Commentary: Human orbital cadaveric dissection: A trainee's gateway into surgical oculoplasty.

Abstract

Acquisition of surgical expertise in the field of ophthalmology requires mastering advanced and precise techniques, which usually is bequeathed upon the novice by their adept seniors. Ophthalmology, being a largely microsurgical arena, demands excellent hand–eye coordination with respect to tissue handling, and thus entails a steeper learning curve. While detailed demonstration of a variety of ocular surgical procedures on animal eyes in order to provide a close simulation has been documented in literature, obtaining orbital and extraocular tissues for the same is far more arduous and may necessitate restructuring of the existing wet lab infrastructure.[1] Pig eyelid models have been utilized for teaching frontalis sling surgery after levator resection and eyelid margin repairs.[2] Sheep cranium has been employed for orbital microsurgical dissection for better understanding of optic nerve and other intra-orbital structures.[3] In a recent review, authors attempted to reproduce the steps of evisceration and implant placement of desired sizes in goats’ eyes for lucid understanding of the anatomy and to aid in the residents’ suturing skills.[1] Human cadaveric dissection, though traditional, provides an opportunity to explore the elusive and inaccessible domains of the surgical field which not only serves as a prudent platform for trainees to create an anatomical mind map of the orbit and its contents, but also makes for an ideal prospect for accomplished surgeons to expand their scope of technical skills.[4] Dissection confers understanding of spatial distribution and surgical tissue planes, offering a sound knowledge of applied anatomy. A study performed at Brighton and Sussex Medical School attempted to test the hypothesis whether there was a significant difference in the educational potential of a dissection-led study of orbital anatomy between participants who were postgraduate ophthalmology trainees and pre-medical school students.[5] It was found that not only was the exercise of a refresher course in anatomy welcomed by the postgraduates but prior expertise in the field enhanced the benefits of dissection-based education. This method was deemed superior because it instigated deep learning, elevated the doctor’s capabilities to draw novel anatomical concepts in relation to pre-existing knowledge of the subject and aided in eliminating the gaps in comprehension which otherwise become apparent even to a trained surgeon only on the operating table. In addition to providing a detailed anatomical blueprint of the orbit, cadaveric simulation has also been noted to improve the self-confidence of ophthalmology residents in executing emergency procedures.[6] Lateral canthotomy and cantholysis for relieving orbital compartment syndrome, temporary tarsorrhaphy for exposure keratopathy, and eyelid laceration repairs were seen to be performed far more assertively by trainees after having rehearsed on human cadavers. The application of cadaveric dissection–led pedagogy is not only limited to functional oculoplastic procedures, but has found its way into the world of esthetic medical education as well. With the exponentially growing market for minimally invasive cosmetic procedures including injectable dermal fillers and botulinum toxin targeting the evolving signs of ageing, a thorough awareness of the facial anatomy and vasculature is of the essence. A novel dissection technique illuminating the lateral orbital anatomy has been devised to mark the periorbital danger zones enabling the trainee to execute safe and confident injectable practices.[7] Such continuing professional development undertakings will develop skilled professionals to navigate through delicate facial anatomy and deliver satisfactory esthetic outcomes. The study by Singh et al. in this journal’s issue highlights the basics of oculoplastic cadaveric dissection, emphasizing on bony anatomy, surface marking, and post-dissection respectful handling of the cadavers.[8] The dissections included a structured protocol beginning from procurement of the human cadaver, soft embalming, holistic theoretical overview of the intended surgical procedure with video assistance followed by demonstration of the actual technique. Oculoplastic surgeries included lid reconstruction, blepharoplasties, ptosis correction, external dacryocystorhinostomy, orbital floor fracture repairs, orbital and optic canal decompression. The protocol also entailed mimicking the operation theatre settings with appropriate surgical site cleansing and draping, utilizing head-mounted loupes or the operating microscope, sterile scrubbing algorithm for the surgeon, and setting of the instrument tray for the procedure. This approach helps students create a mind map which forms a visual memory and is superior to a goal-oriented study for examinations. This mind map translates into deep learning. Additionally, they also place focus on technological advancements in the expanse of cadaveric dissection such as simulation of vasculature with dyed resins, orbital tumors with polyfoam injection, and navigation guidance and three-dimensional printing for accurate localization of surgical landmarks. In conclusion, human cadaveric dissection-led tutelage provides an astute gateway for both novice surgeons and experienced professionals into the land of oculoplastic surgery, encouraging development of surgical confidence and fine tuning of previously acquired skills.