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Surgical simulation from bench to bedside: the evidence is stacking up

eosurgical evidence list


An oft quoted retort to purists seeking an evidence base for everything is whether a randomised controlled trial has ever been performed regarding the benefits of using a parachute, or not, when jumping from an aircraft. That trial, of course, will never happen (despite some larking around from the BMJ). On a similar, more pertinent, note we will also never conduct an RCT to see whether removing an extradural haematoma in a comatose patient works. The operation evidently saves lives.

Confirming the efficacy of surgical simulation is more complex. No one has yet done an RCT of being operated on by new-start surgeons - who have never had any simulation training - versus those surgeons who have.  It is increasingly unlikely that such a trial would receive ethical approval, given an evidence ladder that grows more and more compelling.


Each rung is a logical continuation of the next:

Rung one

Rehearsal with a box simulator improves quantifiable performance metrics over time: 

Johnston TJ, Tang B, Alijani A, Tait I, Steele RJ, Ker J, et al. Laparoscopic Surgical Skills are Significantly Improved by the Use of a Portable Laparoscopic Simulator: Results of a Randomized Controlled Trial. World J Surg. 2013 May;37(5):957–64. 

Rung two

Improved skills in a simulator result in improved skills in theatre: 

Dawe SR, Pena GN, Windsor JA, Broeders JA, Cregan PC, Hewett PJ, Maddern GJ. Systematic review of skills transfer after surgical simulation-based training. Br J Surg. 2014 Aug;101(9):1063-76. doi: 10.1002/bjs.9482.

Rung three

Procedures performed by surgeons with superior objectively measured minimally invasive technical skills have better patient-centred post-op outcomes:

Birkmeyer JD, Finks JF, O’Reilly A, Oerline M, Carlin AM, Nunn AR, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013 Oct 9;369(15):1434–42.


In summary, rehearsing on a box simulator improves measurable metrics. Such improvements translate to improved intra-operative skills. Those with better skills have better outcomes. It is intuitively clear, but this evidence ladder helps to spell it out.


Mark Hughes

Consultant Neurosurgeon and Honorary Senior Lecturer, Edinburgh

Director, eoSurgical


Email: mark.hughes@eosurgical.com

Twitter: @eosurgical




Cover photo by Scott Graham on Unsplash