REVIEW ARTICLE

ANZJSurg.com

From ancient to avant-garde: a review of traditional and modern

multimodal approaches to surgical anatomy education
Minhao Hu ,* David Wattchow† and Dayan de Fontgalland†
*School of Medicine, Flinders University, Adelaide, South Australia, Australia and
†Department of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia

Key words Abstract

anatomy, dissection, surgical education, teaching
modalities, technology.
Correspondence
Mr Minhao Hu, School of Medicine, Flinders
University, Sturt Road, Bedford Park, Adelaide, SA
5042, Australia. Email: hu0132@flinders.edu.au
M. Hu BClinSc; D. Wattchow FRACS, PhD; D. de
Fontgalland FRACS, PhD.
Accepted for publication 14 July 2017.
doi: 10.1111/ans.14189
The landscape of surgical anatomy education is progressively changing. Traditional meth-
ods, such as cadaveric dissection and didacticism are being increasingly phased out in
undergraduate courses for multimodal approaches incorporating problem-based learning,
radiology and computer-based simulations. Although effective at clinically contextualizing
and integrating anatomical information, these approaches may be a poor substitute for fos-
tering a grasp of foundational ‘pure’ anatomy. Dissection is ideal for this purpose and hence
remains the cornerstone of anatomical education. However, novel methods and technologi-
cal advancements continually give way to adjuncts such as cadaveric surgery, three-
dimensional printing, virtual simulation and live surgical streaming, which have demon-
strated significant efficacy alone or alongside dissection. Therefore, although divergent para-
digms of ‘new versus old’ approaches have engulfed and divided the community, educators
should seek to integrate the ancient and avant-garde to comprehensively satisfy all of the
modern anatomy learner’s educational needs.

prosections and surgical observation. These techniques have

Introduction
The practice and discipline of surgery is one that is complex and
multifaceted, incorporating many key elements such as tissue
manipulation, sound clinical judgement, ever-present conscientious-
ness and leadership. Among these, a fundamental element of profi-
ciency is the understanding of operative anatomy; it is the cognitive
roadmap that guides every cut, tie and manoeuvre the operator per-
forms on the table. It is as much a rite of passage as anything in a
budding surgeon’s training to obtain a practical grasp of this
knowledge.
Despite this, widespread concern has continued to arise sur-
rounding the level of anatomical knowledge in junior doctors and
surgeons, with an ever-diminishing trend of undergraduate ana-
tomical education being implicated in increasing medical
litigation,1 an issue attracting considerable attention in both media
and evidence-based literature.2 Australian and New Zealand medi-
cal schools are now reported to provide an average of 171 h of
anatomical teaching in total, significantly less in comparison to
historical data.2
The problem stems fundamentally not only from the gross
amount of education given but also its method of delivery. Tradi-
tionally, anatomical education has been delivered through modal-
ities such as didactic teaching, cadaveric dissection, models/
endured and evolved throughout the ages to the current day, setting
a foundational benchmark for the discipline.
However, in a time of rapid technological development, more
modalities are becoming available as practical avenues of surgical
anatomy education. Learners are no longer limited only to archaic
textbook diagrams and observing procedures from the corner of a
crowded theatre. There now exists a wide variety of online elec-
tronic resources, production devices and interactive three-
dimensional (3D) visualization technologies, which provide
diverse and flexible methods of knowledge acquisition. Newer
‘multimodal’ approaches, including problem-based learning
(PBL), radiology and computer-based learning, are increasingly
gaining dominance in many medical courses, often at the expense
of more conventional core teaching modalities such as dissec-
tion.2,3 Significant controversy has arisen amongst educators and
clinicians as a result of this, with ‘traditionalist’ educators vehe-
mently condemning the change while others actively wel-
come it.3,4
In response to the discord, this review aims to explore and evalu-
ate the role and effectiveness of the various educational approaches
in improving one’s understanding of the anatomical aspect of sur-
gery, with particular emphasis on comparing the new emerging
methods with more traditional ones.

