What Is Minimally Invasive Surgery and How Do You Learn It? Aaron G. Rosenberg Contents Keywords Practical suggestions (cid:129) Practice (cid:129) Criticism (cid:129) HowtoLearnMIS:PracticalSuggestions......... 6 Pressure (cid:129) Multiple learning curves (cid:129) Visuali- IncrementalImprovementThroughPractice......... 6 zation techniques (cid:129) Debriefing (cid:129) Team Practice............................................... 6 approach Criticism.............................................. 6 VariedPressure...................................... 7 Innovationinsurgeryisnotnewandshouldnotbe unexpected. As an example, the history of total AvoidMultipleLearningCurves................... 7 joint replacement has demonstrated continuous Visualization.......................................... 7 evolution, and the relatively high complication Debriefing............................................. 8 rates associated with early prostheses and tech- niques eventually led to the improvement of TeamApproach:Coaching.......................... 8 implants and refinement of the surgical proce- TheFuture............................................ 8 dures. Gradual adoption of these improvements References............................................ 10 andtheireventualdiffusionintothesurgicalcom- munity led to improved success and increased ratesofimplantation[1].Increasedsurgicalexpe- riencewaseventuallyaccompaniedbymorerapid surgical performance and then by the develop- ment of standardized hospitalization protocols, whicheventuallyledtomorerapidrehabilitation and return to function. These benefits are well accepted and can be seen as helping contribute totheestablishmentofamore“consumer-driven” andmedicalpractice. Mostsurgeonswouldagreethatasexperience guides the surgeon to more accurate incision placement, more precise dissection, and more skillful mobilization of structure, the need for wide exposure diminishes. Indeed, less invasive- A.G.Rosenberg(*) nessappearstobeahallmarkofexperiencegained DepartmentofOrthopaedicSurgery,RushMedical withagivenprocedure.Fromahistoricalperspec- College,Chicago,IL,USA e-mail:[email protected] tive, this appears to be true of total hip #SpringerInternationalPublishingSwitzerland2015 1 G.R.Scuderi,A.J.Tria(eds.),MinimallyInvasiveSurgeryinOrthopedics, DOI10.1007/978-3-319-15206-6_1-1 2 A.G.Rosenberg replacement. The operation as initially described Further modifications are then required to over- byCharnleyrequiredtrochantericosteotomy.The comethenewproblemsthatarisefromtheadap- osteotomy served several purposes: generous tation of the innovation. The study of the factors exposure, access to the intramedullary canal for thatleadtotheadoption(andalterations)ofinno- propercomponentplacementandcementpressur- vations has been extensively studied by Rogers ization,andtheabilityofthesurgeonto“tension” and is well described in his landmark work, the theabductorstoimprovestability.However,over DiffusionofInnovation[3]. time, it became apparent that trochanteric non- The trend to less or minimally invasive pro- union and retained trochanteric hardware could cedureshasbeennotedinotherspecialties[4]and be problematic. In attempts to minimize these perhapscanbeseenmostdramaticallyinthefield problems, some worked to develop improved ofinterventionalradiology[5]. techniques for trochanteric fixation. However, It would be fair to say that almost all surgical others went in a different direction, eventually techniques improve over time by leading to less demonstrating that the operation could be invasive approaches, which are frequently performed quite adequately without osteotomy. adopted only reluctantly by the surgical commu- Many purists complained that this was not the nity. For skeptics, it is instructive to review the Charnley operation and that the benefits of tro- careerofDr.KurtSemm[6].Hisreportsofsurgi- chanteric osteotomy were lost. Yet the eventual caltechniqueswereshouteddownatprofessional acceptance of the nonosteotomy approaches by meetings and his lectures were greeted with almost all surgeons performing primary total hip “laughter, derision, and suspicion.” He was for- arthroplasty(THA)inthevastmajorityofcircum- biddentopublishbyhisdean,andhisfirstpapers stanceswouldattesttothefactthatosteotomywas submitted were rejected because they were notrequiredtoachievetheresultthathadcometo “unethical.”ThePresidentoftheGermanSurgical beexpected. Societydemandedthathislicenseberevokedand These developments led to the popularity of he be barred from practice. His associates at the the posterior approach to the hip for THA. Ini- UniversityofKielaskedhimtohavepsycholog- tially, the gluteus maximus tendon insertion into ical testing because his ideas were considered so theposterolateralfemurwasroutinelytakendown radical. Despite this opprobrium, he invented to obtain adequate exposure of the acetabulum. 