Teaching Unilateral Cleft Lip Repair: Lessons Learned from Simulation

Abstract

BACKGROUND: Traditionally, learning how to perform cleft lip repair required becoming familiar with markings, followed by learning the operation through assisting with surgery. During a recent study examining the use of cleft lip simulation for evaluating surgical aptitude and impact on long-term learning, we noticed residents and fellows often skip or inadequately perform crucial steps in the procedure. That surprising observation inspired the current study, which aims to identify specific areas for improvement in teaching of cleft lip repair. METHODS: Secondary analysis of existing data looked granularly at performance during an uncoached cleft lip repair on a high fidelity simulator. Simulation videos were anonymously rated by two surgeons using an 18 item Unilateral Cleft Lip Repair competency assessment tool (1-3 scale for each item), subdivided into ‘Marking’, ‘Performing’, and ‘Result’ sections. Mean scores for each skill were rank ordered to identify elements of the procedure that participants performed best (indicating adequate teaching) and worst (suggesting improvement needed). Association between objective outcome (represented by a digitally measured symmetry index) and performance on particular steps of the procedure was examined using Pearson R to determine which items were most important for a symmetrical result, and which were likely to improve with progression through training (ie. correlated with PGY). RESULTS: Simulation participants (n=26) of all training levels scored highest on skills in the ‘Marking’ subscale (2.38-2.63 mean score). Participants scored relatively poorly on some items of the ‘Performance’ subscale (2.00-2.46 mean score), and most items of the ‘Result’ subscale (1.67-2.25 mean score). Procedural steps that scored lowest were: closing the nasal floor (2.00), repairing oral mucosa (2.15), avoiding over/under-dissection (2.19), avoid unneccessarily retaining or resecting tissue (2.21), and fully mobilizing the lesser segment (2.23). Interestingly, while the latter three items all significantly correlated with symmetry of the repair (R=-0.54, -0.59, and -0.66 respectively) and with PGY (R=0.48, 0.47, and 0.45 respectively), the former two items did not correlate with either symmetry or PGY. CONCLUSION: All elements of marking a unilateral cleft lip repair scored well, suggesting that simulators and likely educators appropriately teach cleft marking. Skills involving tissue handling and understanding tissue mobility improve with higher training levels, likely because these are universal plastic surgical concepts that progress with experience. Scores for closing the nasal floor and repairing the oral mucosa scored lowest and did not improve with higher training levels; this suggests we do not optimally teach these maneuvers, perhaps because they are harder to see and understand while watching an operation. Although they do not correlate with external appearance (symmetry), these elements are important for functional outcome, because leaving the nasal floor open creates a persistent oronasal fistula that allows food escape into the nose. Inadequately repairing oral mucosa can allow the labial sulcus to herniate downward with smiling. Proposed interventions include dedicated teaching for these nuanced steps, and incorporating more video and simulation to demonstrate maneuvers that are difficult to visualize in vivo.