ANZ J Surg 88 (2018) 146–151 © 2017 Royal Australasian College of Surgeons

Review of surgical anatomy teaching approaches
A review of ‘traditional’ modalities
Cadaveric dissection
Perhaps the single most traditional anatomical education method,
cadaveric dissection has been a mainstay for millennia, with an espe-
cially rich history (including grave robbings, criminal punishment
and public humiliation) dating as far back as 300 BC Greece.5 Many
have long regarded cadaver dissection to be an essential developmen-
tal milestone in every medical student’s path, with exuberant empha-
sis placed upon it in medical education until recent decades.
In a surgical context, dissection not only contributes to one’s
anatomical knowledge but also enriches a learner’s experience in
tissue manipulation, manual dexterity, teamwork, professional com-
munication and handling the emotional impact of death.6,7 It is pro-
foundly advantaged in its presentation of truly 3D, interactive
visuo-tactile information in a way that no other teaching modality
can adequately replicate to synthesize meaning and comprehen-
sion.4,7 Despite being an ancient practice, it is not without modern
advancements, with recent trends towards ‘Thiel’ embalming,
enhancing the ability of specimens to replicate the textures of real
patients in an operating theatre (OT) with impressive realism, much
to the satisfaction of clinical educators as well as the visceral dis-
comfort of many a greenhorn medical student.8
Dissectors are also exposed to a variety of anatomical variations,
an aspect that is often scarcely explored in other modalities yet is
so vital in practice. Arguably unique to cadaver dissection is the
presence of connective tissue, in contrast to anatomical pictures or
pre-dissected prosections, where these tissues are pre-removed or
poorly represented, giving the illusion of a ‘clear delineation’
between discrete structures, whereas in practice, they are often
‘blended’ together non-discretely by layers of fascia, adipose and/or
ligamentous fibres – a crucial concept to the prospective surgical
trainee.
Despite all its strengths, dissection is inadequate as a sole method
of learning,6,9 largely deficient in demonstrating functional neuroa-
natomy, microsurgical neurovasculature, contracted musculature
and more,4 therefore necessitating the use of adjunctive modalities.
It is being increasingly phased out likely due to significant upkeep
costs involved with the embalming and storage of the specimens, as
well as the cost and need for the adequate employment of appropri-
ate teaching personnel.6,7
Professional opinion on the place of dissection in the future of
anatomy education is, however, quite polarized, with many regard-
ing it as an indispensable learning tool, strongly advocating for its
preservation, while followers of the opposing view encourage its
replacement by modern approaches.10 The surgical community is
overwhelmingly aligned with the former view, with a survey on a
surgeon cohort (n = 80) yielding a consensus amongst 65% of
respondents (P < 0.001) that ‘cadaver/prosection demonstration’
was the best method of teaching anatomy, advocating for a greater
role of cadaver teaching in current anatomical education.11
Drawing
The use of illustration in studying anatomy is another ancient prac-
tice evolved through centuries, dating back to the times of Andreas
© 2017 Royal Australasian College of Surgeons
147
Vesalius, the Renaissance and beyond,5,12 yet retains its benefits of
being an active, engaging, low-cost method of knowledge acquisi-
tion in the modern day. Being largely free of the resource demands
of cadavers and expensive technology, drawing is a simple and effi-
cacious way of self-study, with the learner simply requiring only
some free time, a set of pencils and a pad.
The use of drawing has also been consistent with the trend of
implementing art in medical studies, conveying the associated psy-
chological benefits whilst honing the common skills of both disci-
plines, including observation, pattern recognition and emotional
interpretation.12 Careful pencil illustrations may likewise benefit
aspects of surgical techniques by exerting similar skill demands,
including hand dexterity, attention to detail, knowledge of form and
spatial awareness.13 The ‘drawbacks’, however, may include the
time requirement, different learning styles and potential dependence
on pre-existing artistic ability. Furthermore, it is intrinsically a two-
dimensional modality, lacking the 3D demonstration of structure
afforded by other modalities.
Apart from leisure or self-study, drawing can be used in the form
of ‘Observe–Reflect–Draw–Edit–Repeat’ (ORDER) classroom
exercises or alongside dissection courses, both methods that have
demonstrated significant efficacy.13,14 Interestingly, improvements
in anatomical knowledge are suggested to be independent of base-
line artistic ability,13,14 implying that poor artistic skill does not
preclude or diminish the educational benefits of illustration, possi-
bly because any attempt to externally express anatomical informa-
tion on paper necessitates extensive internal 3D contemplation.
