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Sharma M, Yadav N, Ratre S, Bajaj J, Kavishwar A, Hadaoo K, Patidar J, Sinha M, Parihar V, Swamy NM, Yadav YR. Endoscopic Posterior Approach for Cervical Myelopathy and Radiculopathy Using Tubular Retractor: Our Experience, Surgical Technique, and Literature Review. World Neurosurg 2024:S1878-8750(24)01329-9. [PMID: 39097083 DOI: 10.1016/j.wneu.2024.07.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Endoscopic posterior approach can effectively decompress cervical root and cord secondary to posterior compression. We present our experience in 229 patients using tubular retractor, and the relevant literature is reviewed. METHODS Retrospective analysis of multilevel myelopathy and or radiculopathy was performed. Indications for posterior approach was primary posterior compressions at cord and or root. Combined compression from posterior side and mild to moderate anterior pressure with acceptable lordosis were also decompressed. Bilateral cord decompression and foraminotomy for radiculopathy was performed using tubular retractor. RESULT Myelopathy and radiculopathy were present in 220 and 9 patients, respectively. A total of 53 foraminotomy procedures were performed in 36 patients. All patients showed improvement, with the mean preoperative Nurick grade decreasing from 2.72 ± 0.799 to 0.78 ± 0.911 after surgery. There was significant improvement in postoperative Nurick grades compared with preoperative grades (Z-value = 13.306, P < 0.0001). Operative results were better in patients with good preoperative Nurick grades (grades 1 and 2) compared with those with poorer grades (grades 3 and 4). Minor bleeding, small dural tear, and root injury were observed in 42, 4, and 8 patients, respectively. CONCLUSIONS Endoscopic approach was effective and safe for root and cord decompression. This study was limited by its single-center, retrospective design, exclusion of some eligible patients, a short postoperative Nurick grade assessment period of 6 months, and absence of a comprehensive long-term postoperative biomechanical assessment. To validate these results, a prospective multicenter study addressing these limitations is needed.
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Affiliation(s)
- Mukesh Sharma
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Nishtha Yadav
- Department of Neuroradiology, NSCB Medical College, Jabalpur, India
| | - Shailendra Ratre
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Jitin Bajaj
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Arvind Kavishwar
- Department of Health Research, Biostatistics, ICMR-National Institute of Research in Tribal Health (NIRTH), Ministry of Health & Family Welfare, Government of India, Jabalpur, India
| | - Ketan Hadaoo
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Jayant Patidar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Mallika Sinha
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Vijay Parihar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Narayan M Swamy
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Yad Ram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India.
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Gosselin LE, Morin N, Gariépy C, Chamberland M, Beaulieu O, Nadeau S, Champagne PO. Development and Validation of a Novel Human-Fixed Cadaveric Model Reproducing Cerebrospinal Fluid Circulation for Simulation of Endoscopic Endonasal Skull Base Surgery. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01248. [PMID: 38995026 DOI: 10.1227/ons.0000000000001272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 05/20/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Endoscopic endonasal surgery is a well-established surgical approach to the skull base. Surgeons need a reusable long-lasting tool to acquire the skills needed for skull base reconstruction. The aim of this study was to elaborate and validate a human formalin-fixed cadaveric model that reproduces a realistic cerebrospinal fluid (CSF) circulation and that adequately renders a CSF leak. METHODS An external ventricular drain that connects with a peristaltic pump is placed in the subarachnoid space, which allows a water circulation that reproduces CSF circulation. Intracranial pressure is measured in real time. Endoscopic endonasal skull base approaches are performed, to create different skull base openings and CSF leaks. Participants were tasked with reconstruction of the defects using a standardized multilayered approach, with the goal of obtaining a watertight closure under normal intracranial pressure ranges. Compiled data included time of reconstruction, years of experience of participants, and success/failure to achieve a watertight reconstruction. A Likert questionnaire was also used. RESULTS The cadaveric model reproduced CSF circulation in 4 types of dural defects: sellar, suprasellar, transcribriform, and transclival. Intracranial pressures were similar to physiological conditions and were reproducible. Each model was tested multiple times, over several months. Success rates concurred with training levels (r = .8282 and P = .0017). A strong inverse correlation was also found between years of experience and time of reconstruction (r = .4977 and P < .0001). Participants agreed that the model was realistic (median Likert score of 4), and they strongly agreed that it allowed for the improvement of their surgical skills (median Likert score of 5). CONCLUSION This novel human-fixed cadaveric model for CSF circulation is efficient and adequately reproduces surgical conditions for skull base approaches. The model is unique, easy to reproduce, and reusable. It can be used as a tool for teaching and for research purposes.
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Affiliation(s)
- Laura-Elisabeth Gosselin
- Department of Otolaryngology - Head and Neck Surgery, Université Laval, Quebec, Québec, Canada
- Université Laval Neurosurgical Innovation Laboratory (ULNIL), Quebec, Québec, Canada
| | - Nicolas Morin
- Université Laval Neurosurgical Innovation Laboratory (ULNIL), Quebec, Québec, Canada
- Department of Neurosurgery, Université Laval, Quebec, Québec, Canada
| | - Charles Gariépy
- Department of Neurosurgery, Université Laval, Quebec, Québec, Canada
| | - Mathieu Chamberland
- Department of Otolaryngology - Head and Neck Surgery, Université Laval, Quebec, Québec, Canada
| | - Olivier Beaulieu
- Department of Otolaryngology - Head and Neck Surgery, Université Laval, Quebec, Québec, Canada
| | - Sylvie Nadeau
- Department of Otolaryngology - Head and Neck Surgery, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, Québec, Canada
| | - Pierre-Olivier Champagne
- Université Laval Neurosurgical Innovation Laboratory (ULNIL), Quebec, Québec, Canada
- Department of Neurosurgery, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, Québec, Canada
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Rullière A, Danion J, Fieux M, Tonnerre D, Faure JP, Legré M, Favier V, Oriot D, Dufour X, Carsuzaa F. SimLife®: A New Dynamic Model for Head and Neck Surgical Oncology Simulation. Otolaryngol Head Neck Surg 2024; 170:972-976. [PMID: 38111133 DOI: 10.1002/ohn.630] [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: 08/28/2023] [Revised: 10/20/2023] [Accepted: 12/02/2023] [Indexed: 12/20/2023]
Abstract
The SimLife® model consists in a human cadaver dynamized by pulsatile vascularization. The objective was to evaluate the face, contents, and constructs validity of the SimLife® model in head and neck surgical oncology simulation. Head and neck surgical oncology simulation sessions on SimLife® models were organized with lateral neck dissection and total laryngectomy. Face and contents validity were addressed by questionnaires. Constructs validity was assessed by objective structured assessment of technical skills (OSATS) score. High realism was demonstrated for consistency of tissues (7.1 ± 1.4), color of arteries and veins (7.3 ± 1.9, 8.5 ± 1.1, respectively), and vein consistency (8.5 ± 1.2). The mean OSATS score was 19.7 ± 5.4 for residents and 32.7 ± 1.9 for senior surgeon (P = .0022). SimLife® is a hyperrealistic model for head and neck surgical oncology simulation and it might become a core component of the surgical resident curriculum.
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Affiliation(s)
- Anne Rullière
- Service ORL et chirurgie cervico-faciale, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Jérôme Danion
- Service de chirurgie viscérale, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- ABS Lab, Université de Poitiers, Poitiers, France
| | - Maxime Fieux
- Service d'ORL, d'otoneurochirurgie et de chirurgie cervico-faciale, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Denis Tonnerre
- Service ORL et chirurgie cervico-faciale, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Jean-Pierre Faure
- Service de chirurgie viscérale, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- ABS Lab, Université de Poitiers, Poitiers, France
| | - Margaux Legré
- Service ORL et chirurgie cervico-faciale, Institut Arthur Vernes, Paris, France
| | - Valentin Favier
- Département d'ORL, chirurgie cervico faciale et maxillo-faciale, Hôpital Gui de Chauliac, CHU de Montpellier, Montpellier, France
| | - Denis Oriot
- ABS Lab, Université de Poitiers, Poitiers, France
| | - Xavier Dufour
- Service ORL et chirurgie cervico-faciale, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Florent Carsuzaa
- Service ORL et chirurgie cervico-faciale, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
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Pérez-Cruz JC, Macías-Duvignau MA, Reyes-Soto G, Gasca-González OO, Baldoncini M, Miranda-Solís F, Delgado-Reyes L, Ovalles C, Catillo-Rangel C, Goncharov E, Nurmukhametov R, Lawton MT, Montemurro N, Encarnacion Ramirez MDJ. Latex vascular injection as method for enhanced neurosurgical training and skills. Front Surg 2024; 11:1366190. [PMID: 38464665 PMCID: PMC10920354 DOI: 10.3389/fsurg.2024.1366190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/14/2024] [Indexed: 03/12/2024] Open
Abstract
Background Tridimensional medical knowledge of human anatomy is a key step in the undergraduate and postgraduate medical education, especially in surgical fields. Training simulation before real surgical procedures is necessary to develop clinical competences and to minimize surgical complications. Methods Latex injection of vascular system in brain and in head-neck segment is made after washing out of the vascular system and fixation of the specimen before and after latex injection. Results Using this latex injection technique, the vascular system of 90% of brains and 80% of head-neck segments are well-perfused. Latex-injected vessels maintain real appearance compared to silicone, and more flexible vessels compared to resins. Besides, latex makes possible a better perfusion of small vessels. Conclusions Latex vascular injection technique of the brain and head-neck segment is a simulation model for neurosurgical training based on real experiencing to improve surgical skills and surgical results.
