Why do they need to end their plans to use live sheep for training?
We are concerned for two main reasons: for the well-being of future human patients, and the wellbeing of the sheep they are performing surgery on.
During the laparoscopic training workshop using live sheep, the lack of repetition and independent assessment may have a detrimental impact on the trainees. There are many laparoscopic box trainers and Virtual Reality simulators that would allow trainees to repeatedly attempt new surgical skills, and these training tools can objectively assess the trainee’s performance. This data could be used to ensure the trainee is improving, and compare their performance with others within the cohort.
The independent nature of these assessments also has the advantage of ensuring that only the best surgical techniques are conveyed throughout the training. Preventing the transmission of poor surgical practice is surely in the best interest of patients.
Our other concern is for the welfare of the sheep. The Animal Welfare Act (1999) stipulates that one of the primary purposes of this piece of New Zealand Legislation is to promote the replacement of animals with non-sentient teaching apparatuses.
Below we have listed some of the many appropriate training devices which do not use sentient beings, and researchers in peer-reviewed academic publications have illustrated why these trainers are more beneficial and appropriate for laparoscopic training.
It is worrying that despite the existence of these training devices, which could be utilised again and again in RANZCOG training programmes, they have planned to use anaesthetised animals.
We believe that human patients deserve the highest standard of care, and we also believe that RANZCOG should adhere to New Zealand Legislation to ensure their medical and ethical practices meet the highest standards!
Available Human-Based Models for Laparoscopic Surgery
There are many box trainers on the market, designed specifically for the purposes of effective training for laparoscopic surgery. These models are affordable and are effective at helping surgeons acquire basic laparoscopic skills.1Dhariwal et al. promote the use of box trainers based on the results of their 2007 study, where they found that intensive courses using box trainers were highly effective in imparting laparoscopic skills to surgical trainees.2They also argue that:
The advantage of box-training for objective evaluation of basic skills is twofold. First, the scenario for testing is easily reproducible. The performance is not biased by the variations in anatomy or physiologic response found in animals. The exact same test can be repeated in identical fashion at any location at any time. Second, the equipment is inexpensive, reusable and easy to set up quickly without an experienced staff.3
There are many box trainers currently available, we have included a selection below:
As Dhariwal et al. have explained, laparoscopic box trainers have an advantage over anaesthetised animal models as the testing scenario is highly reproducible and data is collected.4 With box trainers, trainees are able to rehearse the surgical procedure many more times than using animal would allow for, and data is collected to determine whether the trainee has improved.
Virtual Reality Training
Virtual Reality laparoscopic simulators offer many of the same benefits as box trainers. As McCloy and Stone note, in simulators difficulty, can be increased or decreased, performance can be measured, and rich data is compiled for later analysis.5 Virtual Reality trainers are also able to simulate full surgical procedures.6 In both clinical trials and systematic reviews, researchers have found significant evidence to promote VR training for laparoscopic surgery as skills were vastly improved among trainees.7 Larsen et al. particularly advocate the use of VR trainers for surgical gynaecology.8
Human cadaver models are also used for training laparoscopic surgeons. This model has the obvious advantages of anatomy and tissue consistency.9 The drawback of cadaveric models is, of course, the lack of blood flow. Aboud et. all developed a cadaveric model in 2004 that mimics the vascular system by filling the model with artificial blood and inducing pulsation by connecting an intra-aortic balloon pump to the cannulated artery.10 This type of laparoscopic trainer provides a representative anatomical model while also displaying life-like surgical simulation.11
A 2015 study advocates increasing access to laparoscopic trainers for trainees and encourages the use of simulator data to determine whether trainees are ready for surgery.12 Burden et al. argue that simulation of surgery on a laparoscopic box trainer or VR trainer not only greatly improved the technical skills of trainees, but also non-technical skills; the authors surmised that the repetitive nature of the training allowed surgeons to become more automated, and therefore able to focus to a greater degree on other theatre skills.13 Mohtashami, Dadelszen, and Allaire have argued that the ‘apprentice’ model of training is inadequate as poor surgical skills can be easily passed from mentor to mentee.14 These authors note that trainers that can independently assess skills have the advantage of being objective, and encourage trainers to adopt simulators:
Under the apprentice method, translating the planned to the learned is very much mentor dependent. However, with competency-based education using a variety of tools including surgical simulators and with correctly implemented and valid assessment tools to drive learning, greater confluence of the planned and the learned curricula can occur. More competent surgeons will, therefore, emerge from such programs.15
1 Schrueder et al. (2011) p. 208.
2 Dhariwal et al. (2007) accessed online here: www.ncbi.nlm.nih.gov/pmc/articles/PMC2980722/
5 McCloy and Stone (2001) p. 913.
6 Schrueder et al. (2011). P. 208.
7 Grantcharov et. al. (2003) p. 146; Larsen et al. (2012) p. 1015.
8 Larsen et al. (2012) p. 1015.
9 Yiannakopoulou et al. (2015) p. 61.
10 Aboud et al. (2004) p. 501.
11 Ibid., p. 506.
12 Burden et al. (2016) p. 239.
13 Ibid., p. 238.
14 Mohtashami, Dadelszen and Allaire (2011) accessed here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183557/