Training Surgeons for Rectal Cancer Surgery: Clinical and Simulation

Fig. 43.1

The learning curve for self-taught laparoscopic colorectal surgery is up to 150 procedures (Adapted from Miskovic et al. [1])

43.2 Educational Challenges in Rectal Cancer Surgery

Rectal cancer surgery conveys training challenges on an anatomical, technological and oncological level:

Anatomy: the pelvic anatomy is compact, complex and difficult to conceptualize. Anatomical landmarks of the oncological TME (total mesorectal excision) planes are subtle and failure in recognizing them can have a significant impact on outcome [2]. The three dimensional relationship of visible and hidden structures in the pelvis requires a high degree of spatial imagery. The understanding of anatomical variations (e.g. gender-specific configuration of the pelvis) can significantly increase the surgical complexity of a case. Surgical anatomy teaching for rectal cancer surgery needs to embrace spatial learning methods.
Technology: Minimally-invasive surgery is increasingly accepted as the standard approach for colorectal cancer surgery. Laparoscopic surgery is particularly difficult in the pelvis due to the limited range of movements of the long rigid instruments in a narrow space. Training in rectal surgery must acknowledge the progression of technology since recent developments in robotic, single-port and trans-anal surgery may require specific training modalities. Psychomotor skill training is essential in rectal cancer surgery.
Clinical and oncology: Rectal cancer surgery is high-risk surgery. Outcomes are related to surgical performance. This implies ethical considerations when training surgeons on patients which have hardly been addressed to date. Oncological outcome (cancer recurrence) is directly linked to the quality of surgical resection. Assessment of surgical specimens has been successfully correlated with long-term oncological outcomes. Training rectal cancer surgery requires a thorough auditing and assessment process.
These factors have an impact on shaping training programs for rectal cancer surgery. In order to enhance the training quality and effectiveness a multimodal approach using cognitive training, simulation, direct supervision and assessment is required. Despite this seemingly obvious statement, most training in rectal cancer surgery is still based on a very basic apprenticeship model and the evidence of comprehensive, multimodal and multifocal training programs is sparse.

43.3 On How We Learn

Traditionally, surgeons show very little interest into educational theories which may be surprising to an outside person as surgeons have a reputation of being talented teachers. However, surgeons are pragmatic people with a short attention span and a tendency to angry irritation when bored with information on seemingly meaningless theory. Nevertheless, understanding some very basic principles and educational theories on how we learn are useful when shaping a training program. This is by far not a comprehensive discussion of educational principles but a summary of some examples that hopefully stimulate the interested reader to explore further.

Observations on Deliberate Practice

The aim of surgical training is to gain expertise in knowledge, decision making, communication and technical skills. Previously, expertise has been thought to be closely linked to volume of experience. However, extensive experience alone has been shown to be a poor predictor of expert performance. Instead it is achieved by undertaking deliberate practice; carrying out repetitive tasks, with a clear goal and constructive feedback, in order to improve a specific skill [3]. The accumulated amount of deliberate practice is closely related to attained performance, taking at least 10 years or 10,000 repetitions to become expert. Therefore the progression of learning, although influenced by talent and innate ability, is primarily due to deliberate practice. It is unlikely that a surgeon would carry out the same operation 10,000 times in a lifetime, and it would be wrong to assume that deliberate practice can only be employed in the operating room (OR). Simulating specific parts of a procedure or certain skills can replace ‘practicing’ on a real patient. The relationship of deliberate practice and OR performance in surgery equates to rehearsal and stage performance for a musician. Experts within their field, be it surgery, sport, music or chess have used repetition to not only accrue knowledge, but also organize this information so that it can be rapidly and consistently accessed [3].

A Journey to Expertise

The brothers Hubert and Stuart Dreyfus have described a popular model for the acquisition of expertise. The Dreyfus model of skill acquisition contains five stages; novice, advanced beginner, competent, proficient and finally expert (Table 43.1). These stages define how an individual progresses from learning knowledge without context to analyzing situations holistically and making decisions intuitively. An important part of this development is reflection on failures and successes in order to learn from one’s experiences [4].

Table 43.1

The progression of knowledge and skill level from novice to expert [4]

	Knowledge	Standard of work	Autonomy	Coping with complexity	Perception of context
Novice	Minimal knowledge without connection to practice	Unsatisfactory unless closely supervised	Needs close supervision	Little or no concept of dealing with complexity	Sees actions in isolation
Advanced beginner	Working knowledge of key aspects of practice	Straightforward tasks completed to an acceptable standard	Some steps achieved using own judgement but supervision needed for overall task	Appreciates complex situations but only able to achieve partial resolution	Sees actions as a series of steps
Competent	Good working and background knowledge of area of practice	Fit for purpose, may lack refinement	Able to achieve most tasks using own judgement	Copes with complex situations through deliberate analysis	Sees actions at least partly in terms of longer-term goals
Proficient	Depth of understanding of discipline and area of practice	Fully acceptable standard achieved routinely	Takes full responsibility for own work	Deals with complex situations holistically, decision making more confident	Sees overall picture and how individual actions fit within it
Expert	Authoritative knowledge of discipline and deep tacit understanding across area of practice	Excellence achieved with relative ease	Able to take responsibility for going beyond existing standards and creating own interpretations	Holistic grasp of complex situations, moves between intuitive and analytical approaches with ease	Sees overall picture and alternative approaches; vision of what may be possible

Construction Work: Proximal Development and Scaffolding

The learning of surgical knowledge and skill can be enhanced by using certain educational strategies. An example is the concept of the ‘zone of proximal development’ introduced by the Russian psychologist Lev Vygotsky [5, 6]. This describes the potential difference in development between problem solving, individually and with guidance from a more capable colleague. Although this was initially described for childhood development it is equally applicable to surgery and describes the difference in learning curves between self-taught and supervised training surgeons. This concept can be further extended into the theory of scaffolding; which explains the process of the more competent trainer providing the skills necessary for individual problem solving and the revoking of assistance when the trainee becomes independent [6, 7]. The transfer of information is also influenced by the teaching modality. Some training methods are more effective than others and this has been detailed in Edgar Dale’s Cone of Experience and more recently in the Miller’s Learning Pyramid [8] (Fig. 43.2). Although the actual retention rates have been contested it would seem prudent when learning technical skills to utilize active rather than passive training methods.

