Neurosurgery Simulators Developed for Neurosurgical Training in Brazil: A Systematic Review

Introduction Simulation in neurosurgery is a growing trend in medical residency programs around the world due to the concerns there are about patient safety and the advancement of surgical technology. Simulation training can improve motor skills in a safe environment before the actual setting is initiated in the operating room. The aim of this review is to identify articles that describe Brazilian simulators, their validation status and the level of evidence (LoE). Methodology This study was conducted using the Preferred Reported Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A search was performed in the Medline, Scielo, and Cochrane Library databases. The studies were evaluated according to the Medical Education Research Quality Instrument (MERSQI), and the LoE of the study was established according to the classification system of the Oxford Centre for Evidence-Based Medicine (OCEBM), which has been adapted by the European Association of Endoscopic Surgery. Results Of all the studies included in this review, seven referred to validated simulators. These 7 studies were assigned an average MERSQI score of 8.57 from 18 possible points. None of the studies was randomized or conducted in a high-fidelity environment. The best evidence was provided by the studies with the human placenta model, which received a score of 2b and a degree of recommendation of 3. Conclusion Brazilian simulators can be reproduced in the different laboratories that are available in the country. The average MERSQI score of Brazilian studies is similar to the international average score. New studies should be undertaken to seek greater validation of the simulators and carry out randomized controlled trials.

Coconut Model for Learning First Steps of Craniotomy Techniques and Cerebrospinal Fluid Leak Avoidance.

INTRODUCTION: Neurosurgery simulation has gained attention recently due to changes in the medical system. First-year neurosurgical residents in low-income countries usually perform their first craniotomy on a real subject. Development of high-fidelity, cheap, and largely available simulators is a challenge in residency training. An original model for the first steps of craniotomy with cerebrospinal fluid leak avoidance practice using a coconut is described. MATERIAL AND METHODS: The coconut is a drupe from Cocos nucifera L. (coconut tree). The green coconut has 4 layers, and some similarity can be seen between these layers and the human skull. The materials used in the simulation are the same as those used in the operating room. PROCEDURE: The coconut is placed on the head holder support with the face up. The burr holes are made until endocarp is reached. The mesocarp is dissected, and the conductor is passed from one hole to the other with the Gigli saw. The hook handle for the wire saw is positioned, and the mesocarp and endocarp are cut. After sawing the 4 margins, mesocarp is detached from endocarp. Four burr holes are made from endocarp to endosperm. Careful dissection of the endosperm is done, avoiding liquid albumen leak. The Gigli saw is passed through the trephine holes. Hooks are placed, and the endocarp is cut. After cutting the 4 margins, it is dissected from the endosperm and removed. The main goal of the procedure is to remove the endocarp without fluid leakage. DISCUSSION: The coconut model for learning the first steps of craniotomy and cerebrospinal fluid leak avoidance has some limitations. It is more realistic while trying to remove the endocarp without damage to the endosperm. It is also cheap and can be widely used in low-income countries. However, the coconut does not have anatomic landmarks. The mesocarp makes the model less realistic because it has fibers that make the procedure more difficult and different from a real craniotomy. CONCLUSION: The model has a potential pedagogic neurosurgical application for freshman residents before they perform a real craniotomy for the first time. Further validity is necessary to confirm this hypothesis.