Theatre- and clinical-based learning
Performing effectively in an OT is the end goal of all surgical anat-
omy learners. It, therefore, follows that it is a suitable environment
to acquire anatomical and other field-relevant skills. Despite this,
major barriers to anatomical learning exist here, being a time- and
resource-pressured, unpredictable environment where the emphasis
is not on teaching, with learning being observation-based, self-
driven and dependent on practical factors, including timing, case
availability and willingness/availability of clinicians to teach. Fur-
thermore, learners are often merely exposed to ‘snapshots’ of struc-
tures in the operative field, ineffectively cultivating an
understanding of the ‘bigger picture’.15 In addition, the modern
demand for impeccable patient outcomes makes the traditional
practice of ‘see one, do one, teach one’ increasingly outdated in the
first world16 as, understandably, tasks are geared towards experi-
enced seniors rather than junior learners at the cost of educational
opportunities for the latter, lessening their ability to engage freely,
in contrast to earlier times where a more laissez-faire approach to
student participation in the theatre existed.
Certain strategies can be adopted to maximize one’s learning
experience in the theatre, focused around managing social/profes-
sional relations, learning objectives and reactions to the work envi-
ronment and emotional impact of surgery.17 If students can
successfully manage these factors, there is significant anatomical
educational value present in the theatre; the learner is able to appre-
ciate live in vivo tissue, observe the therapeutic manipulation of
anatomy and apply theoretical knowledge in a clinical context,
148
allowing for reconsolidation and deepening of one’s overall under-
standing. Observing different surgical approaches to the same struc-
tures also strongly facilitates efficacious learning,18 that is, open
versus laparoscopic abdominal approaches and various joint, skele-
tal and intraoral approaches – the list goes on. Visualization from
various exposures allows for deep contextualization of 3D struc-
tural arrangements.
Apart from an anatomical perspective, benefits of OT learning
include observation of team member interactions, developing com-
munication skills, practicing sterile techniques, observing/practicing
(peri)operative skills and surgical reasoning.15 The theatre can be
seen as a setting to apply, solidify and deepen one’s pre-existing
anatomical knowledge in a clinical context, rather than a place to
synthesize new anatomical knowledge; its utility in this fashion is
limited. As such, medical students and junior doctors should
develop a working knowledge of relevant operative anatomy before
attending.
However, although this base knowledge should be accounted for
by students’ preclinical anatomy teaching, the transition to clinical
learning is often poorly addressed; there is often minimal vertical
integration in many institutions, with anatomy education being
almost non-existent in clinical years despite the long gap since stu-
dents’ preclinical teaching – a dilemma attributed partially to diffi-
culties in interdepartmental administrative collaboration.6,9
Cadaveric surgery
Dissection and OT participation act in unison to impart surgical
anatomy knowledge. The former emphasizes pure anatomy but
often neglects clinical aspects, while the latter provides abundant
clinical application in an educationally non-ideal environment.
Given this, a ‘mid-way point’ between the two may be an effica-
cious means of ‘bridging the gap’, that is, cadaveric surgery.18 Akin
to crash-testing motor vehicles before road use, cadaveric surgery
and demonstration has been regarded as the ‘gold standard’ for
developing operative skills in a controlled, ahaemorrhagic setting;18
however, its anatomical utility should also be considered.
Several institutions have built dedicated cadaver-armed surgical
theatre simulation facilities, where small pilot studies (n = 2,
50, 50) have been conducted. Programmes have involved a combi-
nation of surgeon-led teaching/demonstration, with students under-
taking supervised performance of surgical procedures on
cadavers.17–19 Studies yielded varying results, from significant
improvements in 64% of participants19 to nil improvements against
dissection group controls in assessment outcomes.17 Several studies
did, however, lack controls.18,19 Despite this, unanimously positive
subjective assessments praised the engagement of active thought
and directed goals as opposed to typical ‘exploratory’ dissection,
with students finding that they took ‘more care’ while handling tis-
sues and were not distracted in their anatomy learning by tool-
intensive parts of procedures.18,19 The exercises were overall
appreciated by participants as ‘a relaxed introduction to surgery’,
particularly the use of surgeon instructors in providing a clinical
perspective,18 who are generally underutilized yet so vital in surgi-
cal education.20
Hu et al.
