ‡Six per resident. §One per session. ¶Six per session.
$1,049 for 2003-2004 [total cost for 49 residents ⫽ $51,377], and $982 for 2004-2005 [total cost for 49 residents ⫽ $48,120]). We also calculated estimated costs per resident including donated services: $3,702 for 2002-2003, 1,462 for 2003-2004, and $1,066 for 2004-2005 (Table V). The total cost for our skills laboratory over a 3-year period ($154,732 for academic years 2002-2005; $146,884 is the estimated costs of donated equipment and supplies) are not comparable to the purchase price of various commercially available computerbased simulators. To contrast the cost of a single virtual reality laparoscopic simulator, estimates were obtained from vendors in February, 2005, and do not include service contracts, which can approach $3,000 per year. Company A’s laparoscopic virtual reality system was quoted at $49,475. Company B’s laparoscopic virtual reality system was quoted at $61,155. Company B’s endoscopic virtual reality system was quoted at $86,985. These estimates are the up-front purchase costs, do not include service contracts or down time, and have not been depreciated. DISCUSSION The traditional system of educating surgery residents is facing many challenges of time efficiency,
costs, and patient safety.11 These issues have led to the emergence of surgical skills laboratories as important components of curricula for surgery residents in many training programs. Surgical skills laboratories provide residents with the opportunity to acquire technical skills in a low-stress, simulated environment, while focusing on learning and repeating key steps of procedures in a setting where they are able to reduce their learning curve with the goal of decreasing potential harm to patients. Currently, various media, both organic and inorganic, exist for surgical simulation outside of the operating room.5 Organic models include human cadavers, live animals, or animate cadavers. Human cadavers provide the benefit of high fidelity and anatomy identical to the simulated procedure; however, they are costly, not readily available, and owing to individual variability, cannot provide standardized assessments.5 Live animate models are high fidelity with bleeding tissue, but their use is limited by cost, variations from human anatomy, or laws banning their use in some countries.5 We developed in vivo animate models for trauma skills,18 cholecystectomy, Nissen fundoplication, splenectomy, and colectomy. Animal cadaver models are inexpensive, readily available, and provide good
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Table IV. Three-year breakdown of costs incurred for administration of a surgical skills laboratory*
Skill module Open skills Basic skills
Bowel anastomosis Vascular anastomosis Trauma skills
Laparoscopic skills Basic skills
Cholecystectomy
Suturing and knot tying Nissen fundoplication Advanced in vivo skills
Total cost without donations ($)
No. of residents participating
Cost per resident with donations ($)
Cost per resident without donations ($)
Academic year
No. of sessions
Total cost with donations ($)
2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005
None 8 3 None 5 3 9 8 4 None 3 4
— 428.56 137.88 — 0 91.00 423.38 0 0 — 2,352.00 1,796.00
— 1,341.56 1,050.88 — 6,046.30 1,585.30 7,983.38 1,733.00 867.00 — 10,633.00 2,077.00
— 22 22 — 16 10 48 20 10 — 22 22
— 19.48 6.27 — 0 9.10 8.82 0 0 — 106.91 81.64
— 60.98 47.77 — 377.89 158.53 166.32 86.65 86.70 — 483.32 94.41
2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005 2002-2003 2003-2004 2004-2005
9 3 8 8 None 3 13 None 3 8 None 1 2 2 None
4,087.68 1,333.52 1,333.52 1,440.00 — 482.00 2,281.86 — 800.58 192.00 — 40.00 1,233.00 1,016.00 —
90,127.68 1,333.52 1,333.52 24,042.00 — 482.20 4,101.86 — 1,240.58 1,344.00 — 160.00 4,544.00 4,327.00 —
48 22 22 48 — 10 48 — 11 48 — 5 8 8 —
85.16 60.61 60.61 30.00 — 48.20 47.54 — 72.78 4.00 — 8.00 154.13 127.00 —
1,877.66 60.61 60.61 500.88 — 48.20 85.46 — 112.78 28.00 — 32.00 568.00 540.88 —
*Does not include skills laboratory manager and faculty director salary costs. These costs are reflected in total annual costs (see Table V).
