Surgical simulation training: mobile and anywhere

Simulation-based training has gained importance in surgical training worldwide. It allows trainees to learn and consolidate skills without risking patient safety.1,2 Evidence for the educational value of surgical simulation is accumulating rapidly, and several studies have shown that simulator-acquired skills can be successfully transferred to the operating room.3-5 Nonetheless, simulation is still not widely available to Australian surgical trainees. A recent survey showed that 43% of supervisors and 63% of surgical trainee respondents reported having no simulation equipment at their workplace.6

In October 2007, the Royal Australasian College of Surgeons (RACS) received funding from the Australian Government Department of Health to investigate the role of laparoscopic surgical simulation training in surgical education. The Simulated Surgical Skills Program (SSSP) was established to determine whether simulation training for laparoscopic surgery could effectively impart and maintain operative skills in a variety of participants. Aware that the main hindrances to implementing such a curriculum are accessibility, cost and time constraints, the SSSP investigated ways of increasing access to simulation for trainees at a relatively low cost. It proposed using a mobile simulation vehicle to provide access to state-of-the-art equipment and standardised training at trainee workplaces in urban and rural areas.

In 2009, based on the mobile surgical skills educational unit developed by the Royal College of Surgeons in Ireland (consisting of a truck-size unit with internal room to accommodate 10 surgical trainees and two trainers),7 the SSSP developed a version modified for the Australian setting. A primary factor in the development of the RACS mobile simulation unit (MSU) was vehicle size and manoeuvrability. The vehicle needed to travel to metropolitan and rural areas easily, park in the tightly confined spaces of busy hospital grounds, and be operated and driven by a single trainer holding a standard Australian driver’s licence. It also needed to be large enough to enable safe, comfortable and effective simulation training.

The chosen vehicle was a light commercial van (Mercedes-Benz Sprinter), with an interior configured to resemble a dry skills centre. The unit’s long wheelbase and extra high roof provides 17 m3 of internal space, large enough for four workstations along one wall, and provides comfortable headroom and storage space. Internal features include:

• full insulation, air conditioning, and glare reduction using blockout curtains and tinted windows;

• a cabin stabilised by hydraulic legs deployed at the push of a button;

• simulators and surgical instruments housed in padded lockable drawers to protect sensitive equipment during transport and to maintain security;

• an office space created in the passenger side of the cabin, with a chair mounted on a 180° swivel, a retractable laptop stand and a printer installed in the overhead locker; and

• 22-inch LCD audiovisual screens secured to the wall at each workstation.

The simulators, audiovisual screens, computers and air conditioning unit require electricity. To ensure an uninterrupted source, the design of the MSU enables it to be powered from shore power (using hospital outlets) or a diesel generator located in a custom-designed trailer. Solar panels located on top of the vehicle generate energy for internal lights.

The MSU is easily set up and can be ready from arrival to operation in about 30 minutes. It is extremely flexible, as stations can be modified with different simulation activities according to trainee needs.

To ensure that it performed adequately, the MSU was trialled in rural Port Augusta (South Australia) in 2009. Based on the outcomes of this trial, a few minor changes were made before implementing the MSU in New South Wales. During 2009–2010, the MSU was deployed at five NSW hospitals, successfully providing training to 84 participants.

The value of the MSU as a teaching facility was demonstrated by a study that found no significant difference in the basic laparoscopic skills acquisition of participants trained in the MSU compared with those trained at a fixed site.8 This research required the MSU to be configured for laparoscopic training, so the four stations were equipped with laparoscopic simulators — two box trainers (FLS) and two virtual reality laparoscopic simulators (LapSim).

In 2011, the RACS acquired another vehicle, which was customised with small alterations to the original design. Storage cabins were reorganised to provide more space for equipment, and a pull-out awning was installed at the side of the vehicle to provide shade and shelter for participants.

In 2012, the SSSP investigated the role of the MSU in providing educational support to Specialist Training Program trainees in non-traditional training positions. Ease of use, acceptability and participant reactions to the MSU environment were assessed. Over 6 months, the MSU was located at six SA hospitals in Adelaide and in rural areas, and a number of surgical simulated activities were offered to medical personnel. Simulation equipment was configured with different simulators according to trainee needs. Trainees provided very positive feedback about the MSU as a teaching facility. The MSU was tested in different weather conditions and, overwhelmingly, participants reported favourably on the educational content, ease of access and environment of the vehicle.

As well as being deployed for two research projects, the MSU has been present at conferences and meetings throughout SA, Northern Territory, Queensland, NSW, Western Australia and Tasmania, showcasing simulation and encouraging medical students to consider surgery as a career.

The main advantage of the MSU is that it gives trainees, regardless of their geographic location, access to standardised state-of-the-art training and education facilities. The MSU has the potential to reduce costs associated with simulation. Building and maintaining skills laboratory resources in each hospital is prohibitive. As well as the costs of building facilities and equipment, it is essential to have dedicated personnel to provide instruction, maintain equipment and consumables, and provide technological support.

Currently, both vehicles are located in SA and are maintained by the Research, Audit and Academic Surgery Division of the RACS. Funding is being sought to expand the program in Australia. The experience with the MSU has been extremely positive, and it promises to be a strategic tool in the provision of surgical simulation training for the future.

The four simulation stations can be altered according to trainee needs.