Temporal bone dissection for neurosurgery residents: identifying the essential concepts and fundamental techniques for success

Recent advances in Otology: Current landscape and future direction

Hearing is an essential sensation, and its deterioration leads to a significant decrease in the quality of life. Thus, great efforts have been made by otologists to preserve and recover hearing. Our knowledge regarding the field of otology has progressed with advances in technology, and otologists have sought to develop novel approaches in the field of otologic surgery to achieve higher hearing recovery or preservation rates. This requires knowledge regarding the anatomy of the temporal bone and the physiology of hearing. Basic research in the field of otology has progressed with advances in molecular biology and genetics. This review summarizes the current views and recent advances in the field of otology and otologic surgery, especially from the viewpoint of young Japanese clinician-scientists, and presents the perspectives and future directions for several topics in the field of otology. This review will aid next-generation researchers in understanding the recent advances and future challenges in the field of otology.

Needs of Young African Neurosurgeons and Residents: A Cross-Sectional Study

Introduction: Africa has many untreated neurosurgical cases due to limited access to safe, affordable, and timely care. In this study, we surveyed young African neurosurgeons and trainees to identify challenges to training and practice.

Methods: African trainees and residents were surveyed online by the Young Neurosurgeons Forum from April 25th to November 30th, 2018. The survey link was distributed via social media platforms and through professional society mailing lists. Univariate and bivariate data analyses were run and a P-value < 0.05 was considered to be statistically significant.

Results: 112 respondents from 20 countries participated in this study. 98 (87.5%) were male, 63 (56.3%) were from sub-Saharan Africa, and 52 (46.4%) were residents. 39 (34.8%) had regular journal club sessions at their hospital, 100 (89.3%) did not have access to cadaver dissection labs, and 62 (55.4%) had never attended a WFNS-endorsed conference. 67.0% of respondents reported limited research opportunities and 58.9% reported limited education opportunities. Lack of mentorship (P = 0.023, Phi = 0.26), lack of access to journals (P = 0.002, Phi = 0.332), and limited access to conferences (P = 0.019, Phi = 0.369) were associated with the country income category.

Conclusion: This survey identified barriers to education, research, and practice among African trainees and young neurosurgeons. The findings of this study should inform future initiatives aimed at reducing the barriers faced by this group.

Resident simulation training in endoscopic endonasal surgery utilizing haptic feedback technology

Simulated practice may improve resident performance in endoscopic endonasal surgery. Using the NeuroTouch haptic simulation platform, we evaluated resident performance and assessed the effect of simulation training on performance in the operating room. First- (N=3) and second- (N=3) year residents were assessed using six measures of proficiency. Using a visual analog scale, the senior author scored subjects. After the first session, subjects with lower scores were provided with simulation training. A second simulation served as a task-learning control. Residents were evaluated in the operating room over six months by the senior author-who was blinded to the trained/untrained identities-using the same parameters. A nonparametric bootstrap testing method was used for the analysis (Matlab v. 2014a). Simulation training was associated with an increase in performance scores in the operating room averaged over all measures (p=0.0045). This is the first study to evaluate the training utility of an endoscopic endonasal surgical task using a virtual reality haptic simulator. The data suggest that haptic simulation training in endoscopic neurosurgery may contribute to improvements in operative performance. Limitations include a small number of subjects and adjudication bias-although the trained/untrained identity of subjects was blinded. Further study using the proposed methods may better describe the relationship between simulated training and operative performance in endoscopic Neurosurgery.

Getting back together after a break-up: Relationship advice for anatomists and surgeons

The "surgeon-anatomist" was originally a single individual who self-pursued knowledge and understanding of anatomy as the foundation for successful surgical outcomes. However, recent advances in medical education have ironically led to the separation of anatomy and surgery. This physical and emotional "divorce" of anatomists and surgeons into separate individuals has created several critical educational issues for medical and surgical educators including a general lack of anatomical knowledge in medical students and misalignment of graduate medical education procedural specialty training with the Accreditation Council of Graduate Medical Education Core Competencies and now the Next Accreditation System. There are numerous opportunities for anatomists and surgeons to work together to improve educational instruction of established difficult anatomical regions, procedural training, or even develop new techniques and procedures. Similarly, anatomists with specialized training in medical education would be invaluable partners to ensure that procedural assessments align with instructional technologies for truly longitudinal curricula that starts at the medical student level, but stops at the patient outcomes of attending surgeons. This mutually beneficial relationship would be similar to multidisciplinary care teams and current surgeon and PhD/EdD partnerships. The restoration of the relationship between anatomists and surgeons would be invaluable to surgical education and remains an exciting research opportunity.

Evaluation of a haptics-based virtual reality temporal bone simulator for anatomy and surgery training

INTRODUCTION

Virtual reality simulation training may improve knowledge of anatomy and surgical skills. We evaluated a 3-dimensional, haptic, virtual reality temporal bone simulator for dissection training.

METHODS

The subjects were 7 otolaryngology residents (3 training sessions each) and 7 medical students (1 training session each). The virtual reality temporal bone simulation station included a computer with software that was linked to a force-feedback hand stylus, and the system recorded performance and collisions with vital anatomic structures. Subjects performed virtual reality dissections and completed questionnaires after the training sessions.

