Cadaveric surgery: a novel approach to teaching clinical anatomy

Development of a porcine training model for microvascular fasciocutaneous free flap reconstruction

BACKGROUND

In reconstructive surgery, improvements are needed in the effective teaching of free flap surgery. There is a need for easily accessible and widely available training without high financial costs or ethical concerns while still providing a realistic experience. Our aim was to develop an appropriate training model for microvascular flaps.

METHODS

We identified pig head halves as most appropriate regarding availability, cost, and realism. These accrue largely by the food industry, so no animals need to be sacrificed, making it more ethical from an animal welfare perspective. We evaluated the suitability as flap donor site and analyzed the vascular anatomy of 51 specimens.

RESULTS

Anatomical evaluation revealed a reliable and constant vascular anatomy, allowing the design of a flap model that can effectively illustrate the entire process of microvascular flap surgery. The process was divided into 6 key steps. The flap can be harvested after marking the vascular pedicle 5.3 cm from the lateral corner of the mouth. Skin island design and subsequent tissue dissection follow until a fasciocutaneous flap is raised, similar to a radial flap. Upon completion of flap harvesting, it can be freely transferred for defect reconstruction. Microvascular anastomosis can be performed on recipient vessels in the cervical region, and the difficulty can be individually adjusted.

CONCLUSIONS

The developed training model is a reasonable compromise in terms of surgical realism, availability, didactic value, and cost/time effectiveness. We believe it is a powerful and effective tool with high potential for improving surgical education and training.

Cadaveric Simulation Training Improves Residents' Knowledge and Confidence in Performing Fluoroscopic Guided Joint Injections

RATIONALE AND OBJECTIVE

Simulation training has been strongly encouraged to enhance radiology trainees' procedural competency. We aimed to assess whether a cadaveric simulation training session was effective in improving radiology residents' subjective technical ability, knowledge and confidence in performing fluoroscopic-guided joint injections.

METHODS

As part of the residency program's procedural training curriculum, first year radiology resident participated in a cadaveric, musculoskeletal injection training session including a didactic lecture followed by a practical hands-on component. Trainees performed fluoroscopic guided hip and shoulder injections on fresh cadavers, supervised by two fellowship-trained musculoskeletal radiologists. Trainees' knowledge on indications, contraindications, preprocedural care, complications, and technical ability in performing the procedures, as well as their rating of overall session experience were evaluated with pre- and post-session questionnaires (5 point Likert-scale). The mean residents' scores for pre- and post-session questionnaire items were calculated and compared using paired t-test. The magnitude of difference between mean pre- and post-session scores was compared between the items using analysis of variance.

RESULTS

Results Over a 5-year period, 27 trainees participated in the joint injection simulation session. The mean pre- and post-session scores were significantly higher in the post session questionnaire for all five items pertaining to knowledge of indications, contraindications, preprocedural care, complications, and technical ability (all p < 0.0001). The magnitude of improvement was not different between the items (p = 0.45). Most of the participants rated the training facilities, contents, hands-on experience, teaching quality, and session organization as very good or excellent.

CONCLUSIONS

Cadaveric joint injection simulation training significantly improved trainees' subjective knowledge, confidence, and technical ability in performing joint injections.

Inducing pilon fractures in human cadaveric specimens depending on the injury mechanism: a fracture simulation

BACKGROUND

Operative management of pilon fractures, especially high-energy compression injuries, is a challenge. Operative education is of vital importance to handle these entities. Not rarely, it is cut by economics and staff shortage. As public awareness toward operative competence rises, surgical cadaver courses that provide pre-fractured specimens can improve realism of teaching scenarios. The aim of this study is to introduce a realistic pilon fracture simulation setup regarding the injury mechanism.

MATERIALS AND METHODS

8 cadaveric specimens (two left, six right) were fixed onto a custom drop-test bench in dorsiflexion (20°) and light supination (10°). The proximal part of the lower leg was potted, and the specimen was exposed to a high energetic impulse via an axial impactor. CT imaging was performed after fracture simulation to detect the exact fracture patterns and to classify the achieved fractures by two independent trauma surgeons. (AO/OTA recommendations and the Rüedi/Allgöwer).