80 patented surgical devices, published more Indeed, the generous exposure provided by this than 1,000 scientific papers, and developed releasewas needed toadequately controlacetab- dozens of new techniques. His obituary in the ular component position, to reduce bleeding for BritishMedicalJournalhailedhimas“thefather cementinterdigitation,andtoallowpressurization of laparoscopic surgery.” Who today would of acetabular cement. However, this generous choose a standard open cholecystectomy over exposurewasassociatedwithahigherdislocation thebenefitsofthelaparoscopicapproach? ratethanwasseenwiththetrochantericosteotomy Hip replacement is currently being performed technique.Butwiththeadventofimprovedcom- by a variety of minimalist modifications of the ponentdesign(offset)andbetterunderstandingof standard hip approaches as well as by component positioning, as well as the introduc- nontraditional approaches. Knee replacement is tion of cementless techniques,less exposure was similarly being attempted through shorter inci- neededinthemajorityofcases.Eventually,care- sions with various arthrotomy approaches. The fulclosureoftheposteriorstructuresalsoledtoa proponents of all call them minimally invasive, significant reduction in the dislocation rate but this term has really become a catchall and [2]. Seen in this example is a finding typically hasnospecificityoragreed-uponmeaning. notedinthecloseexaminationofmostevolution- The purported benefits of these techniques aryprocesses:initialbenefitsareobtainedatsome include earlier, more rapid, and more complete expenseintheformofnewordifferentcomplica- recoveryoffunction,lessperioperativebleeding, tions or alterations in the complication rate. and improved cosmesis. There has been, to date, WhatIsMinimallyInvasiveSurgeryandHowDoYouLearnIt? 3 few data by other than those proponents of spe- the performance of the technique, as well as a cifictechniquestosubstantiateanyofthesepoten- varyingabilitytotoleratethepotentialcomplica- tial benefits. Of course, these purported benefits tionsencounteredwhileontheso-calledlearning mustbeweighedagainsttheirpotentialtochange curve. Unfortunately, the removal of standard thenatureand/orincidenceofcomplicationsthat visual,auditory,andtactilefeedbackcuesduring mayarisesecondarytothemodificationsofthese the performance of these “less” invasive proce- approaches. dures may require the development of alternate There is general consensus that adoption of cues, which may not be readily available, well new techniques initially results in a greater inci- established,orassimilated[11].Thus,theoverall dence of complications. This is the so-called complication rate may rise while familiarization learningcurve[7,8],wellknowntoallsurgeons with these cues (and the appropriate response to learning a new procedure. Whether this learning them) matures or while alternate methods of curveisextendedorcontractedhasbeenshownto incorporating similar or comparable information depend on both individual and the systemic fea- are developed. As attempts are made to limit the turesoftheoperation[9]. invasiveness of surgical procedures, surgeons Itshouldthereforecomeaslittlesurprisethat, mustbepreparedtocultivateandtakeadvantage in the hands of those initially reporting these ofnontraditionalsensoryfeedbackandotheralter- modified procedures (and presumably who have nate visualization methods to direct their efforts. developedtheirexpertisegraduallyandovercon- As these evolve, it can be expected that surgical siderabletime),thecomplicationratesarecompa- intervention will continue to become less rable to those found in the standard approaches invasive. while others report a higher complication rate Theultimatequestionimpliedinthetitleofthis [10–14]. There has been insufficient time for the chapter,thatis,howtolearnaminimallyinvasive scientificevidencetoaccumulateinsufficientvol- surgery(MIS)technique,canonlybeansweredby ume to clarify the specific benefits and risks of firstunderstandingthecurrentmethodsofsurgical thesemodificationsinthehandsofspecialistsur- training and their relationship to the practice geons,letalonethegeneralistwhoperformsthese requirements of standard orthopedic procedures. procedures. Onlythencanweevaluatethewaythesemethods