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Affiliation(s)
- Julio C. Pérez-Cruz
- Laboratorio de Técnicas Anatómicas y Material Didactico, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico
- Departamento de Anatomía, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Mario A. Macías-Duvignau
- Laboratorio de Técnicas Anatómicas y Material Didactico, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Gervith Reyes-Soto
- Department of Head and Neck, Unidad de Neurociencias, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Oscar O. Gasca-González
- Departamento de Anatomía, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Departamento de Anatomía, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexico City, Mexico
| | - Matias Baldoncini
- Laboratory of Microsurgical Neuroanatomy, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Franklin Miranda-Solís
- Laboratorio de Neuroanatomía, Centro de Investigación de Anatomía y Fisiología Alto Andina, Universidad Andina del Cusco, Cusco, Peru
| | - Luis Delgado-Reyes
- Departamento de Anatomía, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Carlos Ovalles
- Department of Neurosurgery, General Hospital, Durango, Mexico
| | - Carlos Catillo-Rangel
- Department of Neurosurgery, Servicio of the 1ro de Octubre Hospital of the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexico City, Mexico
| | - Evgeniy Goncharov
- Traumatology and Orthopedics Center, Central Clinical Hospital of the Russian Academy of Sciences, Moscow, Russia
| | - Renat Nurmukhametov
- Neurological Surgery, Peoples Friendship University of Russia, Moscow, Russia
| | - Michael T. Lawton
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Nicola Montemurro
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
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Balu A, Kugener G, Pangal DJ, Lee H, Lasky S, Han J, Buchanan I, Liu J, Zada G, Donoho DA. Simulated outcomes for durotomy repair in minimally invasive spine surgery. Sci Data 2024; 11:62. [PMID: 38200013 PMCID: PMC10781746 DOI: 10.1038/s41597-023-02744-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 11/13/2023] [Indexed: 01/12/2024] Open
Abstract
Minimally invasive spine surgery (MISS) is increasingly performed using endoscopic and microscopic visualization, and the captured video can be used for surgical education and development of predictive artificial intelligence (AI) models. Video datasets depicting adverse event management are also valuable, as predictive models not exposed to adverse events may exhibit poor performance when these occur. Given that no dedicated spine surgery video datasets for AI model development are publicly available, we introduce Simulated Outcomes for Durotomy Repair in Minimally Invasive Spine Surgery (SOSpine). A validated MISS cadaveric dural repair simulator was used to educate neurosurgery residents, and surgical microscope video recordings were paired with outcome data. Objects including durotomy, needle, grasper, needle driver, and nerve hook were then annotated. Altogether, SOSpine contains 15,698 frames with 53,238 annotations and associated durotomy repair outcomes. For validation, an AI model was fine-tuned on SOSpine video and detected surgical instruments with a mean average precision of 0.77. In summary, SOSpine depicts spine surgeons managing a common complication, providing opportunities to develop surgical AI models.
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Affiliation(s)
- Alan Balu
- Department of Neurosurgery, Georgetown University School of Medicine, 3900 Reservoir Rd NW, Washington, D.C., 20007, USA.
| | - Guillaume Kugener
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, 1200 North State St., Suite 3300, Los Angeles, CA, 90033, USA
| | - Dhiraj J Pangal
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, 1200 North State St., Suite 3300, Los Angeles, CA, 90033, USA
| | - Heewon Lee
- University of Southern California, 3709 Trousdale Pkwy., Los Angeles, CA, 90089, USA
| | - Sasha Lasky
- University of Southern California, 3709 Trousdale Pkwy., Los Angeles, CA, 90089, USA
| | - Jane Han
- University of Southern California, 3709 Trousdale Pkwy., Los Angeles, CA, 90089, USA
| | - Ian Buchanan
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, 1200 North State St., Suite 3300, Los Angeles, CA, 90033, USA
| | - John Liu
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, 1200 North State St., Suite 3300, Los Angeles, CA, 90033, USA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, 1200 North State St., Suite 3300, Los Angeles, CA, 90033, USA
| | - Daniel A Donoho
- Department of Neurosurgery, Children's National Hospital, 111 Michigan Avenue NW, Washington, DC, 20010, USA
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6
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Balu A, Pangal DJ, Kugener G, Donoho DA. Pilot Analysis of Surgeon Instrument Utilization Signatures Based on Shannon Entropy and Deep Learning for Surgeon Performance Assessment in a Cadaveric Carotid Artery Injury Control Simulation. Oper Neurosurg (Hagerstown) 2023; 25:e330-e337. [PMID: 37655892 DOI: 10.1227/ons.0000000000000888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/27/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Assessment and feedback are critical to surgical education, but direct observational feedback by experts is rarely provided because of time constraints and is typically only qualitative. Automated, video-based, quantitative feedback on surgical performance could address this gap, improving surgical training. The authors aim to demonstrate the ability of Shannon entropy (ShEn), an information theory metric that quantifies series diversity, to predict surgical performance using instrument detections generated through deep learning. METHODS Annotated images from a publicly available video data set of surgeons managing endoscopic endonasal carotid artery lacerations in a perfused cadaveric simulator were collected. A deep learning model was implemented to detect surgical instruments across video frames. ShEn score for the instrument sequence was calculated from each surgical trial. Logistic regression using ShEn was used to predict hemorrhage control success. RESULTS ShEn scores and instrument usage patterns differed between successful and unsuccessful trials (ShEn: 0.452 vs 0.370, P < .001). Unsuccessful hemorrhage control trials displayed lower entropy and less varied instrument use patterns. By contrast, successful trials demonstrated higher entropy with more diverse instrument usage and consistent progression in instrument utilization. A logistic regression model using ShEn scores (78% accuracy and 97% average precision) was at least as accurate as surgeons' attending/resident status and years of experience for predicting trial success and had similar accuracy as expert human observers. CONCLUSION ShEn score offers a summative signal about surgeon performance and predicted success at controlling carotid hemorrhage in a simulated cadaveric setting. Future efforts to generalize ShEn to additional surgical scenarios can further validate this metric.
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Affiliation(s)
- Alan Balu
- Department of Neurosurgery, Georgetown University School of Medicine, Washington , District of Columbia, USA
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles , California , USA
| | - Guillaume Kugener
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles , California , USA
| | - Daniel A Donoho
- Division of Neurosurgery, Children's National Hospital, Washington , District of Columbia , USA
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7
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Farah GJ, Rogers JL, Lopez AM, Brown NJ, Pennington Z, Kuo C, Gold J, Bui NE, Koester SW, Gendreau JL, Diaz-Aguilar LD, Oh MY, Pham MH. Resident Training in Spine Surgery: A Systematic Review of Simulation-Based Educational Models. World Neurosurg 2023; 174:81-115. [PMID: 36921712 DOI: 10.1016/j.wneu.2023.03.032] [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: 12/19/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE With the increasing prevalence of spine surgery, ensuring effective resident training is becoming of increasing importance. Training safe, competent surgeons relies heavily on effective teaching of surgical indications and adequate practice to achieve a minimum level of technical proficiency before independent practice. American Council of Graduate Medical Education work-hour restrictions have complicated the latter, forcing programs to identify novel methods of surgical resident training. Simulation-based training is one such method that can be used to complement traditional training. The present review aims to evaluate the educational success of simulation-based models in the spine surgical training of residents. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, Web of Science, and Google Scholar databases were systematically screened for English full-text studies examining simulation-based spine training curricula. Studies were categorized based on simulation model class, including animal-cadaveric, human-cadaveric, physical/3-dimensional, and computer-based/virtual reality. Outcomes studied included participant feedback regarding the simulator and competency metrics used to evaluate participant performance. RESULTS Seventy-two studies were identified. Simulators displayed high face validity and were useful for spine surgery training. Objective measures used to evaluate procedural performance included implant placement evaluation, procedural time, and technical skill assessment, with numerous simulators demonstrating a learning effect. CONCLUSIONS While simulation-based educational models are one potential means of training residents to perform spine surgery, traditional in-person operating room training remains pivotal. To establish the efficacy of simulators, future research should focus on improving study quality by leveraging longitudinal study designs and correlating simulation-based training with clinical outcome measures.
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Affiliation(s)
- Ghassan J Farah
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California, USA
| | - James L Rogers
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Alexander M Lopez
- Department of Neurosurgery, University of California, Irvine, Orange, California, USA
| | - Nolan J Brown
- Department of Neurosurgery, University of California, Irvine, Orange, California, USA
| | - Zach Pennington
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Cathleen Kuo
- Department of Neurological Surgery, University at Buffalo Jacobs SOM, Buffalo, New York, USA
| | - Justin Gold
- Department of Neurological Surgery, Cooper Medical of Rowan University, Camden, New Jersey, USA
| | - Nicholas E Bui
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Stefan W Koester
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Julian L Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA
| | - Luis Daniel Diaz-Aguilar
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California, USA
| | - Michael Y Oh
- Department of Neurosurgery, University of California, Irvine, Orange, California, USA
| | - Martin H Pham
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California, USA.
