Laparoscopic animal surgery for training without sacrificing animals; introducing the rabbit as a model for infantile laparoscopy

Minimally Invasive Neck Surgery: An Animal Model Study

Background: Minimally invasive surgery (MIS) is replacing conventional surgery as the "gold standard" in different surgical areas. Although cervical MIS is already accepted in the adult population, its use in children is still new and controversial. The natural obstacles to this approach are the absence of a natural cavity, with the inherent complications of creating one artificially, and the limited existing workspace especially in pediatric patients. All endoscopic techniques in the field of neck surgery try to live up to the high cosmetic expectations and the transoral cervical approach as a natural orifice surgery technique excels at it. Aim: Besides the goal of feasibility, we aim to report on the pitfalls of this approach, by using an experimental rabbit model for minimally invasive thyroidectomy. Materials and Methods: Transoral endoscopic thyroidectomies using a vestibular approach were performed in 10 anesthetized rabbits. All surgeries were video recorded. The surgical time, anatomy identified, difficulties, and intraoperative complications were documented. Results: Through one trocar in the vestibular area and two lateral stab incisions, it was possible to create a working space and to reach the peritracheal area. Total thyroidectomies were completed in the 10 animals with a mean operative time of 51 minutes. In all of them we were able to identify the fascial spaces of the neck and the major vessels. During surgery, the lack of space required surgical gestures to be very precise, soft, and gentle. There were 2 cases with a small amount of bleeding and one mild trachea laceration during the procedure, but none of them required suspension or conversion to an open procedure. Animals were euthanized immediately after the surgical procedure. Conclusions: The vestibular approach seems to be a feasible technique to access pediatric neck pathology. Despite the differences in the cervical anatomy, the limited workspace of the rabbit model perfectly matches the requirements of a pediatric training model.

Characterization of technical skill progress in a standardized rabbit model for training in laparoscopic duodenal atresia repair

BACKGROUND

Laboratory skills training is an essential step before conducting minimally invasive surgery in clinical practice. Our main aim was to develop an animal model for training in clinically highly challenging laparoscopic duodenal atresia repair that could be useful in establishing a minimum number of repetitions to indicate safe performance of similar interventions on humans.

MATERIALS AND METHODS

A rabbit model of laparoscopic duodenum atresia surgery involving a diamond-shaped duodeno-duodenostomy was designed. This approach was tested in two groups of surgeons: in a beginner group without any previous clinical laparoscopic experience (but having undergone previous standardized dry-lab training, n = 8) and in an advanced group comprising pediatric surgery fellows with previous clinical experience of laparoscopy (n = 7). Each participant performed eight interventions. Surgical time, expert assessment using the Global Operative Assessment of Laparoscopic Skills (GOALS) score, anastomosis quality (leakage) and results from participant feedback questionnaires were analyzed.

RESULTS

Participants in both groups successfully completed all eight surgeries. The surgical time gradually improved in both groups, but it was typically shorter in the advanced group than in the beginner group. The leakage rate was significantly lower in the advanced group in the first two interventions, and it reached its optimal level after five operations in both groups. The GOALS and participant feedback scores showed gradual increases, evident even after the fifth surgery.

CONCLUSIONS

Our data confirm the feasibility of this advanced pediatric laparoscopic model. Surgical time, anastomosis quality, GOALS score and self-assessment parameters adequately quantify technical improvement among the participants. Anastomosis quality reaches its optimal value after the fifth operation even in novice, but uniformly trained surgeons. A minimum number of wet-lab operations can be determined before surgery can be safely conducted in a clinical setting, where the development of further non-technical skills is also required.

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.

Low-fidelity Paediatric Surgical Simulation: Description of Models in Low-Resource Settings

BACKGROUND

Surgical simulation is an important aspect of competency-based training. Recent trends in paediatric surgical simulations have migrated towards high-fidelity simulation with advanced technology resulting in models which are expensive and largely inaccessible in low- and middle-income countries.

METHODS

This article describes four wet simulation models of common surgical procedures in paediatric population created with animal tissue from local abattoir. The models are designed to provide a framework for others to make the models and benefit from the training opportunity they provide especially in low-middle-income countries.