Clearly,themodernera’scommunicationtech- relatespecificallytotherequirementsofMISand nologies, coupled with more sophisticated mar- so answer the question: Do the specific surgical keting techniques, have dramatically influenced requirements of the MIS procedure require an the speed with which new techniques are recog- alteration in the manner in which we train sur- nized, popularized, and thus demanded by an geons? An additional implied assumption is the easily influenced public. However, continued perception, which appears to be correct but has accumulationofdatathroughtheperformanceof not yet been rigorously established, that the per- appropriate studies will eventually determine the formanceofminimallyinvasiveproceduresinthe most appropriate role for these techniques in the trainingenvironmentsubstantiallyalterstheedu- orthopedic surgeon’s armamentarium [15]. Prior cational experience for the learning surgeon. A tothatoccurrence,whatisthesurgeontodo? series of linked questions is raised that deserves Apurelyprescriptiveapproachisprohibitedby inquiry: (1) What are the performance require- themultifactorialnatureofthesurgicalendeavor. ments for MIS surgery? (2) Do they differ sub- ThevastmajorityofsurgeonswhoperformTHA stantially from that of routine non-MIS surgery on a regular basis have already modified their (beggingthequestionofwhetherwereallyunder- operativeapproachestoincorporatelessinvasive stand these!)? (3) What are the relationships techniques.Eachsurgeonhasanindividualtoler- between surgical training methods and patient anceforandwillingnesstoundergothestruggles outcomes and do we understand these relation- involved in learning a new procedure, differing shipssufficientlywelltoproceedtoalterthemin levels of commitment to the change required for a meaningful fashion? (4) Does the routine 4 A.G.Rosenberg adoption of MIS surgical procedures alter the surgeons[16].Clearly,however,advancesinsur- current teaching environment in a way that is gical technology and technique have led to a deleterious to the learning surgeon? (5) To what renewedinterestintheseissues. extentdotheanswerstotheproceedingquestions While the performance of arthroscopic proce- demand the development of new methods for dureshasresultedinapremiumonspecificthree- surgicalteachingasregardstheMISprocedures? dimensional spacio-visualization and psychomo- And,finally,(6)whatformmightthistake? torapplications[8,17],thesameisnotnecessarily Theoldadage“Ittakes1yeartoteachsomeone true for MIS-type joint replacement procedures. how to operate, 5 years to teach them when to The simple answer to the question regarding the operate,andalifetimetolearnwhennottooper- performance skillsrequirements for MIS surgery ate”seemstomakethepointthat,inthesurgeon’s is that they are basically those that are found in repertoire,itisthepsychomotorskillsthatarethe standardsurgicalproceduresbuttakentoahigher easiestandmostreadilytaught.Theimplicationis level. This arises from specific conditions that that the psychomotor skills required in the oper- appeartobeinherentinMISsurgery[9]. atingroomaresubstantivelydifferent(andeasier to teach) than the cognitive skills required. But 1. Insomerespects,theabilityto“protect”struc- this is clearly simplistic. Surgical performance is turesinthestandardfashionmaybealteredin based on a continuous feedback loop of psycho- specificwaysuniquetothesurgicalprocedure, motor performance intimately coupled with cog- and this may result in a directly proportional nitive function. It is the continuous and ongoing decrease in the margin of error for various making of decisions (albeit almost always at a intraoperativemaneuvers. subconscious level for the experienced) in the 2. Smallerrorsduringthecourseoftheoperation midstofphysicalperformancethatinfluencesthe maybelesseasilyrecognized,andadjustedfor, qualityofthesurgicalintervention. as the procedure progresses, and the implica- Towhatextent thedevelopment ofthese cog- tions of these small errors are potentially nitiveandmotorskills,andtheirinteraction,gov- magnified. erns the eventual outcome is a complex problem 3. Specific anatomic features that increase the that has not yet been fully investigated and degree ofdifficultyencountered intheperfor- remains poorly understood. It has been said, mance of a more “open procedure” (stiffness, “Manymoresurgeonshavedoneavideoanalysis deformity,poortissuequality)maybemagni- oftheirgolfswingthanhaveevaluatedtheiroper- fied when the procedure is performed in a ative performance.” While there are few studies minimallyinvasivefashion. that