MicrosimUC: Validation of a Low-Cost, Portable, Do-It-Yourself Microsurgery Training Kit

Innovative Clinical Scenario Simulator for Step-by-Step Microsurgical Training

BACKGROUND

 Microsurgical training should be implemented with consideration of operative difficulties that occur in actual clinical situations. We evaluated the effectiveness of a novel clinical scenario simulator for step-by-step microsurgical training that progressed from conventional training to escalated training with additional obstacles.

METHODS

 A training device was designed according to multiple and intricate clinical microsurgery scenarios. Twenty surgical residents with no experience in microsurgery were randomly assigned to either the control group (conventional training curricula, n = 10) or the experimental group (step-by-step training courses, n = 10). After 4 weeks of laboratory practice, the participants were scheduled to perform their first microvascular anastomoses on patients in an operating room. The Global Rating Scale (GRS) scores and operative duration were used to compare microsurgical skills between the two groups.

RESULTS

 There were no significant differences in the participants' baseline characteristics before microsurgical training between the groups with respect to age, sex, postgraduate year, surgical specialty, or mean GRS score (p < 0.05). There were also no significant differences in recipient sites between the two groups (p = 0.735). After training, the GRS scores in both groups were significantly improved (p = 0.000). However, in the actual microsurgical situations, the GRS scores were significantly higher in the experimental than control group (p < 0.05). There was no significant difference in the operative duration between the two groups (p < 0.13).

CONCLUSION

 Compared with a traditional training program, this step-by-step microsurgical curriculum based on our clinical scenario simulator results in significant improvement in acquisition of microsurgical skills.

Simulating A Subcondylar Mandibular Fracture With Intraoral Open Reduction and Internal Fixation: A Novel Education Tool for Residents

Study Design

Face and content validation of a surgical simulation model.

Objective

Open reduction and internal fixation in displaced subcondylar mandibular fractures is standard care. This requires an extraoral (eg: retromandibular, transparotideal) or intraoral approach. An intraoral approach requires further training since specialized instrumentation such as the 90° screwdriver system and endoscopes might be needed. Currently, no simulation models are available for training residents in intraoral reduction and fixation of subcondylar mandibular fractures. Therefore, we present a validated simulation model for intraoral treatment of subcondylar mandibular fractures.

Methods

Based on a computer tomography data set, we designed and printed a 3D model of a mandible with a unilateral subcondylar fracture. To simulate intraoral work depth, it was positioned inside a dental phantom. We tested the model by a group of experts (n = 8), simulating intraoral reduction and fixation of a unilateral subcondylar fracture, using a 90° screwdriver system, a 1.0 subcondylar plate (lambda), and 5-6 mm screws.We assessed Face and Content validity by survey.

Results

We provided an open-source printable fracture model. Printing costs were approximately US $10. Experts "Agreed" the model resembling the real scenario and its use for training intraoral reduction and fixation of subcondylar mandibular fractures.

Conclusions

We developed a low cost, reproducible, open-source simulator for subcondylar mandibular fractures. Face and Content validity was achieved through evaluation by a group of experts.

Evaluation of a Microsurgery Training Curriculum

BACKGROUND

 Microsurgery is one of the most challenging areas of surgery with a steep learning curve. To address this educational need, microsurgery curricula have been developed and validated, with the majority focus on technical skills only. The aim of this study was to report on the evaluation of a well-established curriculum using the Kirkpatrick model.

METHODS

 A training curriculum was delivered over 5 days between 2017 and 2020 focusing on (1) microscopic field manipulation, (2) knot tying, nondominant hand usage, (3) 3-D models/anastomosis, and (4) tissue experience. The Kirkpatrick model was applied to evaluate the curriculum at four levels: (1) participants' feedback (2) skills development using a validated, objective assessment tool (Global Assessment Score form) and CUSUM charts were constructed to model proficiency gain (3) and (4) assessing skill retention/long-term impact.

RESULTS

 In total, 155 participants undertook the curriculum, totaling 5,425 hours of training. More than 75% of students reported the course as excellent, with the remaining voting for "good." All participants agreed that the curriculum met expectations and would recommend it. Significant improvement in anastomosis attainment scores between days 1 and 3 (median score 4) and days 4 and 5 (median score 5) (W = 494.5, p = 0.00170). The frequency of errors reduced with successive attempts (chi square = 9.81, p = 0.00174). The steepest learning curve was in anastomosis and patency domains, requiring 11 attempts on average to reach proficiency. In total, 88.5% survey respondents could apply the skills learnt and 76.9% applied the skills learnt within 6 months. Key areas of improvement were identified from this evaluation, and actions to address them were implemented in the following programs.

CONCLUSION

 Robust evaluation of curriculum can be applied to microsurgery training demonstrating its efficacy in reducing surgical errors with an improvement in overall technical skills that can extend to impact clinical practice. It allows the identification of areas of improvement, driving the refinement of training programs.

