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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 14-15

Teaching of cardiac surgery: Learning of complex surgical skills on simulators (simulation) to acquire competency


1 German Heart Centre Berlin, Berlin, Germany; Department of Cardiothoracic Surgery, Faculty of Health Sciences, Bloemfontein, South Africa; Pan-African Society for Cardiothoracic Surgery
2 Department of Cardiothoracic Surgery, Faculty of Health Sciences, Bloemfontein, South Africa; Pan-African Society for Cardiothoracic Surgery, South Africa
3 Department of Cardiothoracic Surgery, Faculty of Health Sciences, Bloemfontein, South Africa; Pan-African Society for Cardiothoracic Surgery; Department of Surgery, University Hospital Zürich, Zürich, Switzerland

Date of Web Publication1-Oct-2019

Correspondence Address:
Prof. Charles Yankah
German Heart Centre Berlin, Berlin, Germany

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njct.njct_6_19

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  Abstract 


The current restriction on surgical residents' work-hours has resulted in reduced operative exposure, making it more difficult to attain technical proficiency in complex procedures, especially in low-volume centers in Sub-Saharan Africa. The use of adjunctive biological and artificial simulators in training may help overcome these challenges.

Keywords: Cardiac surgery, simulation, skill training


How to cite this article:
Yankah C, Smit F, Mestres CA. Teaching of cardiac surgery: Learning of complex surgical skills on simulators (simulation) to acquire competency. Niger J Cardiovasc Thorac Surg 2019;4:14-5

How to cite this URL:
Yankah C, Smit F, Mestres CA. Teaching of cardiac surgery: Learning of complex surgical skills on simulators (simulation) to acquire competency. Niger J Cardiovasc Thorac Surg [serial online] 2019 [cited 2019 Oct 22];4:14-5. Available from: http://www.nigjourcvtsurg.org/text.asp?2019/4/1/14/268466




  Introduction Top


The current restricted working hours for surgical trainees worldwide limits the frequency of teaching of trainees in the operating room. Therefore, the time (“10,000-h rule”) needed to provide skill training to young surgeons will not be met, especially in low-volume centers in Sub-Saharan Africa. This raises both a national/regional and a global concern.[1],[2] It is recognized that cardiac surgery is very demanding; therefore, young surgeons should be given alternatives to overcome these challenges and develop extraordinary surgical skills and mastery to perform complex cases in the early stage of their professional life.[3]


  Materials and Methods Top


Materials

The work-hour restrictions (37 h in Denmark, 48 h in Europe, and 80 h in the United States) for cardiac surgical trainees reduced from 10,000-h “deliberate repetitive practice” needed to become world class in any field to 6000 h in many countries, e.g., in the UK.

Methods

If we remain in our present work-hour restriction schedules, there will be a need to modify the surgical training curriculum to conform to these duty-hour restrictions to prepare residents optimally for practice.[1]

Biological and artificial simulators

In the past, residents were taught at the Research Laboratory of the Charité, University of Medicine, Berlin, using pigs for installation of cardiopulmonary bypass and various perfusion techniques. Isolated normal pig hearts were used for repetitive anastomosis techniques; practicing aortic, mitral, and tricuspid valve repairs and replacements; aortic allograft root procedures; and coronary artery bypass grafting. Artificial simulators are now available for unlimited use for repetitive practice.[4] The simulation programs were aimed at developing skill sets in new procedures and training of residents as well as experienced surgeons with clear basic knowledge of organ and tissue physiology and the underlying topographic and morbid anatomy of operating structures. Initial profound knowledge of cardiopulmonary bypass and various perfusion techniques is imperative to mastery of cardiac surgery by trainee surgeons.


  Results Top


The skill set development for various techniques such as surgical accesses for conventional and minimally invasive procedures, reconstruction of the left ventricular outflow tract (LVOT) and multi-level aortic segments (ascending, arch, and descending) including the aortic homograft and other aortic root surgery, right ventricular outflow tract (RVOT), atrial septal defect (ASD) and ventricular septal defect (VSD) closure, atrioventricular canal, mitral and tricuspid valve repair, and coronary artery bypass grafting can be learned by providing a format for deliberate repetitive practice on biological and artificial “simulators.”[3]

Besides the operating room, adjunctive psychomotor skill set is acquired at biological and artificial simulation for skill training programs. Long-learning curve is minimized and the young generation surgeons can do complex operations so that mastery of true skill set proficiency is acquired in a reasonable time-frame with low rate of procedural-related complications and morbidity.[3],[4],[5],[6]


  Discussion Top


It is amazing that cardiac surgery, as a series of psychomotor skill sets, is still being taught almost exclusively in the operating room, where one requirement for psychomotor skill set acquisition – deliberate repetitive practice – is quite impossible, except for relatively simple procedures.[3]

This explains in part why we have a relative shortage of the technical expertise who need long-term tutorial guidance to train with a relatively long-learning curve to do complex operations such as mitral valve repair and the various aortic procedures (LVOT – aortic root and ascending, arch, and descending aorta), RVOT, and ASD I and VSD closures.

The solution is to introduce the surgical skill training programs on simulators and to acquire adjunctive psychomotor skill set. The curriculum for the trainees, especially in low-volume centers like in Africa, should provide 10% (400 h) of the 4000 h missing from the “10,000-h rule” for skill training on simulators to ensure competence for good surgical practice.

The surgical training program requires competency-based curriculum that would ensure that a surgical trainee is, in fact, safe and proficient and ready to transition into practice.[3],[7]

The challenge for the future is to minimize the long-learning curve by empowering young generation surgeons to do complex operations so that mastery of true skill set proficiency is acquired in a reasonable time-frame with low rate of procedural-related complications and morbidity.[3],[4],[5]


  Conclusion Top


Surgical residents are expected to assist and perform procedures, under tutorial guidance today; however, the complex operations simply cannot be learned exclusively in the operating room. There are just too many procedural steps to master. Simulation has, therefore, become the compliment and supplement to the operating room for this “deliberate repetitive practice skill set acquisition.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Purcell Jackson G, Tarpley JL. How long does it take to train a surgeon? BMJ 2009;339:b4260.  Back to cited text no. 1
    
2.
Mestres CA, Revuelta JM, Yankah AC. The European working time directive: Quo vadis? A well-planned and organized assassination of surgery. Eur J Cardiothorac Surg 2006;30:571-3.  Back to cited text no. 2
    
3.
Feins RH, Burkhart HM, Conte JV, Coore DN, Fann JI, Hicks GL Jr., et al. Simulation-based training in cardiac surgery. Ann Thorac Surg 2017;103:312-21.  Back to cited text no. 3
    
4.
Yankah AC, Pasic M, Klose H, Siniawski H, Weng Y, Hetzer R, et al. Homograft reconstruction of the aortic root for endocarditis with periannular abscess: A 17-year study. Eur J Cardiothorac Surg 2005;28:69-75.  Back to cited text no. 4
    
5.
Yankah AC. Forty years of homograft surgery. Asian Cardiovasc Thorac Ann 2002;10:97-100.  Back to cited text no. 5
    
6.
Rocha e Silva R, Lourenção A Jr. Goncharov M, Jatene FB. Low cost simulator for heart surgery training. Braz J Cardiovasc Surg 2016;31:449-53.  Back to cited text no. 6
    
7.
Northrup WF 3rd. Aortic homograft for treatment of aortic root endocarditis with concomitant mitral valve destruction. Ann Thorac Surg 2010;90:1395-6.  Back to cited text no. 7
    




 

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Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References

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