have effectively evaluated real-time surgical 4. Finally, and perhaps most importantly, the performancecharacteristicsinameaningfulway, developmentofminimallyinvasivetechniques evenmorefundamentallyandunfortunately,there frequentlyinvolvestheremovalordiminution islittleresearchintherealmofsurgicaleducation of traditional feedback signals that surgeons that would help us determine the specific perfor- normally use and have come to rely upon to mancerequirementsformostsurgicalprocedures make continuous adjustments to their perfor- ingeneralandoflessinvasiveproceduresinpar- mance. Thus, skills that are little needed, are ticular. Additionally, there are few data on the infrequently utilized, or have not been previ- pedagogicalaspectsofsurgicalproceduretraining ously recognized become of greater conse- for either minimally or maximally invasive pro- quence.Indeed,thelossofstandardcuesmay cedures.Arecentcomprehensivereviewofexpert need to be compensated for in technique- performance indicates that there has been more specific ways. Ironically, in the hands of the attention directed to the study of musicians, ath- moreexperiencedsurgeon,manyofthesefeed- letes, pilots, and military commanders than to backsignalsarenolonger“conscious,”having WhatIsMinimallyInvasiveSurgeryandHowDoYouLearnIt? 5 been assimilated into almost automatic motor [18]. This pedagogical method, adapted by the responses;thiscanmaketherelearningprocess German surgical schools of Kocher and Billroth, requiredmoredifficult. andmodifiedintheUnitedStatesbyHalsted,has Trainingsurgeonstoperformthesemorediffi- changed relatively little over the years. Thus, culttechniques,bothwithlessroomforerrorand training methodologies used to teach surgical with a different set of feedback signals, would skills remain relatively primitive and have therefore seem to require the development of enjoyed little improvement in either theory or both traditional surgical skills and new ones in practiceoverthedecades.Yetthespecifictechni- ways that guarantee a more demanding perfor- cal requirements of the surgical procedures mancelevelthanhastraditionallybeenrequired. increase steadily. The combined requirements of Thequestionedneedfornewtrainingmethods residency education, that is, service and educa- implies two separate factors that may be driving tion,frequentlyseemtoservethebestinterest of this concern. First, are current training methods neither. Even worse, depending on the specific adequatetothetaskascurrentlyenvisioned?Sec- setting, current training methods may be applied ond,doestheconversioninthetrainingenviron- unevenly and randomly to the resident partici- ment from standard open to MIS procedures pants[19].Thecommon cliché,seeone,doone, degrade the training experience? The answers teach one, seems to summarize the cavalier can be found by evaluating the features of MIS approach to procedural teaching that has been proceduresalreadynoted: the mainstay of surgical pedagogy. Moreover, when real patients are used for surgical teaching 1. Visibility of the surgical field is reduced, purposes, increased morbidity, prolonged inter- compromisingvisualfeedbacknotonlytothe vention times, and suboptimal results may be performing surgeon but also to the learning expected[20].Itisclearthatfuturetechnologies, surgeondependentuponobservationanddem- whethertheybetraditionallysurgicalorotherwise onstrationofanatomyandsurgicalpathology. procedurally interventional, will require more, 2. Loweredmarginsforerrorlimittheopportuni- rather than less, highly structured training and tiesawardedtothelessexperiencedtrainee. assessment methods. It has been demonstrated 3. Thedecreasedabilityoftheinstructortomon- that laparoscopic surgery adapts poorly to the itortraineeperformancedegradesthelearning standardapprenticeshipmodelsforgeneralsurgi- environment. caltraining.Rather,standardizedskillacquisition 4. The alteration of traditional cues and their and validation, performance goals, and a super- replacement with more subtle and poorly vised,enforced,skill-basedcurriculumthatread- defined feedback signals are hallmarks of ily can be shared between trainee and instructor MIStechniques.Thus,thereplacementofstan- are thought to be needed to replace the observa- dardopensurgerybytheMISprocedurewould tionandincrementalskillacquisitionmodelused appear to significantly alter the training inanopensurgicalenvironment[21]. environment. Assumingnodramaticchangeinthenatureof Are the traditional residency education and oureconomyandtheemphasisonhealthcare,itis continuing medical