RESULTS

Residents and students had favorable responses to most questions of the technology acceptance model (TAM) questionnaire. The average TAM scores were above neutral for residents and medical students in all domains, and the average TAM score for residents was significantly higher for the usefulness domain and lower for the playful domain than students. The average satisfaction questionnaire for residents showed that residents had greater overall satisfaction with cadaver temporal bone dissection training than training with the virtual reality simulator or plastic temporal bone. For medical students, the average comprehension score was significantly increased from before to after training for all anatomic structures. Medical students had significantly more collisions with the dura than residents. The residents had similar mean performance scores after the first and third training sessions for all dissection procedures.

DISCUSSION

The virtual reality temporal bone simulator provided satisfactory training for otolaryngology residents and medical students.

Shortening the learning curve in endoscopic endonasal skull base surgery: a reproducible polymer tumor model for the trans-sphenoidal trans-tubercular approach to retro-infundibular tumors

BACKGROUND

Endoscopic endonasal skull base surgery attracts an increasing number of young neurosurgeons. This recent technique requires specific technical skills for the approaches to non-pituitary tumors (expanded endoscopic endonasal surgery). Actual residents' busy schedules carry the risk of compromising their laboratory training by limiting significantly the dedicated time for dissections.

OBJECTIVE

To enhance and shorten the learning curve in expanded endoscopic endonasal skull base surgery, we propose a reproducible model based on the implantation of a polymer via an intracranial route to provide a pathological retro-infundibular expansive lesion accessible to a virgin expanded endoscopic endonasal route, avoiding the ethically-debatable need to hundreds of pituitary cases in live patients before acquiring the desired skills.

METHODS

A polymer-based tumor model was implanted in 6 embalmed human heads via a microsurgical right fronto-temporal approach through the carotido-oculomotor cistern to mimic a retro-infundibular tumor. The tumor's position was verified by CT-scan. An endoscopic endonasal trans-sphenoidal trans-tubercular trans-planum approach was then carried out on a virgin route under neuronavigation tracking.

RESULTS

Dissection of the tumor model from displaced surrounding neurovascular structures reproduced live surgery's sensations and challenges. Post-implantation CT-scan allowed the pre-removal assessment of the tumor insertion, its relationships as well as naso-sphenoidal anatomy in preparation of the endoscopic approach.

CONCLUSION

Training on easily reproducible retro-infundibular approaches in a context of pathological distorted anatomy provides a unique opportunity to avoid the need for repetitive live surgeries to acquire skills for this kind of rare tumors, and may shorten the learning curve for endoscopic endonasal surgery.

Warning navigation system using real-time safe region monitoring for otologic surgery

PURPOSE

We developed a surgical navigation system that warns the surgeon with auditory and visual feedback to protect the facial nerve with real-time monitoring of the safe region during drilling.

METHODS

Warning navigation modules were developed and integrated into a free open source software platform. To obtain high registration accuracy, we used a high-precision laser-sintered template of the patient's bone surface to register the computed tomography (CT) images. We calculated the closest distance between the drill tip and the surface of the facial nerve during drilling. When the drill tip entered the safe regions, the navigation system provided an auditory and visual signal which differed in each safe region. To evaluate the effectiveness of the system, we performed phantom experiments for maintaining a given safe margin from the facial nerve when drilling bone models, with and without the navigation system. The error of the safe margin was measured on postoperative CT images. In real surgery, we evaluated the feasibility of the system in comparison with conventional facial nerve monitoring.

RESULTS

The navigation accuracy was submillimeter for the target registration error. In the phantom study, the task with navigation ([Formula: see text] mm) was more successful with smaller error, than the task without navigation ([Formula: see text] mm, [Formula: see text]). The clinical feasibility of the system was confirmed in three real surgeries.

CONCLUSIONS

This system could assist surgeons in preserving the facial nerve and potentially contribute to enhanced patient safety in the surgery.

Assessing mental representation of mastoidectomy by a computer-based drawing tool

CONCLUSIONS

This simple computer-based drawing tool provides valid information on mental representation of mastoidectomy at its initial phase.

OBJECTIVE

The aim of this study was to elaborate a simple computer-based drawing tool to assess the mental representation of mastoidectomy.

METHODS

Twelve trainees in otology (five beginners, seven mid-level) and four otology experts participated in this prospective study. The image of a mastoid was displayed on a screen. All subjects reproduced the movements of mastoidectomy with a pen on a graphic tablet. Movements appeared as gray lines on the image. Surgeons were evaluated before and after a dissection course. The surface of mastoidectomy, perimeter, circularity, and the angle between traces and cavity edges were measured by Image J software.

RESULTS

The total surface of mastoidectomy was higher in experts than in mid-level and beginner trainees (respectively 99 ± 6.5%, vs 57 ± 1.5%, and 22 ± 5.6%, p < 0.01 for experts vs beginners and p < 0.05 for experts vs mid-level, ANOVA and Bonferroni). Circularity was also higher in experts than in trainees. After training, total surface and circularity increased. The angle between traces and cavity edges was lower in experts than in trainees and was reduced after training.

Review of temporal bone dissection teaching: how it was, is and will be

Objective:

We aimed to review the history of anatomical dissection, and to examine how modern educational techniques will change the way temporal bone dissection is taught to otolaryngology trainees.

Method:

Review of the literature using Medline, Embase and PubMed database searches.

Results:

Temporal bone anatomy has traditionally been taught using cadaveric specimens. However, resources such as three-dimensional reconstructed models and ‘virtual reality’ temporal bone simulators have a place in educating the otolaryngology trainee.

Conclusion:

We should encourage the use of fresh frozen cadaveric temporal bone specimens for future otologists. Artificial three-dimensional models and virtual reality temporal bone simulators can be used to educate junior trainees, thus conserving the scarce resource of cadaveric bones.