An evaluation of live porcine simulation training for robotic surgery

Animals have long been used by surgeons to practice and develop their skills. Yet with the development of virtual reality (VR) and synthetic models, simulation using live animals has become increasingly uncommon. Animal models offer some of the most realistic training models available to surgeons and their teams. These advantages must be weight against a number of moral, ethical and regulatory limitations. The major advantage of animal models is the anatomical similarities and, more importantly, the verisimilitude of the tissues. Simulation training must engage with the complexity and unruliness of real life [1]. This is uniquely offered by live animal models. A wide range of skills ranging from port placement for optimal exposure, cutting, dissection, coagulation and suturing may be practised. Furthermore, using animals for training accurately simulates bleeding enabling the simulation of intraoperative complications [2]. Especially for complications, the reduced clinical experience as a result of the regulatory change in working time has meant that many residents will not be exposed to rare but major complications during training.

Wet laboratory simulation requires dedicated facilities and personnel to ensure that training can be conducted in accordance with ethical and regulatory requirements. The use of animals for training, as for all animal experimentation, must be carefully considered. The principle arguments against the use of live animals for surgical training encompass the ethical and moral objectives to harming animals. If suitable alternatives exist, it is difficult to justify the use of live animals for simulation purposes. The 2002 statement from the American College of Surgeons outlines a similar position that “wherever feasible, alternatives to the use of live animals should be developed and employed”. The college does go on to say that “now and in the foreseeable future it is not possible to completely replace the use of animals ….[in] education and teaching”. Hence, until simulators are able to realistically model the unruly human body accurately, a role for live animal training will continue. For laparoscopic and robotic training, porcine models are most commonly used given the anatomical similarity to humans. Yet to date, only limited assessment of the role of live animal simulation has been undertaken. This study aimed to evaluate the role of live animal simulation for robotic surgical training through a qualitative and quantitative survey of participants at a live porcine robotic training course.

A cross-sectional survey was used to analyse both the population of surgeons undertaking live animal robotic surgical training and the effectiveness of the training programme. The study has highlighted a number of important considerations for porcine robotic training. Despite the course providing relatively advanced robotic skills training, itself a subspecialist surgical field, the majority of participants were in the early stages of their residency training. This was further reflected in low pre-course skill and robotic surgical experience. Trainees had completed limited amounts of robotic training prior to the course. Over 25% of participants (n = 10) had no robotic simulation experience. 41% (n = 16) had used only one simulation training modality of which 6 participants had used only e-learning and undertaken no practical training. In total 16 participants (41%) had not previously undertaken any hands-on training in robotic surgery and had a median console experience of 0 robotic cases.

Live animal simulation has considerable limitations. The main barriers to undertaking such training are the costs and capital requirements necessary to support an animal laboratory. As discussed above full veterinary support is indispensable. From a practical point of view, an appropriate venue is also important. Whilst simulation laboratories are often relegated to a dark corner of the hospital, for animal training well ventilated and spacious premises are required [3]. As a result, it is important to establish the unique benefits of using live animals over other forms of training. The advantages of responsive tissues and the ability to manage complications are not relevant to all trainees. For initial basic training, the emphasis lies on gaining the correct psychomotor skills that can be effectively provided with benchtop models. As our results show, porcine training is attractive to surgeons of all experiences. However, to ensure the optimal use of porcine models, restricting trainees to those with more experience may need to be considered. Combining live porcine training with basic skill workshops using benchtop stimulators could also be considered to allow participants to gain a minimum level of technical ability before the course. It is not surprising that studies of live animal training frequently high satisfaction scores; the ability to practise on a live animal is clearly attractive [4, 5]. Shetty et al. postulated that differences were due to simpler dry and VR models being less stimulating. It is therefore important to note the lower satisfaction scores of the nephrectomy training in particular. This is likely to be due to anatomical variations in swine. The absence of retroperitoneal or perinephric fat in pigs means that nephrectomy is substantial easier to perform than in humans. A study comparing cadaveric to live animal urological training reported that human cadavers were preferred over live animals [6].

Limitations to this study should be considered. A relatively large cohort of participants were included in the survey in comparison with similar studies [7, 8]. Yet the low response rate means selection bias needs to be taken into account. Attempts were made to counter and reduce potential bias; the survey was designed to avoid leading questions and required a variety of response types to prevent acquiescent responses. The high rate of responses to blank box questions supports the active participation of respondents in this survey and the value of the results. Self-reported outcomes are also not equitable to objective assessments of training outcomes but do provide useful insights in the perceived usefulness and acceptability of training. Finally, as the survey included participants from a number of years, recall bias needs also to be considered.

This cross-sectional survey of live porcine robotic training demonstrates it to be a widely valued, acceptable and feasible form of advanced robotic skills training. Despite the relative inexperience of participants prior to undertaking the course, significant improvements in self-assessed outcomes were reported. This was mirrored by high rates of further training and robotic surgical experience undertaken by the trainees. The results of this survey support the use of live porcine training for robotic surgery. Limitations principally due to the cost and infrastructure required to provide mean that careful consideration is required for its implementation in robotic training programmes. Training is best delivered to intermediate and advanced robotic training to ensure the unique benefits of live animal training are realised.