Simple training tricks for mastering and taming bypass procedures in neurosurgery

Simulation-Based Bypass Training and Learning Curves-Resident Experience

Introduction  Bypass surgery is a challenging operative procedure that requires surgical excellence. Achieving the skills required for vascular surgery is difficult to master in the operating room without intensive microsurgical training. Various models have been developed to provide training to young neurosurgeons and increase dexterity and patient safety. Bypass surgery requires complex microsurgical techniques. Methods  Microanastomosis training was performed on plastic tubes and chicken wings for 2 months. Each microanastomosis was evaluated by a senior author. Results  An improvement in the quality and patency of microanastomosis was observed. Conclusion  Microsurgical simulation training can contribute to the improvement of surgical skills and dexterity.

From textbook to patient: a practical guide to train the end-to-side microvascular anastomosis

Microvascular anastomosis is one of the most challenging neurosurgical techniques. Mastering this technique allows to perform intracranial bypass with arteries of small caliber usually placed in deep narrow surgical fields. The aim of this paper is to describe step by step end-to-side microanastomosis training method by using polyvinyl alcohol (PVA) hydrogel tubing as it is easily reproducible. The tubing comes in sizes from 0.3 mm to 5 mm and has a texture and consistency similar to real vessels. This is based on the Teishinkai Hospital anastomosis technique. Continuous practice in microvascular anastomosis is of great importance in training vascular neurosurgeon. The PVA hydrogel tubing described in this article are useful and cost-effective material in the training of microvascular anastomosis. This practical guide model is easy to set up for repeated practice, and will contribute to facilitate 'off-the-job' training by young neurosurgeons and the development and maintenance of microsurgical skills in both resident neurosurgeons and experts who wish to master the various levels of anastomosis technique. There is no shortcut to master this technique, only hard work and perseverance.

Needle Parking Interrupted Suturing Technique for Microvascular Anastomosis: A Technical Note

BACKGROUND

Interrupted and continuous suturing are 2 common techniques for microvascular anastomosis in cerebrovascular surgery. One of the technical complexities of interrupted suturing includes the risk of losing the needle in between interrupted sutures during knot tying, which may result in unnecessary movements and wasted time.

OBJECTIVE

To report a new needle parking technique for microvascular anastomosis that addresses a needle control problem during interrupted suturing.

METHODS

The needle parking technique involves puncturing both vessel walls at the site of the next provisional suture and leaving the needle parked in place while the knots at the first suture are being made. The thread is then cut, the needle is pulled through, and the process is repeated. Illustrative cases in which the needle parking technique was used are presented. We also compared time of anastomosis completion between the conventional interrupted, needle parking interrupted, and continuous suturing techniques during an in vitro study on standardized artificial vessels.

RESULTS

This technique is being used successfully by the senior author for various cerebrovascular bypass surgeries. The in vitro study demonstrated that the needle parking technique can be significantly faster than the conventional interrupted suturing technique and may be as fast as continuous suturing.

CONCLUSION

Needle parking technique is a modification of conventional interrupted suturing and solves the problem of losing the needle during knot tying. This technique is simple, prevents unnecessary movements, and may result in a faster anastomosis time.

Developing microsurgical milestones for psychomotor skills in neurological surgery residents as an adjunct to operative training: the home microsurgery laboratory

OBJECTIVE

A variety of factors contribute to an increasingly challenging environment for neurological surgery residents to develop psychomotor skills in microsurgical technique solely from operative training. While adjunct training modalities such as cadaver dissection and surgical simulation are embraced and practiced at our institution, there are no formal educational milestones defined to help residents develop, measure, and advance their microsurgical psychomotor skills in a stepwise fashion when outside the hospital environment. The objective of this report is to describe an efficient and convenient "home microsurgery lab" (HML) assembled and tested by the authors with the goal of supporting a personalized stepwise advancement of microsurgical psychomotor skills.

METHODS

The authors reviewed the literature on previously published simulation practice models and designed adjunct learning modules utilizing the HML. Five milestones were developed for achieving proficiency with each graduated exercise, referencing the Accreditation Council for Graduate Medical Education (ACGME) guidelines. The HML setup was then piloted with 2 neurosurgical trainees.

RESULTS

The total cost for assembling the HML was approximately $850. Techniques for which training was provided included microinstrument handling, tissue dissection, suturing, and microanastomoses. Five designated competency levels were developed, and training exercises were proposed for each competency level.

