A specialist skills laboratory at Oxford’s Nuffield Orthopaedic Centre is developing new ways to train the surgeons of the future. The specialist hospital in Headington is at the forefront of efforts to use simulators to teach trainee surgeons to perform complex operations, as an alternative to them having to learn many of their skills on patients in operating theatres.

Early evidence already suggests “virtual reality” operations improve both patient safety and operation room efficiency. And the NOC is even taking on a computer games specialist to ensure that surgical trainees get to test themselves in conditions that appear as close to the real thing as possible, although they will be working on plastic rather than flesh, bone and muscle.

Flight simulators have long played an important role in training future pilots. And simulation has played a part in medicine over centuries, in the form of simple models of human patients. Representations in clay and stone have been used to demonstrate clinical features of disease states and their effects on humans since antiquity, with models found from many cultures and continents.

Models are increasingly used today to help students learn the anatomy of the musculoskeletal system and organs. But in the past, these simulations were two-dimensional computer programs that acted more like a textbook than a patient.

The potential of modern simulators as an important training tool in surgery has now been recognised by England’s chief medical officer, Sir Liam Donaldson, who has signalled that doctors from a wide range of disciplines should be spending more time training on computer simulators.

He said: “A surgeon trained on a simulator is twice as fast and twice as accurate as one who has not been. It reduces errors, making surgery much safer. Simulation works and the NHS must be able to provide it to make a difference to patients.”

This view is supported by a major piece of research by the director of the NOC’s skills laboratory, consultant Jonathan Rees, which demonstrated that simulator-trained orthopaedic surgical trainees performed better in operating theatres.

Yet while there is one training simulator for every 300 pilots, there is just one for every 7,300 doctors.

The use of simulators is, however, particularly beneficial to orthopaedic theatre work. Mr Rees said: “The fact is that more and more of our orthopaedic operations are becoming keyhole.”

This means surgeons are faced with carrying out highly complex procedures through the smallest of incisions.

At the same time, European directives to limit the hours junior doctors can spend training mean that trainees can no longer rely on learning their trade the traditional way, by spending hour upon hour watching and assisting consultants in the operating theatre.

Mr Rees said: “Trainee surgeons across Europe face reductions in training time and the implementation of working-hour restrictions. This is now leading to the development of methods of surgical skills and training outside of the operating theatre.”

The skills lab at the NOC was made possible thanks to the £5.7m awarded to the hospital when it secured its status as biomedical research unit in musculoskeletal disease, in partnership with Oxford University’s Nuffield Department of Orthopaedics and Rheumatology.

It is now playing a major role in looking at the best and most efficient way to train surgeons, with Mr Rees and his colleague Will Jackson planning to run a national training course using simulators to improve surgical competence.

The NOC would seem an obvious place to assume such a role, given that 75 per cent of the UK’s professors of orthopaedics trained in Oxford.

On the face of it, the skills lab hardly resembles a modern operating theatre. Plastic models of knees and shoulders sit on benches, with joints, ligaments and tissue replicated inside them.

Small holes represent the incisions that would be made during operations, through which trainee surgeons insert tools with minute cameras on the end.

This allows them to view what they are doing on screen, with trainees, a little like touch typists, obliged to master the art of working with their hands while looking up. Stitching and repairing in such confined spaces is particularly taxing.

The hand movements of surgical trainees can be assessed using a motion tracking system, which involves them wearing sensors on the back of the hands. Research apparently has established that less hand movement usually signifies greater proficiency.

The NOC investigation into the benefits of laboratory-based simulator training was the first major UK study of its kind.

It concluded that the surgical trainees who took part went on “to demonstrate improved technical performance in the operating theatre compared with an untrained group”.

It also found experienced surgeons could benefit from simulators to learn new or complex techniques “before transfer to the operating theatre”. Dr Andy Thornley, chairman of the British Medical Association’s junior doctors committee, said: “At a time when many junior doctors are worried about the implications of reduced working hours on training, the addition of high-tech facilities would be welcomed.

“But while simulations have a role to play there is no substitute for real-life training with an experienced consultant.”