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8
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Belykh E, Abramov I, Bardonova L, Patel R, McBryan S, Enriquez Bouza L, Majmundar N, Zhao X, Byvaltsev VA, Johnson SA, Singla A, Gupta G, Sun H, Liu JK, Nanda A, Preul MC, Lawton MT. Seven bypasses simulation set: description and validity assessment of novel models for microneurosurgical training. J Neurosurg 2023; 138:732-739. [PMID: 35932275 DOI: 10.3171/2022.5.jns22465] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Microsurgical training remains indispensable to master cerebrovascular bypass procedures, but simulation models for training that accurately replicate microanastomosis in narrow, deep-operating corridors are lacking. Seven simulation bypass scenarios were developed that included head models in various surgical positions with premade approaches, simulating the restrictions of the surgical corridors and hand positions for microvascular bypass training. This study describes these models and assesses their validity. METHODS Simulation models were created using 3D printing of the skull with a designed craniotomy. Brain and external soft tissues were cast using a silicone molding technique from the clay-sculptured prototypes. The 7 simulation scenarios included: 1) temporal craniotomy for a superficial temporal artery (STA)-middle cerebral artery (MCA) bypass using the M4 branch of the MCA; 2) pterional craniotomy and transsylvian approach for STA-M2 bypass; 3) bifrontal craniotomy and interhemispheric approach for side-to-side bypass using the A3 branches of the anterior cerebral artery; 4) far lateral craniotomy and transcerebellomedullary approach for a posterior inferior cerebellar artery (PICA)-PICA bypass or 5) PICA reanastomosis; 6) orbitozygomatic craniotomy and transsylvian-subtemporal approach for a posterior cerebral artery bypass; and 7) extended retrosigmoid craniotomy and transcerebellopontine approach for an occipital artery-anterior inferior cerebellar artery bypass. Experienced neurosurgeons evaluated each model by practicing the aforementioned bypasses on the models. Face and content validities were assessed using the bypass participant survey. RESULTS A workflow for model production was developed, and these models were used during microsurgical courses at 2 neurosurgical institutions. Each model is accompanied by a corresponding prototypical case and surgical video, creating a simulation scenario. Seven experienced cerebrovascular neurosurgeons practiced microvascular anastomoses on each of the models and completed surveys. They reported that actual anastomosis within a specific approach was well replicated by the models, and difficulty was comparable to that for real surgery, which confirms the face validity of the models. All experts stated that practice using these models may improve bypass technique, instrument handling, and surgical technique when applied to patients, confirming the content validity of the models. CONCLUSIONS The 7 bypasses simulation set includes novel models that effectively simulate surgical scenarios of a bypass within distinct deep anatomical corridors, as well as hand and operator positions. These models use artificial materials, are reusable, and can be implemented for personal training and during microsurgical courses.
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Affiliation(s)
- Evgenii Belykh
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.,2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Irakliy Abramov
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Liudmila Bardonova
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ruchi Patel
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Sarah McBryan
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Lara Enriquez Bouza
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Neil Majmundar
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.,2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Xiaochun Zhao
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Stephen A Johnson
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Amit Singla
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Gaurav Gupta
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Hai Sun
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - James K Liu
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Anil Nanda
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Mark C Preul
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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9
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Pangal DJ, Kugener G, Cardinal T, Lechtholz-Zey E, Collet C, Lasky S, Sundaram S, Zhu Y, Roshannai A, Chan J, Sinha A, Hung AJ, Anandkumar A, Zada G, Donoho DA. Use of surgical video-based automated performance metrics to predict blood loss and success of simulated vascular injury control in neurosurgery: a pilot study. J Neurosurg 2022; 137:840-849. [PMID: 34972086 DOI: 10.3171/2021.10.jns211064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Experts can assess surgeon skill using surgical video, but a limited number of expert surgeons are available. Automated performance metrics (APMs) are a promising alternative but have not been created from operative videos in neurosurgery to date. The authors aimed to evaluate whether video-based APMs can predict task success and blood loss during endonasal endoscopic surgery in a validated cadaveric simulator of vascular injury of the internal carotid artery. METHODS Videos of cadaveric simulation trials by 73 neurosurgeons and otorhinolaryngologists were analyzed and manually annotated with bounding boxes to identify the surgical instruments in the frame. APMs in five domains were defined-instrument usage, time-to-phase, instrument disappearance, instrument movement, and instrument interactions-on the basis of expert analysis and task-specific surgical progressions. Bounding-box data of instrument position were then used to generate APMs for each trial. Multivariate linear regression was used to test for the associations between APMs and blood loss and task success (hemorrhage control in less than 5 minutes). The APMs of 93 successful trials were compared with the APMs of 49 unsuccessful trials. RESULTS In total, 29,151 frames of surgical video were annotated. Successful simulation trials had superior APMs in each domain, including proportionately more time spent with the key instruments in view (p < 0.001) and less time without hemorrhage control (p = 0.002). APMs in all domains improved in subsequent trials after the participants received personalized expert instruction. Attending surgeons had superior instrument usage, time-to-phase, and instrument disappearance metrics compared with resident surgeons (p < 0.01). APMs predicted surgeon performance better than surgeon training level or prior experience. A regression model that included APMs predicted blood loss with an R2 value of 0.87 (p < 0.001). CONCLUSIONS Video-based APMs were superior predictors of simulation trial success and blood loss than surgeon characteristics such as case volume and attending status. Surgeon educators can use APMs to assess competency, quantify performance, and provide actionable, structured feedback in order to improve patient outcomes. Validation of APMs provides a benchmark for further development of fully automated video assessment pipelines that utilize machine learning and computer vision.
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Affiliation(s)
- Dhiraj J Pangal
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Guillaume Kugener
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Tyler Cardinal
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Elizabeth Lechtholz-Zey
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Casey Collet
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sasha Lasky
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Shivani Sundaram
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Yichao Zhu
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Arman Roshannai
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Justin Chan
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Aditya Sinha
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Andrew J Hung
- 2Center for Robotic Simulation and Education, USC Institute of Urology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Animashree Anandkumar
- 3Computing + Mathematical Sciences, California Institute of Technology, Pasadena, California; and
| | - Gabriel Zada
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Daniel A Donoho
- 4Division of Neurosurgery, Center for Neuroscience, Children's National Medical Center, Washington, DC
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Pangal DJ, Kugener G, Zhu Y, Sinha A, Unadkat V, Cote DJ, Strickland B, Rutkowski M, Hung A, Anandkumar A, Han XY, Papyan V, Wrobel B, Zada G, Donoho DA. Expert surgeons and deep learning models can predict the outcome of surgical hemorrhage from 1 min of video. Sci Rep 2022; 12:8137. [PMID: 35581213 PMCID: PMC9114003 DOI: 10.1038/s41598-022-11549-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/18/2022] [Indexed: 01/28/2023] Open
Abstract
Major vascular injury resulting in uncontrolled bleeding is a catastrophic and often fatal complication of minimally invasive surgery. At the outset of these events, surgeons do not know how much blood will be lost or whether they will successfully control the hemorrhage (achieve hemostasis). We evaluate the ability of a deep learning neural network (DNN) to predict hemostasis control ability using the first minute of surgical video and compare model performance with human experts viewing the same video. The publicly available SOCAL dataset contains 147 videos of attending and resident surgeons managing hemorrhage in a validated, high-fidelity cadaveric simulator. Videos are labeled with outcome and blood loss (mL). The first minute of 20 videos was shown to four, blinded, fellowship trained skull-base neurosurgery instructors, and to SOCALNet (a DNN trained on SOCAL videos). SOCALNet architecture included a convolutional network (ResNet) identifying spatial features and a recurrent network identifying temporal features (LSTM). Experts independently assessed surgeon skill, predicted outcome and blood loss (mL). Outcome and blood loss predictions were compared with SOCALNet. Expert inter-rater reliability was 0.95. Experts correctly predicted 14/20 trials (Sensitivity: 82%, Specificity: 55%, Positive Predictive Value (PPV): 69%, Negative Predictive Value (NPV): 71%). SOCALNet correctly predicted 17/20 trials (Sensitivity 100%, Specificity 66%, PPV 79%, NPV 100%) and correctly identified all successful attempts. Expert predictions of the highest and lowest skill surgeons and expert predictions reported with maximum confidence were more accurate. Experts systematically underestimated blood loss (mean error - 131 mL, RMSE 350 mL, R2 0.70) and fewer than half of expert predictions identified blood loss > 500 mL (47.5%, 19/40). SOCALNet had superior performance (mean error - 57 mL, RMSE 295 mL, R2 0.74) and detected most episodes of blood loss > 500 mL (80%, 8/10). In validation experiments, SOCALNet evaluation of a critical on-screen surgical maneuver and high/low-skill composite videos were concordant with expert evaluation. Using only the first minute of video, experts and SOCALNet can predict outcome and blood loss during surgical hemorrhage. Experts systematically underestimated blood loss, and SOCALNet had no false negatives. DNNs can provide accurate, meaningful assessments of surgical video. We call for the creation of datasets of surgical adverse events for quality improvement research.
