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Deborah L. Benzil, MD, is associate professor at New York Medical College and a neurosurgeon at Westchester Spine and Brain Surgery PLLC, Hartsdale, N.Y. |
Perhaps the greatest impact, however, has been the reorientation of surgical education toward the acquisition of proficiency on models prior to participation on live patients. This approach is now standard in many surgical subspecialties but has yet to become a meaningful component of residency training in neurosurgery. Historically, neurosurgery has embraced such training — for the Midas Rex and spinal instrumentation, for example. Perhaps the time has come to reintroduce this “model” approach to all stages of neurosurgical training.
Instruments of Illumination
Rigid endoscopy was introduced in 1901 and became more widespread after semi-rigid devices became available in the 1930s. These instruments, known as gastroscopes, allowed illumination to be passed into gastrointestinal organs with little instrumentation, though the surgeon’s field of vision was limited, for rudimentary treatments such as polyp resection or biopsy. With the advent of fiber-optic illumination in 1957, the technology began to grow rapidly. Gynecologists expanded the use and indications for endoscopy throughout the 1960s, laying the foundations for general surgeons who finally jumped on board in the 1980s, performing the first laparoscopic cholecystectomies.
Since that time, laparoscopic technology has exploded, ushering in the era of minimally invasive surgery. Lengths of stay have plummeted in hospitals, and every surgical specialty has taken up the call. Minimally invasive surgery has allowed neurosurgeons to enter the ventricle with increasing ease and dexterity. Computer-assisted techniques have led to smaller craniotomy incisions and bone openings. Endoscopic discectomies and thoracoscopic sympathectomies have become part of the standard neurosurgical armamentarium, and neurosurgical patients have gained much by the application of this technology.
Toward a Different Dexterity
Another important change that the endoscopic revolution brought was a redefinition of technical proficiency. The dexterity and skill required to excel in laparoscopic surgery is different than in open surgical procedures. While both procedure types require a thorough understanding of anatomical principles and surgical approaches, endoscopic techniques require a greater ability to understand three-dimensional anatomy. In addition, a greater ability to coordinate both hands is essential, while hand dominance lessens in importance. Directing instruments that are remote from our hands also requires different coordination. In most cases, accomplished laparoscopic surgeons also are excellent at open techniques, but the opposite is not always the case.
The introduction of laparoscopic techniques initially led to high rates of complications, prompting new supervision requirements as well as development of skills laboratories. This new approach allows surgeons to develop proficiency without exposing patients to our learning curve. While the best way to provide surgical simulation is still debated, there is clear evidence that a wide range of skills — from intubation to sentinel node biopsy to reconstructive plastic surgery — are improved when simulators are used for surgical education.
Certainly, endoscopic techniques are not the only ones amenable to using simulators. During the 1960s, the Vermont laboratory of R.M. Peardon Donaghy, MD, provided the first neurosurgical courses in microvascular surgery. Throughout the period from 1970 to 1990, laboratory training for microneurosurgery continued to be required for many of us before entering our senior years of residency. Many neurosurgeons can still recall the numerous sheep scapulas that were requisite training for the Midas Rex. And sawbones were commonly used to demonstrate spinal instrumentation during the explosion of this technology in the 1990s.
At our national meetings, cadavers, simulators and other models for surgical education are still frequently employed, though their use is neither standard nor required. Certainly, current literature strongly supports the use of various models of simulation for surgical training while acknowledging that there are drawbacks to nearly all models. In addition, these studies emphasize that training on models does not guarantee proficiency and should only be viewed as a component of comprehensive education under supervision.
Despite these caveats, perhaps the time has come for neurosurgeons to embrace the successful programs of our surgical colleagues. In this era of work hour restrictions and exploding technology, surgical simulation can help all of us maintain proficiency throughout our careers.
Deborah L. Benzil, MD, is associate professor at New York Medical College and a neurosurgeon at Westchester Spine and Brain Surgery PLLC, Hartsdale, N.Y.