Simulation of plastic surgery and microvascular procedures using perfused fresh human cadavers

Unleashing surgical skills: Ultra-high fidelity trauma thoracotomy training on knowledge donor platform

BACKGROUND

Resuscitative thoracotomies are a time-sensitive emergency surgical procedure with an immediate risk of mortality. We hypothesize that a high-fidelity whole-body donor simulation model, referred to as a Knowledge Donor (KD), with mechanical lung ventilation and expired human blood perfusion could increase learner confidence in performing this critical procedure.

METHODS

General surgery residents and faculty were invited to participate in KD training. Surveys were collected to track participation and confidence.

RESULTS

Simulated resuscitative thoracotomies were performed involving PGY levels I-IV. Mean confidence was highest for residents with both KD and Live Patient experience (5.6 ​± ​1.7), followed by Live Patient only (4.3 ​± ​2.5), and KD only (2.6 ​± ​1.3). The mean confidence rating for residents with neither training opportunity was 1.4 ​± ​1.0.

CONCLUSIONS

The KD platform is a hyper-realistic training modality that closely replicates live surgery. This platform allows residents to practice complex surgical procedures in a safe environment, without risking patient safety. This pilot program yielded early results in improving resident procedural confidence for high-risk surgical procedures, specifically resuscitative thoracotomies.

Recent Advances in Surgical Simulation For Resident Education

PURPOSE OF REVIEW

Surgical simulation has become a cornerstone for the training of surgical residents, especially for urology residents. Urology as a specialty bolsters a diverse range of procedures requiring a variety of technical skills ranging from open and robotic surgery to endoscopic procedures. While hands-on supervised training on patients still remains the foundation of residency training and education, it may not be sufficient to achieve proficiency for graduation even if case minimums are achieved. It has been well-established that simulation-based education (SBE) can supplement residency training and achieve the required proficiency benchmarks.

RECENT FINDINGS

Low-fidelity modules, such as benchtop suture kits or laparoscopic boxes, can establish a strong basic skills foundation. Eventually, residents progress to high-fidelity models to refine application of technical skills and improve operative performance. Human cadavers and animal models remain the gold standard for procedural SBE. Recently, given the well-recognized financial and ethical costs associated with cadaveric and animal models, residency programs have shifted their investments toward virtual and more immersive simulations. Urology as a field has pushed the boundaries of SBE and has reached a level where unexplored modalities, e.g., 3D printing, augmented reality, and polymer casting, are widely utilized for surgical training as well as preparation for challenging cases at both the residents, attending and team training level.

Human body donors at academic institutions in the United States of America: An investigative study

Work with deceased human bodies to enhance anatomical education was first documented in the 3rd century BCE. However, the development of body donation programs provided many new opportunities for medical education. The aim of this study was to investigate the work supported by human body donors at academic institutions in the United States and to evaluate the ethical oversight process and the preparation methods used. A questionnaire was developed using Qualtrics and sent to 125 body donation programs in the United States. Representatives from a total of 69 institutions completed the questionnaire. The data showed that human body donations across the United States are used in teaching, clinical skills training, research, and educational outreach. Most institutions worked with hard-fixed donors for teaching and some with soft-preserved and unembalmed donors for clinical skills training. Among the participating programs, only 33 representatives reported an ethical approval process for conducting research involving human body donors. These findings raise ethical concerns related to the operation of body donation programs due to the lack of oversight. Furthermore, some institutions allowed faculty and staff to take photographs of donated bodies for educational purposes, which is often not disclosed on the consent form. The data also showed the need for more discussion on anatomical legacy collections housed at these institutions in the United States.

Simulation-based training in dermatologic surgery: a literature review

Simulation-based training has been shown to increase confidence and improve technical proficiency in surgical trainees. In this review, we describe the methods of simulation-based training currently being utilized in cutaneous surgery education. PubMed and EMBASE were searched for terms related to dermatologic surgery, education, and simulation. Articles published in English from 2013 onward that discussed simulation-based cutaneous surgery training of dermatology, plastic surgery, or otolaryngology resident physicians were included and summarized. Currently utilized simulation modalities in the training of dermatologic surgeons include skin substitutes, cadavers, and technology-based platforms. While each of these modalities have been shown to enhance trainee confidence and/or skill, head-to-head studies comparing their efficacy and usefulness are limited. Dermatologic surgery training, and therefore patient care, may be enhanced by further incorporation of simulation training. However, further studies are needed to clarify the optimal simulation platforms and delivery.

Exploring the Role of Simulation Training in Improving Surgical Skills Among Residents: A Narrative Review

The role of simulation in medical education is crucial to the development of surgeons' skills. Surgical simulation can be used to improve surgical skills in a secure and risk-free environment. Animal models, simulated patients, virtual reality, and mannequins are some types of surgical simulation. As a result, feedback encourages students to reflect on their strengths and weaknesses, enabling them to focus on improvement. Healthcare simulation is a strong educational instrument, and the main goal of this is to give the students an opportunity to do a practical application of what they have learned through theory. Before taking it to the patients, they will already have certain tools they have previously acquired during the practice. This makes it easier for students to identify the knowledge gaps that they must fill to improve patient outcomes. Moreover, simulation brings a wonderful opportunity for students to acquire skills, gain confidence, and experience success before working with real patients, especially when their clinical exposure is limited. The use of simulation to teach technical skills to surgical trainees has become more prevalent. The cost of setting up a simulation lab ranges from $100,000 to $300,000. There are several ways to evaluate the effectiveness of simulation-based surgical training. Repetitive surgical simulation training can improve speed and fluidity in general surgical skills in comparison to conventional training. Few previous studies compared learners who received structured simulation training to a group of trainees who did not receive any simulation training in single-center randomized control research. Significantly faster and less time-consuming skill proficiency was noticeable in simulated trainees. Despite being anxious in the operating room for the first time, simulated trainees completed the surgery on time, demonstrating the effectiveness of surgical simulation training. Traditional surgical training involves senior-surgeon supervision in the operating room. In simulation-based training, the trainees have full control over clinical scenarios and settings; however, guidance and assessment are also crucial. Simulators allow users to practice tasks under conditions resembling real-life scenarios. Simulators can be compared with traditional surgical training methods for different reasons. For example, intraoperative bleeding may occasionally show up not only visibly on the screen but also by shaking the trocars erratically. Without haptics, training on virtual simulators can cause one's pulling and pushing forces, which are frequently greater than what the tissue needs, to be distorted. A good method of simulation training is using virtual reality simulators with haptics and simulated patients. The availability of these facilities is limited, though, and a typical session might include an exercise involving stacking sugar cubes and box trainers. The degree of expertise or competency is one area that needs clarification as medical education transitions to a competency-based paradigm. The article aims to provide an overview of simulation, methods of simulation training, and the key role and importance of surgical simulation in improving skills in surgical residents.

