Microsurgery Training Research Articles

手術トレーニング バイパス術を中心とした顕微鏡手術トレーニング

It is mandatory to develop microsurgery training methods for young neurosurgeons because the number of surgical cases has been decreasing due to the development of alternative therapy for neurovascular diseases such as radiosurgery, endovascular coil embolization, and stenting. Here we describe our training methods for microvascular anastomosis for young neurosurgeons as well as senior staff with minimum cost and maximum convenience. Our microsurgical training system consists of microanastomosis using an artificial tube and actual surgical microscope in the operating room. The depth and the size of the practical operative field can be changed using simple boxes made by each practitioner. In addition to the basic anastomosis technique, a trainee can anastomose artificial tubes in various surgical environments using an artificial skull and plastic brain with brain retractor. Training for turning the microneedle is also useful for practical microsurgery. Although there are several training systems for microsurgery, including experimental mammals such as rats and/or chicken wings, it is important for young neurosurgeons to practice micro-anastomosis in an environment similar to that of their institutions.

A short history of the microsurgery training and research laboratory at gulhane military medical academy

Microsurgical techniques have played a crucial role in the development of neurosurgery and microsurgical education has an involuting role to gain surgical competence in neurosurgery. Microsurgery laboratory at Gulhane Military Medical Academy (GMMA) was established in 1985 by Prof. Erdener Timurkaynak within the Research-Development Building. From the beginning, education of the surgeons in microsurgery has been regarded as the essential function of this center, but many experimental and anatomical researches have also taken place in this laboratory. Over the past twenty-five years, 288 courses had been held in the microsurgical laboratory and more than 1000 surgeons from different fields and specialties were trained. Many of them conducted hundreds of research projects and published scientific papers during this period. This laboratory enters in the 21st century as a dynamic research and education center committed to the continuing delivery of education, as well as ongoing research of microsurgery for the coming 100 years.

Microsurgical teaching: Our experience

Today, microsurgery plays a fundamental role in plastic surgery, expanding surgical possibilities for cancer, trauma and aesthetic-related surgery. However, throughout the years, teaching and training systems for microsurgery have not evolved in the same manner as its operative techniques. The use of rats has been, and still is, the standard model for microsurgery training. However, stringent laws for animals used in experiments, combined with the rising costs of this model, have instigated the need to find alternative methods. To overcome this dilemma, we have developed a three-step approach to optimise microsurgery training, particularly when there is no access to animal laboratories.

Microsurgery training course, Columbia University, New York

Microsurgery is a technique used in a wide range of surgical specialties, including neurosurgery and cardiothoracic, plastic, orthopaedic hand, and, vascular surgery. The aim of any basic microsurgery course is to introduce the fundamental skills and techniques required for microsurgical dissection, anastomosis, and neurovascular repair. Currently, only two microsurgery courses are run in the United Kingdom, each costing about £1300 (€1500; $2000) for five days. These courses are offered sporadically and infrequently during the year, have relatively high student to teacher ratios, and require animal licences to practise. Furthermore, they are often oversubscribed and have waiting lists. With most surgical departments strictly limiting the number of junior doctors allowed on leave at any given time, trainees often find themselves constrained and competing with colleagues to attend these seldom obtainable courses. Additionally, given that study allowances for trainees have been drastically slashed, the cost and value for money of any course are even more important. On searching the internet, we found several courses around the world, including India, Romania, Singapore, and the United States. We chose to attend the Columbia University microsurgery course 2009 in New York City. Each year the Columbia microsurgery course teaches roughly 80 people in …

The ‘round-the-clock’ training model for assessment and warm up of microsurgical skills: A validation study

Microsurgery is an essential technique in free flap reconstructions today. The technical skills involved require a learning curve, which may be affected by the current issues of limited training resources and patient safety. We describe a study on the value of a microsurgery training device as an assessment and warm up tool in basic microsurgery skills. Forty volunteers with different levels of microsurgery experience performed a microsurgical 'round-the-clock' exercise on the training device three consecutive times. Video-recordings of these performances were rated by two blinded independent assessors using a modified Global Rating Scale to assess basic microsurgery skills on the following parameters: steadiness, instruments handling and speed. Time to complete a round was also recorded objectively. The Kruskal-Wallis test was used to analyse the construct validity of the parameters assessed between the groups of level of microsurgery experience. Crohnbach's coefficient alpha was used to determine the reliability index of the independent assessors. All participants improved their time on consecutive rounds of the exercise. A median of 82 s (range 6-583 s) improvement in time between the first and third round was observed. Different mean performance time could be identified between the groups, but individual speed did not correlate significantly with microsurgery experience. Assessment of microsurgery skills using the modified Global Rating Scale demonstrated statistically significant differences for instruments handling (p=0.03) and speed (p=0.01) between the groups with regard to microsurgery experience, and improvement in the parameters assessed for all groups. Difference in steadiness (p=0.07) was not significant amongst the juniors. Consultants performed better than juniors but, at all levels of experience, significant improvement in skills was demonstrated after practice. The 'round-the-clock' microsurgery training device is an inexpensive and readily available valid tool that provides a useful warm up exercise and instant assessment of basic microsurgical skills.

