A cost-effective training tool for flexor tendon repair: Pig's trotters

Simulation in Hand Surgery: A Literature Review

BACKGROUND

Due to duty hour regulations, patient safety and inadequate operative time simulation have become a necessary part of surgical education and training in residency. Currently, there is no formal adoption of simulators for the use of surgical education or assessment in hand surgery. This literature review analyzes that the simulation techniques established thus far in hand surgery.

METHODS

A comprehensive literature search was performed on PubMed. Search results were filtered by title and abstract to isolate articles that were relevant to simulation in hand surgery. Articles that were nonspecific to the hand, non-English and cadaveric were excluded. Additional articles were identified through references from the initial search.

RESULTS

A total of 1192 articles were yielded from the initial query. After the application of the inclusion criteria, this was narrowed down to 28 articles. Another 8 additional articles were excluded as they did not pertain to the hand although the simulators could be adapted for hand surgery. A total of 20 articles were included in this study.

CONCLUSIONS

Surgical simulation is a growing and essential field of surgical education. Simulators in hand surgery are limited and require further research and validation. Like other surgical subspecialties, hand surgery may benefit from the adoption of an official simulation curriculum for the assessment of residents and enhancement of technical skills.

Toward Competency-Based Training: To What Extent Are We Competency-Based?

BACKGROUND

Time-based training models in plastic surgery vary in exposure, resulting in low confidence levels among graduates. The evolution of postgraduate medical education into a competency-based model to address these issues requires an understanding of interventions described in the plastic surgery literature to identify gaps and guide creation of assessments to demonstrate competence.

METHODS

A systematic search of the MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Cochrane databases from inception until December of 2017 was conducted using search terms and synonyms of educational interventions reported in plastic surgery. Full texts were retrieved following filtering and data extracted were related to intervention design and execution, involvement of competency assessment, and educational objectives and alignment to Accreditation Council for Graduate Medical Education competencies and Royal College of Physicians and Surgeons of Canada Canadian Medical Education Directives for Specialists roles. Study quality was assessed using Kirkpatrick's levels of learning evaluation, validity evidence, and the Medical Education Research Study Quality Instrument score.

RESULTS

Of the initial 4307 results, only 36 interventions met the inclusion criteria. Almost all interventions aligned to medical knowledge and patient care Accreditation Council for Graduate Medical Education competencies. One-fifth of the interventions involved no assessment of competency, whereas most displayed assessment at the level of design as opposed to outcomes. Quality assessment revealed low levels of learning evaluation and evidence of validity; the average Medical Education Research Study Quality Instrument score was 10.9 of 18.

CONCLUSION

A systematic review of educational literature in plastic surgery was conducted to assess the quality of reported educational interventions, and to help guide creating tools that ensure competency acquirement among trainees.

Use of Simulation in Plastic Surgery Training

The nationwide focus on patient safety and the health of residents has increased the demand for educational tools outside the operating room. Simulation is a valuable tool for assessing and developing surgical skills in a controlled and safe environment. The use of simulation as a formal component of training has been increasing in various surgical subspecialties. In general surgery, simulation examinations such as the Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery have become a prerequisite to board certification. Although formal simulation examinations in plastic surgery are not universal, there has been an increase in the use of simulation to increase resident competency in the operating room. For now, we will review the current state of simulation in craniofacial, hand, microvascular, and esthetic surgery and discuss applications for the future. We will also discuss the evolving role of artificial intelligence, virtual reality, and augmented reality in plastic surgery training and testing.

Animal models in plastic and reconstructive surgery simulation-a review

BACKGROUND

The use of live and cadaveric animal models in surgical training is well established as a means of teaching and improving surgical skill in a controlled setting. We aim to review, evaluate, and summarize the models published in the literature that are applicable to Plastic Surgery training.

MATERIALS AND METHODS

A PubMed search for keywords relating to animal models in Plastic Surgery and the associated procedures was conducted. Animal models that had cross over between specialties such as microsurgery with Neurosurgery and pinnaplasty with ear, nose, and throat surgery were included as they were deemed to be relevant to our training curriculum. A level of evidence and recommendation assessment was then given to each surgical model.

RESULTS

Our review found animal models applicable to plastic surgery training in four major categories namely-microsurgery training, flap raising, facial surgery, and hand surgery. Twenty-four separate articles described various methods of practicing microsurgical techniques on different types of animals. Fourteen different articles each described various methods of conducting flap-based procedures which consisted of either local or perforator flap dissection. Eight articles described different models for practicing hand surgery techniques. Finally, eight articles described animal models that were used for head and neck procedures.

CONCLUSIONS

A comprehensive summary of animal models related to plastic surgery training has been compiled. Cadaveric animal models provide a readily available introduction to many procedures and ought to be used instead of live models when feasible.

Animal Models for Tendon Repair Experiments: A Comparison of Pig, Sheep and Human Deep Flexor Tendons in Zone II

Background: This laboratory study compared pig, sheep and human deep flexor tendons in regards to their biomechanical comparability.

Methods: To investigate the relevant biomechanical properties for tendon repair experiments, the tendons resistance to cheese-wiring (suture drag/splitting) was assessed. Cheese-wiring of a suture through a tendon is an essential factor for repair gapping and failure in a tendon repair.

Results: Biomechanical testing showed that forces required to pulling a uniform suture loop through sheep or pig tendons in Zone II were higher than in human tendons. At time point zero of testing these differences did not reach statistical significance, but differences became more pronounced when forces were measured beyond initial cheese-wiring (2 mm, 5 mm and 10 mm). The stronger resistance to cheese-wiring was more pronounced in the pig tendons. Also regarding size and histology, sheep tendons were more comparable to human tendons than pig tendons.

Conclusions: Differences in tendon bio-properties should be kept in mind when comparing and interpreting the results of laboratory tendon experiments.

An analysis of partial width flexor tendon graft preparation on porcine models: the optimal split?

Partial width tendon grafts are commonly used in upper limb reconstructive surgery. Different techniques are described to harvest the graft including a "cheese wire" technique to split the tendon along its fibres with a filament. However no study has looked at the best material for this purpose. Fresh flexor tendons from pigs' trotters were used to analyse the splitting qualities of 11 different suture materials. The qualities assessed were: whether the suture material was successful in splitting the tendon, the average force required to split the tendon and the resulting quality of the spilt tendon graft. Whilst wire sutures produced a high quality of graft, they were awkward to use as they necessitated handling with a holder due to the higher forces required to split the tendon. Fibrewire provided the best result with respect to graft quality and ease of method as it combined the cutting strength of wire with the handling characteristics of a braided suture.

Influence of core suture geometry on tendon deformation and gap formation in porcine flexor tendons

The effects of core suture geometry on the mechanics of failure in flexor tendon surgery are investigated. Forty porcine flexor tendons were repaired using a Kessler; a Kessler-Pennington; a double Kessler; a continuous Kessler; and a cruciate repair. At maximum breaking strength, the cruciate repair gapped more then the double Kessler (12.8 mm vs 9.1 mm), but the double Kessler was less strong (37N vs 45 N). Transverse narrowing was 22% and 24% for the Kessler and the Kessler-Pennington, 11% for the double Kessler, and 0% for the continuous Kessler and the cruciate repair. Kessler-type sutures failed by suture breakage and the cruciate repair by pull-out. Under load, the transverse part of the Kessler sutures narrows, allowing longitudinal parts to lengthen, leading to gapping. The double Kessler shortened transverse segment decreases gapping. Eliminating a transverse component (the cruciate repair) decreased gapping, but the cruciate failed at higher loads by suture pull-out.