Keeping it real

As a trainee surgeon, Dr Ram Nataraja was schooled in the traditional paradigm known as ‘See one, do one, teach one’. “I was very lucky to have great mentors who would take me through the operation, but that wasn’t the case for everyone,” he says of the high-pressure environment in which surgeons effectively learnt under instruction on the job. “But it still didn’t allow people to progress through training at their own rate. It’s not ideal for the surgeon, or for patients.”

The London-trained Dr Nataraja, who joined the Monash Children’s Hospital paediatric surgical team in 2015, is a senior lecturer at Monash University and the director of the Surgical Simulation Unit, where groundbreaking technology and teaching are helping to train the surgeons of tomorrow.

He’s aided in his work by the new Monash Children’s Hospital in Clayton, located not far from the University’s largest campus. Officially opened in March this year, the five-storey, 230-bed facility boasts unique facilities designed by Dr Nataraja with the head of paediatric surgery, Associate Professor Chris Kimber, to train students in virtual scenarios involving paediatric surgery and emergencies.

The rationale behind the growing area of surgical simulation is simple: to allow students to train in a safe environment. Not only does it mean mistakes don’t lead to real-life consequences, it also allows students to become familiar with clinical environments earlier than they otherwise would.

“In my experience, medical students can find the hospital or surgical environment intimidating and hang back, but simulation helps take that factor out of the equation,” he says.

Dr Nataraja’s interest in surgical simulation started when he was the primary researcher in the first validated trainer model, simulating paediatric laparoscopies at Great Ormond Street Hospital, London, in 2003.

Now a global authority on the subject, he’s co-authored several articles in peer-reviewed journals on minimally invasive techniques for common paediatric surgical conditions, including appendicitis. He’s also witnessed the dramatic evolution of surgical simulation over the past 15 years.

“We’re in a privileged time for paediatric surgery. When I first started simulation training it was done in a theatre environment. Now we’ve got accessible, low-cost simulators where people can take these trainers home and use them on their own PC or a tablet. Combined with motion-training software on instruments, you can get more of a quantitative outcome. That’s been a big shift, where this kind of thing has advanced to such a degree from the realm of being able only to do it at certain times to now being able to do it whenever you want.”

Simulation in surgery certainly increases safety and efficiency in training – and what’s better for the child patients is also bound to be better for the surgeons. “It’s one thing to have the skills; it’s another to know you have the constructive feedback on how to improve,” Dr Nataraja says. “That will give you a lot of confidence, which can really be the difference between something that doesn’t go so well to something that goes very well.”

Dr Nataraja (right) uses the bench simulator as a warm-up device when preparing for some operations. “Say I do a congenital diaphragmatic hernia, which is to repair the hole in the diaphragm where the intestines go up into the chest in a baby. We use different types of sutures to perform that procedure, and I’d only use those knots two or three times a year. There’s always an initial slight hesitancy, so I use a bench trainer to throw 20 knots before getting to the real operation. Hence the first knot in the operation is the best it can be.”

Going hand-in-hand with surgical simulation is technological innovation. Dr Nataraja and the Monash surgical simulation team work with the Monash Institute of Medical Engineering (MIME) on various projects involving surgical innovation, robotics and simulation-based research using evolving technologies.

Robotics is becoming increasingly popular to use when dealing with adult patients; less so with children. But robotic surgery is ideally suited for children’s smaller bodies, Dr Nataraja says, as it cuts out tremor and magnifies the operative image at least 10 times.

“Robotics is potentially the future,” he says. “We have a long way to go, but we have some of the best minds in the world at Monash, so combining their expertise and our clinical acumen means the perfect partnership.”

"Medical students can find the hospital or surgical environment intimidating and hang back, but simulation helps take that factor out of the equation."

The teaching at Monash is also focused on communication skills. Vital to the 21st-century surgeon, they’re really the flip side to surgical simulation, paediatric surgeon Dr Amiria Lynch says, and work hand-in-hand. “They’re completely complementary. We’re getting to a stage where every course will have an element of human factors. Things like, how do you communicate to your scrub nurse, how do you communicate to your anaesthetist … when something goes wrong, how do you manage it?” she says. “You can be the best technical person in the whole world, but if you can’t communicate to your team and to your patient and their family, then you’re not the best surgeon overall.”

Monash Children’s Hospital is at the forefront of other pioneering uses of technology to improve health outcomes. Earlier this year it launched its Telesurgery Service, the first of its kind in the state of Victoria, which establishes a live video link from the specialist urban hospital to a number of regional operating theatres and emergency departments.

“When a general surgeon is doing a paediatric case and encounters something slightly outside of the norm, we can hook into the feed and give advice,” Dr Nataraja says. “We might have to say, this case needs to come to us, or we might say, do X, Y and Z and it will be fine. It’s reassuring, and a good backup.”

A crucial supporter of the Monash Children’s Hospital and its new teaching spaces, the University is the hospital’s lead teaching and translational research partner. It invested A$6 million in the innovative new education and research spaces in the hospital.

And seven months after the hospital opened, the gloss hasn’t worn off. “In terms of the operating spaces, we’ve got the most up-to-date facilities I’ve ever worked in,” Dr Nataraja says. “It certainly helps us do the best we can. In terms of teaching, there are four LCD screens on each wall so students watching the operation can see, which is very important as we’re working on a small child. The surgical simulation space is the most unique space in the southern hemisphere, and we also have a simulated ward and simulated procedure room. This job was the reason to come to Australia.”

Simulation, or trainer models, replicate human anatomy, tissue and even blood flow, and can also involve virtual reality and software, to mimic the experience of an operating theatre. They are used for surgical training on a range of procedures or techniques, from suturing to ultrasounds and across general, trauma and keyhole surgery. Simulation is also used to re-create clinical scenarios, such as dealing with colleagues and breaking bad news to patients.