education (CME) surgical notlikelythatthedrivetowardlessinvasivetech- training methods capable of meeting this stan- niques will abate. As technology matures, new dard? The system as currently constituted is and improved techniques for vital structure pro- derived (with little improvement and perhaps tection, component placement and positioning, even development of some newer flaws) from and bone and soft tissue management will come the traditional systems of apprenticeship that on line. As they do, the gradual development of began sometime between the Dark Ages and the improved skill levelsintheperformance of stan- development of city-states in the Renaissance dard procedures coupled with the cautious 6 A.G.Rosenberg adoptionofnewpracticesastheseskillsmatureis practice habits. This is particularly important in warranted. An understanding of the ethical and developinganactionplanforsurgeonswhomay moral responsibilities of the operating surgeon notcurrentlybeperforminganyMISprocedures. mustbeunderstoodastheyrelatetotrainingand surgical performance [22]. An open mind along withacriticaleyewillberequired.Thefollowing Practice suggestionscanbeofferedtothesurgeonwhohas yettoadoptthesetechniques. Correctpracticebeginswiththebreakdownofthe procedure into its component parts, focusing performance-based exercise on those component How toLearn MIS: Practical parts and acquiring and recognizing feedback, Suggestions both during the performance in real time and after. As anexample,surgeonswho arethe most Ithasbeendemonstratedthatdomain-specificand experienced in total knee replacement task-specific skills are not necessarily readily arthroplasty (TKA) frequently perform the vast transferredtonewdomainsortasksinthesurgical majorityoftheneededsofttissuereleasestobal- environment[23–25].Surgeons,likeotheradults, ance the knee during the initial approach and learn best by doing, by practicing what they do, exposureoftheknee.Lessexperiencedsurgeons andbychallengingthemselvestotakeonincreas- tendtomakethesofttissuereleasesaseparatepart ingly difficult scenarios. Practice, in order to be of the technique, independent of the exposure, effective, requires deconstruction of the actual whilethemoreexperiencedsurgeonutilizesfeed- procedure into key elements, each of which is backthroughout theprocedureandemploysitto repeateduntiloptimalresultsareachievedbefore guide thedegree oftissue they arereleasing dur- movingontothenextelement.Thekeyingredient ingtheexposure.Inordertomasterthenewskills to successful practice and ultimate self- that may be required in minimally invasive improvementasasurgeon,asinotherpursuitsin approaches, the surgeon must reenter the mind life,isthatonebeself-motivatedandcompetitive, of the learner that was present at an earlier stage with a strong desire to improve coupled with oftraining.Thebasicstepsmustbeisolated,and appropriate practice routines that can lead to renewedattentionmustbegiven tothedetailsof improvement. This calls to mind the old joke, procedureusedtoisolate thoseparts oftheoper- “Mister, How do I get to Carnegie Hall?” The ation that require more attention, and there must answer,ofcourse,is“practice.” beadetailedfocusonaccomplishingthespecific tasksrequiredateachstepoftheprocedure,spe- cifically, on how they present new or different IncrementalImprovementThrough challenges. Those steps that require the acquisi- Practice tion of new or refined skills can then receive the appropriate attention. The use of computer guid- TheliteratureonCMEprovidesnosupportforthe ance can aggressively strengthen feedback loops hypothesis that didactic CME improves either for surgical technique that might otherwise take practicepatterns,skilllevels,orpatientoutcomes yearstodevelop.Theprecisionofthetechnology –fromthis,onecaninferthat surgeonslearnthe providesobjectiveandexactingcriticism. more complex domain of surgical performance throughrepetitionofprocedures[26].Willingness to engage in repetitive attempts at improving the Criticism qualityofwhatoneisdoingiscrucial.Oneneeds to define clearly the areas requiring practice and Another contributor to effective practice is self- employagradual,repetitivepracticepattern;ulti- grading.Overtime,oneincreasesthepressureon mately, one either improves or must change oneselftoperform,gradestheresult,andseeksto WhatIsMinimallyInvasiveSurgeryandHowDoYouLearnIt? 