Simulation and the New Landscape of Surgical Education

by Harry S. Nayar MD, MBE and Jacqueline S. Israel, MD

The surgical resident made the incision just a few millimeters too ulnarly.  The endoscope entered the carpal tunnel and veered radially off of the hamate as it approached the distal margin of the transverse carpal ligament.  Almost simultaneous with the deployment of the blade, the median nerve popped into view and was nearly severed.

This is one of many possible scenarios that can be reproduced using the endoscopic carpal tunnel release (ECTR) simulator developed at the University of Wisconsin – Madison (UW Madison, Figure 1).  This simulator, like many others throughout the nation, has become a valuable component of our education.

Simulation-based medical training was developed to help standardize surgical performance, enhance knowledge, and avoid errors that jeopardize patient safety and outcomes.  Simulation training has proliferated in recent years; a 2011 AAMC survey revealed that more than 90% of U.S. medical schools and teaching hospitals have utilized simulation in their medical and postgraduate curricula [1].  Medical students and residents routinely use mechanized mannequins to learn the appropriate rate, depth, and force for chest compressions and proper technique for central line placement.   Whatever the purpose, simulation training provides trainees the opportunity to hone their skills in a setting free of culpability, where mistakes are only to be seen as learning opportunities.

Steve Kempton MD, 4th year Plastic Surgery resident (above), is conducting research on the utility and efficacy of the ECTR simulator for educating trainees at UW Madison.

Steve Kempton MD, 4th year Plastic Surgery resident (above), is conducting research on the utility and efficacy of the ECTR simulator for educating trainees at UW Madison.

Simulation has become increasingly prevalent in Plastic Surgery research, education and practice. Early iterations include clay models for forehead flaps, dating back to 600 B.C. [2,3], and René Le Fort’s work on fracture patterns in cadaver skulls [2]. With respect to technical skill acquisition, our teachers likely utilized simpler simulations, such as suturing latex gloves to hone microsurgical skills.  These more basic methods have given way to technically sophisticated simulators.  Perfused cadaver models for use in flap dissections and anastomoses [4], a “Mastotrainer” for breast surgery [5], Biodigital cognitive simulators for cleft lip and palate repair [6], craniofacial procedures [2] and latissimus dorsi musculocutaneous flap elevation [7,8] have all been developed.  Surgical planning simulators for customizing models of individual patients [2] are also becoming relatively commonplace.

Like many surgical simulators, the ECTR simulator provides trainees not only the indications and steps of ECTR, but also the experience itself.  The procedure’s nuances – the proper way to drop one’s hand while entering the carpal tunnel, the subtle change in resistance felt at the distal margin of the ligament, the weight and ripping sound of the endoscope – are felt and experienced via simulation.   This is referred to as “haptic learning,” and was recently the subject of a TEDMed talk (part of, “Play is Not A Waste of Time”) given by Carla Pugh, MD, PhD, director of The Clinical Simulation Center at UW Madison.  Dr. Pugh explained that by combining both the cognitive and the psychomotor through advanced sensor technology, haptics (“the art and science of touch”) can improve surgical performance [9].

While the concrete nature of an ECTR lends itself nicely to a step-wise simulator, lengthier, more complex procedures can be adapted and presented in similar fashion, even if only in parts. For instance, consider a notoriously difficult, multi-layered procedure like cleft lip/palate repair. Cognitive task analysis simulators can adapt critical elements of this procedure to the user, even without providing tactile feedback.  It may be less ideal than the combined, biofeedback experience, but this virtual review is certain to leave the resident better prepared for the operating room.

It would be a mistake to believe that simulation can replace the innumerable lessons learned from the real operating room.  However, its role in training should not be underestimated.  The operating room is an environment with high stakes, high stress, and often unexpected complexity, and residents need to be prepared. The advanced simulators of today and tomorrow will blur the line between the virtual OR and the real OR.  As trainees, we stand to benefit from these advances to become more proficient, more comfortable, and better equipped to work with patients.



  1. Passiment M, Sacks H, Huang G. Medical simulation in medical education: Results of an AAMC survey.
  2. Gurtner GC, Neligan PC. Plastic Surgery, 3rd: Volume One: Principles. Saunders 2012.
  3. Phoebe Arbogast and Joseph Rosen (2012). Simulation in plastic surgery training: Past, present, and future, Current Concepts in Plastic Surgery, Dr. Frank Agullo (Ed.). InTech, Available from:
  4. Carey JN, Rommer E, Sheckter C, et al. Simulation of plastic surgery and microvascular procedures using perfused fresh human cadavers. J Plast Reconstr Aesthet Surg 2014;67(2):e42-8.
  5. Matthes AG, Perin LF, Rancati A, da Fonseca L, Lyra M. Mastotrainer: new training project for breast aesthetic and reconstructive surgery. Plast Reconstr Surg 2012;130(3):502e-4e.
  6. Cutting C et al. Use of a three-dimensional computer graphic animation to illustrate cleft lip and palate surgery. Comp Aid Surg 2002;7:326-31.
  7. Stern C, Oliker A, Napier Z, et al. Integration of surgical simulation in plastic surgery residency training. Stud health technol inform 2012;173:497-9.
  8. Long SA, Stern CS, Napier Z, et al. Educational efficacy of a procedural surgical simulator in plastic surgery: A phase I multicenter study. Plast Reconstr Surg 201;132:4S-1,13.
  9. Pugh C in “Play is not a waste of time.” TEDMed Live 2014: 146 Nations Unlocking Imagination. San Francisco 2014.


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