The Use of an Inanimate Simulation Model for the Correction of an Anorectal Malformation in the Training of Colorectal Pediatric Surgery

Simulation and training for pediatric colorectal surgery and anorectal malformation: a scoping review

PURPOSE

To study the published literature for various models used for simulation and training in the field of pediatric colorectal surgery.

METHOD

A PubMed search was conducted for studies of simulation models in anorectal malformation on 24 March 2024 with the search words 'simulation pediatric colorectal surgery' followed by another search on 'simulation AND anorectal malformation' that gave 22 and 14 results, respectively (total 36). After removing 4 duplicate publications, 12 were found relevant to simulation and training in colorectal diseases. One publication relevant to the topic was added from literature, thirteen articles were studied.

RESULTS

Of these, 5; 1; 4; and 3 were on inanimate models; animate model; 3D reconstructions; and training, respectively. Simulation models are available for posterior sagittal anorectoplasty. The same inanimate model was used in five articles. The animate model was based on a chicken cadaver. 3D models have been made for personalized preoperative assessment and to understand the imaging in anorectal malformation. One 3D model was made by regeneration of organoid epithelium. Training modules were made to evaluate surgical dissection, standardize surgical techniques, and improve proficiency.

CONCLUSION

Simulation models are an important tool for teaching the steps of surgery and discussing the nuances of operative complications among mentors and peers. With advances in this field, the development of high-fidelity models, more training modules, and consensus on surgical techniques will benefit surgical training.

Objective assessment for open surgical suturing training by finger tracking can discriminate novices from experts

It is difficult, time consuming and expensive to assess manual skills in open surgery. The aim of this study is to investigate the construct validity of a low-cost, easily accessible tracking technique for basic open suturing tasks. Medical master students, surgical residents, and surgeons at the Radboud University Medical Center were recruited between September 2020 until September 2021. The participants were divided, according to experience, in a novice group (≤10 sutures performed) and an expert group (>50 sutures performed). For objective tracking, a tablet with SurgTrac software was used, which tracked a blue and a red tag placed on respectively their left and right index finger. The participants executed four basic tasks on a suturing model: 1) knot tying by hand, 2) transcutaneous suturing with an instrument knot, 3) 'Donati' (vertical mattress suture) with an instrument knot and 4) continuous intracutaneous suturing without a knot. In total 76 participants were included: 57 novices and 19 experts. All four tasks showed significant differences between the novice group and expert group for the parameters time (p<0.001), distance (p<0.001 for Task 1, 2 and 3 and p=0.034 for Task 4) and smoothness (p<0.001). Additionally, Task 3 showed a significant difference for the parameter handedness (p=0.006) and Task 4 for speed (p=0.033). Tracking index finger movements using SurgTrac software on a tablet while executing basic open suturing skills on a simulator shows excellent construct validity for time, distance and motion smoothness in all four suturing tasks.

Surgical Simulation of Posterior Sagittal Anorectoplasty for Rectovestibular Fistula: Low-Cost High-Fidelity Animal-Tissue Model

PURPOSE

To provide a high-fidelity, animal tissue-based model for the advanced surgical simulation of a Posterior Sagittal Anorectoplasty (PSARP) for rectovestibular fistula in anorectal malformation (ARM).

MATERIALS AND METHODS

A chicken cadaver was used to assess the feasibility of simulating a PSARP for rectovestibular fistula in ARM. No modification was required to implement the surgical simulation.

RESULTS

A detailed description of the high-fidelity surgical simulation model is provided. The PSARP can be simulated while providing realistic anatomy (e.g. common wall between rectovestibular fistula and vagina), adequate rectal size, location and placement of the rectovestibular fistula, and proximity to the vagina. Haptic conditions of the tissue resemble human tissue and operative conditions as well.

DISCUSSION

Concerning the decreased exposure of index cases of pediatric surgical trainees and pediatric surgeons in practice, simulation-based training can provide means to acquire or maintain the necessary skills to perform complex surgical procedures [1-5] Surgical simulation models for ARM are limited. Few low-cost trainers are available with predominant artificial and mostly unrealistic tissue [6-8] Animal models have the advantage of realistic multilayer tissue haptic feedback [6].

CONCLUSION

We provide a low-cost, high-fidelity model for correcting a rectovestibular fistula in a child with ARM, a complex operative procedure with low incidence but high-stake outcomes. The described tissue model utilizing the chicken cloaca anatomy provides a high-fidelity model for operative correction of rectovestibular ARM. For simulation purposes in the treatment of ARM, this model appears to be promising in terms of providing realistic pathology and haptic feedback in pediatric dimensions.

LEVEL OF EVIDENCE

V.

Feasibility of tracking in open surgical simulation

The aim of this study was to develop an adequate tracking method for open surgical training, using tracking of the instrument or hand motions.

An open surgical training model and the SurgTrac application were used to track four separate suturing tasks. These tasks were performed with colour markings of either instruments or fingers, to find the most promising setting for reliable tracking.

Four experiments were used to find the optimal settings for the tracking system. Tracking of instruments was not usable for knot tying by hand. Tracking of fingers seemed to be a more promising method. Tagging the fingers with a coloured balloon-tube, seemed to be a more promising method (1.2–3.0% right hand vs. 9.2–17.9% left hand off-screen) than covering the nails with coloured tape (1.5–3.5% right hand vs. 25.5–55.4% left hand off-screen). However, analysis of the videos showed that redness of the hand was seen as red tagging as well. To prevent misinterpreting of the red tag by redness of the hand, white surgical gloves were worn underneath in the last experiment. The off-screen percentage of the right side decreased from 1.0 to 1.2 without gloves to 0.8 with gloves and the off-screen percentage of the left side decreased from 16.9–17.9 to 6.6–7.2, with an adequate tracking mark on the video images.

