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BMJ - Surgical simulation training is crucial in covid-19 era

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Posted by Helen Hanson. 16th December 2021

Rapid Response to:

Surgical simulation training is crucial in the covid-19 era and beyond – an augmented-reality solution.

Published December 2021

Dear Editor

Naughton and colleagues kindly responded to Munro et al’s strategies for mitigating the negative effects of the pandemic on surgical training with a focus on developing simulation opportunities [1,2].

Surgical skills are traditionally learned by surgeons through repeated practice on patients [3]. This is a time-consuming, costly and ineffective process with potential negative impact on our patients. During COVID this situation has worsened due to a lack of ability for surgical trainees to operate secondary to redeployment of staff and services. This was compounded by the impact of social distancing on traditional simulated training modalities with simulation centres closed during the pandemic. Even prior to COVID, access to simulation centres was highly limited due to costs with a lack of comparable alternatives for accessible distance learning [4]. This means we can no longer afford to have most of the surgical learning curve on patients. We cannot rely on studying for an operation from a book, a video, or even an expensive one-off course [5].

The pandemic allowed us to evolve into utilising video conferencing technology to remain productive and to see and hear loved ones. This technology allowed us to incorporate video-linked supervised operative training sessions with a new high fidelity surgical training platform. The laparoscopic simulator includes hardware, a native application and a cloud-based learning management system. This “Augmented Reality – AR” solution meant that we were able to increase accessibility by keeping costs down whilst maintaining high enough fidelity to improve surgeon ability through building muscle memory and technical skill.

We implemented this strategy across multiple deaneries and courses throughout the country by providing each trainee with a simulator which allowed the trainee – once requested by their faculty member – to perform a set of tasks ranging from basic “LapPass” modules all the way to full operations such as laparoscopic appendectomies & hysterectomies. Once complete, objective metrics were provided to the trainees, and furthermore the faculty member could provide subjective comments either in real-time on a live course, or remotely and in retrospect. The overarching aim of training in this manner is to reduce operative time, reduce risk of complications and to save the NHS money.

Needham et al estimated the costs of a laparoscopic appendectomy in 2007 [6]. In combining this data with the PSSRU hospital & HCHS community health services index, and total hospital stay [7,8], we estimated that, following the introduction of Augmented Reality simulated training, the potential cost savings per patient would be £79. The cost saving was derived from the estimated increase in efficiency and reduced complication rates as a result of improved surgical skill. Extrapolating this per patient cost saving across all laparoscopic appendectomy procedures performed across 150 acute trusts [9] the yet-to-be peer-reviewed estimated cost saving to the NHS derived from Augmented Reality training is £117 million per year.

In summary, the pandemic has provided us not only with an opportunity to drive the paradigm shift in surgical training to the benefit of our patients’ safety, but also to provide an opportunity for significant cost savings across the NHS. We believe these are just the first steps in a new era of surgical training.


1. Naughton, A., Higham, A., Ong, A. and Wasik, M., 2021. Surgical simulation training is crucial in the covid-19 era and beyond. BMJ, p.n1301.

2. Munro, C., Burke, J., Allum, W. and Mortensen, N., 2021. Covid-19 leaves surgical training in crisis. BMJ, p.n659.

3. Kneebone, R. and Aggarwal, R., 2009. Surgical training using simulation. BMJ, 338 (may14 2), pp.b1001-b1001.

4. Zendejas, B., Wang, A., Brydges, R., Hamstra, S. and Cook, D., 2013. Cost: The missing outcome in simulation-based medical education research: A systematic review. Surgery, 153(2), pp.160-176.

5. The Royal College of Anaesthetists. 2021. Primary FRCA OSCE. [online] Available at: https://www.rcoa.ac.uk/primary-frca-oscesoe/dates-fees-and-applications-… [Accessed 23 November 2021].

6. Needham, P., Laughlan, K., Botterill, I. and Ambrose, N., 2009. Laparoscopic Appendicectomy: Calculating the Cost. The Annals of The Royal College of Surgeons of England, 91(7), pp.606-608.

7. PSSRU, 2021. Unit Costs of Health and Social Care 2017 | PSSRU. [online] Pssru.ac.uk. Available at: https://www.pssru.ac.uk/project-pages/unit-costs/unit-costs-2017 [Accessed 23 November 2021].

8. van der Voort, M., Heijnsdijk, E. and Gouma, D., 2004. Bowel injury as a complication of laparoscopy. British Journal of Surgery, 91(10), pp.1253-1258.

9. NHS CONFED, 2021. NHS Confederation. NHS statistics, facts and figures. [online] NHSCONFED.org. Available at: https://www.nhsconfed.org/publications/key-statistics-nhs [Accessed 23 November 2021].

Competing interests: We are execs within Inovus Medical LTD. Throughout the inception of this response we have under the guidance from the BMJ sought to avoid any product names or to push any sell. Our intention is to increase awareness of alternative augmented-reality training options to drive the paradigm shift in surgical training away from the patient’s bedside.