RESULTS

All cadaveric specimens could be successfully fractured: 6 (75%) were identified as a 43-C fracture and 2 (25%) as 43-B fracture type. Regardless of the identical mechanism two different kinds of fracture types were reported. In five cases (62.5%), the fibula was also fractured and in three specimens, a talus fracture was described. There was no statistically significant correlation found regarding Hounsfield Units (HU) and age as well as HU and required kinetic energy.

CONCLUSION

A high energetic axial impulse on a fixed ankle specimen in light dorsiflexion (20°) and supination (10°) induced by a custom-made drop-test bench can successfully simulate realistic pilon fractures in cadaveric specimens with intact soft tissue envelope. Although six out of eight fractures (75%) were classified as a 43-C fracture and despite putting a lot of effort into the mechanical setup, we could not achieve an absolute level of precision. Therefore, we suggest that the injury mechanism is most likely a combination of axial loading, shear and rotation.

LEVEL OF EVIDENCE

III.

A Surgical View of Anatomy: Perspectives from Students and Instructors

As curricular emphasis on anatomy in undergraduate medical education continues to evolve, new approaches to anatomical education are urgently needed to prepare medical students for residency. A surgical anatomy class was designed for third- and fourth-year medical students to explore important anatomical relationships by performing realistic surgical procedures on anatomical donors. Under the guidance of both surgeons and anatomists, students in this month-long elective course explored key anatomical relationships through performing surgical approaches, with the secondary benefit of practicing basic surgical techniques. Procedures, such as left nephrectomy, first rib resection for thoracic outlet syndrome, and carotid endarterectomy, were adapted from those used clinically by multiple surgical subspecialties. This viewpoint commentary highlights perspectives from students and instructors that suggest the value of a surgical approach to anatomical education for medical students preparing for procedure-oriented residencies, with the goals of: (1) describing the elective at the authors' institution, (2) promoting similar efforts across different institutions, and (3) encouraging future qualitative and quantitative studies of similar pedagogic efforts.

Bariatric Surgical Simulation: Evaluation in a Pilot Study of SimLife, a New Dynamic Simulated Body Model

Background

The demand for bariatric surgery is high and so is the need for training future bariatric surgeons. Bariatric surgery, as a technically demanding surgery, imposes a learning curve that may initially induce higher morbidity. In order to limit the clinical impact of this learning curve, a simulation preclinical training can be offered. The aim of the work was to assess the realism of a new cadaveric model for simulated bariatric surgery (sleeve and Roux in Y gastric bypass).

Aim

A face validation study of SimLife, a new dynamic cadaveric model of simulated body for acquiring operative skills by simulation. The objectives of this study are first of all to measure the realism of this model, the satisfaction of learners, and finally the ability of this model to facilitate a learning process.

Methods

SimLife technology is based on a fresh body (frozen/thawed) given to science associated to a patented technical module, which can provide pulsatile vascularization with simulated blood heated to 37 °C and ventilation.

Results

Twenty-four residents and chief residents from 3 French University Digestive Surgery Departments were enrolled in this study. Based on their evaluation, the overall satisfaction of the cadaveric model was rated as 8.52, realism as 8.91, anatomic correspondence as 8.64, and the model’s ability to be learning tool as 8.78.

Conclusion

The use of the SimLife model allows proposing a very realistic surgical simulation model to realistically train and objectively evaluate the performance of young surgeons.

Inducing life-like distal radius fractures in human cadaveric specimens: a tool for enhanced surgical training

INTRODUCTION

Surgical education consists often times of a discrepancy between necessary amount of provided operative teaching and amount of organizational and ward duties. Operative education is often cut to a minimum. As public awareness toward surgical competence raises, so must the educational system. Courses that provide pre-fractured cadaveric specimens can facilitate surgical teaching realistically, prior to operating on living patients. The aim of this study is to introduce a realistic distal radius fracture simulation setup.

