La « double horloge » ou comment apprendre la microchirurgie sans animal

Nonbiological Microsurgery Simulators in Plastic Surgery Training: A Systematic Review

BACKGROUND

Simulation has gained notable recognition for its role as an effective training and assessment modality in the present era of competency-based medical education. Despite the well-documented efficacy of both live and cadaveric animal models, several ethical, financial, and accessibility issues persist with their use. Lower fidelity nonbiological simulators have gained recognition for their ability to circumvent these challenges. This systematic review reports on all prosthetic and virtual reality simulators in use for microsurgery training, with an emphasis on each model's complexity, characteristics, advantages, disadvantages, and validation measures taken.

METHODS

A systematic search was performed using the National Library of Medicine (PubMed), MEDLINE, and Embase databases. Search terms were those pertaining to prosthetic and virtual reality models with relevance to microsurgical training in plastic surgery. Three independent reviewers evaluated all articles retrieved based on strict inclusion and exclusion criteria.

RESULTS

Fifty-seven articles met the inclusion criteria for review, reporting on 20 basic prosthetic models, 20 intermediate models, 13 advanced models, and six virtual reality simulators.

CONCLUSIONS

A comprehensive summary has been compiled of all nonbiological simulators in use for microsurgery training in plastic surgery, demonstrating efficacy for the acquisition and retention of microsurgical skills. Metrics-based validation efforts, however, were often lacking in the literature. As plastic surgery programs continue to innovate, ensure accountability, and safely meet today's training standards, prosthetic simulators are set to play a larger role in the development of a standardized, ethical, accessible, and objectively measurable microsurgery training curriculum for the modern-day plastic and reconstructive surgery resident.

The Role of Simulation in Microsurgical Training

Simulation has been established as an integral part of microsurgical training. The aim of this study was to assess and categorize the various simulation models in relation to the complexity of the microsurgical skill being taught and analyze the assessment methods commonly employed in microsurgical simulation training. Numerous courses have been established using simulation models. These models can be categorized, according to the level of complexity of the skill being taught, into basic, intermediate, and advanced. Microsurgical simulation training should be assessed using validated assessment methods. Assessment methods vary significantly from subjective expert opinions to self-assessment questionnaires and validated global rating scales. The appropriate assessment method should carefully be chosen based on the simulation modality. Simulation models should be validated, and a model with appropriate fidelity should be chosen according to the microsurgical skill being taught. Assessment should move from traditional simple subjective evaluations of trainee performance to validated tools. Future studies should assess the transferability of skills gained during simulation training to the real-life setting.

Reducing the number of animals used for microsurgery training programs by using a task-trainer simulator

To master the skills needed for microsurgery techniques, residents must enrol in a long and complex training program that includes manipulations on simulators, on ex vivo tissues and finally in vivo training. This final step consists of performing vascular anastomoses on murine models. We propose here a simulation program designed to decrease the number of rats used during the final in vivo training. Our study presents the materials used, the various exercises proposed and their evaluations. Two identical student groups were compared in the framework of the University Diploma of Microsurgery. Group A (seven students) followed a classic training program, all of whom achieved permeable vascular anastomoses. A total of 149 rats were needed for this group. Group B (seven students) first validated their manipulations on the task-trainer simulation program. A mean of 6 h was necessary to obtain this validation. All these students achieved the required permeable vascular anastomoses but only 77 rats were used for this group. This simulation program spared 72 rats, abiding by the Russell and Burch concept of a humane experimental technique, namely the 3R principles. This home-made, cost-efficient and easy-to-use task trainer included various exercises with increasing difficulty levels and a progressive scoring system. We believe that microsurgery training needs to include both simple and sophisticated tools in order to reduce the number of animals used to master these surgical skills.

Microsurgery and liver research: Lumbricus terrestris, a reliable animal model for training?

BACKGROUND

Experiments using animal models are the most common way to learn microsurgery. This expertise is necessary for liver research, microsurgical reconstruction of the esophagus by free jejunum or reconstruction of the hepatic artery during reimplantation from living donors. The goal of this prospective study is to assess the reliability of an invertebrate model for microsurgical training.

METHODS

Between November 2011 and January 2012, 150 microsurgical trainings simulating vascular end-to-end microanastomoses were performed on 134 earthworms. The trainings were divided into 10 periods of 1 week each that included 15 simulations of end-to-end vascular microanastomoses: larger than 1.5mm (n=5), ranging in size from 1.0 to 1.5mm (n=5), and size less than 1.0mm (n=5). The technique is presented and documented.

RESULTS

For diameters greater than 1.5mm, the mean anastomosis time decreased from 17.9 ± 0.9 min to 9.9 ± 0.2 min between the first and last week of training. For training with smaller diameters, the results showed a decrease in execution time of 41.8% (diameters between 1.0 and 1.5mm) and 38.6% (diameters<1.0mm) between the first and last periods. The study underlines an improvement in the dexterity and speed of nodes' execution.

CONCLUSION

The earthworm appears to be a reliable experimental model for microsurgical training. It is more ethical than using rats, less expensive than vertebrate animal models, and allows the operator to gain in both confidence and time of execution.