Applying surgical simulators combined with virtual reality technologies into neurosurgical training

Types of Surgical Simulation: Sharpening Surgical skills


In the realm of medicine’s fast-paced landscape, the paramount role of surgical precision stands as an indomitable truth. Surgeons, often entrusted with making life-altering decisions in the blink of an eye, are the very embodiment of knowledge, innovation, and unwavering confidence. To achieve such precision and expertise, an arduous journey of rigorous training and ceaseless practice is undertaken. It’s in this crucible that surgical simulation emerges as a transformative force. Join UpSurgeOn as we embark on an enlightening exploration into the myriad surgical simulation methodologies that empower aspiring and seasoned surgeons alike.

I. Surgical Simulation categorization 

Surgical simulators can be divided into two main categories: organic and inorganic simulators [1] [2] [3]. Organic simulators consist of live animal and fresh human cadaver models, which are considered to be high-fidelity [1]. However, the use of organic simulators is limited by ethical and practical considerations, such as the availability of cadavers and the cost of maintaining live animal models [3]. Inorganic simulators, on the other hand, comprise synthetic bench models, virtual reality simulators and hybrid simulations [1] [2] [3].  Synthetic Bench models are physical models that simulate human anatomy and physiology using materials such as silicone and plastic [1].  Virtual reality simulators allow trainees to practice surgical techniques on a computer, using tools to manipulate a series of computerized images. Whereas, hybrid simulators combine different simulation methods to create a more realistic training environment, such as virtual reality, standardized patients, and task trainers, in order to optimize the surgical training experience. 

II. Types of simulations 

1. Organic simulation 

The organic surgical simulation can be categorized into two types: Cadaveric simulation and animal model simulation 

1.1. Cadaveric simulation

Cadaveric simulation is a type of simulation used in surgical training that involves the use of deceased, preserved, or fresh human bodies to simulate surgical procedures [4] [5] [6].

Cadaveric simulator
Cadaveric simulator. Source: Wikipedia commons

The merit inherent in this pedagogical approach lies in its provision of the utmost echelon of surgical simulation. It affords a superlative occasion to fathom the intricate nuances of human anatomy, underpinned by empirical evidence  [7] [8] [9]. Besides, cadaveric simulation training allows trainees to practice surgical procedures in a realistic environment with high environmental, equipment, and psychological fidelity [4]. Some commonly simulated procedures include laparoscopy, endoscopy, and saphenous vein cutting [10] [11]. Cadavers are most typically utilized for specific courses in both the United States and the United Kingdom. 

Disadvantageous aspects of this modality include acquisition and maintenance costs, limited availability, and distortion of loco-regional anatomy due to preservatives like formalin. The absence of physiological considerations encountered during surgery is also an issue [12]. Besides, it is important to note that cadaveric simulation can be expensive to provide and is necessarily restricted to specialized wet-laboratory facilities [5] [13]

1.2. Animal model simulation 

The second type of simulation is animal modeling. These models involve using actual animal tissues or organs, such as pigs, for surgical training purposes.The most commonly used models include canines, porcines, and baboons [7],[14],[15].

The advantage of using animal models is that they provide a more realistic simulation of surgical procedures compared to inanimate artificial tissues, notwithstanding the fact that differences exist between human and animal anatomical structures. Operating on actual tissue allows trainees to practice surgical techniques in a setting that closely resembles real-life surgical situations. Proponents argue that this type of simulation provides the best training experience. [16]

Using animal models in medical training also has disadvantages, including high costs, the need for pain management, disease transmission, ethical and legal concerns. While anesthetized animals, particularly pigs, are still used in Europe and America, the ethics of this practice are debated. Besides, availability of fresh tissue or animal models can be limited, and logistical challenges in their maintenance and acquisition can arise, animal models may not fully replicate the complexities and variations seen in human patients.

Overall, animal models offer a more realistic training experience, but there are ethical considerations and practical limitations associated with their use. [12] 

2. Inorganic simulation

Inorganic surgical simulation can be categorized into two types: Bench-top model simulation (Reality-based simulation) and inorganic electronic simulation (Virtual-Based simulation) 

2.1. Synthetic Bench models (Reality-based simulation) 

Trainee practices surture on surgical simulator
Trainee practices surture on Skinpad, the newest bench-top model of UpSurgeOn. Source: UpSurgeOn

Bench-top models are a type of simulation used in surgical training. They involve the use of physical models or simulators that replicate certain aspects of real surgical procedures. These models can be made of synthetic materials or non-live animal tissue that replicate the appearance and texture of human tissues, limbs, organs, or even whole bodies. Synthetic bench models are designed to provide a realistic experience for trainees to practice surgical techniques outside of the operating theater.