MATERIALS AND METHODS

12 cadaveric specimens (3 male, 9 female) were fixed onto a custom drop-test-bench in the hyperextension of the wrist. The forearm was cut midway between elbow and carpus. The distal part of the forearm was potted, and the specimen was exposed to a high energetic impulse. CT imaging was performed after fracture simulation to detect the exact fracture patterns. We used the AO/ASIF recommendations and four-corner concept to classify the achieved fractures by two independent trauma surgeons.

RESULTS

All cadaveric specimens could be successfully fractured. 11 fractures were classified as type 23C3.2 and one was classified as type 23C3.3, as additional fracture of diaphysis occurred. Subclassification according to the four-corner concept showed all fractures to be type C. A concomitant ulnar styloid fracture was observed in 4 cases. Furthermore, all cases showed at least one fragment involving the sigmoid notch. There was no statistically significant correlation found regarding Hounsfield Units (HU) and age (p value 0.402), as well as HU and required kinetic energy (p value 0.063).

CONCLUSION

A high energetic impulse induced by a custom-made drop-test bench can successfully simulate realistic distal radius fractures in cadaveric specimens with intact soft tissue. Furthermore, these pre-fractured specimens can be utilized in surgical education to provide a teaching experience as realistic as possible without harming living patients.

Pedicle Screw Insertion: a Novel Approach to Enhance Anatomic Knowledge and Student Engagement

A procedure experience was incorporated into the anatomy lab to advance knowledge of the spine and enhance student engagement (Nutt et al., Clin Teach 9(3):148-151, 2012). The spine lab was modified to include a scoliosis case with a pedicle screw placement simulation exercise. The experience has been a success for both undergraduate medical students and resident facilitators.

Simulation-Based Learning Strategies to Teach Undergraduate Students Basic Surgical Skills: A Systematic Review

OBJECTIVE

We aimed to identify and critically appraise all literature surrounding simulation-based learning (SBL) courses, to assess their relevance as tools for undergraduate surgical education, and create a design framework targeted at standardizing future SBL.

METHODS

We performed a systematic review of the literature using a specific keyword strategy to search at MEDLINE database.

RESULTS

Of the 2371 potentially eligible titles, 472 were shortlisted and only 40 explored active interventions in undergraduate medical education. Of those, 20 were conducted in the United States, 9 in Europe and 11 in the rest of the world. Nineteen studies assessed the effectiveness of SBL by comparing students' attributes before and after interventions, 1 study assessed a new tool of surgical assessment and 16 studies evaluated SBL courses from the students' perspectives. Of those 40 studies, 12 used dry laboratory, 7 wet laboratory, 12 mixed, and 9 cadaveric SBL interventions. The extent to which positive results were obtained from dry, wet, mixed, and cadaveric laboratories were 75%, 57%, 92%, and 100%, respectively. Consequently, the SBL design framework was devised, providing a foundation upon which future SBL interventions can be designed such that learning outcomes are optimized.

CONCLUSIONS

SBL is an important step in surgical education, investing in a safer and more efficient generation of surgeons. Standardization of these efforts can be accelerated with SBL design framework, a comprehensive guide to designing future interventions for basic surgical training at the undergraduate level.

Techniques of cadaver perfusion for surgical training: a systematic review

PURPOSE

The objective of this study was to identify the most appropriate cadaver perfusion techniques for surgical training through a systematic review with a description of the protocols used.

METHODS

The search strategy included PubMed and reference tracking. Studies were identified by searching the electronic Medline databases. The search concepts included perfusion, cadavers and simulation training, and the protocol used is reported. This resulted in a qualitative review of 12 articles out of 250 articles consulted. We collected all the important data from these 12 articles.

