Aline Joly

HOW TO INTEGRATE SIMULATION IN TRAINING FOR

MAXILLOFACIAL SURGERY RESIDENTS ?

Mémoire pour le DIU de pédagogie médicale

Abstract

Introduction: Simulation is a novate educative process that replaces interaction with real

patients by interaction with artificial models, actors or virtual patients. Thanks to

postgraduate reforms in France, surgical learning is reconsidered in each surgical speciality.

E-learning and simulation have to be included at each step of the teaching.

The aim of this study is to identify how simulation could be included in educative goals for

maxillofacial surgery and to propose this review to the French College of maxillofacial

surgery.

Materials and methods: We reviewed the list of educative goals of the residents’ teaching to

identify those that could be taught with simulation techniques.

We researched on PubMed studies about these educative goals and simulation.

“simulation”, “maxillofacial procedures” and “training” were used for key words. Article with

an abstract in English or French were considered. We also researched training article for each

maxillofacial goal to compare usual teaching and simulation or virtual reality.

Results: We identified 7 goals in the base cycle and 6 in the deepening and consolidation cycles

that could be taught with simulation techniques.

95 articles were selected with these 3 keywords. 21 were included in our study. No study

about microsurgery, tracheotomy and anatomy was found with this keyword research. We

found studies about these goals with specific research extended to other surgical speciality.

Discussion: Despite the development of simulation and virtual reality in surgery training

notably in USA, these innovative techniques are not much used today for French maxillofacial

residents’ training. The ongoing postgraduate reform offers a valuable opportunity to

reconsider how we would like to teach maxillofacial surgery. Because of reduced time for

teaching and highly demanding skills, simulation tools appear as great-value options to

complete conventional approaches.

Introduction:

Historically, residents learned surgical technics on medical books, human cadaveric dissection

and in operating room with a supervisor (Gosh et al. 2015). However, this traditional form of

training questions about didactic efficiency (Desender et al. 2001).

Simulation is a novate educative process that replaces interaction with real patients by

interaction with artificial models, actors or virtual patients (GABA et al, 2004).

The combination of an ever-reducing allocation of time in workplace training with highly

demanding skills has led to the establishment of simulation as an integral part of surgical

training. Mastering these skills cannot be achieved only through observations, as it requires a

significant amount of dexterity and must be practised regularly.

The French National Academy in Medicine and Surgery recommends since 2005 a surgical

learning including medical school lectures, practical training in patient care and in the

operating room and, thirdly, virtual reality training with simulators (Hollender et al., 2005).

Since 2010, HAS, The French National Authority of Health, works on simulation and e-learning

in surgical training and edit some specific recommendations (HAS, best practice guide for

simulation, 2012). Even if the notion of simulation for training is not new, the learning

techniques through simulation have increased in recent years because of the development of

laparoscopy and other new technologies like 3D printer (Breaud et al., 2012).

Thanks to postgraduate reforms in France, surgical learning is reconsidered in each surgical

speciality. E-learning and simulation have to be included at each step of the teaching.

The aim of this study is to identify how simulation could be included in educative goals for

maxillofacial surgery and to propose this review to the French College of maxillofacial surgery.

Materials and methods

During the postgraduate reform of 2017, the College of maxillofacial surgery in France

established a list of educative goals for resident in base (first year), deepening (next 3 years)

and consolidation cycle (last internship year). The goals of the first year of internship (base

cycle) are based on fundamental concept in medicine (patient relationship, anatomy). After

this first year, residents have to be efficient for more and more complicated procedures.

We reviewed the list of educative goals of the residents’ teaching to identify those that could

be taught with simulation techniques.

We also researched on PubMed studies about these educative goals and simulation.

“simulation”, “maxillofacial procedures” and “training” were used for key words. Article with

an abstract in English or French were considered. We also researched training article for each

maxillofacial goal to compare usual teaching and simulation or virtual reality.

Results

We identified 7 goals in the base cycle and 6 in the deepening and consolidation cycles that

could be taught with simulation techniques (Table 1).

