慈濟傳播人文志業基金會
Simulated Surgery - A Learning Curve Buster

Specially preserved corpses offer medical students and physicians an opportunity to build up their skills and confidence by offering them life-like surgical experiences.

A train bound for Vienna, Austria, sped along the Rhine. One of the passengers was Dr. Lin Shinn-zong (林欣榮), then a professor at the National Defense Medical Center and a neurosurgeon at Tri-Service General Hospital, both located in Taipei. He was deep in thought, oblivious to the scenery outside, reviewing in his head what he had just learned at a three-day seminar in Germany about keyhole skull base surgery.

This was more than 20 years ago, and keyhole, or endoscopic, skull base surgery was unavailable in Taiwan at the time. Lin had traveled from Taiwan to Europe to learn about the technique.

The traditional standard surgical procedure in Taiwan at the time was inherently invasive and high-risk, and it resulted in large incision wounds and a long recovery. To remove a tumor from the brain, for example, a surgeon had to saw open the skull, remove the tumor, tie the skull pieces back together with steel wire, and then suture back the muscles and skin. The endoscopic skull base surgery, in stark contrast, was less risky with smaller incisions and quicker recovery.

Eager to learn this endoscopic surgery technique, Lin had signed up for the workshop in Germany and paid the fee of 150,000 NT dollars (US$5,000). Air fare, lodging, and other items had cost him even more.

After a three-day session in Germany, the five-day workshop continued at the University of Vienna, where neurosurgeons from around the world learned to operate endoscopically on the heads of formalin-preserved corpses. This allowed the physicians to gain experience in safely executing skull base surgery for meningioma, angioma, pituitary gland tumors, etc., without disturbing intricate nerves and capillaries.

After the workshop, Lin returned to his post in Taipei and began to put his new experiences and knowledge to work. Far from keeping the new skills to himself, he taught other surgeons what he had learned. In 1998, he hosted the first skull base surgery workshop in Taiwan, in which he trained 40 neurosurgeons. They each paid just 20,000 NT dollars (US$670) to participate, a fraction of what Lin himself had had to fork over for his European workshop.

Due to a lack of human corpses to use, Lin had to import 12 heads. Ten of those were used by the participants, with four surgeons sharing one head. The remaining two heads were used by instructors. With the silent help of the imported heads, Lin was able to teach the novel technique to local surgeons and bring the benefits of endoscopic skull base surgery to local patients.

Lin’s efforts brought to the fore not just the novel endoscopic surgery technique but also the importance—and availability—of corpses for the training of physicians.

At around the time Lin conducted the workshop, the Tzu Chi Foundation established a medical school. In response to Master Cheng Yen’s appeal to “Let your body be put to good use by donating it for medical education after you have passed on,” many people, especially Tzu Chi volunteers, signed up to be body donors. The Tzu Chi medical school has therefore been able to use donated cadavers in all of its teaching programs. Chinese culture traditionally holds that it is necessary to preserve a whole body in order for the deceased to rest in peace, but the Master’s appeal went a long way toward making many people in Taiwan embrace the concept of body donation.

The Tzu Chi medical school started a simulated surgery program in 2002, in which donated bodies are used to help medical students learn and practice surgical skills. In 2003, an operating room with eight operating tables was opened for simulated surgery classes. In 2008, this facility was upgraded to a full-fledged operating room, with additional facilities for surgeons’ dressing rooms, instrument cleaning, storage of instruments and supplies, and interactive classrooms. Surgical simulation training sessions are now conducted eight times a year at the Medical Simulation Center. Participants include medical students at the Tzu Chi University College of Medicine and its sister medical schools abroad, as well as surgeons within or outside the network of the six Tzu Chi hospitals in Taiwan.

Dr. Lin Shinn-zong, who had visited Europe to learn the novel surgical skill in that workshop over 20 years ago, joined Hualien Tzu Chi Hospital in 2001. Barely one year later, he became the superintendent of the hospital. His office is now a five-minute walk to the Tzu Chi University Medical Simulation Center, where no corpses have ever needed to be imported from abroad for use and where physicians can learn and practice advanced surgical skills without having to travel abroad.

Physicians bow to body donors, reverently referred to as “silent mentors” in Tzu Chi, to thank them for donating their bodies for medical education.