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Affiliation(s)
- Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Guillaume Kugener
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Yichao Zhu
- Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - Aditya Sinha
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Vyom Unadkat
- Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - David J Cote
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ben Strickland
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Martin Rutkowski
- Department of Neurosurgery, Medical College of Georgia, Augusta, GA, USA
| | - Andrew Hung
- Center for Robotic Simulation and Education, USC Institute of Urology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Animashree Anandkumar
- Department of Computer Science + Mathematics, California Institute of Technology, Pasadena, CA, USA
- Nvidia Corp., Santa Clara, CA, USA
| | - X Y Han
- Department of Operations Research and Information Engineering, Cornell University, Ithaca, NY, USA
| | - Vardan Papyan
- Department of Mathematics, University of Toronto, Toronto, ON, Canada
| | - Bozena Wrobel
- Department of Otolaryngology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Daniel A Donoho
- Division of Neurosurgery, Center for Neuroscience, Children's National Hospital, Washington, DC, 20010, USA.
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Unadkat V, Pangal DJ, Kugener G, Roshannai A, Chan J, Zhu Y, Markarian N, Zada G, Donoho DA. Code-free machine learning for object detection in surgical video: a benchmarking, feasibility, and cost study. Neurosurg Focus 2022; 52:E11. [PMID: 35364576 DOI: 10.3171/2022.1.focus21652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While the utilization of machine learning (ML) for data analysis typically requires significant technical expertise, novel platforms can deploy ML methods without requiring the user to have any coding experience (termed AutoML). The potential for these methods to be applied to neurosurgical video and surgical data science is unknown. METHODS AutoML, a code-free ML (CFML) system, was used to identify surgical instruments contained within each frame of endoscopic, endonasal intraoperative video obtained from a previously validated internal carotid injury training exercise performed on a high-fidelity cadaver model. Instrument-detection performances using CFML were compared with two state-of-the-art ML models built using the Python coding language on the same intraoperative video data set. RESULTS The CFML system successfully ingested surgical video without the use of any code. A total of 31,443 images were used to develop this model; 27,223 images were uploaded for training, 2292 images for validation, and 1928 images for testing. The mean average precision on the test set across all instruments was 0.708. The CFML model outperformed two standard object detection networks, RetinaNet and YOLOv3, which had mean average precisions of 0.669 and 0.527, respectively, in analyzing the same data set. Significant advantages to the CFML system included ease of use, relatively low cost, displays of true/false positives and negatives in a user-friendly interface, and the ability to deploy models for further analysis with ease. Significant drawbacks of the CFML model included an inability to view the structure of the trained model, an inability to update the ML model once trained with new examples, and the inability for robust downstream analysis of model performance and error modes. CONCLUSIONS This first report describes the baseline performance of CFML in an object detection task using a publicly available surgical video data set as a test bed. Compared with standard, code-based object detection networks, CFML exceeded performance standards. This finding is encouraging for surgeon-scientists seeking to perform object detection tasks to answer clinical questions, perform quality improvement, and develop novel research ideas. The limited interpretability and customization of CFML models remain ongoing challenges. With the further development of code-free platforms, CFML will become increasingly important across biomedical research. Using CFML, surgeons without significant coding experience can perform exploratory ML analyses rapidly and efficiently.
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Affiliation(s)
- Vyom Unadkat
- 1Department of Computer Science, USC Viterbi School of Engineering, Los Angeles, California.,2Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California; and
| | - Dhiraj J Pangal
- 2Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California; and
| | - Guillaume Kugener
- 2Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California; and
| | - Arman Roshannai
- 2Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California; and
| | - Justin Chan
- 2Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California; and
| | - Yichao Zhu
- 2Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California; and
| | - Nicholas Markarian
- 2Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California; and
| | - Gabriel Zada
- 2Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California; and
| | - Daniel A Donoho
- 3Division of Neurosurgery, Center for Neurosciences, Children's National Hospital, Washington, DC
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Kugener G, Pangal DJ, Cardinal T, Collet C, Lechtholz-Zey E, Lasky S, Sundaram S, Markarian N, Zhu Y, Roshannai A, Sinha A, Han XY, Papyan V, Hung A, Anandkumar A, Wrobel B, Zada G, Donoho DA. Utility of the Simulated Outcomes Following Carotid Artery Laceration Video Data Set for Machine Learning Applications. JAMA Netw Open 2022; 5:e223177. [PMID: 35311962 PMCID: PMC8938712 DOI: 10.1001/jamanetworkopen.2022.3177] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Surgical data scientists lack video data sets that depict adverse events, which may affect model generalizability and introduce bias. Hemorrhage may be particularly challenging for computer vision-based models because blood obscures the scene. OBJECTIVE To assess the utility of the Simulated Outcomes Following Carotid Artery Laceration (SOCAL)-a publicly available surgical video data set of hemorrhage complication management with instrument annotations and task outcomes-to provide benchmarks for surgical data science techniques, including computer vision instrument detection, instrument use metrics and outcome associations, and validation of a SOCAL-trained neural network using real operative video. DESIGN, SETTING, AND PARTICIPANTS For this quailty improvement study, a total of 75 surgeons with 1 to 30 years' experience (mean, 7 years) were filmed from January 1, 2017, to December 31, 2020, managing catastrophic surgical hemorrhage in a high-fidelity cadaveric training exercise at nationwide training courses. Videos were annotated from January 1 to June 30, 2021. INTERVENTIONS Surgeons received expert coaching between 2 trials. MAIN OUTCOMES AND MEASURES Hemostasis within 5 minutes (task success, dichotomous), time to hemostasis (in seconds), and blood loss (in milliliters) were recorded. Deep neural networks (DNNs) were trained to detect surgical instruments in view. Model performance was measured using mean average precision (mAP), sensitivity, and positive predictive value. RESULTS SOCAL contains 31 443 frames with 65 071 surgical instrument annotations from 147 trials with associated surgeon demographic characteristics, time to hemostasis, and recorded blood loss for each trial. Computer vision-based instrument detection methods using DNNs trained on SOCAL achieved a mAP of 0.67 overall and 0.91 for the most common surgical instrument (suction). Hemorrhage control challenges standard object detectors: detection of some surgical instruments remained poor (mAP, 0.25). On real intraoperative video, the model achieved a sensitivity of 0.77 and a positive predictive value of 0.96. Instrument use metrics derived from the SOCAL video were significantly associated with performance (blood loss). CONCLUSIONS AND RELEVANCE Hemorrhage control is a high-stakes adverse event that poses unique challenges for video analysis, but no data sets of hemorrhage control exist. The use of SOCAL, the first data set to depict hemorrhage control, allows the benchmarking of data science applications, including object detection, performance metric development, and identification of metrics associated with outcomes. In the future, SOCAL may be used to build and validate surgical data science models.
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Affiliation(s)
- Guillaume Kugener
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Dhiraj J. Pangal
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Casey Collet
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Sasha Lasky
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Shivani Sundaram
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Nicholas Markarian
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Yichao Zhu
- Department of Computer Science, Viterbi School of Engineering, University of Southern California, Los Angeles
| | - Arman Roshannai
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Aditya Sinha
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - X. Y. Han
- Department of Operations Research and Information Engineering, Cornell University, Ithaca, New York
| | - Vardan Papyan
- Department of Mathematics, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Hung
- Center for Robotic Simulation and Education, USC Institute of Urology, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Animashree Anandkumar
- Department of Computer Science and Mathematics, California Institute of Technology, Pasadena
| | - Bozena Wrobel
- Department of Otolaryngology, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Daniel A. Donoho
- Division of Neurosurgery, Center for Neuroscience, Children’s National Hospital, Washington, DC
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13
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Donoho DA, Pangal DJ, Kugener G, Rutkowski M, Micko A, Shahrestani S, Brunswick A, Minneti M, Wrobel BB, Zada G. Improved surgeon performance following cadaveric simulation of internal carotid artery injury during endoscopic endonasal surgery: training outcomes of a nationwide prospective educational intervention. J Neurosurg 2021; 135:1347-1355. [PMID: 33740764 DOI: 10.3171/2020.9.jns202672] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Internal carotid artery injury (ICAI) is a rare, life-threatening complication of endoscopic endonasal approaches that will be encountered by most skull base neurosurgeons and otolaryngologists. Rates of surgical proficiency for managing ICAI are not known, and the role of simulation to improve performance has not been studied on a nationwide scale. METHODS Attending and resident neurosurgery and otorhinolaryngology surgeons (n = 177) were recruited from multicenter regional and national training courses to assess training outcomes and validity at scale of a prospective educational intervention to improve surgeon technical skills using a previously validated, perfused human cadaveric simulator. Participants attempted an initial trial (T1) of simulated ICAI control using their preferred technique. An educational intervention including personalized instruction was performed. Participants attempted a second trial (T2). Task success (dichotomous), time to hemostasis (TTH), estimated blood loss (EBL), and surgeon heart rate were measured. RESULTS Participant rating scales confirmed that the simulation retained face and construct validity across eight instructional settings. Trial success (ICAI control) improved from 56% in T1 to 90% in T2 (p < 0.0001). EBL and TTH decreased by 37% and 38%, respectively (p < 0.0001). Postintervention resident surgeon performance (TTH, EBL, and success rate) was superior to preintervention attending surgeon performance. The most improved quartile of participants achieved 62% improvement in TTH and 73% improvement in EBL, with trial success improvement from 25.6% in T1 to 100% in T2 (p < 0.0001). Baseline surgeon confidence was uncorrelated with T1 success, while posttraining confidence correlated with T2 success. Tachycardia was measured in 57% of surgeon participants, but was attenuated during T2, consistent with development of resiliency. CONCLUSIONS Prior to training, many attending and most resident surgeons could not manage the rare, life-threatening intraoperative complication of ICAI. A simulated educational intervention significantly improved surgeon performance and remained valid when deployed at scale. Simulation also promoted the development of favorable cognitive skills (accurate perception of skill and resiliency). Rare, life-threatening intraoperative complications may be optimal targets for educational interventions using surgical simulation.
