Experience In Microsurgery Research Articles

The modified placenta model for microsurgery training: Recommended methods for comprehensive microsurgery experience

PurposeCurrently, rats are the most preferred models for microsurgery training. However, living rats come with several limitations. The use of the placenta in this field is still restricted. Our aim was to increase the realism of the placenta model by introducing several improvements such as pulsation and thrombus models. Additionally, it was also aimed to provide a specific time schedule for the reliable use of the placenta. MethodsThe study included 30 placentas and 10 participants. Placentas were divided into three groups; Group A (ten placentas) were allocated for training. At the end of each training day, trainees were asked to complete a questionnaire. To obtain samples for histopathological evaluation another group (Group B) was formed. The placentas of both of the groups (A and B) were used as fresh at the first day and then stored in the refrigerator (under 4 ​°C) for the following 3 days. The remaining ten placentas (Group C) were kept at room temperature. This group was also subjected to histopathological analysis. Histopathological evaluation was performed to determine the necrosis ratio within the layers of Endothelium and Media (E/M). Vessels were divided into 6 levels and microscopically analysis was performed to determine the diameters of these vessels. ResultsThe average questionnaire scores throughout the first three days were high enough to indicate a better/significantly better microsurgery experience compared to that on rats. Subsequent necrosis ratios (E/M) were relatively low during the first three days which confirms the results of the questionnaire. This is mainly attributed to the cold ischemia precautions taken during the study. The vessel diameters (A/V) of the placenta from level 1 to level 6 were as follows; 2.95/6.64, 3.56/3.84, 2.65/2.97, 1.63/1.82, 1.19/1.48 and 0.56/0.49 ​mm respectively. ConclusionThe inclusion of pulsation and thrombus models in the modified placenta model enhances the realism of the microsurgery training experience. According to trainee feedback, the modified placenta model offered a superior training experience compared to living rats during the first three days. We recommend integrating this model with a living rat in a hybrid approach to obtain a comprehensive microsurgery training program.

Teaching of Microsurgery and Supermicrosurgery for Residents.

On the basis of our numerous years of experience in teaching residents without microsurgery experience and assisting in the initiation of microsurgery in clinical practice, we herein describe the general procedures and crucial aspects to consider regarding microsurgery and supermicrosurgery training for residents. The description focuses on training methods, surgical skills, and training time and effort. The target audience of the training is residents who have never performed microsurgery. We believe that any person, regardless of operative experience, can acquire the technique for microsurgery and supermicrosurgery by performing 4 to 5 hours of training per day over a total of 30 days within this program setting. Considering individual differences in learning and experience, the training can be completed in a shorter period by performing additional daily training. It is relatively simple for a well-trained microsurgeon to master the uncommon supermicrosurgery techniques. We hope that this report will help as many residents as possible in learning the art of (super)microsurgery.

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

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. 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. 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). 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.

Relaxation and Performance During Microsurgical Learning

Introduction: Microsurgical learning is a difficult and stressful process, requiring self-control to achieve relaxation. The purpose of this study is to evaluate peripheral and central nervous system relaxation during microsurgical training. Methods: This cohort study included ten medical students with no previous experience in microsurgery. The somatic peripheral nervous system was evaluated by the force applied to a custom-designed microsurgical needle holder. The autonomic peripheral nervous system was assessed by a heart rate monitor. Central nervous system relaxation was evaluated by the State and Trait Anxiety Inventory scores. The quality of the anastomosis was graded by the Microsurgical Anastomosis Rating Scale (MARS10). These data were compared to a group of 5 senior microsurgeons who underwent a single assessment. Results: The time to complete the anastomosis and the force decreased significantly with training after only 2 weeks ( P &lt; .05). After 4 weeks of training, no statistical difference was observed between students and experts regarding force while the time of suture was still significantly different at 30 days ( P = .001). The maximum heart rate decreased significantly at 2 weeks ( P = .01). Anxiety scores decreased significantly between days 1 and 15 ( P = .002 and P = .036). The MARS10 score demonstrates that the quality of the suture increases significantly during the first 15 days ( P = .006). Conclusion: Peripheral and central nervous system relaxation as well as the quality of the microsurgical anastomosis increase significantly after only 15 days of learning. The force-sensing microsurgical needle holder offers a new tool for the evaluation of relaxation and can function as a learning aid.

