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Simulation Training

About Simulation

Increasingly, medical students learn ultrasound skills at simulation centers in medical school. Portable ultrasound machines are used on crude, short-lived, gel-and-noodles models of the abdomen. The machines are expensive, and the models are time consuming for the surgeon-teacher to build and therefore expensive also. Measuring/monitoring the students as they practice requires direct expert observation and manual recording of performance and is therefore expensive. Teaching by demonstration requires one-on-one learner to educator.

Solution: The Department is developing an ultrasound simulator with a dummy probe whose position is tracked with 6 degrees of freedom as it is manipulated in contact with a physical model of the abdomen. The coordinate data stream will be used to interrogate a virtual digitized model of the abdomen, resulting in an image that varies in real time with the probe position.

Development stage: We have created a bit array (cube)-based data model for the virtual abdomen, and are in the process of (1) connecting an ultrasound transponder to a CNC machine to reference the data points and (2) creating an algorithm that factors in pitch, roll, and yaw, to determine what view is presented to the user.

Competition: There are some available simulators. Their images are still-frame displays triggered by application of an electromagnetic sensing dummy probe to a physical model containing magnetic targets. The probe is not continuously tracked, only limited pre-stored images are triggered for display at each target site (usually transverse and sagittal). The experience is static and unrealistic. No probe manipulation skills are taught

In addition, fully functioning ultrasound devices may become cheap and small enough that simulators are not needed. But even so, they lack the advantage of being embedded with an academic medical institution that is developing curriculum at the same time as it is building and validating pedagogic measurement metrics and models and standards. MEP and its partners will offer a service that includes not just the simulator but also the curriculum and even the distance teaching of the subject. Doctors tend to be unwilling to teach in simulation labs; they prefer to teach in the OR, so they ought to welcome a system that relieves them of an onerous and often evaded duty.

Surgical Skills and
Simulation Laboratory

The team working on the ultrasound simulator has developed a simulation system to teach surgical students the skills they need to pass the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) exam in the Fundamentals of Laparoscopic Surgery (FLS.) The system is in use and produced such good results for the first class that used it, that non-FLS-trained students from prior classes asked to be trained on the system after seeing their juniors doing better than them in laparoscopy.

The FLS system could be used to identify then specify and measure the skill set needed for laparoscopic surgery. Right now FLS is task-oriented (tie a knot, etc.) But the tasks have no natural link to anatomy. The important skills include (for example) manual dexterity and the handling of a difficult field of view, etc., in the anatomical and physiological context. That, and not the disembodied knot, is what makes and defines a surgeon. Analysis of the video automatically recorded as students train will enable the identification of valid skills.

Surgical Skills and Simulation Training

Various materials and models support our simulation teaching concepts for a wide range of basic surgical skills, intermediate skill tasks, and more advanced surgical procedures. This includes basic knot tying and suturing, forcep handling and needle driver manipulation, surgical instrumentation recognition and categorization, incision creation, basic and advanced wound closure techniques, diagnostic and therapeutic ultrasound techniques, performance of intestinal anastomosis and vascular surgical arterial and venous repairs and anastomoses.

Specific surgical skills and simulation teaching and training modules have been developed for all open skills modules. The curricula for each module a didactic syllabus covering the appropriate knowledge domains necessary for developing expertise in the skill task being taught, procedural checklist of skill task steps, hands-on expert demonstration, practice guideline recommendations, and assessment of competency utilizing procedural checklists, task completion times, and global rating scores.

The Surgical Skills and Simulation Laboratory utilizes 7 FLS trainer boxes to train general surgery residents and medical students in basic laparoscopy skills. The trainer boxes are located in two areas on campus. Two trainer boxes are located in the Department of Surgery Surgical Skills and Simulation Laboratory in the Harper Professional Building and 5 box trainers are situated in the Skills Task and Training room at the Kado Learning Center located within the Mazurek Educational Commons.