Assessment of a Perfusion and Ventilation Method for Detecting Lung and Liver Injury in a Cadaveric Model

Surgical simulation models have been developed using post-mortem human subjects (PMHS). These models involve the pressurization and ventilation of the PMHS to create a more realistic environment for training and the practice of surgical procedures. The overall objective of this study was to determine the feasibility of a previously developed surgical simulation model to detect soft tissue injuries during a ballistic impact to the torso. One of the main limitations of using PMHS for the assessment of soft tissue injuries in the field of injury biomechanics is the lack of physiological blood flow. To overcome this limitation, the assessment of the surgical simulation model for use in injury biomechanics applications was conducted based on data collected from behind armor blunt trauma (BABT) case studies. Documented injuries in real-world cases included anterior lung contusion, posterior lung contusion, and liver contusion. These real-world injuries were compared to those seen post-impact in the PMHS using pathological and histological techniques. Discussion of limitations and future work is presented.

Comparing the volume of vascular intersection of two femoral neck fracture fixation implants using an In silico technique

Femoral neck fracture displacement with subsequent vascular disruption is one of the factors that contribute to trauma-induced avascular necrosis of the femoral head. Iatrogenic damage of the intraosseous arterial system during fixation of femoral neck fracture is another possible cause of avascular necrosis that is less well understood. Recently, Zhao et al (2017) reconstructed 3D structures of intraosseous blood supply and identified the epiphyseal and inferior retinacular arterial system to be important structures for maintaining the femoral head blood supply after femoral neck fracture. The authors therefore recommended placing implants centrally to reduce iatrogenic vascular injuries. Our in vitro study compared the spatial footprint of a traditional dynamic hip screw with an antirotation screw versus a newly developed hip screw with an integrated antirotation screw on intraosseous vasculature.

Methods

Three dimensional (3D) µCT angiograms of 9 cadaveric proximal femora were produced. Three segmented volumes-porous or cancellous bone, filled or cortical bone, and intraosseous vasculature-were converted to surface files. 3D in silico models of the fixation systems were sized and implanted in silico without visibility of the vascular maps. The volume of vasculature that overlapped with the devices was determined. The ratio of the vascular intersection to the comparator device was calculated, and the mean ratio was determined. A paired design, noninferiority test was used to compare the devices.

Results

Results indicate both significant (P < 0.001) superiority and noninferiority of the hip screw with an integrated antirotation screw when compared with a dynamic hip screw and antirotation screw for the volume of vasculature that overlapped with each device in the femoral neck.

Conclusions

Combining established methods of vascular visualization with newer methods enables an implant's impact on vascular intersection to be assessed in silico. This methodology suggests that when used for femoral neck fracture management, the new device intersects fewer blood vessels than the comparator. Comparative clinical studies are needed to investigate whether these findings correlate with the incidence of avascular necrosis and clinical outcomes.

Endoscopic neuroanatomy study using embalmed cadavers

Objectives

A firm understanding of anatomy is foundational for all medical students and residents. As opportunities for cadaveric study dwindle, we propose a simplified perfusion model for formalin fixed cadavers that allow for endoscopic neuroanatomical study and procedural practice. This model is easily accessible, cost effective, and valuable in medical training.

Materials and Methods

Cadavers were fixed through accepted methods that included formalin injection into the cranial vault. The perfusion system was set up using a series of catheters, tubing, and pressurized saline bag that forced saline into the various neuroanatomical spaces chosen for study.

Results

A neuroendoscope was subsequently introduced to explore and identify relevant neuroanatomical structures as well as to perform a 3rd ventriculostomy and filum sectioning.

Conclusion

Using formalin fixed cadavers for neuroendoscopic studies and procedural practice is a cost effective, multipurpose tool that can provide medical trainees with a strong understanding of anatomy as well as procedural practice.

A national needs assessment to identify technical procedures in plastic surgery for simulation-based training

Medical simulation is not developed and integrated into plastic surgery unlike other surgical specialties despite the procedures being complex and require practice. First step in enhancing simulation in plastic surgery is to clarify the need among peers. The objective of the study was to identify and prioritize the technical procedures that should be included in a simulation-based curriculum for residency training in plastic surgery. A panel of participants with key roles in the Danish plastic surgery specialist training program was appointed. Participation was voluntary. A national need assessment study was performed using a three-round Delphi process to collect information from the participants. In round 1, participants reported all the procedures that a newly qualified specialist in plastic surgery should be able to perform. In round 2, participants replied to a survey exploring the frequency of the procedures, the number of surgeons performing the procedure, the risk or discomfort for patients treated by an inexperienced surgeon and the feasibility of training the procedure in simulation, resulting in a preliminary ranking of procedures. In round 3, participants eliminated and reprioritized the identified procedures according to importance. Thirty-five of 37 agreed to enter the expert panel. The response rate was 97%, 86% and 86% for rounds 1, 2 and 3, respectively. Twenty-nine of 136 procedures identified in round 1 reached the final prioritized list of procedures relevant for simulation training in plastic surgery.

Morphodynamic study of the corona mortis using the SimLife® technology

PURPOSE

Open book pelvic ring fractures are potentially life-threatening, due to their instability and major hemorrhage risk. During the open reduction and internal fixation, the pelvic approach remains a technical challenge, as the surgeon wants to prevent any iatrogenic damage of the vascular loop located in the retro-pubic area called corona mortis (CMOR). Recently, the cadaver perfused SimLife^® technology has been developed to improve the surgeon training, out of the operating room. This study aimed to compare two models of cadaveric dissection, to assess the interest of the perfused SimLife^® in providing dynamic aspect of anatomy in the identification of CMOR and its topography.

METHODS

Twelve human cadaveric pelvises have been dissected, following two protocols. 12 hemi-pelvises of the dissections were performed without perfusion (Model A), whereas the 12 other hemi-pelvises have been prepared with the SimLife^® pulsatile perfusion (Model B). The prevalence and morphologic parameters determined: length, diameter and distance between the CMOR and the pubic symphysis.

RESULTS

The CMOR has been found in 66.67% of the cases. The length, the diameter, and the distance between the CMOR and the pubic symphysis were significantly higher in model B (respectively p = 0.029, p = 0.01, and p = 0.022).

CONCLUSION

These results suggest that the CMOR is easier to identify and to dissect with the SimLife^® perfusion. As part of the surgical training of any trauma surgeon, this model could help him to keep in mind the CMOR topography, to improve the open book lesion management.

Development of a post-mortem human specimen flow model for advanced bleeding control training

INTRODUCTION

Prompt and effective hemorrhage control is paramount to improve survival in patients with catastrophic bleeding. In the ever-expanding field of bleeding control techniques, there is a need for a realistic training model to practice these life-saving skills. This study aimed to create a realistic perfused post-mortem human specimen (PMHS) flow model that is suitable for training various bleeding control techniques.

MATERIALS AND METHODS

This laboratory study was conducted in the SkillsLab & Simulation Center of Erasmus MC, University Medical Center Rotterdam, the Netherlands. One fresh frozen and five AnubiFiX® embalmed PMHS were used for the development of the model. Subsequent improvements in the exact preparation and design of the flow model were made based on model performance and challenges that occurred during this study and are described.

RESULTS

Circulating arteriovenous flow with hypertonic saline was established throughout the entire body via inflow and outflow cannulas in the carotid artery and jugular vein of embalmed PMHS. We observed full circulation and major hemorrhage could be mimicked. Effective bleeding control was achieved by placing a resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter in the model. Regional perfusion significantly reduced the development of tissue edema.

CONCLUSION

Our perfused PMHS model with circulating arterial and venous flow appears to be a feasible method for the training of multiple bleeding control techniques. Regional arteriovenous flow successfully reduces tissue edema and increases the durability of the model. Further research should focus on reducing edema and enhancing the durability of the model.