The Medical Simulation Center

University administrators have continued improving the facilities of the Medical Simulation Center. In the last two years, they have installed X-ray and high-end ultrasound machines so as to give surgeons real-time imagery necessary to execute precise operations.

“The resources at the Medical Simulation Center have enabled us to develop many surgical procedures, including minimally invasive heart surgery that spares patients open-chest trauma,” said Dr. Chang Jui-chih (張睿智), a cardiac surgeon at Hualien Tzu Chi Hospital. He was trained entirely within the Tzu Chi medical system, and he has worked at the hospital since he graduated from the Tzu Chi University College of Medicine in 2002.

“I’m confident in operating on a patient so long as I’ve done it on a ‘silent mentor,’” Chang said, referring to the cadavers on whom he had practiced simulated surgery. People who donate their bodies to the Tzu Chi University College of Medicine for use in anatomy classes or surgical simulation training are reverently called “silent mentors” because they teach students and doctors without words. At the Medical Simulation Center, Chang has been able to practice procedures such as endoscopic heart valve surgeries and bypass surgeries on these silent mentors.

Practicing with simulated surgery has evidently gone a long way toward helping Chang build up his surgical skills. Hualian Tzu Chi Hospital is equipped with a da Vinci robotic surgical system. Chang once used it to perform coronary artery bypass surgery, and the day after the operation, the patient was already able to sit up and eat breakfast. The patient couldn’t believe that recovery could happen so quickly—it was as if he had never had that surgery on his heart. “Incredible!” he exclaimed.

It took Lin Shinn-zong a 13-hour flight from Taiwan to Germany—and great expense—to learn his endoscopic surgery skills; Chang Jui-chih was able to take a five-minute walk from Hualien Tzu Chi Hospital to the Medical Simulation Center at Tzu Chi University to learn his. The paths that Lin and Chang took illustrate the evolution and improvement of learning environments for surgeons in Taiwan over the years.

Chang pointed out that surgeon-trainees can learn about surgery through many conduits, such as books, journals, videos, professional medical websites, and surgeon-teachers, but the real key is hands-on experience. That’s why the simulated surgery on silent mentors offered at the Medical Simulation Center is so precious. Not only can surgeon-trainees learn existing techniques but even veteran surgeons can explore novel or tricky ones at the facility too.

At the Tzu Chi University Medical Simulation Center, a team works on the lower body of a cadaver while a physician, right, works an endoscope to look inside the body.

Unaffiliated learners are welcome

In 2010, medical associations in Taiwan began applying for their members to use the resources offered at the Medical Simulation Center. Surgeons in urology, ENT, colon and rectal surgery, spinal surgery, skull base surgery, etc. have since taken advantage of the center’s service.

It’s not only Taiwanese doctors that take advantage of the center’s resources—physicians from abroad do too. When Tzu Chi physicians Drs. Chen Ing-ho (陳英和, orthopedics) and Kuo Hann-Chorng (郭漢崇, urology) were serving as chairmen of their respective professional societies, they invited attendees of medical conferences held in Taiwan to workshops at the Medical Simulation Center. As a result, physicians from more than ten countries visited the center to share their expertise with one another, and in turn learn medical skills and practices they could apply in their home countries. Through such workshops, the simulated surgery program benefits more than doctors and patients in Taiwan. It helps doctors and patients outside Taiwan too.

In August 2016, members of the Taiwan Urological Association came to the center to learn and practice endoscopic bladder neck suspension surgery, a procedure that can be used to treat stress incontinence (the leakage of small amounts of urine when pressure increases on the bladder—for example, when a person sneezes, coughs, or laughs.) Instructor Dr. Tsai Yao-chou (蔡曜州), director of minimally invasive surgery at Taipei Tzu Chi Hospital, demonstrated the procedure to participants. Jiang Yuan-hong (江元宏), head of urologic oncology at Hualien Tzu Chi Hospital, was a student in the simulated session. He commented that though the surgical procedure didn’t take much time to finish, it required great attention to many details to ensure that a patient would be relieved of urine leakage after surgery. He praised Tsai for his excellent skill in this surgery, and he was grateful for the opportunity to learn from him through simulated surgery.