Table V. Total annual costs for administration of a surgical skills laboratory* Academic year 2002-2003 2003-2004 2004-2005
Cost with donations ($)
Cost/resident with donations ($)
Estimated cost without donations ($)
Estimated cost/resident without donations ($)
55,234.32 51,377.19 48,120.14
1,150.72 1,048.51 982.04
177,719.32 71,661.49 52,235.34
3,702.49 1,462.48 1,066.03
*Costs include skills laboratory manager and faculty director salary as described in text.
tissue handling when fresh; however, anatomy differs from that of humans.5 In our skills laboratory, utilizing animate organs, we have employed ex vivo models of bowel anastomosis, vascular anastomosis, cholecystectomy, and Nissen fundoplication.17 Inorganic media are either based on synthetic models or virtual reality systems.5 Synthetic models are reproducible, standardized, and useful for assessing isolated skills. We have adopted various inexpensive synthetic simulation models, including
pegboard, cup drop, rope pass, pattern cutting, and endoscopic application of clips and loops,15,16 and have developed our own models for basic open surgical skills and laparoscopic suturing. Virtual reality systems allow one to perform an operation or individual tasks in real time with instant objective feedback.5 Computer-based technology also may be more effective in training residents in endoscopic and laparoscopic procedures because this technology ensures accurate accomplishment
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of tasks and evaluates trainees using several parameters in addition to speed.12 Currently, however, the cost and absence of virtual reality open surgical procedures limit their widespread use in most surgery residency training programs. As the adoption of surgical skills laboratories into residency training programs becomes more widespread, it is imperative that well-designed, randomized, controlled studies comparing different media and their effects on the acquisition, maintenance, and transferability to the clinical venue of skills attained in the laboratory continue to be conducted. Recently, such studies have investigated bench models, traditional box trainers, and virtual reality systems. These studies are summarized in Table VI. Simple, low-cost bench models are more effective than didactics alone for acquisition of surgical skills, as measured in the laboratory.19,20 Four studies21-24 have gone on to test the transferability of skills learned in the laboratory on laparoscopic box trainers or bench models to performance in an operating room setting. These studies have demonstrated that technical skills and operative performance are improved by formal training on laparoscopic box trainers or bench models when compared with either no training or didactics alone. The concept of virtual reality for surgical skills simulation was introduced in the early 1990s.25 Since then, various commercial virtual reality simulators have been developed for surgical skills training and have been incorporated into residency training programs. Only in the last 5 years, however, have randomized, controlled trials examining their efficacy been completed.3,5,8,10,12,13,26,27 As with box trainers and bench models, the majority of randomized, controlled studies have demonstrated that training on a virtual reality simulator is more effective for transfer of skills to the operating room than no training at all. Of 4 studies comparing virtual reality to no training, 3 studies demonstrated transferability to the operating room8,10,27; one suggested no difference in operative performance.26 With the emergence of virtual reality systems, residency program directors and surgery educators are now faced not only with the task of developing surgical skills laboratories, but must also decide with what to equip the laboratory and how much to spend. To date, 4 randomized, controlled trials have compared traditional box trainers with virtual reality simulators.3,5,12,13 Three of these studies demonstrated that both models were equally effective at improving psychomotor skills,5,12,13 whereas
Surgery November 2007 2 studies3,12 demonstrated better performance by subjects trained on the virtual reality simulators. Although only 2 studies have suggested benefit of virtual reality over box trainers,3,12 it is essential that more studies comparing the 2 modalities are conducted before one can conclude that the potential benefits to resident education gained from costly, virtual reality computer-based surgical simulation are superior to those provided by inexpensive, easily constructed box trainers. Until that time comes, and while programs are currently faced with important decisions regarding mandatory access to technical skills and simulation facilities, our model of a surgical skills laboratory that utilizes animate models, inexpensive bench models, and laparoscopic box trainers represents a costeffective means to provide an adjunct to surgical training outside of the operating room. In our laboratory, we are now able to provide surgical skills training for about $1,000 per resident per year, and for the last 3 years we have successfully provided our surgical residents PGY level-appropriate modules for basic and advanced open and laparoscopic skills. In addition to lower costs, our skills laboratory model provides other benefits over a surgical skills laboratory based entirely on virtual reality. First, current virtual reality technologies preclude simulation of open surgical procedures. Our model provides a means to instruct residents on the basic open surgical skills that will form the foundation of their surgical skill sets. Second, assuming a program has the financial resources to purchase a virtual reality simulator, a single simulator can only train one resident at a time, on a single task or procedure, whereas our model, equipped with multiple stations, affords the opportunity to train several residents simultaneously. Third, the haptics of the box trainers utilized by our skills laboratory are more realistic than those provided by a virtual reality simulator. In fact, in one study, when asked to compare virtual reality to video (box) trainers, residents preferred training on the video trainer, felt it was a more effective training tool, more realistic, and provided better tactile feedback and depth perception.12 Despite the proposed benefits of a skills laboratory model such as we have described, we acknowledge limitations of our cost analysis. As mentioned, we have estimated the cost of donated services, equipment, and supplies. In addition, our instructors were attending surgeons from our department and arranged their clinical schedules graciously to volunteer to lead skills laboratory sessions. They received no compensation in addition to their reg-