Simulation of Reconstructive Microsurgery in Soft Embalmed Cadavers: A Teaching Module for Plastic Surgery Residents

Background  Cadaveric dissection courses—comprising flap harvesting techniques, vessel dissections, flap transfers to the defect, and microvascular anastomosis—would help residents gain confidence and master these difficult major reconstructive microsurgery procedures. Formalin embalmed bodies lack natural softness and many other features of a live body. Many soft embalming techniques have evolved to mimic live tissue and Theil technique is the most popular one among them. We explored alternate soft embalming options and started using Genelyn.

Materials and Methods  Over a span of 2 years (2019–2021), we have conducted three flap dissection workshops using soft-embalmed cadavers. Six soft-embalmed and two formalin-embalmed cadavers were used. Total number of participants was 80.

Results  Feedback of experience from the third course participants in the form of grades (1–5) for different criteria was obtained and evaluated. Confidence in the dissection of the various flaps and microsurgery is noticeable in all the participants.

Conclusion  Based on our experience, we propose that flap dissection and microsurgery training on soft-embalmed cadavers be included as a teaching module in the plastic surgery postgraduate curriculum.

Efficacy of a perfused cadaver model for simulated trauma resuscitation in advanced surgical skills training

Background

To develop a perfused cadaveric model for trauma surgery simulation, and to evaluate its efficacy in trauma resuscitation advanced surgical skills training.

Methods

Fourteen fourth-year general surgery residents attended this workshop at Siriraj Hospital (Bangkok, Thailand). Inflow and outflow cannulae and a cardiopulmonary bypass pump were used to create the perfusion circuit. Inflow was achieved by cannulating the right common carotid artery, and outflow by cannulation of both the right common femoral artery and the internal jugular vein. Arterial line monitoring was used to monitor resuscitation response and to control perfusion pressure. The perfusion solution comprised saline solution mixed 1:1 with glycerol (50%) and water with red food dye added. Advanced surgical skills during life-threatening injuries and damage control resuscitation operations were practiced starting from the airway to the neck, chest, peripheral vessels, abdomen, and pelvis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was also practiced. Post-workshop survey questions were grouped into three categories, including comparison with previous training methods; the realism of anatomical correlation and procedures; and, satisfaction, safety, and confidence. All questions and tasks were discussed among all members of the development team, and were agreed upon by at least 90% of experts from each participating medical specialty/subspecialty.

Results

The results of the three main groups of post-workshop survey questions are, as follows: (1) How the training compared with previous surgical training methods—mean score: 4.26/5.00, high score: 4.73/5.00; (2) Realism of anatomical correlation and procedures—mean score: 4.03/5.00, high score: 4.60/5.00; and, (3) Satisfaction, safety, and confidence—mean score: 4.24/5.00, high score: 4.47/5.00.

Conclusion

The developed perfused cadaveric model demonstrated potential advantages over previously employed conventional surgical training techniques for teaching vascular surgery at our center as evidenced by the improvement in the satisfaction scores from students attending perfused cadaveric training compared to the scores reported by students who attended earlier training sessions that employed other training techniques. Areas of improvement included ‘a more realistic training experience’ and ‘improved facilitation of decision-making and damage control practice during trauma surgery’.

Simulation in plastic and reconstructive surgery: a scoping review

Since the origins of surgery, simulation has played an important role in surgical education, particularly in plastic and reconstructive surgery. This has greater relevance in contemporary settings of reduced clinical exposure resulting in limited work-based learning opportunities. With changing surgical curricula, it is prescient to examine the role of simulation in plastic and reconstructive surgery.

A scoping review protocol was used to identify relevant studies, with an iterative process identifying, reviewing and charting the data to derive reported outcomes and themes.

Of the 554 studies identified, 52 studies were included in this review. The themes identified included simulator modalities, curriculum elements targeted and relevant surgical competencies. There was a predominance of synthetically based simulators, targeting technical skills largely associated with microsurgery, paediatric surgery and craniomaxillofacial surgery.

Existing simulators largely address high-complexity procedures. There are multiple under-represented areas, including low-complexity procedures and simulation activities addressing communication, collaboration, management and leadership. There are many opportunities for simulation in surgical education, which requires a contextual appreciation of educational theory. Simulation may be used both as a learning method and as an assessment tool.

This review describes the literature relating to simulation in plastic and reconstructive surgery and proposes opportunities for incorporating simulation in a broader sense, in the surgical curriculum.

Training on skin flap elevation in hand surgery using cadavers embalmed by the saturated salt solution method: effectiveness and usefulness

Thiel embalmed and fresh-frozen cadavers have been mainly used for hand surgery training. We held a training seminar on skin flap elevation using cadavers embalmed by the saturated salt solution method. This study aimed to evaluate the usefulness of such training and to validate the suitability of saturated salt solution-embalmed cadavers for hand surgery training. Participants were trained in elevation procedures for the oblique triangular, reverse digital artery, reverse radial forearm, and reverse dorsal metacarpal artery flaps. Forty-eight surgeons participated in three seminars (one held in 2017, 2018, and 2019 each). A self-assessment of the participants' confidence levels for their surgical skills was performed before and immediately after the seminar, and the suitability of saturated salt solution-embalmed cadavers was determined in terms of visual perception, tactility, comparison with real-world surgical settings, and usefulness. The confidence level for all skills increased immediately after the seminar. The surgeons reported that the visual perception and tactility of the saturated salt solution-embalmed cadavers were comparable to those of a living body, and the cadavers were rated higher with respect to their usefulness. Hand surgery seminars using cadavers embalmed by the saturated salt solution method are considered useful for training in skin flap techniques.

Mind the Gap: a Competency-Based Scoping Review of Aesthetic and Reconstructive Reported Simulation Training Models

BACKGROUND

Simulation training has become an integral part of plastic surgery postgraduate curricula. It facilitates the acquisition of skills in a safe environment that can be later transferred to real-life settings. A variety of models have been described covering some aspects of the specialty better than others. The aim of this study was to identify and classify all the previously reported plastic surgery simulation models and the possible gaps having the Accreditation Council for Graduate Medical Education (ACGME) list of competencies as a guide.

METHODS

Through a Delphi process, the complete list of ACGME minimum requirements for certification was analyzed to identify domains amenable for simulation training. A systematic search was conducted in Pubmed looking for all previously reported simulation models in plastic surgery. Predefined inclusion and exclusion criteria and parallel blind review were used to identify eligible models.

RESULTS

A total of 81 ACGME competencies were identified. Following a 3-round Delphi process, consensus was reached on 19 reconstructive and 15 aesthetic surgery domains suitable for simulation training. 1667 articles were initially retrieved from Pubmed, of which 66 articles were eligible for inclusion. Descriptive (65%), quasi-experimental (24%) and experimental studies (11%) were found. For the 34 identified ACGME competencies, there were simulation models described for 58.8% of these, mostly covering reconstructive surgery (84.2%) while for aesthetic surgery it was 13.3%.

