Porcine Models for Pediatric Minimally Invasive Surgical Training—A Template for the Future

Residents and patients benefit from surgical simulation on a live porcine model, could we consider it as ethical?

INTRODUCTION

The objective was to evaluate, by self-questionnaire, the feeling of participants in surgical training sessions on a live porcine model.

METHODS

A computerized questionnaire (GoogleForm ©) was sent to the members of the French Association of Urologists-in-Training (AFUF) (fellows and residents). Only questionnaires from Urologists-in-training who had participated in surgical training sessions were included. The sessions consisted of performing surgeries such as laparoscopic nephrectomies or laparoscopic cystectomies.

RESULTS

Overall, 198 met the inclusion criteria. A total of 36.4% (72/198) of the participants were fellows and 63.6% (126/198) were residents. According to the participants, the main interest of sessions was to be able to train for emergency situations. A total of 79.8% (158/198) of the participants wanted surgical simulation to become compulsory. To their opinion, the main advantage of surgical simulation on a live porcine model was: technical progress in 87.4% (173/198) of cases. A total of 13.1% (26/198) of the participants found it was unethical to perform the first technical procedures on live animal models. A total of 65.7% (130/198) of the participants considered that there is currently no system of substitution.

CONCLUSION

For the participants, surgical training on a live porcine model allows technical progress while training for serious emergency situations. Surgeons and patients could benefit from this risk-free mock surgical scenario.

LEVEL OF EVIDENCE

3.

Mentoring in Pediatric Thoracoscopy: From Theory to Practice

Introduction: Thoracoscopy represents the most challenging area of pediatric minimally invasive surgery due to its technical difficulty. A standardized training program would be advisable. The aim of this study is to evaluate the results of our surgical training. Materials and Methods: A retrospective, single-center, cohort study was performed. The following four-step program was tested: (1) theoretical part; (2) experimental training; (3) training in centers of reference; (4) personal operative experience. Particular attention was focused on the choice of mentor. Times and modality of adherence to the program were evaluated. The effectiveness and safety of the training were evaluated according to the surgical results of esophageal atresia (EA/TEF) repair and resection of congenital lung malformations (CLM). The study was conducted from January 2014 to May 2020. Attending surgeons with previous experience in neonatal and pediatric laparoscopy were selected for the training program after being evaluated by the head of Department. Results: The training program was fully completed in 2 years. Twenty-four lobectomies, 9 sequestrectomies, 2 bronchogenic cyst resections and 20 EA/TEF repair were performed. Thoracoscopy was always feasible and effective, with no conversion. The operative times progressively decreased. Only three minor complications were recorded, all treated conservatively. Conclusions: A standardized training program is highly desirable to learn how to safely perform advanced pediatric thoracoscopy. The 4-steps design seems a valid educational option. The choice of the mentor is crucial. An experience-based profile for pediatric surgeons who may teach thoracoscopy is advisable.

Development and Preliminary Validation of a Rabbit Model of Duodenal Atresia for Training in Pediatric Surgical Skills

Duodenal atresia is a congenital defect that requires advanced surgical skills. The objective of this study is to present an anatomical defect of duodenal atresia using a rabbit model and evaluate the preliminary experience for the training of surgical skills with pediatric surgeons. Adult white New Zealand male rabbits weighing 3.0 to 4.5 kg were used to create the defect. To simulate the bottom of the dilated blind pouch, the gastric antrum of the rabbit was obliterated using a 2-0 Prolene suture, and the cecal appendix was dissected to simulate the continuation of the duodenum. Participants performed laparoscopic duodenal atresia repair in this animal model using the iPhone trainer. Thirteen pediatric surgeons with experience in laparoscopic duodenal atresia repair assessed this model with a questionnaire on 5-point Likert-type scale. Overall, the simulated model of duodenal atresia obtained a general average score of 4.39. The highest observed average was for its physical realism, whereas the lowest score was in surgical experience. The global opinion of the model obtained a score of 4.40. In addition, all surgeons answered that this rabbit model showed the same complexity as newborns and young children in the repair of this type of defect. The inclusion of new models through rabbits in pediatric surgery programs will allow the development of advanced skills of pediatric residents and surgeons.

Current status of simulation-based training in pediatric surgery: A systematic review

BACKGROUND

Simulation based training enables pediatric surgical trainees to attain proficiency in surgical skills. This study aims to identify the currently available simulators for pediatric surgery, assess their validation and strength of evidence supporting each model.

METHODS

Both Medline and EMBASE were searched for English language articles either describing or validating simulation models for pediatric surgery. A level of evidence (LoE) followed by a level of recommendation (LoR) was assigned to each validation study and simulator, based on a modified Oxford Centre for Evidence-Based Medicine classification for educational studies.

