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Overview

Surgery is essential for cancer management. It is estimated that only 20% of cancer patients in middle income countries (LMICs) and <5% in low-income countries can access basic cancer surgery. (1) A stark example of this grave global health disparity is the ever-increasing reservoir of women in LMICs diagnosed with, but unable to access treatment for cervical cancer, the most frequently diagnosed cancer in women who reside in LMICs. A bedrock of cervical cancer management is surgery, however, the supply of women’s oncology surgeons in these high disease incidence/high mortality rate global regions is miniscule, particularly in the settings that have the highest disease burden, such as Eastern and Southern Africa. (2) The result is missed opportunities to prevent unnecessary death and suffering.

Traditional models of surgical training have failed to provide the oncologic manpower needed to manage the present cancer crisis and the epidemic predicted to engulf LMIC populations over the next two decades. One of the major barriers to overcoming this problem is the time investment required to build surgical proficiency among surgeons, when using traditional mentor-apprenticeship models. Surgical dexterity is dependent on both psychomotor and cognitive proficiency, manifested in the execution of fine motor movements and the concomitant maintenance of tissue integrity during surgery. Virtual reality surgical simulation aims to create ‘‘pre-trained novices” who have mastered psycho-motor skills, sensory acuity, and to a lesser extent cognitive planning of surgical tasks. (3) Studies of virtual reality training and laparoscopic surgery have shown that the training time needed for a novice to reach the skill level of an intermediately skilled surgeon can be halved. (4) Similarly, virtual reality trained surgeons are much less likely to make errors than those assigned to the standard surgical training. (5) The delivery of a focused, high-intensity surgical oncology training curriculum, by a trained senior surgeon, was found to have immediate impact on the development of surgical proficiency by surgical apprentices. (6) A necessary component of surgical skills transfer is monitoring and measuring surgical proficiency as it is being acquired during the training process. By necessity, the system used for this purpose in LMICs must be reliable, affordable and without need for the physical presence of surgeon mentors, who are very scarce in number. An example is a system that uses video camera recordings of live surgical procedures and computer vision to track physicians’ hand and surgical tool motion with the goal of analyzing surgical dexterity. (7) Our goal is to build on these findings and to investigate, through our proposed research, whether a novel surgical training method incorporating virtual reality simulation and web-based mentoring/monitoring has the potential to exponentially increase the production of oncologic surgical manpower in high burden, low resource global regions.

References

Sullivan R, Alatise O, Anderson B, Audicio R, Autier P, Aggarwal A, Balch C, Brennan M, Dare A, D’Cruz A, Eggermont A, Fleming K, Gueye S, Hagander L, Herrera C, Holmer H, Ilbawi A, Jarnheimer A, Ji Jai-fu, Kingham T, Liberman J, Leather A, Meara J, Mukhopadhyay S, Murthy S, Omar S, Parham G, Pramesh C, Riviello R, Rodin D, Santini L, Shrikhande S, Shrime M, Thomas R, Tsunoda A, Watters D, Wang S, Wu Yi-Long, van de Velde C, Veronesi U, Vijaykumar D, Zeiton M, Purushotham A. Delivering safe and affordable cancer surgery to all. The Lancet Oncology Commission on Global Cancer Surgery. Lancet Oncol. 2015 Sep;16(11):1193-224.

Globocan 2014 Fact Sheet

Gallagher AG, Ritter EM, Champion H, Higgins G, Friend MP, Moses G, et al. Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Ann Surg 2005;241(2):364–72.

Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Bansal VK, Andersen DK, Satava RM. Reality training improves operating room performance: Results of a randomized, double-blinded study. Annals of Surgery: 2002;236(4):458-64.

Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T, Schouenbourg L, Ottosen C, et al. Effect of virtual reality training on laparoscopic surgery: randomized controlled trial. BMJ 2009;338:b1802.

Elit LM, Rosen B, Jimenez W, Giede C, Cybulska P, Sinasac S, Dodge J, Ayush E, Omenge O, Bernardini M, Finlayson S, McAlpine J, Miller D. International Community of Practice Committee of the Society of Gynecologic Oncology of Canada. Teaching cervical cancer surgery in low- or middle-resource countries. Int J Gynecol Cancer. 2010 Dec;20(9):1604-8.

Gurusamy K, Aggarwal R, Palanivelu L, Davidson B R. Systematic review of randomized controlled trials on the effectiveness of virtual reality training for laparoscopic surgery. The British Journal of Surgery:2008;95(9):1088-9.