95 articles were selected with these 3 keywords. 21 were included in our study. 74 were

excluded. These studies were excluded because no abstract was available or presented

training not for resident. We excluded also studies about 3D planner to prepare difficult

operation for graduate surgeon. No study about microsurgery, tracheotomy and anatomy was

found with this keyword research. We found studies about these goals with specific research

extended to other surgical speciality.

Table 1: Goals identified in base, deepening and consolidation cycle and interest with over

speciality

goal Mutual goal in other surgical

speciality

Base cycle tracheotomy ORL

Cardiac arrest care All speciality

Respiratory distress care All speciality

Announcement of a death All speciality

Announcement of a cancer All speciality

anatomy ORL, plastic surgeon, neurosurgeon

Sutures, local skin flap ORL, plastic surgeon

Deepening and

consolidation cycle

Upper airways endoscopy ORL

Craniofacial fractures Neurosurgeon, plastic surgeon

Orthognatic surgery

Cleft lip repair Plastic surgeon

microsurgery All surgical speciality

implantology dentist

Emergency care (cardiac arrest, respiratory distress):

Introduction of training to critical life-threatening emergency situations on high-

fidelity patient simulators seems to be very efficient in medical or dental students (Roy et al.,

2017; Onan et al., 2017). Simulation platforms offer scenarios for emergency care and

dummies that can help improve critical time management, decision-making, communication

and handover between medical and paramedical actors (Annex 1).

A serious game like Staying Alive could be proposed for maxillofacial resident in partnership

with nurse student to improve communication and cooperation.

Relationship with patient (announcement of a death or cancer)

Empathy is a fundamental quality in therapeutic relationship and is very important for

therapeutic adherence. Teaching empathy to medical or nurse students demonstrates its

effectiveness (Batt-Rawden et al., 2013; Bas-Samiento et al., 2017). We propose to develop

scenarios with actor especially about announcement of a death or a cancer (Annex 2).

Anatomy

Craniofacial anatomy is very complex to understand because of internal spaces and cavities

and the presence of a lot of bones, muscles and vessels closely interlinked. Students also face

difficulties to understand craniofacial fractures. In perineal anatomy, 3D virtual simulator

combined with an anatomic dummy demonstrated a better understanding (Legendre et al.,

2014). In maxillofacial surgery, no anatomical virtual simulator is available. Students learn on

CT-Scanners or on medical books. Dr Hossein Khonsari (maxillofacial surgeon) and Donatien

Aubert (doctoral student in numerical art) are about to develop an anatomical virtual project

with ILUMENS platform (Picture 1). Student will be able to walk through a real skull with and

without fractures.

Picture 1 : 3D virtual reality project develop by R. Khonsari and D. Aubert. With patient’s CT

scan, they created a virtual skull representation. Student could walk through the skull and

visualise anatomy or carniofacial fractures.

Tracheotomy

No efficient virtual simulator model for tracheotomy was found in this review. A study about

ovine model demonstrated that fresh ovine tissue is anatomically compatible for training

(Ianacone et al., 2016). At this time, human cadaveric dissection is the gold standard but ovine

model must be taken into account because of availability and affordable price as compared

with human model.

Sutures and local skin flap

Usually, residents learn suture on animal tissue or on human cadaver. A virtual simulator could

be a more affordable and repeatable solution. In a pioneering article on the subject, Pieper et

al. were the first to describe the use of the finite element method to simulate local skin flaps

(Pieper et al., 1995). Over time, simulators became more and more realistic and included

haptic feedback (Mitchell et al., 2016, Picture 2). At the beginning of the internship, teaching

local skin flap with a surgical simulator seems to be an ethical and affordable alternative to

human cadaver.

Picture 2 : A real-time local flap simulator. Plasty to closure a large ovoid scalp defect

Upper airways endoscopy

Upper airways dummies (Woo et al., 2017) and virtual reality simulators (De Oliveira et al.,

2013, picture 3) have been developed for E.N.T and anaesthesiologists needs. They could

easily be adapted to teach upper airways endoscopy to maxillofacial residents.