Use of Earthworms for Microsurgery Training

Microsurgery procedures are widely used in reconstructive surgery after trauma defects, tumor ablation, replantation, and organ transplantation and also in experimental surgery. Training in microsurgery is an exhaustive and expensive process and thus poses a challenge to poorer countries to create and sustain special centers for these training programs. Also, the ethics of using living animals in experimental procedures continues to be challenged, which increases the costs of the last stages of microsurgery training.[1]

Comparison of vasovasostomy with conventional microsurgical suture and fibrin adhesive in rats

Microsurgical procedures are currently the gold standard for vasovasostomy with excellent results, but it takes an increased operative time demanding special training and experience in microsurgery. The objective of this study is to reach the same results with reduced operative time. Male adults Wistar rats were divided into 3 groups: I) 20 rats in control group, II) 20 with conventional one-layer microsuture and III) 20 with fibrin glue. After four weeks each rat was left for two weeks with two female rats. The fertility rates were 80% in group I, 70% in group II and 65% in group III (p > 0.05). In group II granuloma was found in 75% of the rats, while in group III in 85% (p < 0.05). Anastomosis was considered with patency in 75% and 80% of the rats in groups II and III (p > 0.05). Overall operative time was 41.7 +/- 2.49 and 28.55 +/- 1.14 minutes in groups II and III (p < 0.05) and the time to anastomosis of 24.6 +/- 1.8 and 9.35 +/- 0.78 minutes (p < 0.05), respectively. We can conclude that vasovasostomy with fibrin adhesive has the same results of the conventional microsurgery technique but with a reduced operative time and a simplified procedure.

Microsurgery Training on Omentum

Dokuz Eylul University, Medical Faculty Hastanesi, Department of Plastic, Reconstructive, and Aesthetic Surgery, Izmir, Turkey

Microsurgery training courses in Singapore

Microsurgical training is essential for those embarking on a career in plastic surgery, maxillofacial surgery or hand surgery. Training courses in the UK are generally oversubscribed with long waiting lists and course fees are now in excess of £1,000 for a five-day basic microsurgery training course. With our meagre study-leave budgets already stretched beyond breaking point, we decided to look for cheaper alternatives. A Singaporean colleague recommended the department of hand and reconstructive microsurgery at the National University Hospital (NUH), Singapore.

Basic microsurgery training: comments and proposal

Microsurgical techniques have been applied in many surgical specialties and have also a broad application in surgical research. It demands high technical skills and continued training. The microsurgical training is lengthy, very expensive and demands high commitment. The microsurgical skills should be first mastered in the lab and only then applied in the clinic. Here, we propose a model of a training course in microsurgery. We also suggest that surgical societies involved with microsurgery promote training courses on a regular basis.

Continuing Professional Development: Microsurgery Training for Orthopaedic Hand Surgeons