CONCLUSIONS

This scoping review has identified that there are still gaps in ACGME competencies that could benefit from new simulation training models, especially in those related to aesthetic surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Crisis Management Simulation: Review of Current Experience

Crisis management simulation is important in training the next generation of surgeons. In this review, we highlight our experiences with the cavernous carotid injury model. We then delve into other crisis simulation models available for the neurosurgical specialty. The discussion focuses upon how these trainings can continue to evolve. Much work is yet to be done in this exciting arena and we present several avenues for future discovery. Simulation continues to be an important training tool for the surgical learner.

The University of Pennsylvania Flap Course Enters Virtual Reality: The Global Impact

The purpose of this study was to evaluate participants from the in-person Penn Flap Course (PFC) and virtual PFC to determine if the virtual PFC increased diversity in culture, sex, education, and surgical specialties internationally and within the United States. Our hypothesis is that the virtual PFC increases diversity internationally and within the United States.

Methods

A retrospective descriptive comparison was performed between participants from the in-person PFC from the years 2017 to 2019 and virtual PFC in 2020. Frequency maps were generated to determine differences in participation of cultures, sexes, education, and specialties internationally and within the United States. Net Promoter Scores (NPSs) were used to assess participant satisfaction with the virtual course.

Results

The in-person PFC included 124 participants from the years 2017 to 2019, whereas the virtual PFC included 770 participants in the year 2020. Compared to the in-person course, the virtual course included more cultures (countries: 60 versus 11; states: 35 versus 22), women (countries: 38 versus 7; states: 23 versus 9), students/researchers (countries: 24 versus 0; states: 9 versus 0), residents (countries: 44 versus 5; states: 26 versus 15), fellows (countries: 21 versus 2; states: 21 versus 9), attendings (countries: 34 versus 8; states: 16 versus 11), plastic surgery (countries: 54 versus 9; states: 31 versus 18), orthopedic surgery (countries: 12 versus 5; states: 11 versus 9), and other specialties (countries: 19 versus 1; states: 8 versus 2). Our overall NPS for the virtual PFC totaled 75%, categorized as "world class" based on global NPS.

Conclusion

A virtual interface for a flap course increased participation and diversity of culture, sex, education, and specialties internationally and within the United States with "world class" participant satisfaction.

Validated specialty-specific models for multi-disciplinary microsurgery training laboratories: a systematic review

BACKGROUND

Laboratory simulation is increasingly important for teaching microsurgical skills. Training microsurgeons of different specialties within the same simulation laboratory increases efficiency of resource use. For maximal benefit, simulations should be available for trainees to practice specialty-specific, higher-order skills. Selection of appropriate simulations requires knowledge of the efficacy and validity of the numerous described laboratory models. Here we present a systematic review of validated training models that may serve as useful adjuncts to achieving competency in specialty elements of microsurgery, and appraise the evidence behind them.

METHODS

In setting up a multi-disciplinary microsurgery training course, we performed a systematic review according to preferred reporting items for systematic reviews and meta-analyses guidelines. EMBASE, MEDLINE, Cochrane and PubMed databases were searched for studies describing validated, microscope-based, specialty-specific simulations, and awarded a level of evidence and level of recommendation based on a modified Oxford Centre for Evidence-Based Medicine classification.

RESULTS

A total of 141 papers describing specialty-specific microsimulation models were identified, 49 of which included evidence of validation. Eleven were in the field of neurosurgery, 21 in otolaryngology/head and neck surgery, two in urology/gynaecology and 15 plastic and reconstructive surgery. These papers described synthetic models in 19 cases, cadaveric animals in 10 cases, live animals in 12 cases and human cadaveric material in 10 cases.

CONCLUSION

Numerous specialty-specific models for use in the microscope laboratory are available, but the quality of evidence for them is poor. Provision of models that span numerous specialties may encourage use of a microscope lab whilst still enabling more specific skills training over a 'one-size-fits-all' approach.

Validation of an in vivo porcine simulation model of pedicled latissimus dorsi myocutaneous flap elevation

Background

In vivo and ex vivo simulation training workshops can contribute to surgical skill acquisition but require validation before becoming incorporated within curricula. Ideally, that validation should include the following: face, content, construct, concurrent, and predictive validity.

Methods

During two in vivo porcine surgical training workshops, 27 participants completed questionnaires relating to face and content validity of porcine in vivo flap elevation. Six participants’ performances raising a pedicled myocutaneous latissimus dorsi (LD) flap in the pig (2 experts and 4 trainees) were sequentially and objectively assessed for construct validity with hand motion analysis (HMA), a performance checklist, a blinded randomized procedure-specific rating scale of standardized video recordings, and flap viability by fluorescence imaging.

Results

Face and content validity were demonstrated straightforwardly. Construct validity was demonstrated for average procedure time by HMA between trainees and experts (p = 0.036). Skill acquisition was demonstrated by trainees’ HMA average number of hand movements (p = 0.046) and fluorescence flap viability (p = 0.034).

Conclusion

Face and content validity for in vivo porcine flap elevation simulation training were established. Construct validity was established for an in vivo porcine latissimus dorsi flap elevation simulation specifically. Predictive validity will prove more challenging to establish.

Level of evidence: Not ratable .

The Usefulness of Saturated Salt Solution Embalming Method for Oral Surgical Skills Training: A New Cadaveric Training Model for Bone Harvesting

The purpose of this study was to assess the usefulness of saturated salt solution-embalmed cadavers for oral surgical skills training related to bone graft harvesting. Two half-day surgical skills training workshops were held at the Tokyo Medical University utilizing eight cadavers embalmed with the saturated salt solution. A total of 22 participants including oral surgeons, residents, and dentists attended the workshop. Surgical training consisted of six procedures related to intraoral and extraoral bone harvesting. The participants were surveyed to assess self-confidence levels for each surgical procedure before and after completion of each workshop. The Wilcoxon signed-rank test was used to compare the differences between each median score before and after the workshop. There were statistically significant increases in the self-assessed confidence scores in bone harvesting procedures for the zygomatic bone (P = 0.003), maxillary tuberosity (P = 0.002), and other sites (P < 0.001). The anatomical features of saturated salt solution-embalmed cadavers were also examined. The textures of the oral mucosa and skin were similar to those of living individuals. The structure of bone tissues was well-preserved and the hardness was realistic. Consequently, all procedures were performed with sufficient realism. The saturated salt solution method has a relatively low cost of preparation and storage, and almost no odor. The authors suggest that saturated salt solution-embalmed cadavers could provide a new model for oral surgical skills training in bone harvesting.

Novel Simulation Model with Pulsatile Flow System for Microvascular Training, Research, and Improving Patient Surgical Outcomes

BACKGROUND

Simulation allows surgical trainees to acquire surgical skills in a safe environment. With the aim of reducing the use of animal experimentation, different alternative nonliving models have been pursued. However, one of the main disadvantages of these nonliving models has been the absence of arterial flow, pulsation, and the ability to integrate both during a procedure on a blood vessel. In the present report, we have introduced a microvascular surgery simulation training model that uses a fiscally responsible and replicable pulsatile flow system.

METHODS

We connected 30 human placentas to a pulsatile flow system and used them to simulate aneurysm clipping and vascular anastomosis.

RESULTS

The presence of the pulsatile flow system allowed for the simulation of a hydrodynamic mechanism similar to that found in real life. In the aneurysm simulation, the arterial flow could be evaluated before and after clipping the aneurysm using a Doppler ultrasound system. When practicing anastomosis, the use of the pulsatile flow system allowed us to assess the vascular flow through the anastomosis, with verification using the Doppler ultrasound system. Leaks were manifested as "blood" pulsatile ejections and were more frequent at the beginning of the surgical practice, showing a learning curve.

