Simulation training is a complementary educational practice that has become more relevant in recent years. The possibility of experimenting with permission to fail in controlled environments makes possible continuous and repeated practice, the acceleration of the learning curve and the acquisition of skills without compromising patient safety.
But what about the advantages and disadvantages of the different simulation models?
Although the use of cadavers is the gold standard in simulated training due to the high fidelity representation of the surgical anatomy as found in the live patient, the acquisition of these models comes at a higher cost and lower availability.
Regarding the effectiveness of cadaveric simulation training, James et al. indicate that there is abundant evidence of relatively low quality showing that this model induces short-term skill acquisition. There is also a lack of evidence of retention and transfer of skills after training in the live operating room.
The Costello team's research work concurs with the previous point by highlighting the limited evidence describing the effect of cadaveric training on surgical skill enhancement. In fact, in a comprehensive review of the literature on cadaveric surgical simulation, the authors found no studies validating the use of cadavers in robotic surgical training.
Continuing along these lines, the College of Surgeons of England (2011) detected a benefit of cadaveric workshop training with respect to trainees' ability to perform relatively simple emergency procedures, however, weak evidence was found with respect to benefit in performing more complex surgical procedures.
Fig. 1: Advantages and disadvantages of wet lab simulation methods. Source: Al-Jabir et al.
Real tissue. Profitable
One-time use. Storage difficulties
Good face validity. You can do the complete procedure
One-time use. Ethical issues. Cost. Special procedures. Anatomical differences.
Better apparent validity.
Haptic response. Complete procedure. Realistic tissue. 'The gold standard'.
One-time use. Cost. Availability. Risk of infection.
As shown in Figure 1, compared to cadaver simulation, animal models present anatomical differences that may limit their use for training specific pathologies, especially when referring to oncologic procedures.
In both animal and cadaveric models, the difficulty in logistics, storage and preservation, as well as the presence of ethical conflicts linked to culture and religion, can be barriers to their practical use.
In relation to the use of animal models, the American College of Surgeons has stated that "whenever feasible, alternatives to the use of live animals should be developed and employed". On the other hand, Anguiano-Robledo et al. indicate; "The use of animals for scientific or educational purposes should be considered only when no alternative exists and is governed by the principles of replacement, reduction and refinement. Scientists must be confident that the information that can be obtained from the experiments is not yet available or that the protocol was designed with animal protection considerations in mind."
Costello et al. concludes that both live animal and cadaver simulation training do not fit the need for standardized competency-based training and the rapid pace of expansion of surgical procedures.
Are synthetic models a viable alternative?
Several recently published studies support the use of realistic synthetic models as effective surgical training tools as a replacement for animal and cadaver training, a situation that has been amplified after the advent of Covid-19.
Recent advances in materials engineering and 3D printing have made it possible to design high-fidelity soft synthetic models that emulate human tissue composition and coloration as well as mechanical properties and, in many cases, bleeding.
Unlike cadaveric models, the use of synthetic models eliminates the risk of contagion of infectious diseases, offers the possibility of practicing the surgical procedure through unlimited repetition, provides training in complications, pathologies and rare anatomical variants that require knowledge and experience of the medical professional.
On the other hand, given the nature of the synthetic model, it is an alternative free of ethical conflicts, since it does not require the patient's informed consent and there is no evidence of harm to the animals.
In economic terms, the use of simulation in synthetic models has the potential to drastically reduce costs by improving clinical outcomes. In addition, work has been done in recent years to make simulators and synthetic models more affordable, in fact, in the long term, acquisition costs are lower than the costs associated with the use of animals and cadavers.
With a strong trend towards the implementation of less expensive, more efficient and rigorous educational practices to train and evaluate surgical knowledge and skills, synthetic models offer several advantages over traditional training methods.
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- Aedo, R., Kerkebe, M. (2018) Simulation in urology. Revista Chilena de Urología, Volume 83 | Nº 3 year 2018. Recuperado de: https://revistasacademicas.cl/Upload/ArticulosPdf/schu_20210906095440_4c80abd7-3521-404e-b4ba-2ae39d94eed1.pdf
- Al-Jabir, A., Aydin, A., Al-Jabir, H., Khan, M. S., Dasgupta, P., & Ahmed, K. (2020). Current status of wet lab and cadaveric simulation in urological training: A systematic review. Canadian Urological Association journal = Journal de l'Association des urologues du Canada, 14(11), E594-E600. https://doi.org/10.5489/cuaj.6520
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- Costello, DM, Huntington, I., Burke, G., Farrugia, B., O'Connor, AJ, Costello, AJ, Thomas, BC, Dundee, P., Ghazi, A., & Corcoran, N. (2021 ). A review of simulation training and new 3D computer-generated synthetic organs for robotic surgery education. Journal of robotic surgery , 1-15. Advance online publication. https://doi.org/10.1007/s11701-021-01302-8
- Anguiano-Robledo, L., Calzada-Mendoza, C. C. , CornelioBarrientos-Alvarado, C., & Hernández-Campos, M. E. (2018). Alternatives to Animal Experimentation: Its Institutional Teaching and Scientific. In J. A. Morales-González, & M. E. A. Nájera (Eds.), Reflections on Bioethics. IntechOpen. https://doi.org/10.5772/intechopen.74941
- Balcombe, J. (2004). Medical training using simulation: Toward fewer animals and safer patients. Altern Lab Anim, 32(S1): 553-560.