The advantage of using bench-top models is that they are easily accessible and can be used repeatedly for training purposes. Trainees can practice various surgical procedures on these models, gaining hands-on experience and improving their skills. Additionally, these simulations are cost-effective compared to other types of simulations.

However, there are some limitations to using bench-top models. While they can provide a realistic visual representation, they may lack the physiological properties and feedback that real human tissues would provide. Trainees may not experience the same resistance, texture, or haptic feedback as they would in a real surgical procedure. Therefore, the transfer of skills learned in these simulations to real-life situations may not be seamless.

Overall, bench-top models offer a valuable tool for surgical training, allowing trainees to practice and refine their skills in a controlled environment. However, they should be supplemented with other types of simulations to provide a more comprehensive training experience. [16]

2.2. Virtual Reality and computer-based simulation 

UpSurgeOn’s Meta Physical Hub. Source: UpSurgeOn

Virtual reality and computer-based simulation involve the use of computer-generated environments to simulate surgical procedures and training. These simulations aim to provide a realistic experience for trainees, allowing them to practice surgical skills in a virtual setting.

The advantage of virtual reality and computer-based simulations is that they offer a safe and controlled environment for trainees to learn and practice surgical techniques. They can simulate a variety of surgical procedures and provide feedback on performance, allowing trainees to improve their skills without the risk of harming real patients. These simulations can also be accessed at any time, providing flexibility in training.

However, there are also disadvantages to using virtual reality and computerized simulation. One limitation is the lack of haptic feedback, which refers to the sense of touch and physical interaction with tissues. Without haptic feedback, trainees may not fully experience the tactile sensations and resistance encountered during real surgeries. Additionally, while virtual reality and computerized simulation can provide a realistic visual representation, they may not fully replicate the complexity and variability of real surgical scenarios.

Overall, virtual reality and computerized simulation offer valuable tools for surgical training, but they should be used in conjunction with other training methods to ensure a comprehensive learning experience. [16]

2.3. Hybrid Simulation

Hybrid simulation is a type of simulation used in surgical training that combines two or more simulation modalities within the same simulation session to create a more realistic training environment [17]. Hybrid simulators often combine both attributes of physical simulators and VR simulators, taking the form of a mannequin linked to a sophisticated computer programme which provides visual images or feedback [18]. The computer programme can simulate physiological and physical responses, such as bleeding, as a reaction to a procedure.  These simulators allow the production of a realistic clinical environment where teamwork is reinforced, bridging gaps in the operating theatre

One of the advantages of hybrid simulation is that it can provide a more realistic training experience than using only one type of simulation method. This can help develop hand-eye coordination and dexterity in performing surgical tasks, as demonstrated by studies that have proposed objective metrics for hand-movement skills and assessed eye-hand coordination [18] [19]. Additionally, hybrid simulation can be more cost-effective than using high-fidelity simulators alone, making it a more accessible option for colleges and universities with limited budgets. Another advantage of hybrid simulation is that it can enhance learners’ patient-to-caregiver interactions and better immerse the trainee in the feelings and emotions of the scenario. This can help improve communication skills and empathy in trainees, which are essential skills for healthcare professionals [18]

Overall, hybrid simulation can be an effective and cost-efficient method for surgical training, providing a superior training context to enhance learners’ patient-to-caregiver interactions and to better immerse the trainee in the feelings and emotions of the scenario, while also developing hand-eye coordination and dexterity in performing surgical tasks.


Surgical simulation is an indispensable part of surgical training. It offers a safe environment for surgeons to refine their skills and learn new techniques. From virtual reality to hybrid simulations, these methods are revolutionizing the way surgeons prepare for the operating room. As technology continues to advance, we can expect even more realistic and effective training methods in the future. UpSurgeOn is your trusted partner in this transformative journey. Our goal is to provide aspiring neurosurgeons with the ultimate bridge to mastering surgical skills. With our simulation technologies,  we not only enhance the safety and effectiveness of training but also enable trainees to conquer the challenges in this field. Do not hesitate to visit to explore the possibilities of simulation technologies and take your surgical career to a new level! 