RESULTS

The models created in the wet laboratory are neonatal bowel anastomosis, duodenoduodenostomy for discrepancy anastomosis, gastrostomy and pyeloplasty. These models are easily reproducible in resource-challenged healthcare setting as they are low cost, utilise locally available resources and require only a basic set of surgical instruments with which to perform the procedures.

CONCLUSION

These models provide locally accessible material for sustainable training programmes which are fundamental in developing safe and affordable surgical care worldwide.

COMPARAÇÃO CIRÚRGICA E HISTOLÓGICA DE CADÁVERES QUIMICAMENTE PRESERVADOS E CRIOPRESERVADOS

Resumo Este trabalho comparou seis cadáveres de cães, sem predileção por raça, idade ou sexo, com peso entre 2 e 10 kg, provenientes da Diretoria de Vigilância Ambiental do Distrito Federal. Os cadáveres, cujos sistemas vasculares foram limpos com solução salina supersaturada, solução de Larssen modificada e água comum, foram divididos em três grupos aleatórios, respectivamente. EM seguida foram conservados com solução de Larssen modificada na proporção de 10% de seu peso corporal, objetivando-se terminar a durabilidade como modelo para o treinamento cirúrgico. Após seis sucessivos congelamentos e descongelamentos, nos quais foram realizadas cirurgias visando avaliar a resistência, cor, odor, maleabilidade e grau de autólise tecidual através de análises histológicas de coração, fígado, baço, intestino e encéfalo, ficou determinado que todos os grupos apresentaram boa qualidade para treinamento cirúrgico, permitindo cirurgias de órgãos cavitários até o terceiro descongelamento, cirurgias da conjuntiva bulbar por até quatro descongelamentos e cirurgias ortopédicas por até seis descongelamentos, ficando inviáveis a partir deste ponto, devido ao elevado grau de autólise tecidual. O grupo conservado com solução salina supersaturada se destacou por quase não desprender odor desagradável, além do encéfalo e do coração serem os únicos órgãos que praticamente não apresentaram alterações macro e microscópicas nos três primeiros descongelamentos.

Implementation and evaluation of an interprofessional simulation-based education program for undergraduate nursing students in operating room nursing education: a randomized controlled trial

BACKGROUND

The present study was designed to implement an interprofessional simulation-based education program for nursing students and evaluate the influence of this program on nursing students' attitudes toward interprofessional education and knowledge about operating room nursing.

METHODS

Nursing students were randomly assigned to either the interprofessional simulation-based education or traditional course group. A before-and-after study of nursing students' attitudes toward the program was conducted using the Readiness for Interprofessional Learning Scale. Responses to an open-ended question were categorized using thematic content analysis. Nursing students' knowledge about operating room nursing was measured.

RESULTS

Nursing students from the interprofessional simulation-based education group showed statistically different responses to four of the nineteen questions in the Readiness for Interprofessional Learning Scale, reflecting a more positive attitude toward interprofessional learning. This was also supported by thematic content analysis of the open-ended responses. Furthermore, nursing students in the simulation-based education group had a significant improvement in knowledge about operating room nursing.

CONCLUSIONS

The integrated course with interprofessional education and simulation provided a positive impact on undergraduate nursing students' perceptions toward interprofessional learning and knowledge about operating room nursing. Our study demonstrated that this course may be a valuable elective option for undergraduate nursing students in operating room nursing education.

3-Dimensional (3D) laparoscopy improves operating time in small spaces without impact on hemodynamics and psychomental stress parameters of the surgeon

BACKGROUND AND PURPOSE

Three-dimensional (3D) imaging, a recent technical innovation in laparoscopic surgery, has been postulated to enhance depth perception and facilitate operations. However, it has never been evaluated in conditions where the focus is close to the optical system. Thus, it is unclear whether 3D cameras can improve laparoscopic surgical performance in neonates and infants. We tested 3D versus two-dimensional (2D) vision during laparoscopic surgery in rabbits, mimicking the size of a neonatal patient.