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Affiliation(s)
| | | | | | | | - Alexander Micko
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Medical University Vienna, Austria; and
| | - Shane Shahrestani
- Departments of1Neurosurgery and
- 3Department of Medical Engineering, California Institute of Technology, Pasadena, California
| | | | | | - Bozena B Wrobel
- 5Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Yadav YR, Bajaj J, Ratre S, Yadav N, Parihar V, Swamy N, Kumar A, Hedaoo K, Sinha M. Endoscopic Third Ventriculostomy - A Review. Neurol India 2021; 69:S502-S513. [PMID: 35103009 DOI: 10.4103/0028-3886.332253] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Endoscopic third ventriculostomy (ETV) has become a proven modality for treating obstructive and selected cases of communicating hydrocephalus. OBJECTIVE This review aims to summarize the indications, preoperative workup, surgical technique, results, postoperative care, complications, advantages, and limitations of an ETV. MATERIALS AND METHODS A thorough review of PubMed and Google Scholar was performed. This review is based on the relevant articles and authors' experience. RESULTS ETV is indicated in obstructive hydrocephalus and selected cases of communicating hydrocephalus. Studying preoperative imaging is critical, and a detailed assessment of interthalamic adhesions, the thickness of floor, arteries or membranes below the third ventricle floor, and prepontine cistern width is essential. Blunt perforation in a thin floor, while bipolar cautery at low settings and water jet dissection are preferred in a thick floor. The appearance of stoma pulsations and intraoperative ventriculostomography reassure stoma and basal cistern patency. The intraoperative decision for shunt, external ventricular drainage, or Ommaya reservoir can be taken. Magnetic resonance ventriculography and cine phase-contrast magnetic resonance imaging can determine stoma patency. Good postoperative care with repeated cerebrospinal fluid drainage enhances outcomes in selected cases. Though the complications mostly occur in an early postoperative phase, delayed lethal ones may happen. Watching live surgeries, assisting expert surgeons, and practicing on cadavers and models can shorten the learning curve. CONCLUSION ETV is an excellent technique for managing obstructive and selected cases of communicating hydrocephalus. Good case selection, methodical technique, and proper training under experts are vital.
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Affiliation(s)
- Yad Ram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Jitin Bajaj
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Shailendra Ratre
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Nishtha Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Vijay Parihar
- Department of Neuroradiology, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Narayan Swamy
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Ambuj Kumar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Ketan Hedaoo
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Mallika Sinha
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
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Arora RK, Mittal RS, Rekhapalli R, Sadhasivam S, Bhragava P, Deopujari CE, Barua MP, Singla M, Singh B, Arora P. Simulation Training for Neurosurgical Residents: Need versus Reality in Indian Scenario. Asian J Neurosurg 2021; 16:230-235. [PMID: 34211902 PMCID: PMC8202368 DOI: 10.4103/ajns.ajns_463_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/02/2020] [Accepted: 12/17/2020] [Indexed: 11/07/2022] Open
Affiliation(s)
- Rajnish Kumar Arora
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Radhey Shyam Mittal
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Rajasekar Rekhapalli
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Saravanan Sadhasivam
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Pranshu Bhragava
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | | | - Mrinal Parkash Barua
- Department of Anatomy, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Mukesh Singla
- Department of Anatomy, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Brijendra Singh
- Department of Anatomy, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Poonam Arora
- Department of trauma and emergency, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Fujii T, Russin JJ. Commentary: Middle Cerebral Artery Aneurysm Clipping With Immersive 360° Virtual Reality Model: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E390. [PMID: 33554261 DOI: 10.1093/ons/opab022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/14/2020] [Indexed: 11/14/2022] Open
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17
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Byvaltsev V, Polkin R, Bereznyak D, Giers MB, Hernandez PA, Shepelev V, Aliyev M. 3D-printed cranial models simulating operative field depth for microvascular training in neurosurgery. Surg Neurol Int 2021; 12:213. [PMID: 34084640 PMCID: PMC8168712 DOI: 10.25259/sni_849_2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 04/08/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The skills required for neurosurgical operations using microsurgical techniques in a deep operating field are difficult to master in the operating room without risk to patients. Although there are many microsurgical training models, most do not use a skull model to simulate a deep field. To solve this problem, 3D models were created to provide increased training in the laboratory before the operating room, improving patient safety. METHODS A patient's head was scanned using computed tomography. The data were reconstructed and converted into a standard 3D printing file. The skull was printed with several openings to simulate common surgical approaches. These models were then used to create a deep operating field while practicing on a chicken thigh (femoral artery anastomosis) and on a rat (abdominal aortic anastomosis). RESULTS The advantages of practicing with the 3D printed models were clearly demonstrated by our trainees, including appropriate hand position on the skull, becoming comfortable with the depth of the anastomosis, and simulating proper skull angle and rigid fixation. One limitation is the absence of intracranial structures, which is being explored in future work. CONCLUSION This neurosurgical model can improve microsurgery training by recapitulating the depth of a real operating field. Improved training can lead to increased accuracy and efficiency of surgical procedures, thereby minimizing the risk to patients.
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Affiliation(s)
- Vadim Byvaltsev
- Department of Neurosurgery and Innovative Medicine, Irkutsk State Medical University, Irkutsk, Russia
| | - Roman Polkin
- Department of Neurosurgery and Innovative Medicine, Irkutsk State Medical University, Irkutsk, Russia
| | - Dmitry Bereznyak
- Department of Neurosurgery and Innovative Medicine, Irkutsk State Medical University, Irkutsk, Russia
| | - Morgan B. Giers
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon, United States
| | - Phillip A. Hernandez
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon, United States
| | - Valery Shepelev
- Department of Neurosurgery and Innovative Medicine, Irkutsk State Medical University, Irkutsk, Russia
| | - Marat Aliyev
- Department of Neurosurgery and Innovative Medicine, Irkutsk State Medical University, Irkutsk, Russia
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Masalha MA, VanKoevering KK, Latif OS, Powell AR, Zhang A, Hod KH, Prevedello DM, Carrau RL. Simulation of Cerebrospinal Fluid Leak Repair Using a 3-Dimensional Printed Model. Am J Rhinol Allergy 2021; 35:802-808. [PMID: 33745321 DOI: 10.1177/19458924211003537] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acquiring proficiency for the repair of a cerebrospinal fluid (CSF) leak is challenging in great part due to its relative rarity, which offers a finite number of training opportunities. OBJECTIVE The purpose of this study was to evaluates the use of a 3-dimensional (3D) printed, anatomically accurate model to simulate CSF leak closure. METHODS Volunteer participants completed two simulation sessions. Questionnaires to assess their professional qualifications and a standardized 5-point Likert scale to estimate the level of confidence, were completed before and after each session. Participants were also queried on the overall educational utility of the simulation. RESULTS Thirteen otolaryngologists and 11 neurosurgeons, met the inclusion criteria. A successful repair of the CSF leak was achieved by 20/24 (83.33%), and 24/24 (100%) during the first and second simulation sessions respectively (average time 04:04 ± 1.39 and 02:10 ± 01:11). Time-to-close-the-CSF-leak during the second session was significantly shorter than the first (p < 0.001). Confidence scores increased across the training sessions (3.3 ± 1.0, before the simulation, 3.7 ± 0.6 after the first simulation, and 4.2 ± 0.4 after the second simulation; p < 0.001). All participants reported an increase in confidence and believed that the model represented a valuable training tool. CONCLUSIONS Despite significant differences with varying clinical scenarios, 3D printed models for cerebrospinal leak repair offer a feasible simulation for the training of residents and novice surgeons outside the constrictions of a clinical environment.