CONCLUSIONS

The HML offers a unique, entirely home-based, affordable adjunct to the operative neurosurgical education mandated by the ACGME operative case logs, while respecting resident hospital-based education hours. The HML provides surgical simulation with specific milestones, which may improve confidence and the microsurgical psychomotor skills required to perform microsurgery, regardless of case type.

Comparison of Conventional Microscopic and Exoscopic Experimental Bypass Anastomosis: A Technical Analysis

BACKGROUND

Recently, the use of digital exoscopes has been increasingly promoted as an alternative to microscopes. The aim of this study is to compare experimental bypass quality in both visualization methods.

METHODS

This study used two hundred 1-mm chicken wing vessels, which were used for either exoscopic or microscopic (100 samples each) bypass procedures. All procedures were recorded between July 2018 and September 2018. The bypass quality was evaluated according to our published practical scale (time, stitch distribution, intima-intima attachment, and orifice size).

RESULTS

Both methods are effective in doing bypass suturing (practical scale score was good, 86% vs. 85%; P = 0.84). There were no significant differences regarding intima-intima attachment (P = 0.26) and orifice size (P = 0.25). However, suturing time (P < 0.001) was less using the microscope, whereas stitch distribution (P = 0.001) was better using the exoscope. Different suturing techniques (interrupted vs. continuous) had overall comparable results (P = 0.55).

CONCLUSIONS

Both methods produced equally satisfactory results in experimental bypass procedures. The exoscope has the potential for better 3-dimensional visualization and sharing the surgeon's view with others for teaching purposes.

Meditation music improved the quality of suturing in an experimental bypass procedure

BACKGROUND

Neurosurgeons are vulnerable to additional noise in their natural operating environment. Noise exposure is associated with reduced cognitive function, inability to concentrate, and nervousness. Mediation music provides an opportunity to create a calmer environment which may reduce stress during surgery.

METHODS

A pilot study was performed to find a suitable task, meditation music of surgeon's choice, and operation noise and to reach a certain level of training. For the main experiment, two neurosurgeons with different microsurgical experience used real operation noise and meditation music with delta waves as mediating music. Each surgeon performed 10 training bypasses (five with noise and five with music) with 16 stitches in each bypass. The total time to complete 16 stitches, a number of unachieved movements (N.U.Ms), length of thread consumed, and distribution of the stitches were quantified from the recorded videos and compared in both groups.

RESULTS

A N.U.Ms were significantly reduced from 109 ± 38 with operation room (OR) noise to 38 ± 13 (p < 0.05) with meditating music in novice surgeon. Similar results were found in the experienced surgeon performing the same task [from 29 ± 6.94 to 14 ± 3.36 (p < 0.05)]. The total time utilized for the sixteen stitches was slightly improved (not significantly) in the novice surgeon and unchanged in the experienced surgeon. However, the thread length used for 16 stitches was significantly different with OR noise in comparison to meditating music in both surgeons. The distribution stitches showed a non-significant trend toward a uniform distribution with meditation music in both surgeons.

CONCLUSIONS

Meditation music of surgeon's choice is a simple method that improved quality of bypass suturing in an experimental bypass procedure.

The Identification of Factors That Influence the Quality of Bypass Anastomosis and an Evaluation of the Usefulness of an Experimental Practical Scale in This Regard

BACKGROUND

Several factors associated with interrupted and continuous suturing techniques affect the quality of bypass anastomosis. It is difficult to determine the impact of these factors during surgery. The primary objective of this study was to evaluate factors with the potential to influence the quality of bypass anastomosis using either interrupted or continuous suturing. A secondary objective was to evaluate the usefulness of a practical scale when comparing interrupted and continuous suturing techniques to improve bypass anastomosis.

METHODS

Interrupted (n = 100) and continuous (n = 100) suturing techniques were used in 200 end-to-side bypasses to a depth of 3 cm and were assessed by 5 neurosurgeons.

RESULTS

Vessel closing time (P < 0.001), stitch distribution (P < 0.001), intima-intima attachment (P < 0.001), and size of the orifice (P < 0.001) had a significant impact on the quality of the bypass regardless of the suturing technique used. The suturing technique used (interrupted or continuous) and positioning of the recipient vessel (vertical or horizontal) did not significantly influence the quality of anastomosis. Using multivariate analysis, the highest statistical significance with regard to bypass quality was attributed to the large size of the orifice and intimal attachment.

CONCLUSIONS

There were advantages and disadvantages to both suturing techniques. The scale was a practical way to measure and improve performance.