CONCLUSIONS

We have provided a step-by-step guide for the assembly of a replicable and inexpensive pulsatile flow system and its use in placentas for the simulation of, and training in, performing different types of anastomoses and intracranial aneurysms surgery.

Novel Porcine Kidney-Based Microsurgery Training Model for Developing Basic to Advanced Microsurgical Skills

BACKGROUND

 Microsurgery training is critical to the practice of microvascular procedures in many surgical areas. However, even simple procedures require different levels of complex skills. Therefore, simulation-based surgical training, mainly in the area of vascular anastomosis, is of great importance. In this paper, we present a new microsurgery training model for the development of basic to advanced microsurgical skills.

METHODS

 Porcine kidneys were purchased from a legal butchery slaughterhouse. First, kidneys were washed with water to remove blood and clots inside vessels. Then, dissection was performed throughout the vascular pedicle from the renal arteries to the segmentary branches. Finally, the longitudinal sectioning of the kidney parenchyma was performed to expose the vessels necessary for training. Sixty end-to-end anastomoses were performed. Specific instruments and materials were used to perform anastomoses and dissections with magnification by a video system. We evaluated the diameter of vessels, time to perform anastomosis, and patency of anastomosis.

RESULTS

 There was no great anatomical variation among the porcine kidneys. The total length for dissection training was 25.80 ± 7.44 cm using the arterial and venous vessel. The average time to perform arterial anastomoses was 23.79 ± 4.55 minutes. For vessel diameters of ≤ 3, 4 to 6, and 7 to 10 mm, the average procedure times were 27.68 ± 3.39, 22.92 ± 4.12, and 20.77 ± 3.44 minutes, respectively. Regarding venous anastomosis, the average duration of the procedure was 26.17 ± 4.80 minutes, including durations of 31.61 ± 3.86, 25.66 ± 4.19, and 21.24 ± 3.79 minutes for vessel diameters of ≤ 7, 8 to 10, and >10 mm, respectively. Positive patency was achieved in all surgeries.

CONCLUSION

 The porcine kidney provides an inexpensive and convenient biological model for modeling microanastomosis with high fidelity to vascular structures.

Microsurgery Training in Plastic Surgery

Advances in surgical instruments, magnification technology, perforator dissection techniques, and vascular imaging over the past decades have facilitated exponential growth in the field of microsurgery. With wide application potential including but not limited to limb salvage, breast reconstruction, lymphedema treatment, and sex affirmation surgery, microsurgery represents a critical skill set that powerfully augments the reconstructive armamentarium of plastic surgeons. Accordingly, microsurgical training is now a critical component of the plastic surgery residency education curriculum. Trainees must meet minimum microsurgery case requirements in addition to the core competencies outlined by the Accreditation Council for Graduate Medical Education. Through the use of simulation models, residency programs increasingly incorporate early skills development and assessment in microsurgery in the laboratory. Beyond residency, microsurgery fellowships offer additional exposure and refinement by offering volume, complexity, autonomy, and possible focused specialization. With continued refinement in technology and advances in knowledge, new types of simulation training models will continue to be developed and incorporated into microsurgery training curricula.

Cadaveric Simulation Training in Cardiothoracic Surgery: A Systematic Review

Simulation training has become increasingly relevant in the educational curriculum of surgical trainees. The types of simulation models used, goals of simulation training, and an objective assessment of its utility and effectiveness are highly variable. The role and effectiveness of cadaveric simulation in cardiothoracic surgical training has not been well established. The objective of this study was to evaluate the current medical literature available on the utility and the effectiveness of cadaveric simulation in cardiothoracic surgical residency training. A literature search was performed using PubMed, Cochrane Library, Embase, Scopus, and CINAHL from inception to February 2019. Of the 362 citations obtained, 23 articles were identified and retrieved for full review, yielding ten eligible articles that were included for analysis. One additional study was identified and included in the analysis. Extraction of data from the selected articles was performed using predetermined data fields, including study design, study participants, simulation task, performance metrics, and costs. Most of these studies were only descriptive of a cadaveric or perfused cadaveric simulation model that could be used to augment clinical operative training in cardiothoracic surgery. There is a paucity of evidence in the literature that specifically evaluates the utility and the efficacy of cadavers in cardiothoracic surgery training. Of the few studies that have been published in the literature, cadaveric simulation does seem to have a role in cardiothoracic surgery training beyond simply learning basic skills. Additional research in this area is needed.

Review of the First 108 Free Flaps at Public Health Concern Trust-NEPAL Hospitals: Challenges and Opportunities in Developing Countries

BACKGROUND

Free tissue transfer is one of the most important and essential techniques in reconstructive surgery. The underlying complexity, steep learning curve, high cost, and fear of failure make it very difficult to establish as a regular service in developing countries such as Nepal.

METHODS

A retrospective cohort study design was used to analyze the challenges with and opportunities for reconstructive surgery in Nepal. Medical records were reviewed for patient demographics, indications, types of free flaps, hospital stay, complications, and involvement of a microsurgery teaching workshop.

RESULTS

A total of 16 microsurgical workshops were carried out by 3 international organizations over the study period (2007-2017). Altogether 108 free flaps in 103 subjects were reviewed during the study period at different hospitals of the Public Health Concern Trust-NEPAL (phect-NEPAL) and National Trauma Center. Of 103 patients, 60 were males and 43 were females with an average age of 34.5 years (range, 8-73 years). The most common indications for microsurgical reconstruction were tumor, trauma, and burns. Radial artery forearm flap, anterolateral thigh flap, and free fibular flap were the most common types of flaps. Ten different types of flaps were performed. Four cases needed more than 1 flap; one of them needed 3 flaps. Flap success rate approached 90%. Four patients died in the hospital postoperatively.

CONCLUSION

Reconstructive microsurgery is challenging in Nepal and more generally in developing settings. However, persistent technical support such as training and workshops can make it feasible.

The Multifactorial Contribution of Publications in Plastic Surgery Journals in Microsurgery Education

BACKGROUND

Microsurgery is one of the most complex operative skills. Recent restrictions on residents' working hours challenge residency program directors to ensure skill acquisition with scant time dedicated to microsurgery practice. We aimed to summarize the contribution of plastic surgery journals in microsurgical education.

METHODS

A comprehensive literature search was performed.

RESULTS

We observed an increasing number of publications on microsurgery education over the years. This could be due to the adoption of new technologies developed in the last 2 decades, the concerns about quality of resident training in the context of reduced work hours, the well-described benefit of medical simulations in other specialties, and the pressure on trainees to be proficient before operating on patients. The variety of aspects addressed in plastic surgery publications is broad: simulators, courses, skills assessment, national surveys, and technology trends.

CONCLUSION

There is an upward trend in the number of publications and plastic surgery journals, demonstrating a remarkable contribution to microsurgery training.

3-DIEPrinting: 3D-printed Models to Assist the Intramuscular Dissection in Abdominally Based Microsurgical Breast Reconstruction

Supplemental Digital Content is available in the text.