Further studies are needed to evaluate efficacy and practical
resource efficiency, the latter being crucial given the decline of
cadaveric dissection in the face of time/capital costs. Therefore, an
even more resource-intensive method, such as cadaveric surgery, is
unlikely to achieve widespread adoption in undergraduate courses,
reserving it for specialized contexts, that is, possibly in postgradu-
ate courses.
Didactic lectures
As perhaps the most familiar and accessible modality, didactic lec-
tures remain a backbone of most anatomical courses.3 However,
recent trends have seen a movement away from standalone lectur-
ing to more clinically oriented, technology-integrated, team-based
approaches.3,6 The former has been criticized for its focus on pas-
sive learning and limitations in 3D depiction;21 however, this
modality retains value in teaching basic principles (e.g. anatomical
terminology and directions) and foundational ‘pure anatomy’, par-
ticularly in early undergraduate education.3
The application of new technologies
and methodologies in modern surgical
anatomy
The electronic era of anatomy education is a far cry from the days
of old, with each year bringing new technologies that introduce
innovative ways of conveying anatomical concepts. As a trend, ana-
tomical courses are becoming increasingly blended with
electronic-/computer-based platforms, mixing physical lectures sup-
plemented with online recordings, quizzes, animations etc, allowing
for independent self-paced study while alleviating staff resource
demands without completely removing physical teaching.22
PBL, case-based learning and team-based
learning
Revolting against traditional didacticism, problem-based
approaches utilizing student-centred team-based problem solving
have gained widespread adoption by undergraduate courses in
recent decades in general medical and anatomical education.3
Although this has been at the expense of other methods, PBL pro-
motes verbalization, communication, teamwork, active learning,
clinical and conceptualization over fact memorization.3,21 It is,
however, less effective at delivering pure anatomical and other
basic science knowledge, especially in comparison with traditional
dissection methods.3
Radiology and live surgical streaming
These modalities are discussed in Appendix S1.
Anatomage and other 3D simulation
technologies
The recent development of various anatomical simulation software
apps has stimulated interest in their use as potential resource-light
‘virtual’ alternatives to cadaver dissection. Users can interact with
© 2017 Royal Australasian College of Surgeons
Review of surgical anatomy teaching approaches
virtual models, rotating, moving, zooming and slicing it to their
desire, as well as selecting or removing individual structures and
highlighting whole systems. A wide range of functionalities, includ-
ing integration with clinical images, pathological correlates and an
‘undo’ button (much in contrast to physical cadavers), are available
in these virtual simulators, which are available across a range of
platforms, from handheld downloadables (e.g. visible body) to life-
sized tables.
The Anatomage table (Anatomage, San Jose, CA, USA) presents
a virtual to-scale cadaver on a table-sized iPad-type display. The
table has been implemented by several institutions and investigated
for effectiveness, a survey (n = 326) showing that 79.5% and
56.7% of students found Anatomage useful in demonstrating rela-
tive organ sizes and relationships, respectively, with main difficul-
ties lying in software errors, loss of interest after initial novelty and
poor image quality.23 Another 8-week study on four groups of jun-
ior doctors (n = 27) involved the undertaking of a peer-led
Anatomage-based programme, supervised by surgical seniors. A
significant improvement in all exam results were observed at the
conclusion of the study, increasing by a mean of 12% (95% CI:
5–19, P = 0.003), with participants citing the tutelage of the senior
surgeons to be the decisive factor in the programme’s success.24
These ‘virtual dissection’ simulations may be a feasible option
for sites where physical dissection is not practicable or as adjuncts
where they are practicable; however, they are unlikely to fully
replace the former due to their lack of physical feedback, demands
on technological affinity and anatomical detail.25 Their benefits can
be manifested through the facilitation of group learning, especially
when providing a medium of communication between seniors and
peers through shared interest and novelty, as in the case of Anatom-
age, while smaller hand-held apps represent the option of a porta-
ble, interactive reference.