RESULTS

Regarding the characteristics of the studies and the declotting or perfusion techniques, the results were heterogeneous. Indeed, in several studies, a good deal of information was unclear or insufficiently precise, making it unfeasible to summarize the data. The methods used were not sufficiently explicit and detailed. However, a majority of the fresh cadavers used tap water for declotting. Perfusion, type of fluid, number of pumps, pressure, pulsatility, and arterial or venous approaches differed greatly. Only two studies fulfilled five of our six realism criteria for surgical simulation.

CONCLUSIONS

This systematic review provided an overview of all the different cadaver perfusion techniques. It could be used to establish a reference method of a simulation model.

Performance equivalency between computer-based and traditional pen-and-paper assessment: A case study in clinical anatomy

The time, material, and staff-consuming nature of anatomy's traditional pen-and-paper assessment system, the increase in the number of students enrolling in medical schools and the ever-escalating workload of academic staff have made the use of computer-based assessment (CBA) an attractive proposition. To understand the impact of such shift in the assessment method, an experimental study evaluating its effect on students' performance was designed. Additionally, students' opinions toward CBA were gathered. Second-year medical students attending a Clinical Anatomy course were randomized by clusters in two groups. The pen-and-paper group attended two sessions, each consisting of a traditional sectional anatomy steeplechase followed by a theoretical examination, while the computer group was involved in two similar sessions conducted in a computerized environment. At the end of each of the computer sessions, students in this group filled an anonymous questionnaire. In the first session, pen-and-paper group students scored significantly better than computer-group students in both the steeplechase (mean ± standard deviation: 66.00 ± 14.15% vs. 43.50 ± 19.10%; P < 0.001) and the theoretical examination (52.50 ± 12.70% vs. 39.00 ± 21.10%; P < 0.001). In the second session, no statistically significant differences were found for both the steeplechase (59.50 ± 17.30% vs. 54.50 ± 17.00%; P = 0.085) and the theoretical examination (57.50 ± 13.70% vs. 54.00 ± 14.30%; P = 0.161). Besides, an intersession improvement in students' perceptions toward CBA was registered. These results suggest that, after a familiarization period, CBA might be a performance equivalent and student accepted alternative to clinical anatomy pen-and-paper theoretical and practical examinations. Anat Sci Educ 11: 124-136. © 2017 American Association of Anatomists.

From ancient to avant-garde: a review of traditional and modern multimodal approaches to surgical anatomy education

The landscape of surgical anatomy education is progressively changing. Traditional methods, such as cadaveric dissection and didacticism are being increasingly phased out in undergraduate courses for multimodal approaches incorporating problem-based learning, radiology and computer-based simulations. Although effective at clinically contextualizing and integrating anatomical information, these approaches may be a poor substitute for fostering a grasp of foundational 'pure' anatomy. Dissection is ideal for this purpose and hence remains the cornerstone of anatomical education. However, novel methods and technological advancements continually give way to adjuncts such as cadaveric surgery, three-dimensional printing, virtual simulation and live surgical streaming, which have demonstrated significant efficacy alone or alongside dissection. Therefore, although divergent paradigms of 'new versus old' approaches have engulfed and divided the community, educators should seek to integrate the ancient and avant-garde to comprehensively satisfy all of the modern anatomy learner's educational needs.

Can CanMEDS competencies be developed in medical school anatomy laboratories? A literature review

OBJECTIVES

The purpose of this literature review was to identify potential ways in which undergraduate medical anatomy education may be relevant to the CanMEDS Roles, a competency-based framework used throughout Canadian medical training.

METHODS

A scoping review of medical education literature was conducted in March 2017 for English language publications that included key words related to anatomy education and to key competencies formally described for each of the Roles in the CanMEDS 2015 framework. Indicated benefits were then collated, characterized, and synthesized for each CanMEDS Role.

RESULTS

There were 71 studies identified describing original findings. Perceived benefits of anatomy education were most often identified for competencies related to the Medical Expert Role. Multiple studies also cited benefits related to the Scholar, Professional and Collaborator Roles. There was a lack of literature related to the Health Advocate, Communicator, and Leader Roles. The majority of benefits defined in the literature were limited to student perceptions rather than objectively measured outcomes.