MATERIALS AND METHODS

Cadaver New Zealand white rabbits (mean weight 2,755 g) were operated by two surgeons experienced in 2D laparoscopic surgery and two surgical residents (with basic skills in 2D laparoscopy). All surgeons had never performed 3D laparoscopic surgery. Animals underwent six operations: Nissen fundoplication, small bowel anastomosis, and closure of a diaphragmatic defect using either 2D or 3D. Primary endpoint was cumulative operating time and operating time of each operation. Secondary endpoints included the hemodynamic response and psychomental stress level of the surgeons. Finally, subjective data on depth perception were assessed by questionnaires.

RESULTS

Cumulative operating time of all three types of operations was significantly shorter with 3D laparoscopy in experts (3D: 23.01 ± 5.65 min vs 2D: 29.51 ± 7.51 min, p < 0.01) and residents (3D: 27.95 ± 3.69 min vs 2D: 33.95 ± 6.21 min, p < 0.05). This effect could be shown for each operation in the expert group and the Nissen fundoplication in the resident group. There were no differences in the hemodynamic response as well as the psychomental stress level between 2D and 3D imaging. 3D provided better depth perception.

CONCLUSION

3D laparoscopy in small spaces is associated with a significant shorter operating time. It induces no additional physical or psychomental stress in surgeons naive to 3D imaging. 3D may therefore facilitate minimal invasive surgery in neonates and infants.

Saline-filled laparoscopic surgery: A basic study on partial hepatectomy in a rabbit model

BACKGROUND

There is still a poor understanding of the effects of pneumoperitoneum with insufflation of carbon dioxide gas (CO2) on malignant cells, and pneumoperitoneum has a negative impact on cardiopulmonary responses. A novel saline-filled laparoscopic surgery (SAFLS) is proposed, and the technical feasibility of performing saline-filled laparoscopic partial hepatectomy (LPH) was evaluated in a rabbit model.

MATERIAL AND METHODS

Twelve LPH were performed in rabbits, with six procedures performed using an ultrasonic device with CO2 pneumoperitoneum (CO2 group) and six procedures performed using a bipolar resectoscope (RS) in a saline-filled environment (saline group). Resection time, CO2 and saline consumption, vital signs, blood gas analysis, complications, interleukin-1 beta (IL-1β) and C-reactive protein (CRP) levels were measured. The effectiveness of the resections was evaluated by the pathological findings.

RESULTS

LPH was successfully performed with clear observation by irrigation and good control of bleeding by coagulation with RS. There were no significant differences in all perioperative values, IL-1βand CRP levels between the two groups. All pathological specimens of the saline group showed that the resected lesions were coagulated and regenerated as well as in the CO2 group.

CONCLUSIONS

SAFLS is feasible and provides a good surgical view with irrigation and identification of bleeding sites.

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.

A qualitative assessment of human cadavers embalmed by Thiel's method used in laparoscopic training for renal resection

Human cadaveric tissue is the fundamental substrate for basic anatomic and surgical skills training. A qualitative assessment of the use of human cadavers preserved by Thiel's method for a British Association of Urological Surgeons-approved, advanced laparoscopic renal resection skills training course is described in the present study. Four trainees and four experienced laparoscopic surgeons participated in the course. All participants completed a five-point Likert scale satisfaction questionnaire after their training sessions. The quality of cadaveric tissue and the training session were assessed with particular emphasis placed on the ease of patient positioning, the ease of trocar placement, the preservation of tissue planes, the ease of renal pedicle dissection, and the quality of tissue preservation. All of the participants highly rated the quality of the cadaveric tissue embalmed by Thiel's method (mean scores for quality on the five-point Likert scale were 4.5 and 4.3 by the trainees and experienced laparoscopic surgeons, respectively). All of the steps of laparoscopic renal resection were rated 4.0 or more on the Likert scale by both trainees and faculty members. The initial response rates for using a human cadaver embalmed by Thiel's method as a training tool for laparoscopic nephrectomy showed encouraging results. The performance of a laparoscopic nephrectomy on a human cadaver embalmed by Thiel's method bears close resemblance to real laparoscopic nephrectomy procedures, and thus demonstrates added advantages to the previously reported models.