Discussion

There are a number of low-fidelity tonsil tie trainers presented in the literature. These include the Cardiff Cup^{Reference Al-Hussaini, Addams-Williams and Tomkinson1} and the tissue-box tonsillar tie trainer.^{Reference Wasson, De Zoysa and Stephens2} In this study, the Yorick model^{Reference Raja, Haneefa and Chidambaram3} was chosen for enhancement, as it was considered to be higher fidelity than the alternatives, popular and readily available within the department.

The authors acquired the Yorick model from the maxillofacial department, which often use such models for surgical planning and training. Similar models can be bought for approximately £40 pounds from popular online retailers such as Amazon. It is also possible to three-dimensionally print such models if trainees or trainers have access to a three-dimensional printer. The principle, however, is that, with some planning, a number of simulators could be enhanced in the same way.

The electronic enhancement of low-fidelity simulators has been considered for some time, and with the increasing availability of home microprocessor/microcontroller boards this has become a realistic possibility. A number of brands and designs were considered, such as the Microbit, Raspberry Pi and Arduino models. An Arduino board was used in this project given the author's knowledge of the system, its ease of coding and its availability, but a number of alternatives are available. The cost of the Arduino board was approximately £40 pounds and the gyroscope costs around £5 pounds. These items are widely available; the authors bought theirs online.

The Arduino microcontroller board is user-friendly and its software is considered to be easy to use for beginners. It is simple to interface the sensors and other electronic components to an Arduino. In addition, it can be powered using a battery pack. The authors were able to programme for the surgical simulator enhancement with approximately 5 hours of previous experience in total.

It was observed during prototype evaluation of the tonsil tie trainer that novices produced greater directional acceleration movements than experienced practitioners, with these findings being repeatable. There was also a general acceptability of the enhanced low-fidelity simulator by novice and expert users. The benefit to technique training has not been evaluated scientifically during this project but will be a focus of further evaluation in the future.

Simulation training has become a compulsory part of surgical training. Traditionally, surgery was taught purely as an apprenticeship with repeated practice of surgical skills on patients. However, much has changed. Modernising Medical Careers, introduced in 2005,^{Reference Tooke4} altered all aspects of medical training; it shortened the duration of training, introduced ‘run-through training’ and reduced the flexibility of training. It aimed to offer a fairer but shortened, structured career path.

This, combined with the introduction of the European Working Time Directive, developed by the Council of Europe to regulate working hours and protect the health and safety of workers,^{Reference Giles5} resulted in a reduction in the number of working hours, and consequently a reduction in patient experience and concern regarding reduced educational opportunity. Hence, there has been a push to develop surgical techniques (such as tonsillectomy ties) away from the operating theatre. Simulation training is also said to have a role in improving patient safety.^{Reference Aggarwal, Mytton, Derbrew, Hananel, Heydenburg and Issenberg6,Reference Edmond7}

The use of high-fidelity simulation encourages self-directed learning, which has been increasingly promoted within the surgical curricula.^{Reference Swanwick8} High-fidelity surgical simulators are realistic and have the potential to provide both visual and haptic feedback. They allow trainees to be independent learners, not having to rely on an external reviewer. In comparison, the cheaper low-fidelity surgical simulators are less realistic, and rely on observer feedback or self-reflection.

However, high-fidelity surgical simulators are expensive, involve complex technology and are not widely available. The authors therefore demonstrate a means of enhancing a low-fidelity model using a low-cost, simple home microprocessing board. The expectation is that the initial cost will be easily outweighed by the repetitive use of the simulator and the skill acquired by the trainees. Further details on how to build the model can be provided by the authors.