Perforating cutaneous vessels: A key feature of acupoints - Anatomical evidence from five-Shu acupoints in the upper limbs.

Acupuncture has been proven an effective clinical treatment for numerous pathological conditions and malfunctions. However, substantial anatomical evidence for acupuncture points (APs) and meridians is still lacking, so the location of APs is relatively subjective and understanding of the biological mechanisms of acupuncture is limited. All these problems hinder the clinical applications and worldwide acceptance of acupuncture. Our long-term microsurgery experience has indicated that Perforating Cutaneous Vessels (PCVs) are highly relevant to APs but the anatomical evidence is insufficient. To address this lack, two specimens of fresh adult human upper limbs were dissected using an advanced vascular perfusion-fixation method and then examined. The results show that all 30 five-Shu APs in the upper limbs have corresponding PCVs. Both specimens showed a 100% coincidence rate between APs and PCVs, indicating that PCVs could be critical anatomical features of APs. This study also provides an anatomical basis for locating APs objectively via preliminary detection of PCVs. The findings could lead to a better theoretical understanding of mechanisms of acupuncture and the essence of meridians.

An early microvascular training program of dental intern students and junior residents: a comparative prospective study

BackgroundClinical instructional strategies and the climate in which teaching and learning take place have a significant impact on the quality of dental education. Therefore, this study aimed to evaluate the impact of early microsurgery training on the skills of dental intern students who are planning to join an oral and maxillofacial surgical field (DIS) as compared with junior residents within an oral and maxillofacial surgery department who had no microsurgery experience (JR).MethodsA total of 100 trainees, 70 were DIS, while the other 30 were JR. The average age was 23.87 ± 2.05 years for DIS group and 31.05 ± 3.06 for JR group. All trainees attended a microsurgical course (theoretical and practical parts) for seven days within a Microvascular Laboratory for Research and Education of a university-affiliated tertiary hospital. Two blinded examiners had assessed the performance of trainees independently using a specific scoring system. The independent sample t-test was used to compare the effect of microsurgery training between DIS and JR groups. The significance level was set at 0.05.ResultsThe DIS group had showed higher attendance rate than JR group (p < 0.01), with a lower absence score in DIS than JR groups (0.33 ± 0.58 vs. 2.47 ± 1.36). The total score of the theoretical test was significantly different between both groups (p < 0.01). In this context, the DIS group had revealed higher total score than JR group (15.06 ± 1.92 vs. 12.73 ± 2.49). In term of tissue preservation, there was a significant difference between both groups, with the DIS had better performance score than JR (1.49 ± 0.51 vs. 0.93 ± 0.59). Further, the practical exam score was significantly higher in DIS group than JR group (p < 0.01).ConclusionOverall, the performance of dental intern students was favourably compared with junior residents in most aspects. Therefore, it is promising and essential for dental colleges to add a microsurgery course to the curriculum of dental intern students who plan to specialize in oral and maxillofacial surgery.

33. Microsurgical Simulation Training Enhances Medical Student Acting Internship Experience

Background: Microsurgical education typically does not begin until surgical residency, and requires significant investment of time and practice.1,2 Various models and simulations have been reported to support microsurgical training, and have mostly focused on post-graduate surgical trainees.3 It has been demonstrated that medical students are capable of learning microsurgical techniques and exposure to microsurgery may improve their interest in plastic surgery.4 There is limited literature on how exposure to microsurgery training influences senior medical students applying to plastic surgery residency. Methods: Fourth year medical students completed a four hour, individual training session with expert microsurgeon (WZ) during their acting internship. Pre-training and post-training survey responses were compared using Wilcoxon signed rank test. Results: Twelve medical students completed the training session. Eighty-three percent of students (10/12) came from institutions without a microsurgery fellowship program. Two-thirds of students had no prior hands-on microsurgery experience. Ninety-one percent of students (11/12) were either extremely or somewhat uncomfortable performing end-to-end anastomoses of synthetic vessels. After the session, 58% of students (7/12) felt extremely or somewhat comfortable, with only 17% feeling somewhat uncomfortable (p=0.003). All students rated the session as very or extremely useful, with 91% finding the level of instruction and skills practiced reasonable. When asked to rank their interest in plastic surgery subspecialties, one-third of students ranked microsurgery higher than they did prior to the training session (p=0.450). Ninety-one percent of students reported that it was important for them to be at a residency program that would prepare them to perform microsurgery independently after graduation. Conclusion: Medical students can successfully learn microsurgical skills, including vessel anastomoses, in just a single training session. Hands-on microsurgical practice opportunities enrich the acting internship experience, and may inspire greater medical student interest in the subspecialty as well as the hosting residency program. A microsurgical curriculum for medical students is in development, with plans to further optimize learning and professional growth.