RESULTS

Forty-nine articles were identified describing 44 training models and courses. Of these articles, 44 were validation studies. Face validity was evaluated by 20 studies, 28 for content, 24 demonstrated construct validity and 1 showed predictive validity. Of the validated models, 3 were given an LoR of 2, 21 an LoR of 3 and 12 an LoR of 4. None reached the highest LoR.

CONCLUSIONS

There are a growing number of simulators specific to pediatric surgery. However, these simulators have limited LoE and LoR in current studies. The lack of NoTSS training is also apparent. We advocate more randomized trials to validate these models, and attempts to determine predictive validity.

TYPE OF STUDY

Original / systematic review.

LEVEL OF EVIDENCE

1.

Simulation and its role in training

Despite its short history, surgical simulation has been successfully introduced into surgical residency programs in an effort to augment training. A wide range of simulator types and levels of complexity have proven an effective teaching method for surgical trainees. They have been used for training in areas such as general surgery, urology, gynecology, and ophthalmology among others. Coincident with the introduction of simulators is the need for objective evaluation of skills learned on them, which has led to the development and validation of multiple evaluation tools. This article evaluates the drivers for simulation, types of simulators, training, and evaluation of them especially as it pertains to laparoscopic colorectal surgery.

Technical tips and advancements in pediatric minimally invasive surgical training on porcine based simulations

BACKGROUND

Minimal access techniques have transformed the way pediatric surgery is practiced. Due to various constraints, surgical residency programs have not been able to tutor adequate training skills in the routine setting. The advent of new technology and methods in minimally invasive surgery (MIS), has similarly contributed to the need for systematic skills' training in a safe, simulated environment. To enable the training of the proper technique among pediatric surgery trainees, we have advanced a porcine non-survival model for endoscopic surgery.

MATERIALS AND METHODS

The technical advancements over the past 3 years and a subjective validation of the porcine model from 114 participating trainees using a standard questionnaire and a 5-point Likert scale have been described here. Mean attitude scores and analysis of variance (ANOVA) were used for statistical analysis of the data.

RESULTS

Almost all trainees agreed or strongly agreed that the animal-based model was appropriate (98.35%) and also acknowledged that such workshops provided adequate practical experience before attempting on human subjects (96.6%). Mean attitude score for respondents was 19.08 (SD 3.4, range 4-20). Attitude scores showed no statistical association with years of experience or the level of seniority, indicating a positive attitude among all groups of respondents.

CONCLUSIONS

Structured porcine-based MIS training should be an integral part of skill acquisition for pediatric surgery trainees and the experience gained can be transferred into clinical practice. We advocate that laparoscopic training should begin in a controlled workshop setting before procedures are attempted on human patients.

Evaluation of a Bochdalek diaphragmatic hernia rabbit model for pediatric thoracoscopic training

BACKGROUND/AIM

This study evaluated the usefulness of a Bochdalek hernia rabbit model as a tool for advanced thoracoscopic training, teaching the specific skills required for thoracoscopic repair of congenital diaphragmatic hernia.

MATERIALS AND METHODS

An incision was made in the Bochdalek triangle of 25 New Zealand rabbits (weighing 3-3.5 kg) to induce an experimental diaphragmatic hernia. At 72 hours later, a thoracoscopic repair of the hernia as described for newborns was performed by 25 pediatric surgeons divided into two groups: expert and novice. The tasks assessed were organ relocation and diaphragm suture. A visual analog scale was used to evaluate technical performance. The objective performance measure was completion time. Complications were recorded, and suture quality was scored. The surgeons evaluated the model by completing a questionnaire, grading items on a 5-point scale.

RESULTS

All 25 animals developed a diaphragmatic hernia with protrusion of the intestine into the thoracic cavity. Expert trainees had significantly shorter completion times and better performance scores than novices. Experts also received higher scores for suture quality. Five novices caused perforations or bleeding, but no experts did. The surgeons rated the model positively, highlighting the similarities between the model and newborn hernias and its usefulness for pediatric training programs.

CONCLUSIONS

The Bochdalek hernia rabbit model can be used to detect different levels of experience in pediatric thoracoscopy. This realistic and easily reproducible model can help to perfect thoracoscopic skills in a realistic recreation of a pediatric Bochdalek hernia repair.

Cadavers versus pigs: which are better for procedural training of surgery residents outside the OR?

BACKGROUND

Our objective was to compare the value of porcine versus cadaveric models for procedural training of general surgery residents outside the operating room (OR).