3D printing
Another innovative technology that has gained biomedical promi-
nence in recent years is 3D printing, showing applications in preop-
erative planning, simulation and implant production across several
surgical specialties.26 Originating from the engineering field, the
technique can utilize computer-aided design (CAD) data exported
from computed tomography or magnetic resonance imaging scans
in Digital Imaging and Communications in Medicine (DICOM) for-
mat to print by a precise, individualized layering process.26
Its value in education lies in its production of models that are
inherently more than its conventional plastic counterparts (which
are idealized ‘cartoons’ in comparison), demonstrating even small
nerves, vessels and other negative spaces (e.g. paranasal sinuses,
cochlea, etc) and tissue planes with high resolution and accuracy,
being manifestations of real clinical image data.6,26 Individualized
models can be printed in a variety of views and layers, allowing for
the generation of multiple cross sections and prints from one image
file, as well as an effective depiction of pathoanatomy and atypical
variations where present. These characteristics, along with the
repeatability of production, allow for a potentially powerful, versa-
tile and economic way of generating teaching materials in the
absence of cadaveric options.
© 2017 Royal Australasian College of Surgeons
149
The drawbacks include reliance on high-quality source images
and cost/availability, with prices ranging from US$200 000 to
US$400 000, simple plastic printers on the low end and multi-
material printers on the high end.26 Yet, when these costs are com-
pared with plastination facilities, quoting upwards of US$600 000,
3D printing may well be the more economical option, particularly
when considering that technological advances will continue to opti-
mize cost efficiency and accessibility.26 The ability to depict ana-
tomical variations can also be a double-edged sword, particularly
when abnormalities are mistaken to be normal; caution must there-
fore be taken to expose materials to the correct populations, that is,
those who have a pre-existing grasp of ‘typical’ anatomy.
One randomized control trial on three groups of undergraduate
students (n = 52) studying cardiac anatomy showed significantly
higher post-test scores in the 3D printing group compared with con-
trol groups (P = 0.012), although authors noted variable pre-
existing knowledge levels as possible confounders.26
The promising preliminary evidence and increasing adoption of
3D printing technologies in surgical fields may well present viable
way of producing high-quality anatomy-learning resources in com-
ing times, particularly with prospects such as multi-material and
biological printing on the horizon.26
Traditional teaching versus the
multimodal approach in surgical
anatomy education
The landscape of anatomical education is changing,3,4,7 with partic-
ular relevance to the surgically inclined candidate. New multimodal
approaches are increasingly crowding out traditional approaches in
the face of the changing demands of modern undergraduate educa-
tion, with dissection shifting progressively towards a solely post-
graduate practice.2,27 These multimodal approaches often combine
PBL, radiology, computer-assisted learning and multimedia simula-
tion, likely due to economic reasons as they generally require less
contact hours, staff and resources to maintain.
The evidence base for modern teaching tools is expanding: a sys-
tematic review on 29 articles concluded that computer-assisted
learning and instruction showed better results than traditional teach-
ing interventions, being a valuable adjunct to dissection.10 Another
meta-analysis of 36 studies (n = 2226) demonstrated that 3D visu-
alization technologies yielded significantly higher test scores, spa-
tial contextualization and user satisfaction compared with all other
methods.25
This is certainly not to suggest that they are superior alternatives
to cadaveric dissection, with equally significant evidence to the
contrary,28 although institutions have already been reported to act
on this by phasing out dissection.2
It is important to emphasize that the use of each approach is by
no means mutually exclusive – adjunctive modalities can and
should be used together, each individual modality having its own
role and suitable complements. In fact, studies have largely shown
superior learning results when dissection was combined with other
modalities than in isolation.9,14,29
Overall, the heterogeneous results are difficult to generalize, but
several key findings can be concluded:
150
• For surgical learners, cadaveric methods are still recom-
mended as the central cornerstone of anatomical learning, with
important adjunctive modes including theatre observation,
drawing, models, radiology, computer-assisted learning and
others.