Are cross finger and thenar flaps effective in the treatment of distal finger amputations with the reposition-flap method?

The aim of this study was to evaluate the effectiveness of using cross finger and thenar flaps in treatment of distal fingers amputations with reposition-flap method. Between September 2017 and January 2020, a total of 20 fingers of 19 patients (15 males, 4 females; mean age: 31.6±10.4 years; range, 19 to 52 years) who were treated with repositioning using a cross finger or thenar flap were retrospectively analyzed. Finger length, flap status, pain, cold intolerance, two-point discrimination, bone healing and appearance of the nail were recorded. Functional evaluation was performed using the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) score and range of motion. The mean follow-up was 19.5±5.2 months. A poor result was seen in one patient with the development of necrosis in the flap. With the exception of one finger with necrosis in the flap, no major complications were observed. Union was achieved in all other bones. The mean shortness was 3.7±1.9 mm. The mean Quick-DASH score was 4.5±5.0 and the mean two-point discrimination test was measured as 6.8±0.9. In fingertip amputations repositioning with a cross finger or thenar flap can achieve a near-normal fingertip appearance with the advantages for the surgeon of a short learning curve and no requirement for microsurgery experience. If replantation cannot be applied in fingertip amputations, this method should be considered among the treatment options, particularly for patients with high aesthetic expectations.

The Learning Curve of Murine Subretinal Injection Among Clinically Trained Ophthalmic Surgeons.

PurposeSubretinal injection (SRI) in mice is widely used in retinal research, yet the learning curve (LC) of this surgically challenging technique is unknown.MethodsTo evaluate the LC for SRI in a murine model, we analyzed training data from three clinically trained ophthalmic surgeons from 2018 to 2020. Successful SRI was defined as either the absence of retinal pigment epithelium (RPE) degeneration after phosphate buffered saline injection or the presence of RPE degeneration after Alu RNA injection. Multivariable survival-time regression models were used to evaluate the association between surgeon experience and success rate, with adjustment for injection agents, and to calculate an approximate case number to achieve a 95% success rate. Cumulative sum (CUSUM) analyses were performed and plotted individually to monitor each surgeon's simultaneous performance.ResultsDespite prior microsurgery experience, the combined average success rate of the first 50 cases in mice was only 27%. The predicted SRI success rate did not reach a plateau above 95% until approximately 364 prior cases. Using the 364 training cases as a cutoff point, the predicted probability of success for cases 1 to 364 was 65.38%, and for cases 365 to 455 it was 99.32% (P < 0.0001). CUSUM analysis showed an initial upward slope and then remained within the decision intervals with an acceptable success rate set at 95% in the late stage.ConclusionsThis study demonstrates the complexity and substantial LC for successful SRI in mice with high confidence. A systematic training system could improve the reliability and reproducibility of SRI-related experiments and improve the interpretation of experimental results using this technique.Translational RelevanceOur prediction model and monitor system allow objective quantification of technical proficiency in the field of subretinal drug delivery and gene therapy for the first time, to the best of our knowledge.