Microsurgical training is essential for those embarking on a career in hand surgery. Training courses in the UK are generally oversubscribed with long waiting lists and fees are now in excess of £1000 for a five day basic microsurgery training course. With meagre study leave budgets already stretched beyond breaking point, trainees may decide to look further a field for cheaper alternatives. Singapore has a world-renowned expertise in microsurgery reconstruction techniques and the Department of Hand and Reconstructive Microsurgery at the National University Hospital (NUH) Singapore (figure 1) runs regular training courses for surgeons working within their unit and throughout the rest of Asia. The NUH website describes the courses available. They run microsurgery training courses throughout the year. There are two Basic Courses per month and Advanced, Refresher, Free Flap and Replant courses are available on request. The Basic Course costs $800 Singapore (about £270 or US $600). The course administrator may be contacted via email and places reserved. Helpful information regarding hostel accommodation is also provided. Figure 1 Figure 1: NUH Singapore The courses are conducted in the Microsurgery Training Laboratory on the NUH campus (figure 2). The courses are limited to three participants. There is one technician, a former theatre sister, who is highly skilled and is always on hand to offer advice and assistance. The laboratory is small but well equipped and most importantly, air-conditioned. The courses are run to worldwide recognised standards. There are video presentations that are followed by practical sessions. Continuing Professional Development: Microsurgery Training for Orthopaedic Hand Surgeons 2 of 4 Figure 2 Figure 2: Microsurgery Training Laboratory THE BASIC MICROSURGERY COURSE AND CERTIFICATION EXAMINATION Day 1 concentrates on the mental and physical preparation necessary for good microsurgical practice. It also covers instrumentation and instrument care, basic suture techniques and principle of vascular anastomosis. The afternoon session culminates with vessel repair in a chicken thigh. Day 2 each candidate is provided with an anaesthetised albino rat and performs a dissection of the tail vessels under the microscope and then at least 3 anastomoses of the tail vessels before lunch. The afternoon session involves a groin dissection and preparation, division and anastomosis of the femoral arteries. Day 3 there is another rat and bilateral femoral artery and vein anastomoses with an inferior epigastric vein interposition graft to one of the arteries (figure 3). Day 4 there is an arterial end to side anastomosis and creation of AV fistula. Day 5 there is a formal practical examination with a timed exercise to perform a rat groin dissection and mobilisation of the femoral vessels, resection of a small segment and repair of both artery and vein with satisfactory and sustained flow all in less than 2 hours. Figure 3 Figure 3: Testing Patency in Rat Femoral Artery Repair Although the course timetable is full, there is ample time for free practice. Arrangements are informal and breaks can be taken at any time – very important when performing microsurgical procedures. The courses at NUH are usually attended by trainee surgeons from throughout Asia. European surgeons may be put off by the distance involved and the cost of travel, but even with flights, accommodation, food and taxis the European trainee will spend far less than the equivalent course fee closer to home. We would recommend the NUH courses to any UK trainees considering a microsurgery instructional course. FOR MORE INFORMATION CONTACT Department of Hand and Reconstructive Microsurgery National University Hospital 5 Lower Kent Ridge Road Singapore 119074 Email: AWYongLC@nuh.com.sg Continuing Professional Development: Microsurgery Training for Orthopaedic Hand Surgeons 3 of 4 References Continuing Professional Development: Microsurgery Training for Orthopaedic Hand Surgeons 4 of 4 Author Information Dominic Power Birmingham Hand Service, Selly Oak Hospital Simon Tan Birmingham Hand Service, Selly Oak Hospital

Validation of microsurgical models in microsurgery training and competence: A review

Microsurgery has expanded the scope of many surgical specialties and is evolving into an integral part of training programmes. The complexity of microsurgery requires considerable time and resources for adequate training and practice. This article reviews the validation of microsurgical models for microsurgery training and competence.

Video‐assisted versus conventional microsurgical training: A comparative study in the rat model

Recent technical development has led to remarkable performances in video-guided surgical procedures. A video-endoscopic system (VES) is evaluated as an alternative magnifying solution for microsurgical procedures and compared to table-top microscopes in terms of technical and surgical aspects. Six surgical residents without microsurgical experience, alternating both systems, performed each 12 aortic end-to-end anastomoses on Sprague-Dawley rats using the triangulation technique. All anastomoses underwent quality review, total and single suture time, suture spacing, vessel bite, vessel overlapping and wall penetration were evaluated and graded. Overall anastomosis quality score was 52.28 (out of a maximum of 140) using the microscope and 42.7 using the VES. Despite significant differences in total anastomosis time, the learning curves are similar for the two systems and no major differences were noted in terms of overall anastomosis quality. Video-assisted microsurgery can become a useful instrument for microsurgery training.

Teaching intestinal transplantation in the rat for medical student

Technical difficulties hamper the widespread use of intestinal transplantation in rats. We evaluated the feasibility in training this microsurgical model for medical students. Thirty eight students were assessed. After information about intestinal transplantation in rats, they spontaneously agreed to be trained for this procedure. The course consisted of 4-h weekly lessons during 4-month period. The teaching process includes assessment in four phases: I) conception of intestinal transplantation and rat anatomy; II) basic microsurgery training; III) donor operation; IV) donor/recipient operation. Wistar rats were used as donors and recipients in one-step small bowel transplantation. All students (100%) reached phase II, seven students (18.42%) reached phase III and two students (5.26%) reached phase IV. Decreased interest about the theme, lack of time and patience, frustration and/or inability were all reasons given by the student that may have contributed to the low rate of success. Medical students achieved a low rate of completion for training in rat intestinal transplantation microsurgical procedures.

