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Laurent D, Lucke-Wold B, Pierre K, Bardhi O, Yue S, Brennan M, Fox WC, Chalouhi N, Koch MJ, Hoh B, Dow JS, Murad GJA, Polifka A. Focused selection of open cerebrovascular cases for residents interested in cerebrovascular neurosurgery. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:53-59. [PMID: 36754760 PMCID: PMC9994638 DOI: 10.1016/j.neucie.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/23/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION National and international trends continue to show greater emphasis on endovascular techniques for the treatment of cerebrovascular disease. The cerebrovascular neurosurgeon however must be adequately equipped to treat these patients via both open and endovascular techniques. METHODS The decline in open cerebrovascular cases for aneurysm clipping has forced many trainees to pursue open cerebrovascular fellowships to increase case volume. An alternative strategy has been employed at our institution, which is early identification of subspecialty focus with resident driven self-selection of open cerebrovascular cases. RESULTS This has allowed recent graduates to obtain enfolded endovascular training and a significant number of open cerebrovascular cases in order to obtain competence and exposure. DISCUSSION We advocate for further self-selection paradigms supplemented with simulation training in order to obviate the need for extended post-residency fellowships.
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Affiliation(s)
- Dimitri Laurent
- Department of Neurosurgery, University of Florida, Gainesville, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, United States.
| | - Kevin Pierre
- Department of Neurosurgery, University of Florida, Gainesville, United States
| | - Olgert Bardhi
- Department of Neurosurgery, University of Florida, Gainesville, United States
| | - Sijia Yue
- Department of Neurosurgery, University of Florida, Gainesville, United States
| | - Meghan Brennan
- Department of Neurosurgery, University of Florida, Gainesville, United States
| | - W Christopher Fox
- Department of Neurosurgery, University of Florida, Gainesville, United States
| | - Nohra Chalouhi
- Department of Neurosurgery, University of Florida, Gainesville, United States
| | - Matthew J Koch
- Department of Neurosurgery, University of Florida, Gainesville, United States
| | - Brian Hoh
- Department of Neurosurgery, University of Florida, Gainesville, United States
| | - Jamie S Dow
- Department of Neurosurgery, University of Florida, Gainesville, United States
| | - Gregory J A Murad
- Department of Neurosurgery, University of Florida, Gainesville, United States
| | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville, United States
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Muirhead WR, Layard Horsfall H, Khan DZ, Koh C, Grover PJ, Toma AK, Castanho P, Stoyanov D, Marcus HJ, Murphy M. Microsurgery for intracranial aneurysms: A qualitative survey on technical challenges and technological solutions. Front Surg 2022; 9:957450. [PMID: 35990100 PMCID: PMC9386123 DOI: 10.3389/fsurg.2022.957450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/06/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Microsurgery for the clipping of intracranial aneurysms remains a technically challenging and high-risk area of neurosurgery. We aimed to describe the technical challenges of aneurysm surgery, and the scope for technological innovations to overcome these barriers from the perspective of practising neurovascular surgeons. Materials and Methods Consultant neurovascular surgeons and members of the British Neurovascular Group (BNVG) were electronically invited to participate in an online survey regarding surgery for both ruptured and unruptured aneurysms. The free text survey asked three questions: what do they consider to be the principal technical barriers to aneurysm clipping? What technological advances have previously contributed to improving the safety and efficacy of aneurysm clipping? What technological advances do they anticipate improving the safety and efficacy of aneurysm clipping in the future? A qualitative synthesis of responses was performed using multi-rater emergent thematic analysis. Results The most significant reported historical advances in aneurysm surgery fell into five themes: (1) optimising clip placement, (2) minimising brain retraction, (3) tissue handling, (4) visualisation and orientation, and (5) management of intraoperative rupture. The most frequently reported innovation by far was indocyanine green angiography (84% of respondents). The three most commonly cited future advances were hybrid surgical and endovascular techniques, advances in intraoperative imaging, and patient-specific simulation and planning. Conclusions While some surgeons perceive that the rate of innovation in aneurysm clipping has been dwarfed in recent years by endovascular techniques, surgeons surveyed highlighted a broad range of future technologies that have the potential to continue to improve the safety of aneurysm surgery in the future.