7 improve.Self-gradingrequiresmeasurement,and example, it would be less than optimal to try a one needs to have some surgical goals in mind, newtechniqueoranewapproachwithnewinstru- such as tourniquet time, time to complete the ments,anewimplantdesign,anewscrubtechni- procedure,orspecificobjective characteristics of cian, and a new surgical assistant all at the same operative performance – cement mantle quality, time.Avoidingmultiplelearningcurvesisessential component position, limb alignment, etc. For inensuringthatthepressureyouexertuponyour- more detail on this technique, see the Debriefing self represents a systematic increase and not an sectionbelow. overload;youcansequentiallyaddmorecomplex- ityandvariationasyougetbetteratwhatyoudo. Varied Pressure Visualization Surgeons can expand or contract the amount of pressureexperienced,becausetheselessinvasive Another important technique that has been well approachesandtheproceduresthemselvesare,for publicized in other areas of psychomotor skill the most part, relatively extensile. Beginning a acquisitionandperformance,butnotaswellpub- TKA as an MIS procedure does not lock the licizedinsurgery,istheuseofvisualizationtech- surgeon into that pathway; if, at any point, the niques. Great athletes will all admit to using surgeon deems the case too complex or the soft visualizationasanimportantpartoftheirpractice tissue considerations are becoming unexpectedly regimen. Similarly, most high-performing sur- difficult,noharmisdonebyincreasingthesizeof geonswillalsorehearsetheoperation,literallyin theincisiontoexpandtheexposure.Surgeonscan their “mind’s eye,” before proceeding with the literally “push the envelope” by working their case. Most of us who perform complex surgery wayfromthelargerincisiondowntothesmaller have the experience of repeatedly reviewing the and, as a consequence, gradually increase the steps and sequences in a new operation before- pressureonthemselves.Butthesurgeoncanalso hand, particularly when learning something reduce that stress when desired or, more impor- completelynew. tantly, when necessary to achieve the optimal Visualizationhasbeenusedinsports,musical surgicaloutcome. performance,andinotherformsofphysicalactiv- ity, including dance and even acrobatic flying. Acrobatic pilots not only visualize the expected Avoid Multiple Learning Curves sequenceofflightmaneuversintheirmindsalong with the control manipulation needed to achieve It is essential to avoid combining multiple learn- them but also assume the corresponding body ing curves when learning a new procedure. The postures, as if they are experiencing the forces outcome of any surgical intervention is clearly associated with the acrobatic flight maneuver. multifactorial. Beyond the limitation of one’s This visualization technique combines psycho- own surgical skill set and one’s intuition, each motor and cognitive skill sets. One can similarly operationencompassesacomplexsetofmultiple see downhill ski racers mentally rehearsing the factors, some of which may remain below the race course, accompanied by hand and body radar screen of the most experienced surgeon. motion. In the same way, surgeons using similar These factors include, but are not limited to, the visualization might “think through” a particular relative contributions of our assistants, the char- operationsequentiallywhileimaginingthepoten- acteristicsofthespecificoperatingroom,andthe tialproblems,structuresatrisk,andspecificgoals typeofanesthesiabeingused.Multiplealterations oftheprocedure,whileactuallypositioningtheir tosuchacomplexsystemaremuchmoredifficult hands as if they were grasping a specific instru- to assimilate than the incremental addition of ment for a specific task during a surgical small changes approached one at a time. For procedure. 8 A.G.Rosenberg Debriefing TheFuture Another self-improvement method involves The characteristics that make up surgical perfor- debriefing, a more formal model for self, group, mance include preoperative, intraoperative, and or mentor after-activity assessment [27, 28]. The postoperativefactors.Whilethefocusonsurgical classicroleofdebriefingisinthemilitary,whereit training must be on all three arenas, it is mainly hasbeenusedforgenerationstotrainandimprove the intraoperative phase, where actual physical the skills of warriors, particularly pilots. skills are required, that is seen by most trainees Debriefing or after-action reviews involve the asbeingtheareawherethereistheleastopportu- meticulous creation of a specific checklist of the nity to develop experience. Experience is ideally goals of any given performance followed by the gained in an environment where feedback is ruthlessassessmentofhowthosegoalswereactu- immediate and mistakes are tolerated as part of