[Flap harvest training on a new ultrarealistic simulation model: In-training operator feedback about a pulsating reperfused and reventilated cadaver Simlife®]. / Prélèvement des lambeaux sur sujet anatomique et nouveau modèle de simulation ultra-réaliste : retour d'expérience d'un opérateur en formation sur corps reperfusé pulsatile et reventilé Simlife®.

INTRODUCTION: The anatomical subject is still a key element to learn complex procedures in plastic surgery. We present here the evaluation of an in-training operator on a SIMLIFE® model, hyper realistic model consisting in human bodies donated to science equipped with pulsating recirculation and reventilation device. MATERIAL AND METHODS: From February 2019 to October 2019, 8 forearm flaps with radial proximal pedicle were harvested by the learner on a SIMLIFE® model. Conditions were as close as possible to the operating room : asepsy, sterile draping, assistant and instrumentation including electrocoagulation. RESULTS: The procedure was decomposed in 13 distinct steps. Mean total surgery time was 90,5±11,62minutes. There was only one case of arterial pedicle lesion resulting in major blood leak. Bleeding was measured by fake blood loss from the SIMLIFE® console. Mean intraoperatoy bleeding was 171±108 milliliters. We review pros and cons of this new technology particulary suited for complex plastic and reconstructive surgery training. CONCLUSION: Using SIMLIFE® technology we have a new mean to train for complex procedures in plastic and reconstructive surgery. This new technology could be applied to numerous other surgical procedures. Broader applications are still limited by cost and cadaver use legislation.

[Male to female sex reassignment surgery with a new surgical simulation device using a human perfused cadaver SIMLIFE®: New paradigm in transsexual surgery education ?] / Aïdoïopoïèse sur modèle cadavérique humain revascularisé pulsatile et ventilé SIMLIFE® : cas isolé ou futur changement de paradigme en chirurgie de réassignation génitale ?

INTRODUCTION: In 2015, we reported our experience with the learning curve in genital reassignment surgery and highlighted a four-step learning concept. CLINICAL CASE: In this article, we present our first vaginoplasty performed on a humanoid model SIMLIFE®, a human body associated with a pulsating circulation device and a ventilation device. RESULTS: The surgical technique included 14 steps. The total surgical time was 182minutes. There was no intraoperative complication, and there was no damage to the urethra or rectum. The intraoperative bleeding measured by the loss of operative fluid was 280mL. We discuss the advantages of this technology perfectly adapted to transsexual surgery. CONCLUSION: We demonstrated the feasibility of vaginoplasty performed on a humanoid model SIMLIFE® and highlighted improvement of the surgical skills with this model. This technology could find many other surgical applications. However, it faces cost constraints and legislation on corpses.

SIM Life: a new surgical simulation device using a human perfused cadaver.

PURPOSE: In primary and continuing medical education, simulation is becoming a mandatory technique. In surgery, simulation spreading is slowed down by the distance which exists between the devices currently available on the market and the reality, in particular anatomical, of an operating room. We propose a new model for surgical simulation with the use of cadavers in a circulation model mimicking pulse and artificial respiration available for both open and laparoscopic surgery. METHODS: The model was a task trainer designed by four experts in our simulation laboratory combining plastic, electronic, and biologic material. The cost of supplies needed for the construction was evaluated. The model was used and tested over 24 months on 35 participants, of whom 20 were surveyed regarding the realism of the model. RESULTS: The model involved a cadaver, connected to a specific device that permits beating circulation and artificial respiration. The demonstration contributed to teaching small groups of up to four participants and was reproducible over 24 months of courses. Anatomic correlation, realism, and learning experience were highly rated by users CONCLUSION: This model for surgical simulation in both open and laparoscopic surgery was found to be realistic, available to assessed objectively performance in a pedagogic program.

From anatomy to laparoscopic surgery, or how to reconcile surgeons to embryology.

PURPOSE: With the development of laparoscopy, new surgical techniques for colon resection were required. New anatomic plans of dissection were described for laparoscopic technique (medial to lateral approach) and the surgeons had to learn a complete different anatomy known as "laparoscopic anatomy". To help the surgeon through the milestones of laparoscopic colon resection, we propose an embryological and anatomical analysis of the changes of the colon and peritoneum during the foetal period to highlight the laparoscopic approach and surgical landmarks. METHODS: Seventeen human foetuses, age ranged from 7½ to 33 weeks were studied by dissections and histology. Three adult cadavers underwent laparoscopic colon surgery. RESULTS: Photographic representations of surgical views are displayed, and detailed descriptions applicable to anatomical structures are presented. CONCLUSION: Understanding the changes in the colon and peritoneum morphology leads to a clarification of the surgical technique for laparoscopic colon surgery.

SimLife model: introducing a new teaching device in endocrine surgery simulation.