Harvest of the deep inferior epigastric vessels for microsurgical breast reconstruction can be complicated by an intricate and lengthy subfascial dissection. Although multiple preoperative imaging modalities exist to help visualize the vascular anatomy and assist in perforator selection, few can help clearly define the intramuscular course of these vessels. The authors introduce their early experience with 3D-printed anatomical modeling (to-scale) of the infraumbilical course of the deep inferior epigastric subfascial vascular tree to better assist in executing the intramuscular dissection.

A Randomized Controlled Trial using iTClamp, Direct Pressure, and Balloon Catheter Tamponade to Control Neck Hemorrhage in a Perfused Human Cadaver Model

BACKGROUND

Penetrating neck wounds are common in the civilian and military realms. Whether high or low velocity, they carry a substantial morbidity and mortality rate.

OBJECTIVES

We endeavored to ascertain whether the iTClamp is equivalent to direct manual pressure (DMP) and Foley catheter balloon tamponade (BCT).

METHODS

Using a perfused cadaver, a 4.5-cm wound was made in Zone 2 of the neck with a 1-cm carotid arteriotomy. Each of the hemorrhage control modalities was randomized and then applied to the wound separately. Time to apply the device and fluid loss with and without neck motion was recorded.

RESULTS

There was no significant difference between the fluid loss/no movement (p > 0.450) and fluid loss/movement (p > 0.215) between BCT and iTClamp. There was significantly more fluid lost with DMP than iTClamp with no movement (p > 0.000) and movement (p > 0.000). The iTClamp was also significantly faster to apply than the Foley (p > 0.000).

CONCLUSIONS

The iTClamp and BCT were associated with significantly less fluid loss than DMP in a perfused cadaver model. The iTClamp required significantly less time to apply than the BCT. Both the iTClamp and the BCT were more effective than simple DMP. The iTClamp offers an additional option for managing hard-to-control bleeding in the neck.

Pathophysiology Study of Filler-Induced Blindness

Background

A number of authors have proposed retrograde arterial embolism as the responsible mechanism for filler-induced blindness. However, no previous human study has substantiated this proposed mechanism.

Objectives

The aim of this study was to investigate the pathophysiology of filler-induced blindness using a fresh cadaver perfusion technique.

Methods

A fresh cadaver head perfusion model that simulates both physiologic blood pressure and flow rate of the carotid artery, ophthalmic artery, and supratrochlear artery was used. The common carotid artery was cannulated and the internal jugular vein exposed for open venous drainage. A plasma-based perfusate was circulated through the cadaver head, which was connected to a perfusion system consisting of a roller pump, preload reservoir, and pressure monitor. The hyaluronic acid filler mixed with methylene blue was injected into the cannulated superficial branch of the supratrochlear artery. Cadaver dissection, angiographic study, and histology were used to investigate filler-induced blindness.

Results

Cannulation of the superficial branch of the supratrochlear artery was successful in all six cadavers. Emboli to the ophthalmic artery was successfully demonstrated in the three out of 6 fresh cadaver heads. The C-arm angiogram documented a cut-off sign in the ophthalmic artery due to hyaluronic acid filler emboli. An average intravascular volume of the intraorbital part of the supratrochlear artery was 50.0 µL. The average depth of location of the superficial branch of the supratrochlear artery from the epidermal surface was 1.5 mm.

Conclusions

Our cadaveric study demonstrated that retrograde hyaluronic acid filler emboli to the ophthalmic artery could be produced by the cannulation of the supratrochlear artery. The superficial location of the supratrochlear artery, the rich vasculature surrounding it, and the variability in the anatomy make this possible.

Redefining the Anatomic Boundaries for Safe Dissection of the Skin Paddle in a Gracilis Myofasciocutaneous Free Flap: An Indocyanine Green Cadaveric Injection Study

The gracilis free flap remains a versatile option in the reconstructive ladder. The flap itself can be harvested with or without a skin paddle. The gracilis myocutaneous free flap, however, is known for partial skin flap necrosis, especially in the distal one-third of the skin island. The gracilis myofasciocutaneous flap has been previously described as a technique to improve perfusion to the skin by harvesting surrounding deep fascia in a pedicled flap. However, limitations to this study required injection of multiple pedicles to demonstrate its perfusion. We demonstrate a novel technique using a cadaveric model that shows perfusion through injection via a single dominant pedicle (medial circumflex) with a large cutaneous paddle (average 770 cm²) with included deep fascia, using indocyanine green and near-infrared imaging. For comparison, we are also able to confirm the lack of perfusion to the distal cutaneous paddle when the fascia is not harvested, correlating with previous findings and ink injection studies. This novel technique is versatile, relatively inexpensive, and can demonstrate perfusion patterns via perforasomes that were otherwise not possible from previous techniques. Additionally, real-time imaging is possible, helping to elucidate the sequence of flow into the flap and potentially predict areas of flap necrosis.

Porcine As a Training Module for Head and Neck Microvascular Reconstruction

Live models that resemble surgical conditions of humans are needed for training free-flap harvesting and anastomosis. Animal models for training purposes have been available for years in many surgical fields. We used the female (because they are easy to handle for the procedure) Yorkshire pigs for the head and neck reconstruction by harvesting the deep inferior epigastric artery perforator or the superior epigastric artery perforator flap. The anastomosis site (neck skin defect or tracheal wall defect) was prepared via the dissection of the common carotid artery and the internal jugular vein, in which 3.5× loupe magnification was used for anastomosis as we use on human cases in real life. This procedure demonstrates a new training method using a reliable learning model and provides a detailed anatomy in a live scenario. We focused on the ischemia time, harvesting, vessel anastomosis, and designing the flap to fit the defect site. This model improves tissue handling and with the use of proper instruments can be repeated many times so that the surgeon is fully confident before starting the surgery on humans.

Current status of simulation training in plastic surgery residency programs: A review

Increased emphasis on competency-based learning modules and widespread departure from traditional models of Halstedian apprenticeship have made surgical simulation an increasingly appealing component of medical education. Surgical simulators are available in numerous modalities, including virtual, synthetic, animal, and non-living models. The ideal surgical simulator would facilitate the acquisition and refinement of surgical skills prior to clinical application, by mimicking the size, color, texture, recoil, and environment of the operating room. Simulation training has proven helpful for advancing specific surgical skills and techniques, aiding in early and late resident learning curves. In this review, the current applications and potential benefits of incorporating simulation-based surgical training into residency curriculum are explored in depth, specifically in the context of plastic surgery. Despite the prevalence of simulation-based training models, there is a paucity of research on integration into resident programs. Current curriculums emphasize the ability to identify anatomical landmarks and procedural steps through virtual simulation. Although transfer of these skills to the operating room is promising, careful attention must be paid to mastery versus memorization. In the authors’ opinions, curriculums should involve step-wise employment of diverse models in different stages of training to assess milestones. To date, the simulation of tactile experience that is reminiscent of real-time clinical scenarios remains challenging, and a sophisticated model has yet to be established.

A Novel Expeditionary Perfused Cadaver Model for Trauma Training in the Out-of-Hospital Setting

BACKGROUND

Cadaver training for prehospital surgical procedures is a valid training model. The limitation to date has been that perfused cadavers have only been used in wet laboratories in hospitals or university centers. We endeavor to describe a transportable central-perfused cadaver model suitable for training in the battlefield environment. Goals of design were to create a simple, easily reproducible, and realistic model to simulate procedures in field and austere conditions.