Microsurgical skills training course and impact on trainee confidence and workload

<h2>Summary</h2><h3>Introduction</h3> Our objective was to measure the impact of a basic microsurgery training course on trainees' confidence and workload in performing microsurgery. <h3>Methods</h3> A prospective study of participants in an accredited 5-day microsurgery course over a 3-month period. The confidence and workload of the participants were assessed after the first and final day. The workload was assessed using the validated NASA Task Load Index composed of 6 subscales scored on a 20-point visual analog scale (VAS). Confidence was assessed over 5 dimensions on a 5-point VAS for anastomosis performance, vessels preparation, knot tying, training effectiveness, and future practice of microsurgery. <h3>Results</h3> A total of 31 participants completed the study with 55% reporting some previous microsurgery experience. All confidence dimensions improved significantly after completing the course, regardless of prior experience (<i>p</i><0.01). Those with prior experience started and finished the course at higher confidence levels in anastomosis performance and vessel preparation than the non-experienced group (<i>p</i><0.05). Overall workload showed a downward trend (improvement) at the end of the course, but no significant changes in the experienced and non-experienced groups (<i>p</i>>0.05). Most participants scored above the 50% "sustainability threshold" for mental demand, both before (71%) and after the course (73%), however, perceived physical demand significantly reduced, <i>p</i> = 0.01. <h3>Conclusion</h3> The microsurgery course teaches fundamental skills and principles; therefore, it has merit in those who will utilize these skills in their future practice. Although there is increased confidence in skill acquisition, the impact on perceived workload during a short 5-day basic microsurgery course did not significantly change.

A portable, low-cost practice model for microsurgical skills training.

We describe a portable practice model for acquisition of microsurgical skills using widely available inexpensive tools and materials as a model in learning ophthalmic corneal suturing skills. Interested participants without prior microsurgery experience affiliated with the Jacobs School of Medicine and Biomedical Sciences with no prior microsurgical experience qualified to participate. Each participant completed written informed consent. We developed a 3-dimensional micro-stellated icosahedron model using microtubules, monofilament fishing line, jewelers' forceps, and a basic laboratory dissection microscope. We tested this model in improving microsurgical skills in a randomized, controlled intervention trial. Following a pre-assessment task of passing a microsurgical needle and performing a tie, participants were randomized to a control or an intervention (building the micro-stellated icosahedrons) group. The assessment task was repeated after two weeks. Videos of pre- and post-assessments were rated by two masked ophthalmologists. Technique scores and time to complete microsurgical tasks were analyzed to determine improvement in skills. A total of 27 microsurgically naïve participants were recruited and randomized (14 Intervention / 13 Control). Comparing pre- and post-assessments, the intervention group showed significant decrease in time required to pass the needle (P = 0.018) and significant improvement in technical scores. (P = 0.001). In the control group, there was no significant decrease in time or improvement in technical scores. The portable inexpensive micro-stellated icosahedron skills acquisition model is an effective practice model to acquire skills necessary to perform a microsurgical tie. The similarity in dimensions between the model and the eye suggests translatability to ophthalmic surgery.

Is reimplantation surgery an option in resource constrained countries?

Re-implantation of a severed body part is a demanding procedure that requires consolidated surgical efforts. Many factors influence the outcome, amongst them being availability of re-implantation team and necessary support structure. There is paucity of data on the management and outcome of the severed extremities in many resource constrained settings especially in Africa. To determine clinical presentation and outcomes of patients offered re-implantation after cut extremities. We carried out a prospective cohort study of patients presenting with cut extremities managed by re-implantation in our center between January2018 and December 2019. Variables determined included anatomical locations, ischemic time, length of surgery, grafts utilized and outcome. A total of 11 patients with 12 cut extremities requiring re-implantation were managed at Kenyatta National Hospital during the period of our study. The age range was six to forty five years. Majority were male [11] with only one female. Most injuries involved the upper limb (11 patients) with one the lower limb. The mean ischemia time was 13.3 h. Ten patients required venous or arterial grafts during the surgery. The overall success rate was 71% for the re-implantations. The functional recovery varied from fair to good in all the patients whose limbs were saved. Re-implantation surgery is a viable option in many countries with limited resources. Determinants of success rate include multidisciplinary team approach as well as motivation and necessary experience in microsurgery. Post-operative follow up is critical for functional outcome. • Male patients more affected that female. • Mean ischemic time of more than 12 h. • More than 80% required vascular grafts. • Overall reimplantations success of greater than 70%. • -multidisciplinary approach with plastic and orthopaedic surgeons is critical.