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Table VI. Summary of randomized, controlled trials for surgical simulation Reference Bench model Matsumoto et al (2002)20
Grober et al (2004)19
Media tested
Skill tested
Comparison
Bench model
Ureteroscopy and stone extraction
Performance on highor low-fidelity model versus didactic only
Bench model
Microsurgical technique
Performance on highor low-fidelity model versus didactic only
Bench model/box trainer transferability to OR Fried et al (1999)22 Lap video box Technical skills in trainer vivo (animal)
Formal training versus no training of lap skill drills Formal training versus no training of lap skill drills
Scott et al (2000)24
Lap video box Technical skills trainer LC in OR
Naik et al (2001)23
Bench model
Orotracheal intubation in OR
Coleman et al (2002)21
Laparoscopic video box trainer
Technical skills Lap Formal training versus salpingectomy in no training of lap skill OR drills
VR simulator
Basic lap skills in vivo (animal)
VR training versus no training
Seymour et al (2002)10
VR simulator
LC in OR
Ahlberg et al (2002)26
VR simulator
Simulated lap appendectomy (animal)
VR training versus no training VR training versus no training
VR transferability to OR Hyltander et al (2002)27
Hamilton et al (2002)12 See VR versus box trainer Grantcharov et al VR simulator (2004)8
Youngblood et al (2005)3 Virtual reality versus box trainer Torkington et al (2001)13 Hamilton et al (2002)12
Fiberoptic intubation model versus didactic only
Significant findings Hands-on better than didactic; low better than high fidelity; low-fidelity more cost effective Hands-on better than didactics; low and high fidelity equally effective
Improved in vivo performance in formal training group Improved technical skills and operative performance in formal training group Bench model more effective in clinical setting than didactic only Improved technical skill and operative performance in formal training group VR performed basic lap skills better than untrained VR performed LC better than untrained No difference in performance
LC in OR
VR training versus no training
VR performed LC better than untrained VR had better improvement in error and economy of movement
Standardized lap skill tests
VR simulator versus box trainer versus no training VR simulator versus box trainer
Both equally effective at improving skills over control Both effective at improving psychomotor skills VR simulator performed better in OR
See VR versus box trainer
VR simulator and box trainer VR simulator and box trainer
Psychomotor skill development LC in OR
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Table VI. (Continued) Reference
Media tested 5
Munz et al (2004)
Youngblood et al (2005)3
VR simulator and box trainer VR simulator and box trainer
Skill tested Basic lap psychomotor skills Lap tasks, global assessment in vivo (animal)
Comparison
Significant findings
VR simulator versus box trainer versus no training VR simulator versus box trainer versus no training
Both equally effective at improving skills over control VR simulator performed better
lap, laparoscopic; LC, laparoscopic cholecystectomy; OR, operating room; VR, virtual reality.
ular salary. We did not provide an estimate of the cost of attending physician instructor time, which likely would have incurred substantive charges had instructors required compensation, a realistic situation for a smaller department whose limited faculty resources might require such arrangements. Last, our data did not include cost estimates for physical space and facilities, because this infrastructure already existed as part of the department at the time we began our skills laboratory. Our surgical skills laboratory utilized a portion of the Surgery Research laboratory; approximately 2,000 square feet were available for this activity (once a week during the academic year). In addition, we have not addressed components of training that are an essential part of surgery education, such as team training, interdisciplinary training, and communication skills. We have described the costs associated with specific task training and procedural training that are essential to start a successful surgical skills laboratory. We have expanded our laboratory and offer the above skills currently to our residents, but an analysis of the costs associated with training in these skills was not the intent of this paper. REFERENCES 1. Gawande AA. Creating the educated surgeon in the 21st century. Am J Surg 2001;181:551-6. 2. Lehmann KS, Ritz JP, Maass H, et al. A prospective randomized study to test the transfer of basic psychomotor skills from virtual reality to physical reality in a comparable training setting. Ann Surg 2005;241:442-9. 3. Youngblood PL, Srivastava S, Curet M, Heinrichs WL, Dev P, Wren SM. Comparison of training on two laparoscopic simulators and assessment of skills transfer to surgical performance. J Am Coll Surg 2005;200:546-51. 4. Villegas L, Schneider BE, Callery MP, Jones DB. Laparoscopic skills training. Surg Endosc 2003;17:1879-88. 5. Munz Y, Kumar BD, Moorthy K, Bann S, Darzi A. Laparoscopic virtual reality and box trainers: is one superior to the other? Surg Endosc 2004;18:485-94. 6. Conn J. The games doctors play. Physicians are turning to high-tech simulators to practice their clinical techniques. Even video-game skills prove valuable in the OR. Mod Healthc 2004;34:32-3. 7. Strom P, Kjellin A, Hedman L, Johnson E, Wredmark T,
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