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Affiliation(s)
- W. R. Muirhead
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - H. Layard Horsfall
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - D. Z. Khan
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - C. Koh
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - P. J. Grover
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - A. K. Toma
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - P. Castanho
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - D. Stoyanov
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - H. J. Marcus
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Wellcome Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - M. Murphy
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Focused selection of open cerebrovascular cases for residents interested in cerebrovascular neurosurgery. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Carlos GF, Enrrique FS, Aylen Andrea TG, Sabrina MN, Silvina M, Clara M, Santiago BJ, Marcelo OC, Noel AL, Augusto RP. Introducing a Realistic, Low-Cost Simulation Model for Clipping of Brain Aneurysms. World Neurosurg 2021; 158:305-311.e1. [PMID: 34774805 DOI: 10.1016/j.wneu.2021.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The current trend toward endovascular treatment of brain aneurysms may have a negative impact on young neurosurgeons who are less exposed to these lesions, thus affecting the acquisition of surgical skills in the field. Different training models have emerged to help cope with this issue, but these have specific pitfalls. Training models based on live animals or cadaveric specimens face increasing restrictions as regulations become a barrier in accessibility for everyday skills development. We introduce a novel, realistic, and inexpensive simulation model using a fresh bovine brain, and we assess its face and content validity as a training tool. METHODS A fresh bovine brain is used to simulate microsurgical fissure dissection. Arterial and aneurysmal components are created with arteries and veins harvested from chicken thigh. A 12-item questionnaire using the Likert numeric scale (grades 1 - 5) was used to assess the validity of model in 10 surgeons. RESULTS Ten neurosurgeons performed the simulated clipping of the aneurysm and completed a questionnaire. All surgeons surveyed responded "agree" or "strongly agree" that the simulator, and the skills trained with it, are comparable to clipping brain aneurysms. All respondents believed that this simulator could improve patient safety. CONCLUSIONS We present a novel, realistic, and inexpensive simulation model for the clipping of brain aneurysms. This model was partially validated by the opinion of field experts. We believe this model has the potential to become a useful training tool for young neurosurgeons who have little exposure to real aneurysm cases.
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Affiliation(s)
- Gallardo Federico Carlos
- Department of Neurosurgery, Hospital de Alta Complejidad en Red "El Cruce", Florencio Varela, Buenos Aires, Argentina.
| | - Feldman Santiago Enrrique
- Department of Neurosurgery, Hospital de Alta Complejidad en Red "El Cruce", Florencio Varela, Buenos Aires, Argentina
| | - Targa García Aylen Andrea
- Department of Neurosurgery, Hospital de Alta Complejidad en Red "El Cruce", Florencio Varela, Buenos Aires, Argentina
| | - Morales Nadia Sabrina
- Department of Neurosurgery, Hospital de Alta Complejidad en Red "El Cruce", Florencio Varela, Buenos Aires, Argentina
| | - Martinez Silvina
- Department of Neurosurgery, Hospital de Alta Complejidad en Red "El Cruce", Florencio Varela, Buenos Aires, Argentina
| | - Martin Clara
- Department of Neurosurgery, Hospital de Alta Complejidad en Red "El Cruce", Florencio Varela, Buenos Aires, Argentina
| | - Bottan Juan Santiago
- Division of Neurosurgery, Hospital General de Niños "Pedro De Elizalde", Buenos Aires, Argentina
| | - Orellana Cristian Marcelo
- Department of Neurosurgery, Hospital de Alta Complejidad en Red "El Cruce", Florencio Varela, Buenos Aires, Argentina
| | - Almerares Leandro Noel
- Department of Neurosurgery, Hospital de Alta Complejidad en Red "El Cruce", Florencio Varela, Buenos Aires, Argentina
| | - Rubino Pablo Augusto
- Department of Neurosurgery, Hospital de Alta Complejidad en Red "El Cruce", Florencio Varela, Buenos Aires, Argentina
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Perin A, Gambatesa E, Galbiati TF, Fanizzi C, Carone G, Rui CB, Ayadi R, Saladino A, Mattei L, Legninda Sop FY, Caggiano C, Prada FU, Acerbi F, Ferroli P, Meling TR, DiMeco F. The "STARS-CASCADE" Study: Virtual Reality Simulation as a New Training Approach in Vascular Neurosurgery. World Neurosurg 2021; 154:e130-e146. [PMID: 34284158 DOI: 10.1016/j.wneu.2021.06.145] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Surgical clipping has become a relatively rare procedure in comparison to endovascular exclusion of cerebral aneurysms. Consequently, there is a declining number of cases where young neurosurgeons can practice clipping. For this reason, we investigated the application of a new 3-dimensional (3D) simulation and rehearsal device, Surgical Theater, in vascular neurosurgery. METHODS We analyzed data of 20 patients who underwent surgical aneurysm clipping. In 10 cases, Surgical Theater was used to perform the preoperative 3D planning (CASCADE group), while traditional imaging was used in the other cases (control group). Preoperative 3D simulation was performed by 4 expert and 3 junior neurosurgeons (1 fellow, 