Tumor-Related and Patient-Related Variables Affecting Length of Hospital Stay Following Vestibular Schwannoma Microsurgery.

Review a single institution's vestibular schwannoma (VS) microsurgery experience to determine (1) correlations between demographics, comorbidities, and/or surgical approach on hospital length of stay (LOS) and discharge disposition and (2) trends in surgical approach over time. Retrospective case series from a multidisciplinary skull base program at a tertiary care, academic hospital. All adult (>18 years) patients undergoing primary microsurgery for VS between 2008 and 2018 were included. A total of 147 subjects were identified. Surgical approach was split between middle fossa (MF) (16%), retrosigmoid (RS) (35%), and translabyrinthine (TL) (49%) craniotomies. For the 8% of patients had other than routine (OTR) discharge. Mean LOS was significantly longer for patients undergoing RS than either MF or TL. Brainstem compression by the tumor was associated with longer LOS as were diagnoses of chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD). For all discharges, the 40 to 50- and 50 to 60-year-old subgroups had significantly shorter LOS than the 70-years-and-older patients. For the 92% of patients routinely discharged, there was a significantly shorter LOS in the 40 to 50-year-olds compared to the 70-years-and-older patients. There was a significant shift in surgical approach from RS to TL over the study period. Over 90% of VS microsurgery patients were routinely discharged with a median hospital LOS of 3.2 days, both of which are consistent with published data. There is an inverse relationship between age and LOS with patients older than 70 years having significantly longer LOS. Brainstem compression, COPD, PVD, and the RS approach negatively affect LOS. 4.

Learning microvascular anastomosis: Analysis of practice patterns

BackgroundPerforming a successful microsurgical vascular anastomosis (MVA) is challenging and requires lots of practice. However, the most efficient practice protocol is yet to be found. We aimed to compare and analyze two major practice patterns for fine motor tasks as applied to learning MVA: distributed and mass practice protocols. Ten neurosurgeons with comparable experience in microsurgery (but no experience in vascular anastomosis) were randomized to practice MVA either using a distributed (1 session/day) or a mass practice (6 sessions/day) protocol. A total of 24 sessions of practice and 2 recall test sessions were given. Anastomosis score, time to complete a single stitch and the total time to complete an anastomosis were recorded. Mass practice protocol caused a clear fatigue effect observed toward the end of each mass practice trial block. Statistical comparison using one-way analysis of variance showed significantly higher anastomosis scores and shorter times to place a single stitch as well as to complete the anastomosis in distributed practice group for the last 3 acquisition practice trials, and the 2 recall tests (p < 0.05). The relative advantage of the distributed practice protocol could be attributed to forgetting/spacing effect. Although mass practice protocol resulted in worse performance, it still showed a gradual improvement trend in performance from beginning to the end. Therefore, certain adjustments to a mass practice protocol (such as increasing the number of practice blocks) could potentially lead to an eventual performance level comparable to a distributed protocol. This point is a subject of further investigation.

Partial Heterotopic Hindlimb Transplantation Model in Rats.

Vascularized composite allotransplantations (VCA) represent the most advanced reconstruction option for patients without autologous surgical possibilities after a complex tissue defect. Face and hand transplantations have changed disfigured patients' lives, giving them a new aesthetic and functional social organ. Despite promising outcomes, VCA is still underperformed due to life-long immunosuppression comorbidities and infectious complications. The rat is an ideal animal model for in vivo studies investigating immunological pathways and graft rejection mechanisms. Rats are also widely used in novel composite tissue graft preservation techniques, including perfusion and cryopreservation studies. Models used for VCA in rats must be reproducible, reliable, and efficient with low postoperative morbidity and mortality. Heterotopic limb transplantation procedures fulfill these criteria and are easier to perform than orthotopic limb transplants. Mastering rodent microsurgical models requires solid experience in microsurgery and animal care. Herein is reported a reliable and reproducible model of partial heterotopic osteomyocutaneous flap transplantation in rats, the postoperative outcomes, and the means of prevention of potential complications.