Picture 3 : Virtual simulation for fibroptic intubation. This software could be use for upper

airways endoscopy for maxillofacial residents.

Craniofacial fractures or reconstruction

Surgeon must be very careful to apply appropriate forces and operate at appropriate speeds

in maxillofacial procedures. Inexperienced surgeons need a long-time practice to learn how to

minimize the risks caused by the uncontrolled contacts and cutting motions in manipulation

of instruments with high-speed reciprocation or rotation.

High-fidelity visual and haptic feedbacks are provided to enhance the perception in a realistic

virtual surgical environment. A lot of maxillofacial training simulators have been developed to

apply appropriate forces for drilling, milling or sawing with efficient results (Wang et al., 2012;

Schartzman et al., 2014; Lin et al., 2014; Hollensteiner et al., 2017; Lichtenstein et al., 2017;

Picture 4a)

Specific virtual simulators with or without haptic feedback were also developed for orbital

reconstruction (Khelemsky et al., 2017) (Picture 4b)

Picture 4a : simulator with virtual reality and haptic feedback for maxillofacial fractures

management training.

Picture 4b : a virtual training on Iphone or Ipad for orbital floor defect training.

Orthognatic surgery

Like maxillofacial fractures, simulation in orthognatic surgery is important to develop surgical

skills. Training simulators with virtual reality and haptic feedback (Picture 5) were created for

bilateral split osteotomy (Sofronia et al., 2013) and for Le-Fort I osteotomy (Wu et al., 2014).

Combined with maxillofacial fractures and orthognatic surgery, a training simulator with

different surgical techniques seems to be a positive and great-value investment.

Picture 5 : simulator for Le-Fort 1 procedure with haptic feedback (a) and virtual reality (b)

Microsurgery

Studies demonstrated that the competency of residents improves to a level comparable to

that of experts after intensive repetition of anastomoses over a relatively short space of time,

which is inversely proportional to the previous experience of the trainee (Lascar et al., 2007).

Usually, residents in surgery learn microsurgery during a specific university degree. They use

different simulation models with low-fidelity (surgical gauze, rubber glove...) or high-fidelity

like human cadaveric or alive animals. Studies showed that low-fidelity models were a good

great-value simulator for beginner residents and cadavers or alive animals have to be reserved

for more experimented residents (Evgeniou et al., 2017). A human vascularised and ventilated

cadaver (simLife, Delpech et al., 2016) was created to learn surgical procedures in a better

realistic simulation context, but this model is expensive (2,000 euros per student). If this

model is to be used in maxillofacial resident training, it has to be reserved for very last

simulation and evaluation.

Implantology

Many simulators were developed for dentist training. For maxillofacial resident goals, we can

use simulators developed for implantology. The ideal training combines 3D planning (like

Simplant) and a simulator with virtual reality and haptic feedback (Afshari et al., 2017). A

collaboration with the Faculty of Dentistry could help reduce costs.

Cleft lip repair

Cleft lip repair is a very careful procedure. Usually, students train on photos of faces to identify

the anatomical landmarks of the cleft lip. But this technique excludes 3D topography and

depends on photo quality. Zheng et al., 2015 offered an interesting silicone cleft lip model to

draw anatomical landmark and training on incisions and surgical techniques, Picture 6.

Picture 6 : silicone cleft lip model before and after training surgery.

Discussion

Despite the development of simulation and virtual reality in surgery training notably in USA,

these innovative techniques are not much used today for French maxillofacial residents

training. The ongoing postgraduate reform offers a valuable opportunity to reconsider how

we would like to teach maxillofacial surgery. Because of reduced time for teaching and highly

demanding skills, simulation tools appear as great-value options to complete conventional

approaches.

The medicolegal and economic impact of simulation training prior to certification in certain

specialties or for ‘‘high risk’’ techniques is now well-recognized (Gallagher et al., 2004).

Moreover, patients may feel reassured to know that their surgeon has trained on a simulator

before performing an invasive procedure on their body (Graber et al., 2005).

