Simulation has always been an essential pillar of surgical training, but is has acquired a new meaning in modern surgical education. The complexity of the procedures, the focus on patient safety, and new simulation technologies, have all contributed to an increasing acquisition of skills outside the operating room.
Traditionally, this role has been fulfilled by cadaveric dissection. Human cadaveric models have long been considered the gold standard for surgical training, also in head and neck surgery, where anatomical complexity and variability are critical. They provide unmatched realism in tissue handling, spatial orientation, and anatomical understanding. However, cadaveric training comes with limitations (cost, availability, lack of repeatability…) prompting the search for complementary solutions. We do have now very good physical models available, with a highly realistic simulation of human tissues, but also virtual training. How do they mix?
The advent of robotic surgery has prompted virtual simulation as the new training paradigm. Robotic surgery is, by definition, telesurgery. The surgeon operates remotely through a console, manipulating instruments via a digital interface. This unique feature allows virtual training environments to closely replicate real surgical conditions. Virtual robotic training uses the same console, the same hand controls, and the same visual interface as actual surgery. The transition from conventional endoscopy to robotic platforms is not just technological, it is also conceptual. Surgeons are no longer directly interacting with tissues but with a mediated digital environment. This takes virtual simulation training to a new dimension.
I have recently begun the virtual training protocol with the da Vinci 5, and the advancements are clear. The system offers enhanced simulation modules, improved haptic feedback approximation, and more structured training pathways. It represents a significant step forward in accessibility and standardization of surgical training.
Virtual simulation excels in repetition without resource constraints, objective performance metrics, safe acquisition of basic and intermediate skills, and familiarization with robotic interfaces. For many aspects of robotic surgery, particularly those related to dexterity and console navigation, virtual training is not only sufficient, it is optimal.
But, physical simulation is still essential. Why?
Despite the advantages of virtual platforms, physical simulation remains indispensable. Intuitive Surgical has actually recognized this need, establishing training centers, where surgeons can combine virtual modules with hands-on practice using physical models. These hybrid environments attempt to bridge the gap between digital proficiency and real-world surgical execution.
Physical simulation is still essential to bridge the gap between digital proficiency and real-world surgical execution
There are several commercial solutions for physical models.
See First Touch Academy. It offers highly refined physical simulation models, designed with remarkable attention to anatomical and procedural detail. Similarly, ProDelphus has developed a range of surgical simulators that are impressively realistic, particularly in their tactile feedback and anatomical fidelity.
Now take a look at the TORS physical model by ProDelphus. It might be either that not all procedures are equally suited to simulation or that the current generation does not yet capture the critical challenges of the procedure. While technically well-designed, it oversimplifies the procedure, and in some aspects resembles a gamified experience rather than a true surgical challenge.
TORS is not fundamentally about instrument manipulation, it is about anatomy. Specifically, it is about mastering the intricate and high-risk anatomy of the parapharyngeal space. Understanding the relationship between the internal carotid artery, cranial nerves, and deep muscular planes is not something that can currently be learned through simplified models or virtual abstractions.
TORS is about mastering the intricate and high-risk anatomy of the parapharyngeal space
These systems represent a significant advancement in physical simulation. They are thoughtfully engineered, visually convincing, and educationally valuable. In many areas of surgery, they may effectively complement, or even partially replace, traditional cadaveric training. But as a tutor, I am increasingly concerned that cadaveric dissection in TORS training is sometimes being deprioritized, or even omitted, in favor of more accessible simulation-based pathways. This is a mistake. There is, at present, no substitute for cadaveric training in TORS. Not virtual simulation. Not physical models. Not hybrid systems.
doi: 10.1002/hed.27902.
Cadaveric dissection provides dimensional anatomical understanding, exposure to anatomical variability, realistic tissue behavior, and the ability to explore surgical planes safely but authentically. Until simulation technologies evolve to accurately replicate these elements we must be cautious not to overestimate their capabilities.
Virtual simulation is transforming surgical training. It offers scalability, safety, and standardization that were previously unimaginable. Physical simulation is evolving rapidly, with impressive contributions from innovative companies pushing the boundaries of realism. But in certain domains simulation has not yet reached the level required to replace traditional methods. For now, cadaveric dissection remains irreplaceable. And as educators, we must ensure that in our enthusiasm for innovation, we do not lose sight of what truly prepares surgeons for the realities of the operating room.
J Granell. May 1, 2026