Validating a Low-Fidelity Model for Microsurgical Anastomosis Training.

Background:With cost, size, and availability in mind, we developed a low-fidelity microsurgery anastomosis model for mastery of the tool skills needed to execute microsurgical procedures. The model combined the use of a cannulated Konnyaku Shirataki (KS) noodle with a low-cost, industrial inspection, trinocular stereo (IITS) microscope. The purpose of this study was to establish face and construct validity of this novel “combined” microsurgery training tool.Methods:Fifteen participants, divided into 3 groups based on microsurgery experience, attempted microsurgical anastomoses of a cannulated KS noodle using the IITS microscope. Participants were asked to (1) manipulate the noodle ends adjacent to each other, (2) place a single 7-0 nylon suture through the opposed ends, and (3) complete the anastomosis. To determine construct validity, the performance of the microsurgical repair (maximum score 53 points) and time-to-anastomosis was assessed. To determine face validity, microsurgeons were given a 25-item, 5-point scale survey rating their experience with the model.Results:Participants included 5 microsurgeons, 5 experienced trainees, and 5 novices. The microsurgeons judged the IITS microscope to be a close analog to an operating microscope (4.6/5 points), the combined model to have high educational value (4.7/5 points), and somewhat technical similarity with microsurgery in the operating room (OR) (3.7/5 points). The median technical score was 50 among microsurgeons, 40 among experienced trainees, and 27 among novices. Increased training level was associated with greater technical score among all 3 groups (p=0.002). The median time-to-anastomosis was 5.88 minutes for microsurgeons, 8.37 minutes for experienced trainees, and 17.10 minutes for novices. Increased training level was associated with shorter time-to-anastomosis (p=0.003).Conclusion:The use of the KS noodle with a benchtop stereo microscope is a novel approach to microsurgical training. It is inexpensive, available, conducive to high-repetition training, and suited to many learning environments. Microsurgeons found that this combined model was representative of microsurgery in the OR, and we concluded face validity. Furthermore, an association was demonstrated between training level and performance on the model, suggesting construct validity.

Combined Gaze Metrics as Stress-Sensitive Indicators of Microsurgical Proficiency.

Background. Evaluation of microsurgical proficiency is conventionally subjective, time consuming, and unreliable. Eye movement–based metrics have been promising not only in detection of surgical expertise but also in identifying actual cognitive stress and workload. We investigated if pupil dilations and blinks could be utilized in parallel to accurately classify microsurgical proficiency and its moderating features, especially task-related stress. Methods. Participants (n = 11) were divided into groups based on prior experience in microsurgery: novices (n = 6) with no experience and trained microsurgeons (n = 5). All participants conducted standardized suturing tasks with authentic instruments and a surgical microscope. A support vector machine classifier was used to classify features of microsurgical expertise based on percentage changes in pupil size. Results. A total of 109 successful sutures with 1090 segments were recorded. Classification of expertise from sutures achieved accuracies between 74.3% and 76.0%. Classification from individual segments based on these same features was not feasible. Conclusions. Combined gaze metrics are applicable for classifying surgical proficiency during a defined task. Pupil dilation is also sensitive to external stress factors; however, the usefulness of blinks is impaired by low blink rates. The results can be translated to surgical education to improve feedback and should be investigated individually in the context of actual performance and in real patient operations. Combined gaze metrics may be ultimately utilized to help microsurgeons monitor their performance and workload in real time—which may lead to prevention of errors.