The goals of the FLS educational module are to improve the clinical care of patients undergoing laparoscopic surgery by enhancing knowledge base and technical skills, provide a hands-on skills training component and validated assessment tool designed to teach the physiology, fundamental knowledge and technical skills required in basic laparoscopic surgery, to ensure competency in basic laparoscopy skills while setting minimal standards for these skills.

The assessment of competence is determined through a cognitive examination using a 80 question multiple-choice test examination and a hands-on skills examination consisting of 5 manual skills tasks. The cognitive examination is based upon four components; preoperative considerations, intraoperative considerations, basic laparoscopic procedures, and postoperative considerations. The hands-on skills examination is comprised of 5 manual skills tasks; peg transfer, precision pattern cutting, ligating loop placement, extracorporeal knot tying, and intracorporeal knot tying.

SurgicalSim VR (METI): a learning system displaying a virtual reality fixed camera view. The simulation training exercises within this educational platform cover basic, intermediate, and advanced laparoscopic skill tasks including laparoscopic camera navigation (visualize target and scope, visualize and acquire target and scope, tissue and instrumentation manipulation (retract tissue, retract and dissect tissue, traverse tube, arrow placement, retraction and clip application, gallbladder dissect), basic suturing (needle adjust, one-handed and two-handed stitch-traction or no traction), advanced suturing (abstract and realistic square, surgeon and free knot, abstract and realistic continuous and interrupted suture). There is no haptic feedback to the instruments but rather virtual visual feedback is provided from sophisticated anatomic simulations. This program can objectively measure performance, identify problem areas, assess an individual learner’s progress, and ensure competency standards are met and mastered.

SurgicalSim LTS (METI): A training and testing program for basic skill in laparoscopic surgery. The training exercises include 10 skill and coordination skill tasks that are performed with real laparoscopic instruments. These tasks focus on coordination (peg manipulation [#1], ring manipulation [#2/3], rod cannulation [#4/5]), knot tying (extracorporeal and intracorporeal knots [#6/7/8]), knot integrity (suturing flaps and foam [#9]) and cutting (disc cutting [#10]). Live video review of task performance can be viewed on the incorporated computer monitor. Scores for each task, based on speed and accuracy, are calculated and recorded within the program data system. Data can be printed or exported for later evaluation and comparison.

Laparoscopic Box Trainer (Medical Applied Research Corporation [MARC], Olympus Medical): A modular lap trainer developed by MARC in conjunction with Olympus Visera and cameras and video display unit allows for integration of more advanced laparoscopic skills training. The MARC trainer box accurately simulates the abdominal cavity and allows for actual camera views utilized in clinical laparoscopic surgical procedures (and different from the FLS trainer box). Resident performance can be recorded for immediate debriefing and/or later review and feedback.

Endoscopic Skills Module Training

Accutouch Endoscopy Simulator (Immersion Medical): A simulation endoscopic training program which utilizes mock, gastroscopes, colonoscopes, and bronchoscopes with active controls but no view channel or active tip motion. Following insertion of the different scopes into the simulator an intraluminal view is initiated where the view can be altered simulating a realistic clinical exam with manipulation of the scope controls. Haptic feedback resistance is provided to the user as the simulator will grip the scope during the exam. Diagnostic and therapeutic training exercises provided include the opportunity to negotiate the entire upper GI tract (EGD, cytology sampling, ERCP, papillotomies, cholangiopancreatograms), lower GI tract (flexible sigmoidoscopy, colonscopy, biopsy, basic polypectomy), and bronchial tree (flexible bronchoscopy, bronchoalveolar lavage, endobronchial sampling and biopsy, transbronchial needle aspiration, bronchoscopy-assisted endotracheal tube placement). Various performance metrics are obtained and recored including percentage of mucosa viewed, task completion time, and pressure exerted. In addition, cheat views showing the true position of the scope and its orientation can be toggled on as insets overlaying the intraluminal view.

Certification and Testing

Certification testing appointments at our center scheduled via on-line through web-based FLS testing schedules.

To find out more about our Surgical Skills and Simulation Laboratory and FLS testing center please call: (313) 745-0462 or Fax (313) 745-1873.

Answers to general questions about the FLS program can be found at and