In September 2016, members of the Taiwan Association of Endocrine Surgeons (TAES) used the center to practice transoral thyroidectomy, a new technique to remove the thyroid gland. A traditional thyroidectomy, through a neck incision, leaves a permanent scar. Some female patients wear scarves year-round just to conceal it. The previous alternative to this was to make the incision in the armpit or areola. The resulting scar might not be visible, but the cut had to be quite large and the path to the thyroid gland very long. The advent of minimally invasive surgery brought about a new alternative: transoral thyroidectomy—the surgical removal of the thyroid through the mouth.

Wu Hung-sheng (吳鴻昇), chairman of TAES, pointed out that Police General Hospital in Bangkok, Thailand, had performed transoral thyroidectomy hundreds of times, while that number for Taiwan was about a hundred. The incision for this endoscopic procedure is inside the mouth. Consequently, this surgery leaves no scars on the exposed skin. The procedure can be used to remove tumors up to four centimeters (1.6 inches) in size. The surgeon must take care to avoid oral infections or damaging the nerves though—two goals made easier to achieve when the surgeon has gained experience with practice. That’s why TAES members applied to use the Tzu Chi center’s service.

In June 2018, more than 60 members of the Asia Pacific Spine Society visited the Medical Simulation Center to practice cervical spine surgery. Chen Yen-jen (陳衍仁), deputy superintendent of the Taipei branch of China Medical University Hospital and the head of the visiting group, had taken part in simulated surgery at the center several times before. He pointed out that cervical spine surgery was rarely performed because it was particularly risky among operations to correct deformity. Simulated surgery allowed surgeons to explore such procedures, thus helping build up their confidence in performing this kind of delicate surgery.

Silent mentors, by offering their bodies for physicians to practice on, allow surgeons—rookies and veterans alike—to avoid making mistakes on real patients. Each mistake on a cadaver may mean one less mistake on a real patient. Those who donate their bodies for medical education after they pass away are indeed letting their bodies be put to good use through this admirable act.

Medical students, some of them from Singapore, the United States, and Poland, take part in a silent mentor inauguration ceremony in June 2018 at the Tzu Chi University Medical Simulation Center. Simulated surgery courses are conducted four times a year at the center for medical students at Tzu Chi University and from other schools.

A local touch

Facial reconstruction has been depicted in dramatic or theatric productions, such as the movie Face/Off. In November 2016, such “face changing” surgery first appeared at the Medical Simulation Center when a plastic surgery team from National Taiwan University Hospital (NTUH) attempted a whole-face transplant using the resources at the center.

Dr. Hsieh Mon-Hsian (謝孟祥), an NTUH plastic surgeon, pointed out that patients with most of their faces surgically removed—be it due to burn injuries, automobile accidents, or tumors—would need this delicate and complicated surgery. With the help of simulated surgery, surgeons can acquire first-hand and in-depth knowledge about the anatomical details of the nerves in the face. Only a silent mentor would allow surgeons to peel layer after layer off their face for such close observation.

At the same workshop where the whole-face transplant practice took place, a team of plastic and orthopedic surgeons from Chang Gung Memorial Hospital in Linkou, northern Taiwan, performed a simulated arm transplant. A patient had signed up with the hospital for such an operation and had undergone the necessary medical and psychological evaluations. The transplantation could take place as soon as there was a suitable donor, but of course the team of surgeons had to practice the procedure first. So, they were here at the center to run through the process on a cadaver.

“Tzu Chi silent mentors have a special significance because of their local touch,” said Liu Chih-Ho (劉致和), who was at the time the secretary-general of the Taiwan Society of Aesthetic Plastic Surgery. Liu indicated that similar dissection courses in the past in Taiwan, whether in neurosurgery, general surgery, or ENT, almost always had to import specimens such as heads or necks from abroad for use. The imported specimens were most often of Western origin, and the anatomical differences between Caucasian and Asian people could become a problem.

Take reconstruction surgeries of the nose, for example. Western and Eastern noses are anatomically different in height, volume of flesh, and even distribution of blood vessels. These differences, though minuscule, may have consequences in shaping the knowledge of learners and their ability to safely perform plastic surgeries, in which the aesthetics of appearance is often judged in seemingly minuscule measurements.