Variable Experience in Microsurgery and Flap-Based Procedures Among Canadian Plastic Surgery Residents

Variable experience in microsurgery and flap-based procedures among Canadian plastic surgery residents. Plastic surgery residencies are transitioning toward a competency-based education model. It is not known whether trainees can realistically achieve proficiency in microsurgical techniques during their training. This study aims to define the operative experience in the core microsurgical flap procedures among Canadian plastic surgery residents. Microsurgical core procedural competencies (CPCs) have been described. A retrospective review was conducted, evaluating case logs recorded by graduating plastic surgery residents at 10 Canadian English-speaking training programs between 2004 and 2014. Perceived role and competence scores were also collected and analyzed. University of Toronto, Toronto, ON, Canada; University of British Columbia, Vancouver, BC, Canada. Among 27 microsurgical CPCs, 2082 procedures were logged and each resident performed an average of 37.9 (±21.7) procedures. Anterolateral thigh flaps, radial forearm-based flaps, and digit replants were the most common; however, 10.9% to 14.5% of residents did not have any operative experience with these flaps. Most residents reported zero operative experience with many of the CPCs (10.9%-100%). Co-Surgeon (50%) and First Assistant (30%) were the most common roles. None of the graduating residents reported feeling competent enough to independently perform 50% of the microsurgery CPCs. There was no difference in perceived roles when programs with ≥5 residents were compared against programs with fewer trainees. There were weak to moderate correlations between role and self-perceived competence, and between Post Graduate Year and self-perceived competence. There is wide variation in resident operative experience in microsurgical CPCs. Many residents graduate with little to no experience in many of the core procedures. Identifying areas of deficiency may help guide curriculum development in the new competency-based education model.

Learning Curve and Early Results of Interlaminar and Transforaminal Full-Endoscopic Resection of Lumbar Disc Herniations.

BackgroundFull-endoscopic spinal surgery is an evolving technique. A laborious learning phase is inevitable due to the complexity of the orientation and instrumentation. The goal of the present study is to evaluate a single surgeon’s learning curve and early outcomes in full-endoscopic resection of lumbar disc herniations.MethodsThis was a prospective non-controlled single-surgeon cohort study. In 54 patients with 57 herniations, 41 interlaminar and 16 transforaminal resections were performed. Surgery time, severity of adhesive process in the spinal canal, complication rates and clinical outcomes (VAS, ODI, custom questionnaire, recurrence and re-operation rate) were assessed.ResultsIn the interlaminar group, operative time has decreased from 60 ± 20 min in the first 20 operations to 45 ± 14 min in the following 17 (p=0.023). In the transforaminal group, operative time has decreased from 60 ± 16 min in the first 7 operations to 41 ± 12 min in following 9 (p=0.023). Severe adhesive process in spinal canal was associated with duration of symptoms greater than 2 years, longer surgery and higher risk of surgical complications. Four recurrent disc herniations were re-operated using full-endoscopic technique. VAS, ODI and pain medications significantly decreased in both groups and in re-operated patients.ConclusionThe plateau of the learning curve and good short-term clinical results of full-endoscopic interlaminar and transforaminal surgery may be achieved after twenty operations, given extensive previous experience in microsurgery. Risk of complications at the learning phase may be decreased by excluding the patients with symptoms lasting over two years.

Starting an autologous breast reconstruction program after plastic surgical training. Is it as good as it gets?

Today, the deep inferior epigastric perforator (DIEP) flap is considered to be the gold standard in microvascular breast reconstruction. Although this procedure is known as technically demanding, novice plastic surgeons must be able to perform these procedures to meet the rising demand. The purpose of this study was to evaluate if the young junior professional is trained adequately to set up and safely perform microsurgical breast reconstructions. We compared outcomes of three identically trained novice plastic surgeons who introduced the DIEP flap in their working environment. Their hospitals differed in size and experience in microsurgery. Outcomes were compared between all start-ups and a center of excellence (EMC). A total of 152 DIEP flaps were performed in 123 patients among all start-ups together. Baseline characteristics and major complications were comparable between all groups. The total flap loss rate was 2% in the start-ups versus 3.9% in the control group (p = 0.5). Although there seems to be a trend in a longer operating time in both training and nontraining academic centers, no statistical significance was found between start-ups (p = 0.13) and the control group (p = 0.17). However, a learning curve seems to be present when it comes to duration of surgery and is greatest in the community centers with zero experience in microsurgery (ZGT p = 0.002, Amphia p = 0.065). The same accounts for hospital stay. Although there seems to be a learning curve in terms of duration of surgery in hospitals with no experience in microsurgery, it is safe to perform microvascular breast reconstructions as a novice plastic surgeon.