This study shows that tagging of the index fingers with a red (right) and blue (left) balloon-tube while wearing surgical gloves is a feasible method for tracking movements during basic open suturing tasks.

Validation of a Newly Developed Competency Assessment Tool for the Posterior Sagittal Anorectoplasty

INTRODUCTION

 The correction of an anorectal malformation (ARM) is complex and relatively infrequent. Simulation training and subsequent assessment may result in better clinical outcomes. Assessment can be done using a competency assessment tool (CAT). This study aims to develop and validate a CAT for the posterior sagittal anorectoplasty (PSARP) on a simulation model.

MATERIALS AND METHODS

 The CAT-PSARP was developed after consultation with experts in the field. The PSARP was divided into five steps, while tissue and instrument handling were scored separately. Participants of pediatric colorectal hands-on courses in 2019 and 2020 were asked to participate. They performed one PSARP procedure on an ARM simulation model, while being assessed by two objective observers using the CAT-PSARP.

RESULTS

 A total of 82 participants were enrolled. A fair interobserver agreement was found for general skills (intraclass correlation coefficient [ICC] = 0.524, p < 0.001), a good agreement for specific skills (ICC = 0.646, p < 0.001), and overall performance (ICC = 0.669, p < 0.001). The experienced group scored higher on all steps (p < 0.001), except for "anoplasty (p = 0.540)," compared with an inexperienced group.

CONCLUSION

 The CAT-PSARP is a suitable objective assessment tool for the overall performance of the included steps of the PSARP for repair of an ARM on a simulation model.

A Promising Future for Hands-On At-Home Training in Pediatric Surgery

INTRODUCTION

 Sufficient training is needed to acquire and retain the procedural skills needed for the surgical correction of congenital anatomical malformations. This study aims to assess the opinions of trainees and pediatric surgeons on the use of simulation-based continued at-home training, which can help to acquire these skills.

METHODS

 This study consisted of two parts. First, an international survey among trainees and pediatric surgeons assessed their opinions on simulation-based at-home training for pediatric surgical procedures (5-point Likert scale). Second, participants of pediatric colorectal courses were instructed to practice the posterior sagittal anorectoplasty procedure at-home on a simulation model and, subsequently, complete a questionnaire regarding their opinions on continuous at-home training (5-point Likert scale).

RESULTS

 A total of 163 participants (83% pediatric surgeons) completed the international survey (response rate 43%). Overall, participants considered the training useful for both laparoscopic (mean 4.7) and open procedures (mean 4.2) and agreed that it may be used at home after a hands-on course (mean 4.3).Twenty participants completed the questionnaire on continued training (response rate 36%). All agreed that at-home training was of added value (mean 4.5) and that the skills were transferable to the clinical setting (mean 4.3). At-home training was regarded a suitable exercise after a hands-on workshop (mean 4.3), but less so without a workshop (mean 3.7, p=0.017).

CONCLUSION

 Participating trainees and pediatric surgeons were of the opinion that simulation models and at-home training have added value. This implies that simulation-based training may be used more often in pediatric surgical training.

The "chicken-leg anastomosis": Low-cost tissue-realistic simulation model for esophageal atresia training in pediatric surgery

INTRODUCTION

Shifting the training from the operating room (OR) to simulation models has been proven effective in enhancing patient safety and reducing the learning time to achieve competency and increase the operative efficiency. Currently the field of pediatric surgery only offers few low-cost trainers for specialized training and these feature predominantly artificial and often unrealistic tissue. The aim of this study was to develop an easy access low-cost tissue-realistic simulation model for open training of esophageal atresia and to evaluate the acceptance in trainees and junior pediatric surgeons.

MATERIALS AND METHODS

The model is fashioned using reconfigured chicken skin from a chicken leg. To create a model of esophageal atresia, the chicken skin is dissected off the muscle and reconfigured around a foley catheter balloon to recreate the proximal pouch and a feeding tube to recreate the distal pouch. Surrounding structures such as the tracheo-esophageal fistula and the azygos vein can be easily added, obtaining a realistic esophageal atresia (Type C) prototype. Evaluation of model construction, usage and impact on user were performed by both a self-assessment questionnaire with pre- and post-training questions as well as observer-based variables and a revised Objective Structured Assessment of Technical Skills (OSATS) score.

RESULTS

A total of 10 participants were constructing and using the model at two different timepoints. OSATS score for overall performance was significantly higher (p = 0.005, z = -2.78) during the second observational period [median (MD): 4,95% confidence interval CI: 3.4, 5.1] compared to the first (MD: 3, 95% CI 2.4, 4.1). Self-reported boost in confidence after model usage for performing future esophageal atresia (EA) repair and bowel anastomosis (BA) in general was significantly higher (EA: U = 1, z = -2.3, p = 0.021, BA: U = 1, z = -2.41, p = 0.016) in participants with more years in training/attending status (EA MD:5, BA MD: 5.5) compared to less experienced participants (EA MD: 1.5, BA: 1).

CONCLUSION

Our easy access low-cost simulation model represents a feasible and tissue realistic training option to increase surgical performance of pediatric surgical trainees outside the OR.