• Didactic methods are preferred for conferring basic pure
knowledge, while peer-based methods are suited towards
active learning and idea conceptualization.
• Increasingly utilized developing technologies, such as 3D
printing, surgical streaming and virtual simulation, pose signif-
icant potential benefits for future use, warranting further
exploration.
• 3D multimedia simulations cannot yet replace dissection but
may be a beneficial ‘compromise’ when the latter is
unavailable.
• Surgeon educators and vertical integration of anatomical
teaching are both commonly underutilized but efficacious and
desired.
• The use of multiple harmonious modalities brings about a
more complete understanding of anatomical structures, their
spatial relations and a superior learning outcome.
Limitations to the studies examined include the lack of small
cohort sizes, lack of randomization and high risk of bias. Future
studies should focus on using rigorous research designs, validated
measurement tools and adequate analysis of the outcomes of
knowledge improvement in cadaveric dissection against or in con-
junction with newer multimodal modalities.
Conclusion
Anatomy is the fundamental principle of surgery – its mastery gives
way to success, efficiency and satisfying patient outcomes, whereas
its failure results in the opposite.1 Learning anatomy for surgery is
unique in that it demands minutely detailed knowledge of special-
ized regional anatomy and relations, whereas most other specialties
require a more system-based, functional understanding. Surgical
anatomy education, therefore, specifically requires a mix of modal-
ities that cement ‘pure’ anatomical foundational knowledge as well
as emphasize clinical aspects.6,9
Traditional methods such as dissection and didacticism are inte-
gral in building this pure knowledge, while many of the newer mul-
timodal approaches are adept at expanding it and contextualizing it
clinically, although providing a questionable supplement for the
aforementioned ‘core’ aspect.3,9,30 It follows that learners should
ideally be administered the former before the latter so as to ‘lay the
foundations before building the skyscraper’ – so to speak. Yet, the
current system is bizarrely trending towards the opposite, with mul-
timodal approaches dominating undergraduate courses, while more
traditional cadaveric-focused approaches are becoming increasingly
widespread in postgraduate courses.3,27,31 It is unsurprising that
many graduates face anatomical knowledge inadequacies.
This problematic situation is an unfortunate, yet ultimately neces-
sary, adverse effect of an increasingly encumbered medical educa-
tion system, emphasizing the need for proactivity in those with a
surgical interests, who are more-than-ever required to actively pur-
sue learning opportunities through self-study, student-run interest
Hu et al.
societies and accessory/postgraduate courses, etc.32,33 Anatomically
focused surgical pre-entry examinations (i.e. generic surgical
sciences examination and Membership of the Royal College of Sur-
geons of Great Britain (MRCS) examinations) are effective in
assuring candidate benchmark knowledge,1 but do little to facilitate
the process, leaving the onus solely on the candidates.
It appears that we have arrived at a setting where two divergent,
opposing ‘paradigms’ of new versus old anatomical education have
formed, this distinction being more obstructive than productive.
Although emotive calls by traditionalists channelling memories of
‘the glory days’ resonate strongly with many reverent anatomy ‘dis-
ciples’, a disproportionate fixation on the past unnecessarily obfus-
cates future innovation. Likewise, phasing out all traditional
cadaveric learning in preference of futuristic virtual simulations is
equally inadequate and actively detrimental to the contemporary
surgical apprentice. No matter how great technology is, it will never
be a substitute for poor teaching, and the only ones capable of com-
prehensively teaching surgical anatomy are, at the end of the day,
surgeons. To this end, the future of anatomy education lies not in
conforming to the dogma of the past or in indulging excessive
novel modernity but in utilizing and integrating both the ancient
and avant-garde together to comprehensively satisfy all of the mod-
ern anatomy learner’s educational needs in a practical and efficient
manner.
Acknowledgements
We acknowledge Dr Nicola Dean for inspiring and prompting this
study through her innovative surgical anatomy programme and Pro-
fessor Rainer Haberberger with the Flinders University Anatomy
Department for providing a high-quality learning environment.
Conflicts of interest
None declared.
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Supporting information
Additional Supporting Information may be found in the online ver-
sion of this article at the publisher’s web-site:
Appendix S1. Radiology and live surgical stream.