To perform any surgical procedure safely, both didactic knowledge and technical skills are essential. Adequate knowledge is necessary to understand the indications for surgery, recognize the intraoperative situation, select the correct technique and provide appropriate postoperative management. Accurate technical skills are indispensable to complete any surgical procedure. Therefore, when creating a teaching program for a surgical procedure, it must include both didactic knowledge and technical skills. To effectively and safely perform a complex procedure such as PJ, a surgeon must acquire both advanced knowledge and advanced technical skills.
Didactic knowledge of surgical procedures can be generally divided into general knowledge and specific knowledge for each procedure. In general, standardization is effective for teaching and learning surgical procedures. However, there are many kinds of techniques to perform a PJ and there is no single technique that has emerged as the gold standard for PJ. Using a standardized technique and consistent practice of that single technique may lead to a decreased rate of complication, but defining that standard technique remains problematic. [5] [6]
In this study, we first created a detailed procedure manual for our own PJ technique because there were differences in the technique even among surgeons at the same institution. Basic agreement was obtained by a repeated anonymous questionnaire to obtain a consensus view of the best way to teach PJ. This approach was embraced by the faculty and assured them that everyone’s opinion would be considered in defining the best way to teach PJ, rather than everyone following the ideas of just one person. The purpose and tips for each step were verbalized, digitized and illustrated in order to improve the trainee’s understanding.
To acquire surgical skill, training both in the OR and outside the OR with simulation has become required in many training programs. Until recently, surgical skills were acquired through a traditional apprenticeship model of training. Almost all surgical training took place in the OR with trainees performing more or fewer components of a procedure with varied levels of supervision by faculty, and varied levels of awareness of these realities by the patients. Simulation training has been a part of surgical education over the past few decades. [7] Many reports show the usefulness of the simulation training in many aspects. [8] [9] [10]
There are various kinds of simulation training, such as cadaver training, animal laboratory training, virtual reality training and training with inanimate models. Each of these scenarios is associated with various advantages and disadvantages. Cadaver training has limited opportunities for trainees usually because of the lack of cadavers. In animal laboratory training, the anatomy may not be similar to humans and there may be ethical issues. In virtual reality training, development of the training software and user interfaces is expensive and still limited in scope. In training with manufactured models, the trainee can have numerous training opportunities and there are no ethical concerns. However, suitable models do not exist for training for many complex procedures. Development of meaningful training programs with inanimate models requires a great deal of input by clinicians and educators.
With the recent development of three-dimensional modeling technology, it has become possible to create models to use for training in complex procedures. [11] [12] [13] We used this technology to develop training models for PJ. These models reproduce human anatomy with great accuracy to facilitate PJ training. These teaching models made it possible to teach suturing and ligation on anatomically accurate models, which can be used multiple times. A simple frame box was added to the simulation to adjust the difficulty of training. The difficulty of PJ is influenced by access through the abdominal incision and depth of the surgical field. Especially, the depth of the operative field is a risk factor of the postoperative pancreatic fistula. [14] The influence of both of these factors on training for PJ can be adjusted with this teaching system.
Simulation training with this program facilitates team training. Trainees can alternate roles as both primary surgeon and assistant which increases the overall understanding of the procedure. This also helps trainees and trainers develop non-technical skills which are necessary for surgeons. [15] [16]
There are two major issues which remain to be solved. The first issue is the cost of the program. The dry lab training model set including the pancreas and the small intestine costs about US$100 to produce. It is possible to use one set for four PJ anastomoses. The needles cost about US$70 for a single anastomosis. Therefore, it costs about US$380 (set of models plus needles) to perform four anastomoses during a training session. Further cost reductions may be possible with mass production and devising new materials. The second issue to be solved is how to evaluate the effectiveness of this program. There are many studies about usefulness of the simulation training in minimally invasive surgery, however evaluation in open surgery is still inadequate. [17] [18] [19] Since it is difficult to assess patient outcomes from an ethical point of view, both objective and subjective assessments are needed. We are currently devising an evaluation to improve the program and increase competency of the trainees.