CONCLUSIONS

There is some evidence to suggest that anatomy education can facilitate the development of core competencies related to several CanMEDS Roles, outside of simply developing medical knowledge in the Medical Expert Role. Future studies need to develop methods to objectively assess outcomes related to these competencies.

Design, Implementation, and Evaluation of a Simulation-Based Clinical Correlation Curriculum as an Adjunctive Pedagogy in an Anatomy Course

PROBLEM

Because reported use of simulation in preclinical basic science courses is limited, the authors describe the design, implementation, and preliminary evaluation of a simulation-based clinical correlation curriculum in an anatomy course for first-year medical students at Perdana University Graduate School of Medicine (in collaboration with Johns Hopkins University School of Medicine).

APPROACH

The simulation curriculum, with five weekly modules, was a component of a noncadaveric human anatomy course for three classes (n = 81 students) from September 2011 to November 2013. The modules were designed around major anatomical regions (thorax; abdomen and pelvis; lower extremities and back; upper extremities; and head and neck) and used various types of simulation (standardized patients, high-fidelity simulators, and task trainers). Several methods were used to evaluate the curriculum's efficacy, including comparing pre- versus posttest scores and comparing posttest scores against the score on 15 clinical correlation final exam questions.

OUTCOMES

A total of 81 students (response rate: 100%) completed all pre- and posttests and consented to participate. Posttest scores suggest significant knowledge acquisition and better consistency of performance after participation in the curriculum. The comparison of performance on the posttests and final exam suggests that using simulation as an adjunctive pedagogy can lead to excellent short-term knowledge retention.

NEXT STEPS

Simulation-based medical education may prove useful in preclinical basic science curricula. Next steps should be to validate the use of this approach, demonstrate cost-efficacy or the "return on investment" for educational and institutional leadership, and examine longer-term knowledge retention.

Outcomes and satisfaction of two optional cadaveric dissection courses: A 3-year prospective study

Teaching time dedicated to anatomy education has been reduced at many medical schools around the world, including Nova Medical School in Lisbon, Portugal. In order to minimize the effects of this reduction, the authors introduced two optional, semester-long cadaveric dissection courses for the first two years of the medical school curriculum. These courses were named Regional Anatomy I (RAI) and Regional Anatomy II (RAII). In RAI, students focus on dissecting the thorax, abdomen, pelvis, and perineum. In RAII, the focus shifts to the head, neck, back, and upper and lower limbs. This study prospectively analyzes students' academic achievement and perceptions within the context of these two, newly-introduced, cadaveric dissection courses. Students' satisfaction was assessed anonymously through a questionnaire that included items regarding students' perception of the usefulness of the courses for undergraduate teaching, as well as with regards to future professional activity. For each of the three academic years studied, the final score (1 to 20) in General Anatomy (GA), RAI, and RAII was on average 14.26 ± 1.89; 16.94 ± 1.02; 17.49 ± 1.01, respectively. The mean results were lower in GA than RAI or RAII (P < 0.001). Furthermore, students who undertook these courses ranked them highly with regards to consolidating their knowledge of anatomy, preparing for other undergraduate courses, and training for future clinical practice. These survey data, combined with data on participating students' academic achievement, lend strong support to the adoption of similar courses as complementary and compulsory disciplines in a modern medical curriculum. Anat Sci Educ 10: 127-136. © 2016 American Association of Anatomists.