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Affiliation(s)
- Muhamed A Masalha
- Department of Otolaryngology, Head and Neck Surgery, Emek Medical Center, Afula, Israel.,Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.,Department of Academy and Research, Assuta Medical Center, Tel Aviv, Israel.,Faculty of Medicine, Ben Gurion University, Tel Aviv, Israel
| | - Kyle K VanKoevering
- Department of Otolaryngology-Head and Neck Surgery, Michigan University, Ann Arbor, Michigan
| | - Omar S Latif
- Faculty of Medicine, The Ohio State University, Columbus, Ohio
| | - Allison R Powell
- Department of Otolaryngology-Head and Neck Surgery, Michigan University, Ann Arbor, Michigan
| | - Ashley Zhang
- Department of Otolaryngology-Head and Neck Surgery, Michigan University, Ann Arbor, Michigan
| | - Keren H Hod
- Department of Academy and Research, Assuta Medical Center, Tel Aviv, Israel.,Faculty of Medicine, Ben Gurion University, Tel Aviv, Israel
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.,Department of Neurological Surgery, The James Cancer Hospital at The Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.,Department of Neurological Surgery, The James Cancer Hospital at The Wexner Medical Center at The Ohio State University, Columbus, Ohio
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Tracking Scan to Incision Time in Patients with Emergent Operative Traumatic Brain Injuries as a Measure for Systems-Based Practice in Neurosurgical Trainees. World Neurosurg 2021; 149:e491-e497. [PMID: 33556603 DOI: 10.1016/j.wneu.2021.01.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Evaluation of trainee performance remains a challenge in resident education, particularly for systems-based practice (SysBP) metrics including care coordination and interdisciplinary teamwork. Time to intervention is an important modifiable outcome variable in severe traumatic brain injury (TBI) and may serve as a trackable metric for SysBP evaluation. METHODS We retrospectively studied time from computed tomography head scan to surgical incision (CTH-INC, minutes) among neurosurgical trainees treating patients with emergently operative TBI as a proxy SysBP measure. Our institutional operative database was utilized to identify all emergent TBI cases between July 2015 and June 2020. Patients evaluated by program year (PGY)-2 residents proceeding directly to the operating room from the emergency department were included. Statistical analysis was performed using linear regression. RESULTS One hundred sixty-six cases triaged by 14 PGY-2 neurosurgical trainees were analyzed. Median CTH-INC was 104 minutes (interquartile range, 82-136 minutes). CTH-INC improved 20.1% over the academic year (95% confidence interval, 4.3%-33.2%, P = 0.015). Between the first and second 6-month periods, the rate of CTH-INC within 90 minutes (29% vs. 46%, P = 0.04) improved. On a per-individual PGY-2 basis, median CTH-INC ranged from 83-127 minutes, 25th percentile CTH-INC ranged from 62-108 minutes, and fastest CTH-INC ranged from 45-92 minutes. CONCLUSIONS CTH-INC is an objective and trackable proxy measure for evaluating SysBP during neurosurgical training. Use of CTH-INC or other time metrics in resident evaluations should not supersede the safe and effective delivery of patient care.
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20
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Strickland BA, Ravina K, Kammen A, Chang S, Rutkowski M, Donoho DA, Minneti M, Jackanich A, Bakhsheshian J, Zada G. The Use of a Novel Perfusion-Based Human Cadaveric Model for Simulation of Dural Venous Sinus Injury and Repair. Oper Neurosurg (Hagerstown) 2020; 19:E269-E274. [PMID: 31961930 DOI: 10.1093/ons/opz424] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 12/01/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Dural sinus injuries are potentially serious complications associated with acute blood loss. It is imperative that neurosurgery trainees are able to recognize and manage this challenging scenario. OBJECTIVE To assess the feasibility of a novel perfusion-based cadaveric simulation model to provide the fundamentals of dural sinus repair to neurosurgical trainees. METHODS A total of 10 perfusion-based human cadaveric models underwent superior sagittal sinus (SSS) laceration. Neurosurgery residents were instructed to achieve hemostasis by any method in the first trial and then repeated the trial after watching the instructional dural flap technique video. Trials were timed until hemostasis and control of the region of injury was achieved. Pre- and post-trial questionnaires were administered to assess trainee confidence levels. RESULTS The high-flow extravasation of the perfusion-based cadaveric model mimicked similar conditions and challenges encountered during acute SSS injury. Mean ± standard deviation time to hemostasis was 341.3 ± 65 s in the first trial and 196.9 ± 41.8 s in the second trial (P < .0001). Mean trainee improvement time was 144.4 s (42.3%). Of the least-experienced trainees with longest repair times in the initial trial, a mean improvement time of 188.3 s (44.8%) was recorded. All participants reported increased confidence on post-trial questionnaires following the simulation (median pretrial confidence of 2 vs post-trial confidence of 4, P = .002). CONCLUSION A perfusion-based human cadaveric model accurately simulates acute dural venous sinus injury, affording neurosurgical trainees the opportunity to hone management skills in a simulated and realistic environment.
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Affiliation(s)
- Ben A Strickland
- Department of Neurosurgery, The Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kristine Ravina
- Department of Neurosurgery, The Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Alexandra Kammen
- Department of Neurosurgery, The Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Stephanie Chang
- Department of Neurosurgery, The Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Martin Rutkowski
- Department of Neurosurgery, The Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Daniel A Donoho
- Department of Neurosurgery, The Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Mike Minneti
- Department of General Surgery, University of Southern California, Los Angeles, California
| | - Anna Jackanich
- Department of Neurosurgery, The Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Joshua Bakhsheshian
- Department of Neurosurgery, The Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurosurgery, The Keck School of Medicine of the University of Southern California, Los Angeles, California
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21
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AlQahtani A, Albathi A, Castelnuovo P, Alfawwaz F. Cerebrospinal Fluid Leak Repair Simulation Model: Face, Content, and Construct Validation. Am J Rhinol Allergy 2020; 35:264-271. [DOI: 10.1177/1945892420952262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Cerebrospinal fluid leak (CSFL) repair simulation models are scarce; however, these models are valuable tools for skull base reconstruction surgery training. Objectives This study aims to assess the face, content, and construct validity of a CSFL repair simulation model. Method Eight novices (residents- PGY3) and eight experts have performed skull base reconstruction in multiple sites in twelve human cadaveric heads in simulated surgical environment. The experts completed a post-study 21-item questionnaire to assess the face and content validity. The performances of the participants were recorded and scored by two independent investigators who were blinded to the participant's level. Global Rating Scale of Operative Performance (GRSOP) and a Specific Skull Base Reconstruction Checklist (SBRC) were used to score the performances. Results The responses from the expert group for the 21-item questionnaire were high for all items (4.13–4.88 out of 5). The internal consistency reliability of the questionnaire and the intraclass correlation, which was derived by Cronbach’s Alpha, were 0.913 and 0.941 respectively. Differences in construct validity between the two groups were statistically significant for both the GRSOP and SBRS (P-value < 0.001). Conclusion We demonstrated the face, content, and construct validity of the CSFL repair simulation model, which facilitates the acquisition of technical skills necessary for skull base reconstruction surgery. The model includes realistic features that make it useful in educational courses.
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Affiliation(s)
- Abdulaziz AlQahtani
- Department of Otorhinolaryngology/Head and Neck Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abeer Albathi
- Department of Otorhinolaryngology/Head and Neck Surgery, Prince Sultan Military City, Riyadh, Saudi Arabia
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Fahad Alfawwaz
- Department of Otorhinolaryngology/Head and Neck Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
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Robinson DA, Piekut DT, Hasman L, Knight PA. Cadaveric Simulation Training in Cardiothoracic Surgery: A Systematic Review. ANATOMICAL SCIENCES EDUCATION 2020; 13:413-425. [PMID: 31232510 DOI: 10.1002/ase.1908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 06/19/2019] [Accepted: 06/19/2019] [Indexed: 06/09/2023]
Abstract
Simulation training has become increasingly relevant in the educational curriculum of surgical trainees. The types of simulation models used, goals of simulation training, and an objective assessment of its utility and effectiveness are highly variable. The role and effectiveness of cadaveric simulation in cardiothoracic surgical training has not been well established. The objective of this study was to evaluate the current medical literature available on the utility and the effectiveness of cadaveric simulation in cardiothoracic surgical residency training. A literature search was performed using PubMed, Cochrane Library, Embase, Scopus, and CINAHL from inception to February 2019. Of the 362 citations obtained, 23 articles were identified and retrieved for full review, yielding ten eligible articles that were included for analysis. One additional study was identified and included in the analysis. Extraction of data from the selected articles was performed using predetermined data fields, including study design, study participants, simulation task, performance metrics, and costs. Most of these studies were only descriptive of a cadaveric or perfused cadaveric simulation model that could be used to augment clinical operative training in cardiothoracic surgery. There is a paucity of evidence in the literature that specifically evaluates the utility and the efficacy of cadavers in cardiothoracic surgery training. Of the few studies that have been published in the literature, cadaveric simulation does seem to have a role in cardiothoracic surgery training beyond simply learning basic skills. Additional research in this area is needed.