  1. Tan, S. S. Y., & Sarker, S. K. (2011). Simulation in surgery: a review. Scottish medical journal, 56(2), 104-109.
  2. Sarker, S., & Patel, B. (2007). Simulation and surgical training. International journal of clinical practice, 61(12), 2120-2125.
  3. Badash, I., Burtt, K., Solorzano, C. A., & Carey, J. N. (2016). Innovations in surgery simulation: a review of past, current and future techniques. Annals of translational medicine, 4(23).
  4. James, H. K., Chapman, A. W., Pattison, G. T. R., Griffin, D. R., & Fisher, J. D. (2019). Systematic review of the current status of cadaveric simulation for surgical training. Journal of British Surgery, 106(13), 1726-1734.
  5. James, H. K., Pattison, G. T., Fisher, J. D., & Griffin, D. (2020). Cadaveric simulation versus standard training for postgraduate trauma and orthopaedic surgical trainees: protocol for the CAD: TRAUMA study multicentre randomised controlled educational trial. BMJ open, 10(9), e037319.
  6. Hazan, E., Torbeck, R., Connolly, D., Wang, J. V., Griffin, T., Keller, M., & Trufant, J. (2018). Cadaveric simulation for improving surgical training in dermatology. Dermatology Online Journal24(6).
  7. Sturm LP, Windsor JA, Cosman PH, Cregan P, Hewett PJ, Maddern GJ: A systematic review of skills transfer after surgical simulation training. Ann Surg. 2008, 248:166-79. 10.1097/SLA.0b013e318176bf24
  8. Carey JN, Rommer E, Sheckter C, et al.: Simulation of plastic surgery and microvascular procedures using perfused fresh human cadavers. J Plast Reconstr Aesthet Surg. 2014, 67:e42-8. 10.1016/j.bjps.2013.09.026
  9. Parker LM: Anatomical dissection: why are we cutting it out? Dissection in undergraduate teaching. ANZ J Surg. 2002, 72:910-2. 10.1046/j.1445-2197.2002.02596.x
  10.  Scott DJ, Bergen PC, Rege RV, et al.: Laparoscopic training on bench models: better and more cost effective than operating room experience?. Jr Ame Col Surg. 2000, 191:272-283. 10.1016/s1072-7515(00)00339-2
  11. Goova MT, Hollett LA, Tesfay ST, Gala RB, Puzziferri N, Kehdy FJ, Scott DJ: Implementation, construct validity, and benefit of a proficiency-based knot-tying and suturing curriculum. J Surg Educ. 2008, 65:309-15. 10.1016/j.jsurg.2008.04.004
  12. Cardoso, S. A., Suyambu, J., Iqbal, J., Jaimes, D. C. C., Amin, A., Sikto, J. T., … & Kuruba, V. (2023). Exploring the Role of Simulation Training in Improving Surgical Skills Among Residents: A Narrative Review. Cureus, 15(9).
  13. James, H. K., & Fawdington, R. A. (2022). Freestyle deliberate practice cadaveric hand surgery simulation training for orthopedic residents: cohort study. JMIR Medical Education, 8(2), e34791.
  14. Chapman DM, Rhee KJ, Marx JA, et al.: Open thoracotomy procedural competency: validity study of teaching and assessment modalities. Annals of emergency medicine. 1996, 28:641-647. 10.1016/s0196-0644(96)70087-2
  15. Korndorffer JR Jr, Dunne JB, Sierra R, Stefanidis D, Touchard CL, Scott DJ: Simulator training for laparoscopic suturing using performance goals translates to the operating room. J Am Coll Surg. 2005, 201:23-9. 10.1016/j.jamcollsurg.2005.02.021
  16. Torkington, J., Smith, S. G., Rees, B. I., & Darzi, A. (2000). The role of simulation in surgical training. Annals of the Royal College of Surgeons of England, 82(2), 88.
  17. Brown, W. J., & Tortorella, R. A. (2020). Hybrid medical simulation–a systematic literature review. Smart Learning Environments, 7(1), 1-16.
  18. Topalli, D., & Cagiltay, N. E. (2018). Eye-hand coordination patterns of intermediate and novice surgeons in a simulation-based endoscopic surgery training environment. Journal of Eye Movement Research, 11(6).
  19. Tsai, C. L., & Heinrichs, W. L. (1994). Acquisition of eye-hand coordination skills for videoendoscopic surgery. The Journal of the American Association of Gynecologic Laparoscopists, 1(4, Part 2), S37-S37.

Mastering the Horizontal Mattress Suture

Beyond the Basics: Simple buried suture

Experience the Future of Spine Surgery Training with UpSurgeOn at Spine Summit 2024

Simple Running Suture Technique. How to master it.