allymetduringtheperformance.Debriefingtech- the learning experience. One of the things that niqueshaveapplicationsinteachingresidentsand have prevented surgeons from acquiring greater fellowsaswellasinimprovingone’sownperfor- levels of skill prior to entering practice or even mance. Such sessions have an important role in during practice is the lack of such a practice improvingperformanceatthestepwhereyouare environment. ataswellasinsuccessfullyascendingtheladder Theperformanceofsurgeryitselfisdependent ofsurgicalcomplexity[29]. on performing multiple “subroutines,” most of which have only been available for the surgeon to experience during the performance of actual Team Approach: Coaching surgicalproceduresandthereforepresentthesur- geon with no real opportunity to “practice” the TheMISeffortgenerallyleadstoanappreciation psychomotorskillsrequiredduringtheprocedure. oftheimportanceofteamworkanditsimpacton Inaddition,thereislittleinthewayofimmediate surgical outcome. Perfect performance of the information available to the surgeon during the operation without appropriate attention given to courseoftheoperationthatwouldallowthesur- perioperativefactors,suchaspaincontrol,reha- geon to make the type of adjustments that are bilitation, etc., will not yield an optimal result. based on cause-effects/feedback loops. As noted Similarly,increasedcoordinationbetweenassis- earlier,evenintheperformanceofphysicalskills, tants and surgeon is another requisite for the there are multiple cognitive processes that must successful performance of thismore demanding function correctly and efficiently to maximize type of surgical procedure. Thus, a continuous surgicalperformance. focus on the need for a team approach through- With modern technology, many of the factors out,frompreoperativeconsiderations,tothesur- that contribute to surgical performance can be gical phase, and continuing through to the simulatedandrepeatedlyexperiencedwithimme- postoperativeenvironment,isakeydeterminant diatefeedbackonthecorrectnessofdecisionsand of optimal outcome. Every team needs a coach, behaviors. Development and utilization of this and, in most cases, the responsibility will and technology would be expected to result in any should rest with the surgeon. What do coaches given surgeon moving more rapidly along the do? Their primary role is to create a feedback learning curve, allowing the surgeon to perform loop; this is done by developing performance atahigherlevelduringtheactualsurgicalencoun- expectations, monitoring performance in a criti- ter. Despite the obstacles present to the current cal way, and, finally, providing feedback that employment of actual psychomotor skill simula- leads to improvement and both motivates and tion, these devices will eventually be part of the empowersteammembers. surgical training environment. In the coming era WhatIsMinimallyInvasiveSurgeryandHowDoYouLearnIt? 9 ofvirtualrealityenvironmentsandsurgicaltrain- skill acquisition, several requirements must be ingsimulators,thereisgoodreasontobelievethat met.Thefirstrequirementiscreationofaknowl- the coupling of these technologies to assist the edge base that will be utilized as the cognitive surgeon in acquiring both motor and cognitive foundation for the simulation technology. This skillswillresultinimprovedsurgicalperformance so-called content knowledge currently exists in aswellasimprovedpatientoutcomesasaresultof the mind of the surgeons who currently provide theclinicalencounter. education to trainees as well as in text and tech- Acurrentpotentialmodelforimprovingsurgi- niquemanuals.Second,theknowledgebasemust calresponsivenessandjudgmentcanbeobtained be structured so that it can be represented in an by using the interactive video game as a model. algorithmic format with eventual conversion of Several features of the modern interactive video these algorithms into the type of appropriate game make it both compelling and popular. One branching chain pathway environment, which primary feature is the need for continuous can be made accessible and modifiable at the involvement by the participant. Lapses of atten- computerinterface. Third,multiplesupplemental tion cause failure (or loss to an opponent). This elements must be developed to provide a more needforcontinuousvigilancebytheparticipantis challenging and robust learning environment. structured into the gaming environment. This Fourth, an assessment module with accompany- forcing function of involvement leads to a ing grading mechanism must be developed to “flow” experience that has been described