Fundamentals of Microsurgery: A Novel Simulation Curriculum Based on Validated Laparoscopic Education Approaches

BACKGROUND

 Microsurgical techniques have a steep learning curve. We adapted validated surgical approaches to develop a novel, competency-based microsurgical simulation curriculum called Fundamentals of Microsurgery (FMS). The purpose of this study is to present our experience with FMS and quantify the effect of the curriculum on resident performance in the operating room.

METHODS

 Trainees underwent the FMS curriculum requiring task progression: (1) rubber band transfer, (2) coupler tine grasping, (3) glove laceration repair, (4) synthetic vessel anastomosis, and (5) vessel anastomosis in a deep cavity. Resident anastomoses were also evaluated in the operative room with the Stanford Microsurgery and Resident Training (SMaRT) tool to evaluate technical performance. The National Aeronautics and Space Administration Task Load Index (NASA-TLX) and Short-Form Spielberger State-Trait Anxiety Inventory (STAI-6) quantified learner anxiety and workload.

RESULTS

 A total of 62 anastomoses were performed by residents in the operating room during patient care. Higher FMS task completion showed an increased mean SMaRT score (p = 0.05), and a lower mean STAI-6 score (performance anxiety) (p = 0.03). Regression analysis demonstrated residents with higher SMaRT score had lower NASA-TLX score (mental workload) (p < 0.01) and STAI-6 scores (p < 0.01).

CONCLUSION

 A novel microsurgical simulation program FMS was implemented. We found progression of trainees through the program translated to better technique (higher SMaRT scores) in the operating room and lower performance anxiety on STAI-6 surveys. This suggests that the FMS curriculum improves proficiency in basic microsurgical skills, reduces trainee mental workload, anxiety, and improves intraoperative clinical proficiency.

Reduction of the Number of Live Animals Used for Microsurgical Skill Acquisition: An Experimental Randomized Noninferiority Trial

BACKGROUND

 Live animals have been used for decades as one of the many training models for developing surgical skills. Microsurgery in particular relies on training for skill acquisition and maintenance, using live animal models, especially rats (murine models). Efforts are underway to reduce the number of rats sacrificed to achieve this objective.

METHODS

 A group of students with minimal microsurgical experience, after having gone through a basic microsurgical course, were randomly split into three equal groups, all three groups following a 24-week standard training program based on low- and medium-fidelity training models with standardized murine training days. In addition to the standard training regimen, each participant performed supplementary training on live rats every 4, 6, or 8 weeks. According to the training program, the procedures have been performed on chicken legs, flower petals, and rats, each procedure being blindly assessed and evaluated using validated models and scales. The primary evaluated outcome was the Stanford Microsurgery and Resident Training (SMaRT) scale result of the final rat anastomosis performed by each group, for which the tested hypothesis was one of noninferiority. The secondary outcomes were represented by the final rat anastomosis time, final chicken leg anastomosis result and time, and the final petal score.

RESULTS

 After the 24th week, no differences were observed between the three groups regarding their microsurgical skills, as measured by the aforementioned surgical outcomes. All participants improved significantly during the study (mean [standard deviation] 19 ± 4 points on the SMaRT scale), with no significant differences between the groups, p < 0.001 for noninferiority.

CONCLUSION

 A training regimen based on low- and moderate-fidelity models, with the addition of training on a live rat every 8 weeks was noninferior to a training regimen that used a live rat every 6 weeks and also noninferior to a training regimen that used a live rat every 4 weeks.

Video-Based Microsurgical Education versus Stationary Basic Microsurgical Course: A Noninferiority Randomized Controlled Study

BACKGROUND

 Repetitive training is essential for microsurgical performance. This study aimed to compare the improvement in basic microsurgical skills using two learning methods: stationary microsurgical course with tutor supervision and self-learning based on digital instructional materials. We hypothesized that video-based training provides noninferior improvement in basic microsurgical skills.

METHODS

 In this prospective study, 80 participants with no prior microsurgical experience were randomly divided into two groups: the control group, trained under the supervision of a microsurgical tutor, and the intervention group, where knowledge was based on commonly available online instructional videos without tutor supervision. Three blinded expert microsurgeons evaluated the improvement in basic microsurgical skills in both groups. The evaluation included an end-to-end anastomosis test using the Ten-Point Microsurgical Anastomosis Rating Scale (MARS10) and a six-stitch test on a latex glove. Statistically significant differences between groups were identified using standard noninferiority analysis, chi-square, and t-tests.

RESULTS

 Seventy-seven participants completed the course. Baseline test scores did not differ significantly between groups. After the 4-day microsurgical course, both groups showed statistically significant improvement in microsurgical skills measured using the MARS10. The performed tests showed that data for self-learning using digital resources provides noninferior data for course with surpervision on the initial stage of microsurgical training (7.84; standard deviation [SD], 1.92; 95% confidence interval [CI], 7.25-8.44) to (7.72; SD, 2.09; 95% CI, 7.07-8.36).

CONCLUSION

 Video-based microsurgical training on its initial step provides noninferior improvement in microsurgical skills to training with a dedicated instructor.