Cleft Palate Surgical Skills Training Using an Alternative Synthetic Bench Model.

Abstract

To the Editor: Although there have been numerous reports[1,2,3,4,5] of different synthetic simulators that can provide cleft palate training, none offers a completely ideal model. We proposed an alternative three-dimensional (3D) cleft palate bench model to improve understanding and conceptualization of cleft palate repair, as well as offer deliberative and repetitive hands-on training of basic cleft palate repair skills [Figure 1] before applying surgical techniques on live patients. Figure 1 Step-by-step description of the assembly of our cleft palate bench model. (a) Materials: 2-mm-thick plates of ethylene-vinyl acetate (Eureka E.V.A., Brazil; simulating the oral [skin color], muscle [red], and nasal [white] layers); a red drinking straw ... As we used a life-sized maxillary dental cast, all the training processes were carried out with reliable anatomical relationships and surgical movements (i.e., incision, dissection, flaps, and sutures), and individuals can be trained using important referential anatomical points (e.g., Ernst's space, pterygoid hamulus, palatine canals, and palatine vessel localizations). The synthetic material we adopted to simulate the oral, muscle, and nasal layers allowed dissection and suturing under reasonable tension. Further, as the texture of this material mimics the fragility of the palate soft tissues, gentle tissue handling is necessary. In fact, this synthetic material can tear; as this occurs when the trainee make a wrong movement (e.g., does not follow the curvature of the needle, applies excessive force), this feature might serve as an excellent evaluation mechanism and provide opportunities for feedback from the faculty trainers. Numerous important anatomical structures (oral cavity, muscle layer, and blood vessels) are not simulated in some of the available cleft palate bench models;[1,2] therefore, these simulators do not allow the hands-on training of relevant surgical skills, such as dissection and suturing of the muscles of the soft palate. High cost and limited accessibility and reproducibility are also limitations of previous 3D cleft palate simulators.[4,5] We, therefore, proposed a 3D, homemade, simple, inexpensive, portable, reproducible, and life-sized bench model of the oral cavity of a pediatric cleft palate patient. Although these features have also been described as advantages of a previous cleft palate bench model,[3] we can simulate greater palatine vessels and the nonanatomic orientation of the soft palate musculature. In addition, as similar to some available cleft palate bench models,[3,4] our simulator was developed to facilitate trainees’ acquiring of cleft palate repair skills, including operating in a small cavity, poor depth perception, awkward angles, limited access, poor visualization, fragile soft tissue, delicate tissue handling, small flaps, in-depth suturing, simultaneous access by the trainee surgeon and the assistant faculty, and the use of the operating microscope. The primary criticism of both our and previous synthetic cleft palate bench models[1,2,3,4,5] has been their lack of fidelity with actual surgical practice. Surgical practice on living animals and human cadavers, however, has been associated with infection risks, high costs, need for specialized installations, and ethical and legal concerns. Further, the use of virtual reality simulators has been hampered by high costs and lack of access. Therefore, these synthetic inanimate bench models offer cleft palate surgical training opportunities that can develop trainees’ knowledge, skills, and attitudes while protecting patients from unnecessary risks.[1,2,3,4,5] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.