New Microvenous Anastomosis Model for Microsurgical Training: External Jugular Vein

In microsurgical training, the femoral vein is used frequently for a microvenous anastomosis model. But the femoral vein in the rat does not completely simulate the human vein because of its thin wall, fragility, and tendency to collapse. These anatomic characteristics cause some difficulty in carrying out anastomoses in microsurgery training particularly for beginners. The authors propose the external jugular vein of the rat for microsurgical training in microvenous anastomoses. In 10 Wistar rats, the anatomy of the external jugular vein was studied by dissection and histology. Anatomic dissections demonstrate that the external jugular vein has an average diameter of 1.9 mm (range: 1.6 to 2.1 mm) without tendency to collapse. The vein is easily dissected without any accompanying anatomic structure for an average segment of 45 mm, allowing effortless approximator clamp placement. Comparison of its cross section with that of the femoral vein and other previously described models by light microscopy and scanning electron microscopy reveals a larger diameter and much thicker vessel wall with a prominent tunica media and adventitia. Based on the anatomic findings in 20 rats, the external jugular vein was anastomosed with end-to-end standard microsurgical technique using 8-0 (n = 10) and 10-0 (n = 10) nylon sutures. Results indicate a 100 percent patency rate immediately after the anastomosis for the two subgroups and 100 percent and 90 percent patency rates 1 week after the procedure for the 10-0 and 8-0 nylon suture groups, respectively. This model presents some advantages: the vein is easily dissected with the naked eye without using the operating microscope because it is the largest vein among the superficially located veins in the rat, and has a thick vessel wall without tendency to collapse. The operative area allows for training inbilateral microsurgical anastomoses using a single skin incision and is safe from autocannibalization. The model simulates clinical microvenous anastomosis better because of its similarities to human large diameter flap veins.

Invited Discussion

In this era of cost containment in resident education, the article by Rayan and Rayan represents a simple, economic method for introducing trainees to microsurgery. The logistics of maintaining independent microsurgical laboratories with microsurgical teachers, whether basic scientists or physicians, have become more difficult. In our institution, the microsurgery training laboratory has been discontinued with the retirement of Jim Urbaniak, and a decision was made by the Division of Orthopaedics not to continue microsurgery training. On the other hand, the Division of Plastic Surgery has an active microsurgical service, and our residents go to Louisville, where bench training is done in Bob Acland's lab. I'm afraid that as the future unfolds and microsurgery becomes less lucrative, there will be fewer opportunities for trainees to have a mentorship in a laboratory before they are asked to go into the clinical arena. I know that Maria Siemionow at the Cleveland Clinic teaches microsurgery in the Department of Surgery, including all the subspecialties.

Microsurgery Training Card: A Practical, Economic Tool for Basic Techniques

The Microsurgery Tranining Card is a useful, practical, economic, easily assembled and used device, and provides a valuable tool for basic microsurgical training, especially for residents and fellows in teaching programs.

Microsurgery Training on Discarded Abdominoplasty Material

Microsurgery Training on Discarded Abdominoplasty Material

Design and creation of an experimental program of advanced training in reconstructive microsurgery

In this study, we design an experimental protocol for the purpose of enhancing performance in training in microsurgery. It is based on five free tissue transfer exercises in rat (epigastric cutaneous flap, saphenous fasciocutaneous flap, epigastric neurovascular flap, saphenous muscular flap, and hindlimb replantation), which simulate the principal clinical procedures of reconstructive microsurgery. The first part of the study consists of an anatomical review of the flaps of 5 rats and in the second part we have carried out the free transfer of flaps on 25 rats divided into 5 groups. To differentiate between them, we have created a mathematical function, referred to as difficulty in a microsurgical exercise, which has enabled us to establish a scale of progression for training, ranging form the easiest to the most difficult. As a conclusion, we believe that this protocol is a useful instrument as it allows for a more precise assessment of microsurgical capacity due to enhanced accuracy in the reproduction of global procedures and the fact that the quantification of progress in training is based on clinical monitoring after 7 days.

3314 平行光による術具の影を利用した微細手技計測装置の開発(OS15 人工現実感援用教育訓練(II),未来社会を支えるものづくりとひとづくり(設計・システムから))

Microsurgery training using a rat or other animals has been essential for both novices and skilful surgeons, which would be hard to execute under the current circumstances. Instead of using animals, a virtual microsurgery training system is proposed and precise three-dimentional motion tracking system has been developed in this paper. Motion tracking achieved by calculating an orientation of an operating tool from two images of tool's shadows generated by two parallel ray optical systems crossed at right angles.