METHODS

Two procedural workshops for general surgery residents based on the American College of Surgeons/Association of Program Directors in Surgery national skills curriculum were administered. During each workshop, 7 surgery faculty taught 16 residents level-appropriate operative procedures on 4 training models (2 cadaver torsos; 2 pigs). Participants compared the 2 models at the end of the workshops using a 10-point Likert scale and indicated their training model preference. Ratings were compared using a paired t test.

RESULTS

Among the 39 participants (9 faculty and 30 residents) who provided ratings, the porcine models were rated lower for anatomic relevance (6.8 ± 2.1 vs 9.1 ± 1.5; P < .01) but higher for tissue handling (8.4 ± 1.3 vs 7.2 ± 2.0; P < .01) and ability to dissect/identify planes (8.6 ± 1.2 vs 6.7 ± 2.4; P < .01) compared with the cadavers. There were no differences in perceived similarity to live patient surgery and overall value of the 2 models for training (7.2 ± 2.2 vs 6.9 ± 2.5 and 8.5 ± 1.6 vs 8.5 ± 1.5, respectively). There were no differences between resident and faculty ratings. Eight (20%) participants preferred the porcine model for training, 5 (13%) the cadaveric model, 16 (41%) both, and 10 (26%) indicated differences in preference based on operative procedure. Participants rated highly the overall quality and value of these procedural workshops for their learning (8.4 ± 1.1).

CONCLUSION

Based on resident and faculty evaluations, both porcine and cadaveric models are deemed necessary and valuable for procedural training outside the OR. Such skills workshops should be incorporated into the surgical curriculum.

Collaboration in simulation: the development and initial validation of a novel thoracoscopic neonatal simulator

PURPOSE

We sought to create and validate a high fidelity, anatomically correct real tissue simulation model for thoracoscopic esophageal atresia/tracheoesophageal fistula (EA/TEF) repair.

METHODS

A scale reproduction of a neonatal rib cage was created. Surgically modified (EA/TEF) fetal bovine tissue completed the simulator. Nine pediatric surgery fellows and two attending pediatric surgeons (n=11) performed the simulated thoracoscopic EA/TEF repair. Participants completed a self-report rating scale, ranging from 1 (Don't know) to 5 (Highly realistic). Construct validity relevant to test content was evaluated by examining the ratings using the many-Facet Rasch model.

RESULTS

Analyses indicated no differences when comparing faculty (Observed Average (OA)=4.5/5.0) to fellow (OA=3.3) ratings, p=.71. In descending order, observed averages of the domains were 4.7 (Relevance), 4.5 (Physical attributes), 4.5 (Realism of materials), 4.4 (Ability to perform task), and 4.2 (Value). The observed Global opinion rating indicated the simulator can be considered for teaching thoracoscopic EA/TEF repair but could be improved slightly.

CONCLUSIONS

Fellow and faculty ratings indicated the simulator was valuable as a learning tool with minor modifications. Comments were consistent with high physical attribute ratings.

Feasibility and value of a procedural workshop for surgery residents based on phase II of the APDS/ACS national skills curriculum

OBJECTIVES

The Association of Program Directors in Surgery/American College of Surgeons national skills curriculum provides residency programs with a great educational tool for their residents. Our objective was to assess the feasibility, value, and cost required to administer a procedural workshop for general surgery residents based on phase II of the national skills curriculum.

DESIGN, SETTING, AND PARTICIPANTS

Surgery faculty instructed residents on a variety of level-appropriate surgical procedures during a procedural workshop using 4 training models (2 cadaver torsos and 2 pigs). The educational value of the workshop, the quality of teaching, the instruction and feedback received, and the training models used were evaluated by participants on a 10-point Likert scale. Resident performance and workshop cost were also assessed.

RESULTS

Seven faculty instructed 16 residents (postgraduate year 1-4) on 23 surgical procedures (median 4 procedures per resident). Participants rated the overall value of the workshop as 8 (range, 7-10). Residents rated the quality of teaching as 9 (range, 6-10) and the quality of instruction and feedback received as 8.5 (range, 6-10). Overall resident performance was rated as 8 (range, 5-10) by faculty. The factors most positively impacting the quality of the workshop were reported to be the close interaction between residents and faculty, the training models, and the protected time. Sixty-eight percent of participants indicated that both cadaver and pig models were necessary for this course, and all participants believed that such workshops should be part of the general surgery curriculum. Overall cost reached just under $10,000 excluding supplies and faculty time.

CONCLUSIONS

The feasibility of a cadaveric and animal-based procedural workshop for surgery residents based on phase II of the national skills curriculum was demonstrated. While very resource-intensive and costly, the educational value of this workshop was rated highly by residents and faculty because of their close interaction in a relaxed environment. Such workshops should be incorporated into the surgical curriculum.