Figure 1.6 Endoscopic Pong Game (1977): Tested hand–eye coordination.
(Courtesy: Dr. Christopher Williams.)
In 1992, Leung and Chung developed a static model and described its use in teaching ERCP [21]. Unfortunately, the utility of each of these models has been limited by their inability to truly simulate realistic conditions. To date, while these static learning devices can be useful in instruction and learning of appropriate manipulation of the endoscope within the bowel lumen, they offer little in the way of simulated pathology. The lack of motility, the “feel” of actual compliant tissue, and the inability to practice therapeutic maneuvers have largely limited the use of static models to introductory training.
Perhaps, the most comprehensive application of static models in endoscopic teaching was described by Lucero et al. in 1995 [22]. This group designed a psychomotor training program called SimPrac‐EDF y VEE (simulator for the practice of fiberoptic digestive endoscopy and electronic video endoscopy). Moreover, they described a series of courses in which they included static models and superimposed painted pictures to recreate frequently seen endoscopic abnormalities. These courses featured didactic lessons, slides, tapes, and supervised hands‐on training on models. In addition to the Lucero model, those of Classen and Heinkel were also used. A specific Billroth II model was designed to demonstrate the unique features of this altered anatomy. Participants were offered sessions with increasingly challenging manual and cognitive tasks; faculty at the course assessed objective skills of the participants [22].
In Lucero’s courses, 8–25 individuals were included in each particular workshop, and trainees had a mean duration of hands‐on practice of 28 hours. In all, 422 trainees in over 22 such courses were described, and the authors noted that 95% of trainees demonstrated an “acceptable level of skill” by the end of the training [22]. However, the authors failed to describe other details of the possible benefits of such training. Such courses would appear to be difficult logistically to conduct and hugely labor intensive. Perhaps, the most important contribution of this work was the concept of integrating various hands‐on training tools into a comprehensive training program that combined didactic lesions, cognitive training, and specific hands‐on exercise geared to develop particular skill sets. Lucero’s use of a patterned lesson plan integrated into multimodality workshops using expert faculty, a blend of manual training and cognitive skills, and immediate feedback and evaluation served as a model for subsequent efforts using more realistic and sophisticated simulators. As such, it remains an important example for future endeavors in endoscopic training.
Figure 1.7 Imperial College/St Mark’s simulator (1980): Limited shaft insertion, but feasibility of simulator demonstrated.
(Courtesy: Dr. Christopher Williams.)
Figure 1.8 Imperial College/St Mark’s simulator MK2 (1985): Full shaft insertion and audible “complaints.”
(Courtesy: Dr. Christopher Williams.)
Since that time, static models evolved in two distinct directions. Two ERCP static trainers were designed that allow for complex therapeutic procedure performance and team training between endoscopist and assistant. These are described in detail in Chapter 8 (Figure 1.9a,b).
Figure 1.9 (a) Novel ERCP endotrainer introduced by Joseph Leung, MD that allows for simulated sphincterotomy and fluorosocpy equivalent. (b) Rome ERCP trainer designed by Dr. Guido Costamagna and colleagues allows for cannulation and endotherapy of bile and pancreatic ducts and ability to interchange papillae of different orientation and cannulation difficulty
(Photo courtesy of Cook Medical, Winston‐Salem, NC).
Ex vivo artificial tissue models: the “Phantom” Tübingen models
A further advance in endoscopic simulation was developed by Grund et al. at the University of Tübingen in Germany [24]. In this “Interphant” or “Phantom” model, artificial electrically conductive tissue called Artitex is used to fashion abnormalities such as polyps and strictures and incorporate this into static models. These “pathologies” are in place of the painted‐on abnormalities used in some of the pure static models mentioned above. Grund’s “Artitex” abnormalities are sewn directly into a three‐dimensional latex anatomical model (Figure 1.10a,b). While these models generally lack a realistic representation of bowel wall compliance and motility, the integrated pathology appears realistic and allows practice in electrosurgical techniques.
In order to simulate the resistance to endoscope passage in an actual procedure, this colon model uses a semiflexible series of coils. In addition, to allow for a still wider possibility of simulated techniques, Grund’s model can incorporate real animal tissue into the existing framework. For example, using a chicken heart, they can fashion an ampulla of Vater replete with separate pancreatic and biliary orifices and insert this into their upper endoscopy simulator (Figure 1.10b). The advantage of using this type of system is that several “polyp‐laden” colons and “chicken‐heart papillae” can be prepared in advance and quickly inserted into the chassis of the model during a training session, after the initially prepared material has been depleted.
The Tübingen simulators made possible the teaching of polypectomy and provided an excellent means of teaching therapeutic procedures such as argon plasma coagulation and simple therapeutic ERCP. In particular, the orientation of the man‐made papilla more closely resembled that of humans than the porcine papilla found in the Erlangen models described below. Pancreatic cannulation and endotherapy was possible, in contrast to the porcine tissue models in which the pancreatic orifice was not readily accessible. However, procedures that required submucosal injection were still not feasible.