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Affiliation(s)
- Davida A Robinson
- Division of Cardiac Surgery, Department of Surgery, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Diane T Piekut
- Department of Neuroscience, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Linda Hasman
- Division of Research and Clinical Information Services, University of Rochester, Rochester, New York
| | - Peter A Knight
- Division of Cardiac Surgery, Department of Surgery, School of Medicine and Dentistry, University of Rochester, Rochester, New York
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23
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A Systematic Review of Simulation-Based Training in Neurosurgery, Part 1: Cranial Neurosurgery. World Neurosurg 2020; 133:e850-e873. [DOI: 10.1016/j.wneu.2019.08.262] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/23/2019] [Indexed: 01/10/2023]
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24
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Patel EA, Aydin A, Cearns M, Dasgupta P, Ahmed K. A Systematic Review of Simulation-Based Training in Neurosurgery, Part 2: Spinal and Pediatric Surgery, Neurointerventional Radiology, and Nontechnical Skills. World Neurosurg 2020; 133:e874-e892. [DOI: 10.1016/j.wneu.2019.08.263] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/23/2019] [Indexed: 02/08/2023]
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25
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Mattavelli D, Ferrari M, Rampinelli V, Schreiber A, Buffoli B, Deganello A, Rodella LF, Fontanella MM, Nicolai P, Doglietto F. Development and validation of a preclinical model for training and assessment of cerebrospinal fluid leak repair in endoscopic skull base surgery. Int Forum Allergy Rhinol 2019; 10:89-96. [PMID: 31574591 DOI: 10.1002/alr.22451] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/21/2019] [Accepted: 09/13/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Achieving an effective endoscopic skull base reconstruction in case of large dural defects requires specific training and can be extremely challenging. The aim of this study was to describe the development and validation of a preclinical model for cerebrospinal fluid (CSF) leak repair, which can be used for training and to test the mechanical efficacy of endoscopic skull base reconstruction. METHODS Eleven fresh-frozen cadaver heads were dissected. A catheter was inserted in the subdural space via a cervical access, which was sealed with mastic; a vertical graduated tube connected to the catheter measured intracranial pressure (ICP), while stained water was injected intracranially. After endoscopic skull base reconstruction was performed, an expert surgeon assessed its efficacy. ICP was then gradually increased until a leak was evident and CSF leak pressure value was recorded. The correlation between subjective and quantitative evaluations was investigated through Pearson and Spearman correlation tests. RESULTS The model was successfully tested in 11 specimens. A single, large dural defect was created in each model (transplanum-transtuberculum = 4; transplanum-transtuberculum-transsellar = 3; transclival = 3; transcribriform-transplanum = 1). Skull base reconstruction always comprised a rigid buttress with temporal fascia and/or fat. The CSF leak pressure ranged from 4 to 110 cmH2 O. The correlation between expert subjective and quantitative assessment of skull base reconstruction mechanical efficacy was high (r = 0.7; rs = 0.7; p = 0.010 and p = 0.006, respectively). CONCLUSION This preclinical model is simple, easily reproducible, and effective in simulating an intraoperative leak and objectively measures the CSF leak pressure point of a skull base reconstruction.
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Affiliation(s)
- Davide Mattavelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ferrari
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Schreiber
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alberto Deganello
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Luigi F Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco M Fontanella
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Perry A, Graffeo CS, Meyer J, Carlstrom LP, Oushy S, Driscoll CLW, Meyer FB. Beyond the Learning Curve: Comparison of Microscopic and Endoscopic Incidences of Internal Carotid Injury in a Series of Highly Experienced Operators. World Neurosurg 2019; 131:e128-e135. [PMID: 31319187 DOI: 10.1016/j.wneu.2019.07.074] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 07/06/2019] [Accepted: 07/08/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND As the endoscopic endonasal approach (EEA) has gained popularity as an alternative to microsurgery (MS) for transsphenoidal resection (TSR), numerous studies have attempted to assess the differential risk of internal carotid artery (ICA) injury between the techniques, yet results have been equivocal and contradictory. The aim of this study was to evaluate ICA injury in MS versus EEA among highly experienced neurosurgeons. METHODS We performed a systematic literature review of publications from 2002-2017 reporting ICA injury outcomes in ≥250 cases using MS or EEA. RESULTS Seventeen series reporting 11,149 patients were included: 3 MS series, 13 EEA series, and 1 series with adequate samples for each. ICA injury incidences were 0.0%-1.6% in cohorts of 275-3000. MS series documented 5 ICA injuries in 2672 operations, for an overall incidence of 0.2% (range, 0.0%-0.4%), and EEA series reported 30 ICA injuries in 8477 operations, for a 0.4% injury rate (range, 0.0%-1.6%); the difference was nonsignificant (P = 0.25). Increased operative experience was associated with decreased incidence of ICA injury, a finding preserved in the overall study cohort and within discretely examined MS and EEA subgroups (overall r2 = 0.08, MS r2 = 0.23, EEA r2 = 0.07). CONCLUSIONS ICA injury is the most serious complication of TSR of pituitary neoplasms. Operator inexperience may be a more important risk factor than choice of surgical technique, given the comparably low rates of injury obtained by highly experienced surgeons independent of technique. This emphasizes the need for consolidated care in pituitary centers of excellence, improvement of high-fidelity simulators, and skull base mentorship between senior and junior staff.
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Affiliation(s)
- Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jenna Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lucas P Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Soliman Oushy
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Colin L W Driscoll
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Buchanan IA, Min E, Pham MH, Donoho DA, Bakhsheshian J, Minneti M, Zada G, Giannotta SL, Hsieh PC, Liu JC. Simulation of Dural Repair in Minimally Invasive Spine Surgery With the Use of a Perfusion-Based Cadaveric Model. Oper Neurosurg (Hagerstown) 2019; 17:616-621. [DOI: 10.1093/ons/opz041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/14/2019] [Indexed: 01/22/2023] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
In an era of curtailed work hours and concerns over achieving technical proficiency in the repertoire of procedures necessary for independent practice, many residencies have turned to model simulation as an educational adjunct. Cerebrospinal fluid (CSF) leak repair after inadvertent durotomy in spine surgery is a fundamental skillset for any spine surgeon. While primary closure with suture is not always necessary for small durotomies, larger defects, on the other hand, must be repaired. However, the dire consequences of inadequate repair dictate that it is generally performed by the most experienced surgeon. Few intraoperative opportunities, therefore, exist for CSF leak repair by trainees.
OBJECTIVE
To simulate dural repair in spine surgery using minimal-access techniques.
METHODS
A cohort of 8 neurosurgery residents was evaluated on their durotomy repair efforts in a perfusion-based cadaveric model.
RESULTS
Study participants demonstrated consistent improvement across trials, with a significant reduction in closure times between their initial (12 min, 7 sec ± 4 min, 43 sec) and final attempts (7 min, 4 sec ± 2 min, 6 sec; P = .02). Moreover, all trainees—irrespective of postgraduate year—were able to accomplish robust dural closures resistant to simulated Valsalva maneuvers. Participants reported high degrees of model realism and exhibited significant increases in postprocedure confidence scores.
CONCLUSION
Our results support use of perfusion-based simulation models as a complement to neurosurgery training, as it affords unrestricted opportunities for honing psychomotor skillsets when resident learning is increasingly being challenged by work-hour limitations and stricter oversight in the context of value-based healthcare.
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Affiliation(s)
- Ian A Buchanan
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Elliot Min
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Martin H Pham
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Daniel A Donoho
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael Minneti
- Department of General Surgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Steven L Giannotta
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Patrick C Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - John C Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Donoho DA, Johnson CE, Hur KT, Buchanan IA, Fredrickson VL, Minneti M, Zada G, Wrobel BB. Costs and training results of an objectively validated cadaveric perfusion-based internal carotid artery injury simulation during endoscopic skull base surgery. Int Forum Allergy Rhinol 2019; 9:787-794. [PMID: 30884191 DOI: 10.1002/alr.22319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/14/2018] [Accepted: 01/29/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Internal carotid artery injury (ICAI) is a rare, life-threatening complication of endoscopic endonasal approaches (EEAs). High-fidelity simulation methods exist, but optimization of the training cohort, training paradigm, and costs of simulation training remain unknown. METHODS Using our previously validated, high-fidelity, perfused-cadaver model, participants attempted to manage a simulated ICAI. After a brief instructional video and coaching, the simulation was repeated. Training success was defined as successful ICAI control on the second attempt after failure on the initial attempt. Marginal costs were measured. RESULTS Seventy-two surgeons participated in the standardized simulation, which lasted ≤15 minutes. The marginal cost of simulation was $275.00 per surgeon. A total of 44.4% (n = 32) succeeded on the first attempt before training (previously proficient); 44.4% (n = 32) failed the first attempt, but succeeded after training (training successes); and 11.1% (n = 8) failed both attempts. The cost per training success was $618.75. Forty-two surgeons had never treated an ICAI, with 24 becoming training successes (57.1% overall, 82.8% when excluding previously proficient surgeons). Twenty-nine had experienced a real or simulated ICAI, with 8 (27.6% overall, 72.7% excluding previously proficient surgeons) becoming training successes. The cost per training success was lowest in the ICAI-naive group ($481.25) and highest among surgeons with simulated and real ICAI experience ($1650). CONCLUSIONS Surgeons can be trained to manage ICAI in a single, brief, low-cost session. Although all groups improved, training an ICAI-naive or resident cohort may maximize training results. A perfused-cadaver model is a reproducible, realistic, and low-cost method for training surgeons to manage life-threatening ICAI during an EEA.