Interactive anatomical and surgical live stream lectures improve students' academic performance in applied clinical anatomy

Tuebingen's Sectio Chirurgica (TSC) is an innovative, interactive, multimedia, and transdisciplinary teaching method designed to complement dissection courses. The Tuebingen's Sectio Chirurgica (TSC) allows clinical anatomy to be taught via interactive live stream surgeries moderated by an anatomist. This method aims to provide an application-oriented approach to teaching anatomy that offers students a deeper learning experience. A cohort study was devised to determine whether students who participated in the TSC were better able to solve clinical application questions than students who did not participate. A total of 365 students participated in the dissection course during the winter term of the 2012/2013 academic year. The final examination contained 40 standard multiple-choice (S-MC) and 20 clinically-applied multiple-choice (CA-MC) items. The CA-MC items referred to clinical cases but could be answered solely using anatomical knowledge. Students who regularly participated in the TSC answered the CA-MC questions significantly better than the control group (75% and 65%, respectively; P < 0.05, Mann-Whitney U test). The groups exhibited no differences on the S-MC questions (85% and 82.5%, respectively; P > 0.05). The CA-MC questions had a slightly higher level of difficulty than the S-MC questions (0.725 and 0.801, respectively; P = 0.083). The discriminatory power of the items was comparable (S-MC median Pearson correlations: 0.321; CA-MC: 0.283). The TSC successfully teaches the clinical application of anatomical knowledge. Students who attended the TSC in addition to the dissection course were able to answer CA-MC questions significantly better than students who did not attend the TSC. Thus, attending the TSC in addition to the dissection course supported students' clinical learning goals. Anat Sci Educ 10: 46-52. © 2016 American Association of Anatomists.

A brief history of topographical anatomy

This brief history of topographical anatomy begins with Egyptian medical papyri and the works known collectively as the Greco-Arabian canon, the time line then moves on to the excitement of discovery that characterised the Renaissance, the increasing regulatory and legislative frameworks introduced in the 18th and 19th centuries, and ends with a consideration of the impact of technology that epitomises the period from the late 19th century to the present day. This paper is based on a lecture I gave at the Winter Meeting of the Anatomical Society in Cambridge in December 2015, when I was awarded the Anatomical Society Medal.

Impact of cadaveric surgical anatomy training on urology residents knowledge: a preliminary study

OBJECTIVE

Cadaveric dissection is used as a major tool for anatomy education at the medical school. In this study we aimed to determine how a uro-anatomy cadaveric dissection course would impact urology residents knowledge.

MATERIALS AND METHODS

A three days course was given to 50 urology residents by experienced trainers in 1-3 June 2012 at Ege University Medical School's Anatomy Department, İzmir, Turkey. Efficacy of the course was assessed using a multiple choice questionnaire of 20 questions given before and after the course.

RESULTS

Completed questionnaires before and after the course were available for 25 residents (50%) that were included. Residents answered correctly to 11.7 out of 20 questions (59%) before the course and 13.0 out of 20 (65%) after (p<0.05). In individuals analysis, 16 residents (64%) increased their scores, 4 (16%) had similar scores and 5 (20%) had lower scores. The number of correct answers for 6 out of the 20 questions was lower following the course.

CONCLUSION

This cadaveric surgical anatomy course was effective in improving surgical anatomy knowledge for most urology residents but not all and helped to identify ways to improve the course in the future.

Students' perception of anatomy education at a Korean medical college with respect to time and contents

Among medical education institutions worldwide, the time allotted for anatomy instruction has decreased without any reasonable time optimization suggestions. In addition, the utility of cadaver dissection has long been debated. Herein, we surveyed students' perceptions of anatomy education with respect to time and hands-on cadaver dissection, at Seoul National University College of Medicine. With the help of a questionnaire, we surveyed third- and fourth-year students at our institute who had completed the anatomy module as freshmen as well as their clinical clerkship. At our institute, students complete 50 hours of anatomy lectures and 120 hours of dissection laboratory during their first year. According to the survey responses, they generally considered these durations to be adequate for achieving their anatomy education goals. Almost all the students regarded the dissection laboratory as an essential and most helpful modality. Thus, we suggest that these ranges of time along with cadaver dissection could be useful guidelines for optimized anatomy education. The survey data also indicated that a more clinically oriented anatomy education could improve students' results.