as couple the quality and intensity of the learning exhilarating and involving, compelling attention experience to the performance level and other andparticipation. individualeducationalneedsofthelearner.Work Ashasbeendemonstratedinflightsimulators, on cognitive skill development, as well as visual the same environment, appropriately structured, skill acquisition, can be accomplished with little canbeusedtoimprovebothcognitivejudgments other than content knowledge coupled to appro- andresponsetimes.Theapplicationofstructured priatesoftwareandcomputers.Thisshouldbethe learning experiences in this type of environment initial focus of development efforts for several might be expected to achieve remarkable reasons.First,investmentneednotbeparticularly improvementsininformationtransmission,apri- large for the development of the cognitive skill marygoaloftheeducationalexperience. applications of this technology. Much of the Of additional import is the current status of appropriate software currently exists and is uti- computer-guided and computer-assisted proce- lizedinthevideogamingindustrytostructureand dures to the surgeon’s armamentarium. As these create complex interactive environments where technologies become more widely available, the multiple elements combine to provide an ever- surgeon will need opportunities to practice in the changing and stimulating participatory environ- newenvironmentcreatedbytheadditionofacom- ment. The addition of specific physical skills puterizedguidanceinterfaceduringsurgicalperfor- willfollow. mance. Familiarity with the structure and content Enhancementsthatwillfurtherimprovesurgi- of guidance information, as well as integration of cal performance can also be introduced to this thisinformationwiththetraditionalinputsacquired environment.Appropriatelystructuredtoapprox- duringsurgery,willbeneededtoimprovethereal- imate the real-life decisions and judgments that timeintraoperativejudgmentsandphysicalperfor- the surgeon will be called upon to make, the mance measures needed to perform surgery. This addition of creative elements, such as complica- familiarity can best be accomplished in a highly tion/disaster management, head-to-head or integratedsimulationenvironment. machine-based competition, continuous probing Inordertostructureanenvironmentthatwould forknowledge deficits,andreinforcingfunctions provide for progressive advances in cognitive used to transmit important supplementary and 10 A.G.Rosenberg supportingcontent,willproducearobustlearning 9.McCormick PH, Tanner WA, Keane FB, Tierney environmentthatwillmaketheeducationalexpe- S.Minimallyinvasivetechniquesincommonsurgical procedures: implications for training. Ir J Med Sci. rience engaging, stimulating, challenging, 2003;172(1):27–9. andfun. 10.BergerRA,DuweliusPJ.Thetwo-incisionminimally While there have been progressive advance- invasive total hip arthroplasty: technique and results. ments in surgical technology and techniques OrthopClinNorthAm.2004;35(2):163–72. 11.Hartzband MA. Posterolateral minimal incision for over the past century, there is excellent evidence total hip replacement: technique and early results. that exponentially increasing rates of technology OrthopClinNorthAm.2004;35(2):119–29. growthwillprovideanevermorerapidlygrowing 12.HowellJR,MasriBA,DuncanCP.Minimallyinvasive rateofchangeinthemethodswherebysurgeryis versusstandardincisionanterolateralhipreplacement: acomparativestudy.OrthopClinNorthAm.2004;35 performed. While manual skill performance is (2):153–62. likelytoremainamainstayofthesurgeonsexpe- 13.Wright JM, Crockett HC, Delgado S, Lyman S, rience, increasing reliance on machine perfor- Madsen M, Sculco TP. Mini-incision for total hip mance and even intelligence would seem to be arthroplasty: a prospective, controlled investigation with 5-year follow-up evaluation. J Arthroplasty. likely. The surgeon trained today is not likely to 2004;19(5):538–45. be using technologies similar to those learned 14.Woolson ST, Mow CS, Syquia JF, Lannin JV, during training in the practice environment Schurman DJ. Comparison of primary total hip encountered in 2016. It is incumbent upon the replacementsperformedwithastandardincisionora mini-incision. J Bone Joint Surg Am. 2004;86A surgeon to maintain an adaptable posture toward (7):1353–8. acquiring new skills, as well as to maintain and 15.Callaghan JJ, Crowninshield RD, Greenwald AS, hone current skills in order to prepare for future Lieberman JR, Rosenberg AG, Lewallen developmentsinthefield. DG. 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