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Affiliation(s)
- Daniel A Donoho
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Cali E Johnson
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Kevin T Hur
- Tina and Rick Caruso Department of Otorhinolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ian A Buchanan
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Vance L Fredrickson
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Michael Minneti
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Bozena B Wrobel
- Tina and Rick Caruso Department of Otorhinolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Step-up Establishment of Neurosurgical Laboratory Starting with Limited Resources-Tips and Tricks. World Neurosurg 2019; 126:83-89. [PMID: 30797916 DOI: 10.1016/j.wneu.2019.02.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/04/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Neurosurgical diseases have a devastating impact on society. It is estimated that approximately 14 million essential neurosurgical cases develop worldwide annually, of which more than 80% arise in low- and middle-income countries. Neurosurgical cadaveric dissection remains largely unexploited as a learning tool for the training of surgeons in developing countries, often because of the assumed high costs. METHODS The minimum requirements to establish a neurosurgical cadaver laboratory are the availability of minimally equipped environment to perform dissection, respecting safety requirements, fitting surgical instruments, anatomic samples, and materials to be used for preservation and preparation of anatomical specimens. Moving from these basic foundations, we established our Neurosurgical Dissection Laboratory at Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome, Italy. The laboratory is located at the Institute of Public Health Section of Legal Medicine of University. RESULTS After reviewing relevant literature and discussing our experience, we provide advice for setting up a neurosurgical dissection cadaver laboratory with specific focus on suitable location identification, surgical equipment procurement, fresh cadaver and frozen specimen acquisition, and preparation and description of a step-up strategy to progressively enrich the laboratory. CONCLUSIONS Our study demonstrates the feasibility of establishing a neurosurgical cadaver dissection laboratory for training and research purposes even in presence of limited resources. The introduction of cost-effective guidelines and targeted funding could represent an added value to target the unmet neurosurgical disease need by promoting development of local neurosurgical expertise with the aim of providing health coverage for the treatment of common neurosurgical pathologies in developing countries.
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Perry A, Graffeo CS, Carlstrom LP, Anding WJ, Link MJ, Rangel-Castilla L. Novel rodent model for simulation of sylvian fissure dissection and cerebrovascular bypass under subarachnoid hemorrhage conditions: technical note and timing study. Neurosurg Focus 2019; 46:E17. [DOI: 10.3171/2018.11.focus18533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVESylvian fissure dissection following subarachnoid hemorrhage (SAH) is a challenging but fundamental skill in microneurosurgery, and one that has become increasingly difficult to develop during residency, given the overarching management trends. The authors describe a novel rodent model for simulation of sylvian fissure dissection and cerebrovascular bypass under SAH conditions.METHODSA standardized microvascular anastomosis model comprising rat femoral arteries and veins was used for the experimental framework. In the experimental protocol, following exposure and skeletonization of the vessels, extensive, superficial (1- to 2-mm) soft-tissue debridement was conducted and followed by wound closure and delayed reexploration at intervals of 7, 14, and 28 days. Two residents dissected 1 rat each per time point (n = 6 rats), completing vessel skeletonization followed by end-to-end artery/vein anastomoses. Videos were reviewed postprocedure to assess scar score and relative difficulty of dissection by blinded raters using 4-point Likert scales.RESULTSAt all time points, vessels were markedly invested in friable scar, and exposure was subjectively assessed as a reasonable surrogate for sylvian fissure dissection under SAH conditions. Scar score and relative difficulty of dissection both indicated 14 days as the most challenging time point.CONCLUSIONSThe authors’ experimental model of femoral vessel skeletonization, circumferential superficial soft-tissue injury, and delayed reexploration provides a novel approximation of sylvian fissure dissection and cerebrovascular bypass under SAH conditions. The optimal reexploration interval appears to be 7–14 days. To the authors’ knowledge, this is the first model of SAH simulation for microsurgical training, particularly in a live animal system.
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Affiliation(s)
| | | | | | | | - Michael J. Link
- Departments of 1Neurologic Surgery,
- 3Otolaryngology–Head and Neck Surgery, and
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Maza G, VanKoevering KK, Yanez-Siller JC, Baglam T, Otto BA, Prevedello DM, Carrau RL. Surgical simulation of a catastrophic internal carotid artery injury: a laser-sintered model. Int Forum Allergy Rhinol 2018; 9:53-59. [PMID: 30376606 DOI: 10.1002/alr.22178] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 05/18/2018] [Accepted: 05/25/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The catastrophic and rare nature of an internal carotid artery (ICA) injury during endonasal surgery limits training opportunities. Cadaveric and animal simulation models have been proposed, but expense and complicated logistics have limited their adoption. Three-dimensional (3D) printed models are portable, modular, reusable, less costly, and proven to improve psychomotor skills required for managing different lesions. In this study we evaluate the role of a simplified laser-sintered model combined with standardized training in improving the effectiveness of managing an ICA injury endoscopically. METHODS A 3-mm defect was created in the parasellar carotid canal of a laser-sintered model representing a sphenoid sinus. Artificial blood was directed to simulate the copious bleeding arising from an ICA injury. Twenty otolaryngologists and 26 neurosurgeons, with varying training and experience levels, were individually asked to stop the "bleeding" as they would in a clinical scenario, and provided no other instructions. This was followed by individualized formative training and a second simulation. Volume of blood loss, time to hemostasis, and self-assessed confidence scores were compared. RESULTS At the end of the study, time to hemostasis was reduced from 105.49 seconds to 40.41 seconds (p < 0.001). The volume of blood loss was reduced from 690 to 272 mL (p < 0.001), and the confidence scores increased in 95.7% of participants, from an average of 3 up to 8. CONCLUSION This ICA injury model, along with a formal training algorithm, appears to be valuable, realistic, portable, and cost-effective. Significant improvement in all parameters suggests the acquisition of psychomotor skills required to control an ICA injury.
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Affiliation(s)
- Guillermo Maza
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH
| | - Kyle K VanKoevering
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH
| | - Juan C Yanez-Siller
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH
| | - Tekin Baglam
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH
| | - Bradley A Otto
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH.,Department of Neurosurgery, The Ohio State University, Columbus, OH
| | - Daniel M Prevedello
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH.,Department of Neurosurgery, The Ohio State University, Columbus, OH
| | - Ricardo L Carrau
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH.,Department of Neurosurgery, The Ohio State University, Columbus, OH
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Innovative real CSF leak simulation model for rhinology training: human cadaveric design. Eur Arch Otorhinolaryngol 2018; 275:937-941. [DOI: 10.1007/s00405-018-4902-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 02/05/2018] [Indexed: 01/16/2023]
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The use of a novel perfusion-based cadaveric simulation model with cerebrospinal fluid reconstitution comparing dural repair techniques: a pilot study. Spine J 2017; 17:1335-1341. [PMID: 28412565 DOI: 10.1016/j.spinee.2017.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/14/2017] [Accepted: 04/10/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Watertight dural repair is crucial for both incidental durotomy and closure after intradural surgery. PURPOSE The study aimed to describe a perfusion-based cadaveric simulation model with cerebrospinal fluid (CSF) reconstitution and to compare spine dural repair techniques. STUDY DESIGN/SETTING The study is set in a fresh tissue dissection laboratory. SAMPLE SIZE The sample includes eight fresh human cadavers. OUTCOME MEASURES A watertight closure was achieved when pressurized saline up to 40 mm Hg did not cause further CSF leakage beyond the suture lines. METHODS Fresh human cadaveric specimens underwent cannulation of the intradural cervical spine for intrathecal reconstitution of the CSF system. The cervicothoracic dura was then exposed from C7-T12 via laminectomy. The entire dura was then opened in six cadavers (ALLSPINE) and closed with 6-0 Prolene (n=3) or 4-0 Nurolon (n=3), and pressurized with saline via a perfusion system to 60 mm Hg to check for leakage. In two cadavers (INCISION), six separate 2-cm incisions were made and closed with either 6-0 Prolene or 4-0 Nurolon, and then pressurized. A hydrogel sealant was then added and the closure was pressurized again to check for further leakage. RESULTS Spinal laminectomy with repair of intentional durotomy was successfully performed in eight cadavers. The operative microscope was used in all cases, and the model provided a realistic experience of spinal durotomy repair. For ALLSPINE cadavers (mean: 240 mm dura/cadaver repaired), the mean pressure threshold for CSF leakage was observed at 66.7 (±2.9) mm Hg in the 6-0 Prolene group and at 43.3 (±14.4) mm Hg in the 4-0 Nurolon group (p>.05). For INCISION cadavers, the mean pressure threshold for CSF leakage without hydrogel sealant was significantly higher in 6-0 Prolene group than in the 4-0 Nurolon group (6-0 Prolene: 80.0±4.5 mm Hg vs. 4-0 Nurolon: 32.5±2.7 mm Hg; p<.01). The mean pressure threshold for CSF leakage with the hydrogel sealants was not significantly different (6-0 Prolene: 100.0±0.0 mm Hg vs. 4-0 Nurolon: 70.0±33.1 mm Hg). The use of a hydrogel sealant significantly increased the pressure thresholds for possible CSF leakage in both the 6-0 Prolene group (p=.01) and the 4-0 Nurolon group (p<.01) when compared with mean pressures without the hydrogel sealant. CONCLUSIONS We described the feasibility of using a novel cadaveric model for both the study and training of watertight dural closure techniques. 6-0 Prolene was observed to be superior to 4-0 Nurolon for watertight dural closure without a hydrogel sealant. The use of a hydrogel sealant significantly improved watertight dural closures for both 6-0 Prolene and 4-0 Nurolon groups in the cadaveric model.
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