TEP and Lichtenstein anatomy: does simulation accelerate acquisition among interns?

PURPOSE: The anatomy of the inguinal region is notoriously challenging to master. We sought to teach open inguinal hernia (OIH) and totally extraperitoneal (TEP) anatomy with simulation models among general surgery (GS) interns. METHODS: Low-fidelity OIH and TEP models were constructed out of cardboard, plastic bins, fabric, and yarn. GS interns (n = 30) participated in a 3-h hernia session including a pretest, anatomy lecture, simulated OIH and TEP hernia repair, and posttest. Pre- and posttest scores were based on a difficult 30-point exam which included didactic questions (10 points), drawing relevant TEP (10 points), and OIH (10 points) anatomy. Participants were surveyed following the session. RESULTS: Median pretest scores were 13 % (range 0-60 %). Median posttest scores improved to 47 % (range 20-93 %, p < 0.001). Median number of structures drawn in the TEP image improved from 2 (range 0-14) to 11 (range 1-21, p < 0.001). Median number of structures drawn in the OIH image improved from 3 (range 0-15) to 7 (range 1-19, p < 0.001). 67 % (12/18) demonstrated improvement in knowledge of abdominal wall layers. 23 % (7/30) knew the triangles of pain/doom on the pretest vs. 77 % (23/30) on the posttest. Mean Likert scores favored session enjoyability (4.5), not a waste of training time (4.4), and improved understanding of OIH and TEP anatomy (4.4, 4.2). CONCLUSIONS: Low-fidelity simulators can be used to teach and assess knowledge of TEP and OIH anatomy. While enjoyable and useful, one 3-h session does not create master hernia surgeons or expert anatomists out of novice trainees.

A technique for visual confirmation of intrathoracic placement of tube thoracostomy using a fiberoptic laryngoscope in a cadaver.

PURPOSE: Safe intrathoracic placement of chest tubes is a continual challenge. Current techniques for determining the intrathoracic location of the thoracostomy site include blunt dissection and digital exploration, with subsequent tube placement. Using current techniques, complication rates for this procedure approach 30%. We present a novel technique using available endotracheal intubation technology for determining intrathoracic placement of tube thoracostomy. METHODS: One cadaver was used for placement of tube thoracostomy. Both sides of the thorax were prepared in the standard fashion for tube thoracostomy placement, and tube thoracostomy was performed on each hemithorax at interspaces 3 through 7. The right side of the thorax was used for standard thoracostomy placement, and the left side was used for fiberoptic visualization of thoracostomy placement using a video laryngoscope. Thoracic wall thickness was measured at all thoracostomy sites. Proper placement and any injuries were documented for each site. RESULTS: Chest wall thickness ranged from 2.4 to 3.8 cm on the right and 2.8 to 4.0 cm on the left. With use of fiberoptic thoracostomy, no injuries were generated. During the standard thoracostomy placement in the sixth intercostal space, a pulmonary laceration was caused using blunt dissection. CONCLUSIONS: Use of a fiberoptic laryngoscope offers a novel technique for direct visualization the thoracic space during tube thoracostomy. Further studies are needed to determine the safety of this technique in patients.

Investigation on the reduction of electron contamination with a 6-MV x-ray beam.

Experimental investigations have been carried out on the reduction of electron contamination of a 6-MV x-ray beam of Clinac model 1800 for square field sizes 5 X 5 to 30 X 30 cm2 in steps of 5 cm and for rectangular field sizes 19 X 7 and 7 X 19 cm2. The electron contamination of both the open beam and the beam with the tray can be effectively reduced by placing a lead foil filter immediately below the blocking tray. Measurements at 100-cm source-skin distance with filter in place showed a reduction in dose in the buildup region and also a displacement of the location of Dmax to greater depths, even for small field sizes such as 10 X 10 cm2.

Investigations on the near surface dose for three 10-MV x-ray beam accelerators with emphasis on the reduction of electron contamination.

A study of three 10-MV x-ray clinical accelerators with emphasis on the reduction of electron contamination was conducted. This study, which was performed with different types of trays and filters, suggests that, at 100-cm source-surface distance (SSD), Pb can be used as an effective filter material up to 30 X 30 cm2; however, due to its transparency, a Clear-Pb tray is useful for field sizes up to a 20 X 20 cm2. Percent depth doses for a few selected depths and field sizes at this nominal SSD were examined. No significant differences, with the exception of the location of Dmax, amongst the three accelerators were noticed.