2 residents). During postoperative debriefings, expert surgeons explained the different aspects of the operation to their younger colleagues in an interactive way using the simulator. Questionnaires were given to the surgeons to get qualitative feedback about the simulator, and the junior surgeons' performance at simulator was also analyzed. RESULTS There were no differences in surgery outcomes, complications, and surgical duration (P > 0.05) between the 2 groups. Senior neurosurgeons performed similarly when operating at the simulator as compared with in the operating room, while junior neurosurgeons improved their performance at the simulator after the debriefing session (P < 0.005). CONCLUSIONS Surgical Theater proved to be realistic in replicating vascular neurosurgery scenarios for rehearsal and simulation purposes. Moreover, it was shown to be useful for didactic purposes, allowing young neurosurgeons to take full advantage and learn from senior colleagues to become familiar with this demanding neurosurgical subspecialty.
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Affiliation(s)
- Alessandro Perin
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy; Department of Life Sciences, University of Trieste, Trieste, Italy.
| | - Enrico Gambatesa
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Tommaso Francesco Galbiati
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Claudia Fanizzi
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Giovanni Carone
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Chiara Benedetta Rui
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Roberta Ayadi
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Andrea Saladino
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Luca Mattei
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Francois Yves Legninda Sop
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Chiara Caggiano
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Francesco Ugo Prada
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy; Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy
| | - Torstein Ragnar Meling
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy; EANS Training Committee, Sint Martens Latem, Belgium; Neurosurgery Department, Hopitaux Universitaires de Genève, Geneva, Switzerland
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale "C. Besta", Milan, Italy; EANS Training Committee, Sint Martens Latem, Belgium; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Department of Neurological Surgery, Johns Hopkins Medical School, Baltimore, Maryland, USA
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Bowden SG, Siler DA, Radu S, Woll SCS, Rae AI, Cheaney B, Nugent JG, Stedelin B, Cetas JS, Dogan A, Han SJ. Changing Hands: A Rising Role of the Tumor Surgeon in Teaching Sylvian Fissure Dissection. World Neurosurg 2020; 146:e86-e90. [PMID: 33059079 DOI: 10.1016/j.wneu.2020.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/05/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The landscape of microneurosurgery has changed considerably over the past 2 decades, with a decline in indications for open surgery on cerebrovascular pathology and ever-increasing indications for open resection of brain tumors. This study investigated how these trends in case volume affected residents' training experiences in microsurgery and, specifically, Sylvian fissure dissection. METHODS Resident case logs were reviewed, identifying open cerebrovascular operations and craniotomies for tumor. Operations involving Sylvian fissure dissection were identified through operative reports. Changes in case number by resident were plotted over time, and linear regression was applied. RESULTS Among 23 chief residents, 3045 operations were identified, 1071 of which were for cerebrovascular pathology and 1974 for tumor. Open cerebrovascular experience decreased (P < 0.0001) while tumor volume remained unchanged (P = 0.221). The number of Sylvian fissure dissections per resident did not change over time overall (P = 0.583) or within cerebrovascular operations (P = 0.071). The number of Sylvian fissure dissections in tumor operations increased (P = 0.004). This effect was predominated by an increase in intraaxial tumors approached via Sylvian fissure dissection (P = 0.003). The proportion of Sylvian fissure dissections in tumor surgery increased from 15% in 2009 to 34% by 2019 (P = 0.003). CONCLUSIONS Residents are seeing an increasing proportion of their Sylvian fissure dissection experience during tumor operations. The distribution of this experience will continue to evolve as surgical indications change but suggests a growing role for tumor surgeons in resident training in microsurgery.
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Affiliation(s)
- Stephen G Bowden
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Dominic A Siler
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Stephanie Radu
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - S Cody Schoettler Woll
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Ali I Rae
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Barry Cheaney
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Joseph G Nugent
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Brittany Stedelin
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Justin S Cetas
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Aclan Dogan
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Seunggu J Han
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA.
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