Liu was therefore grateful to the Medical Simulation Center for providing plastic surgeons such as himself with an opportunity to work on local specimens and to find answers to some problems that had bothered them for years.

Technical aspects aside, Liu mentioned how in Tzu Chi the donated bodies are treated with a touching reverence. This is shown for example in the holding of funeral and memorial services for the donors. Such reverence for the silent mentors touched a chord in many participants and prompted them to cherish the opportunity to work on the donated bodies.

Dr. Wu Chao-chuan, second from left, teaches in a simulated surgery session. Dexterous and quick in actual surgery, he slows down in such sessions to teach medical students the basics of surgery.

Caring teachers

Wu Chao-chuan (伍超群), a general surgeon at Taipei Tzu Chi Hospital, has often taught in simulated surgery courses since they were first offered at the Tzu Chi University College of Medicine.

Dexterous and quick in his surgeries on real patients, Wu works slowly and patiently at the Medical Simulation Center when he teaches the basics of surgery to medical students who are just beginning to learn to work with scalpels and sutures.

In one such session, a student practiced on opening the abdominal cavity. Being a novice, he failed to cut in a straight line and couldn’t control how deep his scalpel went under the skin. As a result, he accidentally cut the intestines underneath, causing air to slowly enter them.

Seeing this, Wu discussed with the students around how to avoid damaging organs when cutting the abdomen open. He first gave them a quick review of anatomy, a course that they had taken in their third year in medical school. Then he took over the scalpel with one hand and showed them how to use the other hand to lift up the abdominal skin to create a little extra space as a buffer zone to avoid cutting into the organs underneath.

Then Wu showed them how to take care of the cut that the first student had accidentally inflicted. “The safety of the patient is more important than anything else in an operation,” Wu observed. He pointed out that if that cut was not quickly treated, the patient might be back in the near future for another surgery to treat peritonitis or other conditions caused by the inadvertent wound.

Later, students practiced suturing, which is another fundamental surgical skill. As they sewed together what they had opened, Wu pointed out the mistakes the students had made and the possible consequences of such errors—including infections and a longer recovery time for the incisions.

“Hold your head high, shoulders relaxed, hands gentle,” Wu told the students. “Face the patient and suture elegantly.”

Dr. Li Pei-zhen (李佩蓁), a physician of obstetrics and gynecology at Hualien Tzu Chi Hospital, taught Pap smear and gynecologic examinations in another simulated surgery session. Among other things, she showed students the correct way of using instruments to collect specimens and minimizing patient discomfort during an examination. She also covered some common OB/Gyn diseases, such as ovarian tumors, and gave students opportunities to gain hands-on experience.

“When you examine patients at the hospital, be sure to tell them before your every move what you are going to do next so as to prevent them from feeling uneasy,” Li said to the students.

At the Medical Simulation Center, students can learn a lot by observing carefully and performing procedures in person. The curriculum on simulated surgery is not yet available in any other medical school in Taiwan.

At the end of a simulated surgery course, students carefully prepare a silent mentor, whose picture hangs on the far wall, for the funeral service soon to follow.

The Tzu Chi University Medical Simulation Center is open four times a year to medical societies and associations in and outside of Taiwan, and it charges no fees for using the center’s resources.

“If it were up to me, I would certainly charge for the simulated surgery program,” Lin Shinn-zong said. In his mind, it is a matter of course that users of services pay. “But Master Cheng Yen thinks differently,” he said. Participants pay out-of-pocket for food, lodging, and the cost of course instructors, but the center’s services are offered completely free.

“The center not only doesn’t charge participants anything—it even provides general medical supplies,” said Tseng Guo-Fang, Ph.D., (曾國藩), director of the Medical Simulation Center and a professor of anatomy at Tzu Chi University. “Participants only need to bring special-purpose supplies that they need for their surgeries.”

Tseng tries to explain Master Cheng Yen’s rationale for making the program free. He pointed out that most body donors had been the Master’s monastic disciples or lay followers. They had donated their bodies without asking for anything in return. The spirit behind their actions was selfless; the gift of their bodies will benefit countless patients and hopefully plant a seed of love in the participants. “Silent mentors are priceless,” Tseng said. How could one put a price tag on that?

November 2018