METHODS

We conducted a review of the published literature on cadaver models, conducted virtual-reality simulator training, performed interviews with subject matter experts, and visited the laboratories at the Centre for Emergency Health Sciences in Spring Branch, TX, the Basic Endovascular Skills in Trauma laboratory in Baltimore, MD, and the Fresh Tissue Dissection Laboratory at Los Angeles County and University of Southern California, Keck School of Medicine, Los Angeles, CA.

PROCEDURE

This article will describe a five-step procedure that utilizes extremity tourniquets, right common carotid intra-arterial and distal femur intraosseous (IO) access for perfusion, and oropharynx preparation for airway procedures. The model will then be ready for all tactical combat casualty care procedures, including nasopharyngeal airway, endotracheal intubation, cricothyroidotomy, central-line access, needle decompression, finger and tube thoracostomy, resuscitative endovascular balloon occlusion of the aorta, junctional tourniquets, IO lines, and field amputations.

CONCLUSIONS

This model has been used in the laboratory, field, ground ambulance, and military air ambulance (UH-60) settings with good results. The model described can be used in the field setting with minimal resources and accurately simulates the critical skills for all combat trauma procedures.

Factors Correlating With Microsurgical Performance: A Clinical and Experimental Study

BACKGROUND

Microsurgery is one the most complex surgical skills to master. The factors correlating with microsurgical performance, however, are poorly understood. Understanding these factors will aid in the training and assessment of microsurgeons.

METHODS

A total of 29 microsurgery fellows enrolled in a dedicated 1-year microsurgery fellowship were included in the study. For the clinical evaluations, microsurgical anastomosis performance was evaluated during multiple procedures in the operating room at the start, midpoint, and end of the fellowship by all departmental faculty using a validated microsurgical assessment tool. For the laboratory evaluations, blinded video recordings of each fellow performing an arterial femoral anastomosis in a live rat model at the start and end of the fellowship were evaluated using 3 validated microsurgical global ratings scale tools. Correlations between performance and the factors assessed by the tools were evaluated.

RESULTS

In the clinical study there were a total of 474 anastomosis evaluations; clinical performance correlated best with speed, instrument handling, and motion. In the laboratory study 58 evaluations were conducted, and performance tracked most closely with instrument handling, flow of operation, and operative steps, as well as correlating significantly inversely with time taken. The most common errors committed were unequal stitch bites, wrong grasp/damage tissue, and loose knot.

CONCLUSIONS

Speed, both subjective and objective, instrument handling, operative flow, and motion, were relevant to performance of a microsurgical anastomosis. A prospective trial is now necessary to determine whether these factors should be considered in definitions of competency in microsurgery training pathways.

Systematic review of surgical training on reperfused human cadavers

BACKGROUND

The role of reperfused human cadavers in surgical training has not been established.

METHODS

Reports describing reperfused human cadaver models in terms of simulated surgeries, the use of tools to assess technical competency and skills transfer to patients, cadaver status and reperfusion techniques were included.

RESULTS

Thirty-five reports were included. Most participants practised vascular (n = 27), flap (n = 6) and trauma (n = 4) procedures. Training progression was evaluated objectively in only two studies. In two publications, flap techniques were practised on cadavers and repeated successfully in patients. Eighteen studies employed whole bodies. Fresh and embalmed cadavers were both used in 17 publications. Most embalmed cadavers were formalin-fixed (n = 10), resulting in stiffness. Few trainings were offered on soft Thiel-embalmed cadavers (n = 5). Only arteries were reperfused in 20 studies, while in 13 publications, the arteries and veins were filled. Arteries and/or veins were mostly pressurized (n = 21) and arterial flow was generated in 14 studies.

CONCLUSIONS

Various reperfused human cadaver models exist, enabling practise of mainly vascular procedures. Preservation method determines the level of simulation fidelity. Thorough evaluation of these models as surgical training tools and transfer effectiveness is still lacking.

An enhanced fresh cadaveric model for reconstructive microsurgery training

BACKGROUND

Performing microsurgery requires a breadth and depth of experience that has arguably been reduced as result of diminishing operating exposure. Fresh frozen cadavers provide similar tissue handling to real-time operating; however, the bloodless condition restricts the realism of the simulation. We describe a model to enhance flap surgery simulation, in conjunction with qualitative assessment.

METHODS

The fresh frozen cadaveric limbs used in this study were acquired by the University. A perfused fresh cadaveric model was created using a gelatin and dye mixture in a specific injection protocol in order to increase the visibility and realism of perforating vessels, as well as major vessels. A questionnaire was distributed amongst 50 trainees in order to assess benefit of the model. Specifically, confidence, operative skills, and transferable procedural-based learning were assessed.

RESULTS

Training with this cadaveric model resulted in a statistically significant improvement in self-reported confidence (p < 0.005) and prepared trainees for unsupervised bench work (p < 0.005). Respondents felt that the injected model allowed easier identification of vessels and ultimately increased the similarity to real-time operating. Our analysis showed it cost £10.78 and took 30 min.

CONCLUSIONS

Perfusion of cadaveric limbs is both cost- and time-effective, with significant improvement in training potential. The model is easily reproducible and could be a valuable resource in surgical training for several disciplines.Level of Evidence: Not ratable.

Techniques of cadaver perfusion for surgical training: a systematic review

PURPOSE

The objective of this study was to identify the most appropriate cadaver perfusion techniques for surgical training through a systematic review with a description of the protocols used.

METHODS

The search strategy included PubMed and reference tracking. Studies were identified by searching the electronic Medline databases. The search concepts included perfusion, cadavers and simulation training, and the protocol used is reported. This resulted in a qualitative review of 12 articles out of 250 articles consulted. We collected all the important data from these 12 articles.

RESULTS

Regarding the characteristics of the studies and the declotting or perfusion techniques, the results were heterogeneous. Indeed, in several studies, a good deal of information was unclear or insufficiently precise, making it unfeasible to summarize the data. The methods used were not sufficiently explicit and detailed. However, a majority of the fresh cadavers used tap water for declotting. Perfusion, type of fluid, number of pumps, pressure, pulsatility, and arterial or venous approaches differed greatly. Only two studies fulfilled five of our six realism criteria for surgical simulation.

CONCLUSIONS

This systematic review provided an overview of all the different cadaver perfusion techniques. It could be used to establish a reference method of a simulation model.

The Role of Simulation in Microsurgical Training

Simulation has been established as an integral part of microsurgical training. The aim of this study was to assess and categorize the various simulation models in relation to the complexity of the microsurgical skill being taught and analyze the assessment methods commonly employed in microsurgical simulation training. Numerous courses have been established using simulation models. These models can be categorized, according to the level of complexity of the skill being taught, into basic, intermediate, and advanced. Microsurgical simulation training should be assessed using validated assessment methods. Assessment methods vary significantly from subjective expert opinions to self-assessment questionnaires and validated global rating scales. The appropriate assessment method should carefully be chosen based on the simulation modality. Simulation models should be validated, and a model with appropriate fidelity should be chosen according to the microsurgical skill being taught. Assessment should move from traditional simple subjective evaluations of trainee performance to validated tools. Future studies should assess the transferability of skills gained during simulation training to the real-life setting.

