WHAT IS SIMULATION? Training experience in aviation and space flight has shown that simulation and virtual reality (VR) can also achieve prominence in training for other high-responsibility fields such as surgery. Since adequate training models for complex operations are not generally available, the necessity for training simulators has become acute in recent years. Dramatic increases in computer performance have made mathematical remodelling of biological and medical reality possible. Trainees can interactively handle familiar surgical instruments and "tools".

WHAT SURGICAL SKILLS CAN BE TRAINED ON SIMULATORS?

Spatial skills: In contrast to open surgery, minimally invasive surgery is much more demanding on the spatial skills of the surgeon. As long as 3-dimensional images are unavailable in the general setting, surgeons involved in minimally invasive surgery have to manage with a 2-dimensional view of the operating site displayed on the monitor. Simulators are excellent tools for training the spatial skills needed in endoscopic surgery in a realistic setting.

Eye-hand coordination: The most important of the psychomotor skills required by a surgeon in performing minimally invasive procedures is
 

eye-hand coordination. MIS differs from open surgery in that the operator does not see his own hands and is initially subject to the fulcrum effect, i.e. the technical reversal of the intended instrument movement. There is evidence that simulator training is the best way of overcoming the dissociation of intention and manual execution.

Anatomy: Another area in which simulation can be useful is the visualization of anatomical details. The less direct information is available from touch and vision, the more important it is to recognize anatomical structures. Simulation makes the recognition of typical changes and the diagnosis of pathological alteration considerably easier.

Complication management: Until now, coping with stress or complications during an operation had to be learnt in theater, where the conditions, according to educational theory, are not at all conducive to learning. Scientific evidence proves that learning potential is highest under moderate stress, but not at the high stress-level that often prevails in an operating room. Stress and complications can be reduced by the use of simulation, to which unforeseen actions can be added under controlled conditions. Thus, the demands on the learners can be modified according to the stage of training and their success rate. The learning curve takes place in the simulator.

ADVANTAGES OF SIMULATION IN SURGICAL TRAINING

Unbiased assessment and feedback: Simulators help to assess and evaluate the performance of
the trainees at any time. This permits a quantitative appraisal of the progress made, which can be depicted as a learning curve.

Repeatability: All simulator sessions can be repeated at any time in a defined identical setting.  Repetition is the best guarantee of a lasting training effect.

Scalability: Simulators allow for the complexity and difficulty of tasks to be scaled to the skills and experience of the trainee.

INTEGRATION OF SIMULATION INTO ESI CURRICULA

The development of motor skills and three-dimensional perception on the simulator is an integral part of all ESI courses and was quickly recognized as a valuable enhancement of laboratory training. In particular, immediate feed back from the exercises enables the trainee to recognize strengths and weaknesses, thereby rapidly improving performance