Simulation in Vascular Surgery Training
Year: 2025
Type: article
Abstract: Use of simulation in vascular surgical training offers a technological platform, which helps in replicating the real-life schema of the surgical environment that an operating room offers but within the confines of a safe, regulated, and reproducible surgical habitat. Leaf and clay models from India of 600 BC have been labeled as one of the earliest surgical simulation models, where the art of nasal reconstruction was perfected using forehead flaps.[1] The practice of using embalmed cadavers for surgical skill refinement was documented by the celebrated military surgeon Ambroise Pare, one of the neoteric wizards of battlefield medicine and surgical techniques, also considered the “Father of Surgery.”[2] The intellectual transformation of Europe under the Renaissance period led to the development of early nonelementary simulation models, especially in the field of obstetrics and gynecology, which resonates with the high peripartum mortality of those times, and surprisingly, some of the models boasted of the first simulated venous circulation.[3,4] A major limitation of these cadaveric models for use in as training models in vascular surgery was the lack of malleability and vascularity, which even in the contemporary teaching forms the cornerstone of basic and complex open and endovascular procedures. Fresh cadaveric models simulated anatomical details akin to the actual human tissues but could not mimic the physiological intraoperative conditions. The embalmed ones on the other hand had a poor tissue compliance. A need to shift focus from cadaveric to animal models was, therefore, strongly felt.[5] Sudi Carnot, the President of the French Republic, was assassinated in 1894 and could not be saved as the stab injury to the abdomen had lacerated the portal vein which was irreparable at those times, and he bled to his death. This had a profound effect on one of the young surgeons of those times, Alexis Carrel. He in his quest for refinement of the art of arteriovenous anastomosis spent the following 5 years perfecting the art on animals using fine threads and needles, sourced from embroiders. This likely first act of simulation training in vascular surgery paved the way for the fundamentals of arterial anastomosis, including the “triangulation technique,” which is still revered and earned Alexis Carrel the Nobel Prize in 1912. Julius H. Comore Jr described it as “Carrel using experimental animals, performed every feat and developed every technique known to vascular surgery today.”[6] The father of intervention radiology, Charles T. Dotter, improved upon his initial attempts at percutaneous angioplasties, when practicing on the animal models in the early 1900s dealing with the peripheral arterial stenosis, an act now commonly known as “Dottering an arterial stenosis.”[7] Col Michael Debakey established the Foundation for Biomedical Research, which advocated the need of animal models for simulation of improving medical knowledge. The first Dacron graft was sewed and tested on dogs by Debakey for nearly 2 years before it was finally done on a human. Series of other innovations in the field of cardiovascular medicine, which were once thought impossible, could see the light of the day due to the animal models that spearheaded the progress in optimal training and refinement for later optimal patient outcomes.[8] Training on animal models has its own demerits. There are structural differences with-respect to humans, including the size mismatch of the vasculature. Lately, the ethical concerns on usage of animal models have forbidden their usage in many countries like, United Kingdom.[5,9] The latter half of the 19th century saw the advent of computer-controlled simulators (1960s, Abrahamson and Denson). These models could mimic realistic intraoperative hemodynamic changes and physiological responses.[10] By now, the simulation models were segregated into two main types: high fidelity and low fidelity. Whereas the high-fidelity models offer high degree of realism and can clone an entire surgical procedure, low-fidelity models were the ones that allowed individual skills and practice.[11] The next enhancement in simulation in vascular surgery was seen in the form of pulsatile cadaveric models, bench and porcine models which aided in offering realistic environment with complication management exercises and practicing vascular anastomosis.[12,13] The simulation training should ideally start from a low-fidelity model and progress to a high-fidelity model for graded skill enhancement. The ex vivo models are pivotal in replacing and reducing the use of live animal models, which seems to be the sentiment of the current environment, but these animal models still are the keystone at each level of vascular training. The European Society for Surgical Research also validates the cause with robust scientific literature.[14] It was only a matter of time that simulation got validated as an educational tool in nonmedical disciplines with high safety and accountability, like aviation. Collaterally, not only did simulation evolve in surgical residency program for training but also, as an evaluative tool to ascertain competencies in a near real-world operative scenario.[15] The value amalgamation of virtual reality (VR) and artificial intelligence to the existing computer-based programs has added a new dimension to the simulation training and will go a long way in assuring continuing professional competence. The addition of the haptic-enabled software solutions to the anatomical software physics engine has paved the way for VR simulators for image-guided vascular therapies, for example, the VIST® G7 and G7+. The innovative technology offers the ability to measure real force and can self-calibrate, thus adding tangible metrics to the subjective performance evaluations.[16] Training evaluation by analyzing learning effectiveness in most of the studies on simulation in medical learning is based on the Kirkpatrick model, which consists of four levels: reaction, learning, behavior, and results. Some authors have suggested a fifth level, which has been labeled as return of investment. Most of the contemporary studies are at Level 2 (learning) of the Kirkpatrick model, which suggests learning changes in the skill set of the trainees. Very little is currently known about the on-the-job noticeable improvement (Level 3). This becomes particularly important in a subject like vascular surgery because in several open and endovascular procedures, like abdominal aortic aneurysms, carotid endarterectomies, lower extremity bypasses, and hybrid procedures, a higher operative volume directly corresponds to lower mortality.[17] Digressing from the principles of the time-tested Halstedian model of residency and adapting to the simulation-based contemporary surgical residency programs is a herculean task. In a recent systemic review of 76 eligible articles on simulation-based training in vascular surgery, 34 simulators were found validated; however, only seven studies had a level of effectiveness of 3/5 and only one simulator was found to have a level of effectiveness of 5/5.[18] India too has seen the rise in simulation training with centers like Vydehi Advanced Simulation Academy, in Bengaluru, which is southeast Asia’s largest multidisciplinary medical simulation center. To sum it up, repetitive surgical simulator training can increase operative speed and offer fluidity, without abdicating patient safety. It gives a sense of self-efficacy and improves device proficiency, clinical workflow, and procedural efficiency. The latest VR-enhanced models offer immersive training experiences/solutions, from onset to the resolution of the entire clinical disease pathway. They offer a teaching module to not only the surgeon but also his entire multidisciplinary team, revolutionizing modern vascular surgery teachings. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Authors: Rohit Mehra, Ajay Kumar Dabas
Institution: Army Hospital Research and Referral
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4410586339