Robotic Pancreatoduodenectomy Biotissue Curriculum has Validity and Improves Technical Performance for Surgical Oncology Fellows

OBJECTIVE

Obtaining the proficiency on the robotic platform necessary to safely perform a robotic pancreatoduodenectomy is particularly challenging. We hypothesize that by instituting a proficiency-based robotic training curriculum we can enhance novice surgeons' skills outside of the operating room, leading to a shorter learning curve.

DESIGN

A biotissue curriculum was designed consisting of sewing artificial organs to simulate a hepaticojejunostomy (HJ), gastrojejunostomy (GJ), and pancreaticojejunostomy (PJ). Three master robotic surgeons performed each biotissue anastomosis to assess validity. Using video review, trainee performance on biotissue drills was evaluated for time, errors and objective structured assessment of technical skills (OSATS) by 2 blinded graders.

SETTING

This study is conducted at the University of Pittsburgh Medical Center (Pittsburgh, PA), a tertiary care academic teaching hospital.

PARTICIPANTS

In total, 14 surgical oncology fellows completed the biotissue curriculum.

RESULTS

Fourteen fellows performed 196 anastomotic drills during the first year: 66 (HJ), 64 (GJ), and 66 (PJ). The fellows' performances were analyzed as a group by attempt. The attendings' first attempt outperformed the fellows' first attempt in all metrics for every drill (all p < 0.05). More than 5 analyzed attempts of the HJ, there was improvement in time, errors, and OSATS (all p < 0.01); however, no metric reached attending performance. For the GJ, time, errors, and OSATS all improved more than 5 attempts (all p < 0.01), whereas only errors and OSATS reached proficiency. For the PJ, errors and OSATS both improved over attempts (p < 0.01) and reached proficiency; however, time did not statistically improve nor reach proficiency. The graders scoring correlated for errors and OSATS (p < 0.0001).

CONCLUSION

A pancreatoduodenectomy biotissue curriculum has face and construct validity. The curriculum is feasible and improves errors and technical performance. Time is the most difficult technical parameter to improve. This curriculum is a valid tool for teaching robotic pancreatoduodenectomies with established milestones for reaching optimum performance.

Can hyper-realistic physical models of peripheral vessel exposure and fasciotomy replace cadavers for performance assessment?

BACKGROUND

Work-hour restrictions have reduced operative experience for residents. The Advanced Surgical Skills for Exposure in Trauma (ASSET) course fills this training gap. Cadaver use has limitations including cost and availability. Hyper-realistic synthetic models may provide an alternative to cadavers. We compared same surgeon performance between synthetic and cadaveric models to determine interchangeability for formative evaluation.

METHODS

Forty residents (<4 weeks after ASSET) and 35 faculty (mean, 2.5 ± 1.3 years after ASSET) exposed axillary, brachial, and femoral arteries, and performed lower extremity fasciotomy. Separate evaluators and random starting order between models were used for participants. Individual procedure scores and aggregate procedure scores, a trauma readiness index, evaluated participants. Student's t and χ tests were used where appropriate. p Values less than 0.05 were considered significant.

RESULTS

For same surgeons, faculty, but not residents, had higher trauma readiness index on the synthetic model (0.63 vs. 0.70, p < 0.01; 0.63 vs. 0.67, p = 0.06, respectively). Scores were not significantly different between models for residents except for the brachial artery exposure (0.68 vs. 0.75, p < 0.01), which was the least realistic of all procedures. Faculty did significantly better on the synthetic model in all procedures. All participants completed procedures nearly twice as quickly (5.61 ± 3.21 vs. 10.08 ± 4.66 minutes) and performed fewer errors on the synthetic model (113 vs. 53, p < 0.01; 118 vs. 76, p = 0.03, respectively).

CONCLUSION

Same surgeons performed procedures quicker and with fewer errors on the synthetic model. Residents performed similarly on both model types, this likely represents the unfamiliarity neophytes bring to new procedures. This suggests that the synthetic model, with easily discernible and standardized anatomy, may be useful in the early stages of training to understand critical procedural steps. The difficulty of the cadaver is more apt to assess and evaluate the experienced surgeon and identify opportunities for improvement.

LEVEL OF EVIDENCE

Prognostic, level III.

Preoperative surgical rehearsal using cadaveric fresh tissue surgical simulation increases resident operative confidence

BACKGROUND

Rehearsal is an essential part of mastering any technical skill. The efficacy of surgical rehearsal is currently limited by low fidelity simulation models. Fresh cadaver models, however, offer maximal surgical simulation. We hypothesize that preoperative surgical rehearsal using fresh tissue surgical simulation will improve resident confidence and serve as an important adjunct to current training methods.

METHODS

Preoperative rehearsal of surgical procedures was performed by plastic surgery residents using fresh cadavers in a simulated operative environment. Rehearsal was designed to mimic the clinical operation, complete with a surgical technician to assist. A retrospective, web-based survey was used to assess resident perception of pre- and post-procedure confidence, preparation, technique, speed, safety, and anatomical knowledge on a 5-point scale (1= not confident, 5= very confident).

RESULTS

Twenty-six rehearsals were performed by 9 residents (PGY 1-7) an average of 4.7±2.1 days prior to performance of the scheduled operation. Surveys demonstrated a median pre-simulation confidence score of 2 and a post-rehearsal score of 4 (P<0.01). The perceived improvement in confidence and performance was greatest when simulation was performed within 3 days of the scheduled case. All residents felt that cadaveric simulation was better than standard preparation methods of self-directed reading or discussion with other surgeons. All residents believed that their technique, speed, safety, and anatomical knowledge improved as a result of simulation.

CONCLUSIONS

Fresh tissue-based preoperative surgical rehearsal was effectively implemented in the residency program. Resident confidence and perception of technique improved. Survey results suggest that cadaveric simulation is beneficial for all levels of residents. We believe that implementation of preoperative surgical rehearsal is an effective adjunct to surgical training at all skill levels in the current environment of decreased work hours.

A survey of current state of training of plastic surgery residents

Background

Plastic surgery training is undergoing major changes however there is paucity of data detailing the current state of training as perceived by plastic surgical trainees. Our aim was to determine the quality of training as perceived by the current trainee pool and their future plans.

Methods

A 25-item anonymous survey with three discrete sections (demographics, quality of training, and post-graduate career plans) was developed and distributed to plastic surgery residents during the academic year 2013. With the confidence interval of 95% and margin of error of 10%, our target response rate was 87 responders.

Results

We received a total of 114 respondents with all levels of Post Graduate Year in training represented. Upon comparison of residents with debt of <100,000 to residents with a debt of >250,000, those with higher debt were significantly less interested in fellowship training (p value 0.05) and were more likely to pursue private practice (p value <0.01). Disciplines within plastic surgery least offered as a separate rotation were microsurgery (45%) followed by aesthetic surgery (33%). 53.7% of the residents felt that they were least trained in aesthetic surgery followed by burn surgery 45.4%. Of note 56.4% intended to seek additional training after residency. Moreover residents with an average of 6.4 months of experience in an individual subspecialty were more likely to feel comfortable with that specialty.

Conclusions

This survey highlights the areas and subspecialties that deserve attention as perceived by the current trainee pool.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2561-5) contains supplementary material, which is available to authorized users.