Fig. 43.2

The learning pyramid: active learning styles are more efficient than passive ones (Adapted from National Training Laboratories. Bethel, Maine; with kind permission)

43.4 Training Modalities

Research in Surgical Education has a relative short history and flourished recently with the introduction of novel simulation technologies. Providing evidence for clinical effectiveness of a training method or a whole training curriculum is more difficult than assumed and randomized controlled trials are often impractical and impose ethical dilemmas. Although evidence on simulation technology makes a high proportion of research, a good training program should not rely solely on expensive simulation technology but also make use of other resources—learning opportunities within a clinical setting are readily available but often grossly underused. In the following section we discuss the effectiveness and opportunities of different training modalities and their relevance to rectal cancer surgical training.

Cognitive Training and Mental Practice

According to the Learning Pyramid by Miller the acquisition of knowledge through textbook reading or lectures is highly inefficient. How can we increase the efficiency of cognitive training? A good example of changing a classically passive training domain into an active learning opportunity is mental practice. Mental practice is nothing novel or fancy, in fact most surgeons consciously or more often unconsciously use mental practice methods. This may include mental imagery of certain steps of a procedure or perioperative requirements several days or just minutes before a challenging operation. Just think of that operation you are doing tomorrow or next week and you are already performing mental practice—you are rehearsing the procedure in your mind. Nevertheless, despite this natural behavior, the opportunities of this potentially very effective training method have been poorly studied and insufficiently exploited for surgical training. Other high complexity performers, such as athletes or musicians, have implemented mental practice as an integral part of their training and rehearsing techniques [9]. Current evidence of mental practice in surgical training is based on low complexity procedures (laparoscopic cholecystectomy) for relatively junior trainees demonstrating a potential benefit [10, 11]. Rectal surgery with all its complexities described above lends itself for mental practice. Mental practice can not only be enhanced by using mental practice protocols such as a task analysis of the procedure (breakdown of the procedure into steps) but could be extended to radiologist-guided reviews of CT or MRI scans, review of (interactive) teaching videos and anatomy rehearsals using virtual computer technology. Several techniques have been described previously in parts or as isolated interventions, but there is no consensus on a combined, integrated approach using a multitude of these methods.

Simulation

Surgical simulation has often been compared with commercial or combat pilot training. Nevertheless, the two professions are very dissimilar and the fidelity, realism, controllability and observability of surgical simulation lacks far behind aviation training. So, what surgical skills can be trained through simulation and what simulation modalities are available?

The value of surgical simulation has been increasingly studied over the past 20 years. Advancements in simulation technology have opened new avenues using virtual and augmented reality. However, before purchasing the latest and most sophisticated virtual surgical simulator, it is worth taking a step back to ask the question what is the purpose of simulation. Should it be used for the acquisition of some basic manual skills, for the training of a full procedure or certain steps of it, or can it be used to train whole operating teams?

Skills Training

There is pretty compelling evidence of the effectiveness of simulation training programs for the development of basic laparoscopic skills. The most widely studied such curriculum is the Fundamentals of Laparoscopic Surgery (FLS), which was designed to train basic laparoscopic skills [12, 13]. It is a box trainer system with a competency-based curriculum for five different tasks. This program has been shown to reduce the learning curve and is widely accepted for teaching and assessing laparoscopic skills [12, 13]. Similar results can be achieved with other simulation modalities, such as virtual reality or augmented reality simulations (Fig. 43.3).

Fig. 43.3

Example of a virtual reality simulator. The trainee is using a robotic interface that translates the movements of the surgeon into motion within a virtual reality environment. Haptic feedback to the instruments can enhance the perceived level of reality

Procedural Training

Currently there is no simulation model available for the training of rectal cancer surgery. There have been attempts to construct a low cost model using cheap materials and a virtual reality simulation model, but no commercialized product has emerged yet. Several training centers use animal models and human cadavers for training. Anesthetized, living animals (usually pigs) have the advantage of providing perfused and realistic tissues, however the anatomy is significantly different and the purpose of full procedural training is questionable. Ethical questions arise whether it is necessary to use animals solely for training standard surgical procedures. Trainees and faculty have rated human cadavers to be better in terms of anatomy and training value [14]. The disadvantage of a lacking bloodstream was not considered to be a major disadvantage for training. Special embalming techniques reduce unpleasant smells without compromising the tissue properties [15].

Team Simulation Training

Full OR team simulations can be used to teach team behavior and communication skills. These so-called “non-technical” skills are probably an underestimated entity with a significant impact on surgical outcome. Nevertheless, it may be questionable if the high level of complexity, manpower and investment required to run full theater team simulations is justified for rectal cancer surgery. However, the concept of team simulations could also be applied to other aspects in the area of rectal cancer, such as decision-making exercises for multidisciplinary teams; an example within the UK is the national training program in low rectal cancer surgery (Lorec).

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