With time, simulation training could become a medicolegal certificate to perform specific

procedures or to evaluate residents. Investment could also be beneficial for younger medical

students (anatomy, sutures, 3D fractures reconstruction) or for graduated surgeon in ongoing

training.

Thanks to progress on haptic feedback and graphic resolution, simulators are a more efficient

tool to surgery training.

However, not many comparative studies were published specially in maxillofacial surgery.

Ioannou et al., 2015 found that oral surgical technique training on a simulator is similar that

training on an ovine setting. More comparative studies and research with cost-benefit analysis

are required.

Whatever the final choice of the college of maxillofacial surgery, this education programme

has to be evaluated on resident satisfaction and profit for surgical skill acquisitions

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Annex 1: example of simulation platform offer

Annex 2: Scenario with actors for announcement of a cancer, template found on urgences-

simulation.com.

Nom du scénario : Annonce d’un cancer

Objectifs pédagogiques Médicaux Empathie Information claire et simple

Briefing général : Un paient de 55 ans alcoolo-tabagique, vous a consulté la semaine dernière pour une ulcération endobuccale qui ne cicatrise pas depuis 1 mois. La lésion est ulcéro-bourgeonnante et vous décidez de réaliser une biospie. Vous revoyez votre patient au bout d’une semaine avec les résultats. Il s’agit d’un carcinome épidermoide de haut grade. Vous devez lui annoncer le diagnotic et la suite de la prise en charge.

Formateurs, apprenants et rôles

Débriefing : …avec les formateurs (chirurgiens maxillofaciaux qualifiés, psychologue)

Nombre d’apprenant : …1……………………………………………………………………………………………

Acteurs : ………2………………………………………………………………………………………

Préparation de la salle Environnement type : un bureau, trois chaises (une pour le médecin, deux pour patient et un accompagnant, sa femme) Le dossier médical La feuille de résultat de l’analyse anatomopathologique Telephone

Fiche acteur patient • Nom, âge, sexe :

Roger Dupont, 55 ans

• Comportement et état émotionnel :

angoissé

• Contexte social, professionnel, habitudes de vie

Alcool : 3 verres par repas

Tabac : 1 paquet par jour depuis 30 ans, 30 PA

• ATCD particuliers :

Fracture de la cheville il y a 3 ans

• Idées que le patient se fait du problème actuel – Inquiet? oui

– Impact sur sa vie? oui

– Attentes envers la prise en charge

Peur du cancer, de la chimio surtout

• Interactions avec les autres membres présents lors de la

simulation (femme)

La femme pose beaucoup de question. Le mari reste assez

mutique

• Mise en œuvre du jeu de rôle – Jean et chemise à carreaux pour le mari

– Robe à fleur pour la femme

• Fils conducteur du scénario – Indices attendus/à donner

3 informations :

– Cancer

– Bilan d’extension

– RCP pour meilleur traitement : chirurgie ou radiothérapie ou

chimiothérapie

– Phrases précises attendues par le médecin :

– Cancer de la bouche au début du scénario

– Bilan à la recherche d’autre localisation :

Scanner

Panendoscopie= aller regarder dans toute la bouche juqu’à l’entrée

de l’œsophage sous anesthésie générale

– Avec tous ces résultats, réunion avec plusieurs spécialistes pour

savoir quel est le traitement le plus adapté à la situation de

monsieur

– Traitement possible : chirurgie, radiothérapie, chimiothérapie

– Consultation infirmière pour refaire le point à proposer en fin de

consultation

– Fin du scénario Vous allez refaire le point avec une infirmière du service. N’hésitez

pas si vous avez des questions à lui poser ou lui demander de

revenir vers moi.

Déroulé du scénario Accueil le médecin doit débrancher le téléphone Annonce du diagnostic, le patient est mutique, sa femme pleure et vous demande si il va mourir ? A quoi cela est du ? Explications du bilan d’extension RCP Traitement possible A la fin de la consultation, le patient vous demande si c’est grave. Si il sera encore là à Noel ? (nous sommes en Aout) Phrases simples et mots simples ne pas faire utiliser de jargon médical