To evaluate the validity and reliability of an innovative training model for endocrine surgical procedures. A simulator training model for endocrine procedures (SimLife) was developed at an academic center. The model consisted of a realistic operating environment with a coherent simulated patient dynamized by pulsatile vascularization with simulated blood warmed to 37 °C, and ventilation. Training sessions were designed for adrenal and thyroid surgery, as well as neck dissection. The primary outcome of interest was to evaluate learners' performance and satisfaction. Learners' performance was evaluated based on a scoring scale that followed the Downing method for the assessment of competency. While learners' satisfaction was evaluated using a Likert scale of 1 to 10 on four items (ease of learning, anatomic correspondence of landmarks, realism, and overall satisfaction). Participants were engaged in 32 training sessions. These included 24 adrenalectomies (conventional and laparoscopic both transabdominal and posterior), and 4 thyroid lobectomies with concomitant functional lateral compartment neck dissection. competency scores were procedure-specific addressing specific core components of a given procedure. Learners' performance scored above average in all procedures evaluated. Satisfaction scores for the specified four items ranged between 8.43 (SD 0.87) and 8.89 (SD 0.96). No major events were reported for the adrenalectomies, while only one jugular vein injury occurred during neck dissection. SimLife is a hyper-realistic training model that allows for satisfactory acquisition of skills and the evaluation of performance progression. It has the potential to become a cornerstone in specialized surgical training.

SimLife® technology in surgical training - a dynamic simulation model.

In initial surgical formation and continuing surgical education, simulation has become a compulsory technique. Just as becoming an airplane pilot requires skills, the acquisition of technical skills is essential to becoming a surgeon. The old apprenticeship model "I see, I do, and I teach" is no longer entirely compatible with the socio-economic constraints of the operating room, demands for guaranteeing patient safety, and the compulsory reduction in resident working hours. We propose a new surgical simulation model, using cadavers donated to science that are rendered dynamic with pulsatile vascularization and ventilation. Such models are available for simulation of both open surgery and laparoscopy. Surgery on a human body donated to science makes it possible to accurately reproduce the hand gestures characteristic of surgical procedures. Learning in an appropriate and realistic simulation context increases the level of skills acquired by residents and reduces stress and anxiety when they come to perform real procedures.

Bariatric Surgical Simulation: Evaluation in a Pilot Study of SimLife, a New Dynamic Simulated Body Model.

BACKGROUND: The demand for bariatric surgery is high and so is the need for training future bariatric surgeons. Bariatric surgery, as a technically demanding surgery, imposes a learning curve that may initially induce higher morbidity. In order to limit the clinical impact of this learning curve, a simulation preclinical training can be offered. The aim of the work was to assess the realism of a new cadaveric model for simulated bariatric surgery (sleeve and Roux in Y gastric bypass). AIM: A face validation study of SimLife, a new dynamic cadaveric model of simulated body for acquiring operative skills by simulation. The objectives of this study are first of all to measure the realism of this model, the satisfaction of learners, and finally the ability of this model to facilitate a learning process. METHODS: SimLife technology is based on a fresh body (frozen/thawed) given to science associated to a patented technical module, which can provide pulsatile vascularization with simulated blood heated to 37 °C and ventilation. RESULTS: Twenty-four residents and chief residents from 3 French University Digestive Surgery Departments were enrolled in this study. Based on their evaluation, the overall satisfaction of the cadaveric model was rated as 8.52, realism as 8.91, anatomic correspondence as 8.64, and the model's ability to be learning tool as 8.78. CONCLUSION: The use of the SimLife model allows proposing a very realistic surgical simulation model to realistically train and objectively evaluate the performance of young surgeons.

Influence of nephron mass and a phosphorylated 38 mitogen-activated protein kinase inhibitor on the development of early and long-term injury after renal warm ischaemia.

BACKGROUND: Renal ischaemia is accompanied by acute and chronic complications. Tumour necrosis factor (TNF) alpha production via p38 mitogen-activated protein kinase (MAPK) is one of the pivotal mechanisms linking ischaemia to inflammation and could be a therapeutic target. FR167653 (FR), an inhibitor of p38 MAPK and TNF-alpha production, may ameliorate renal damage through its effects on TNF-alpha. METHODS: Warm ischaemia (WI) was induced in male pigs by bilateral clamping of the renal pedicle for 60 min or unilateral renal clamping after contralateral nephrectomy. FR was administered before and during WI, and continuously for 3 h during reperfusion in pigs exposed to the same WI conditions. Experimental groups were compared with sham-operated pigs and those subjected to unilateral nephrectomy without renal ischaemia. Renal function, fibrosis and inflammation were evaluated, and expression of monocyte chemoattractant protein 1, transforming growth factor beta and TNF-alpha was determined after 12 weeks. RESULTS: FR significantly reduced renal failure in groups subjected to unilateral nephrectomy and bilateral renal ischaemia. Proteinuria was significantly reduced, and inflammation and expression of proinjury proteins were diminished, accompanied by a reduction in renal fibrosis. CONCLUSION: Control of TNF-alpha production and activity prevents renal damage after prolonged WI.

[The anatomical substrate of muscle contractility]. / Le support anatomique de la contraction musculaire.

Muscle fiber action participates in a true contractile machinery associated with noncontractile components providing mechanical stability. The myofibril, the muscle fiber subentity, has an extremely consistent architecture, composed of longitudinal cylindrical units called sarcomeres, the skeletal muscle length functional unit, a highly important place in the transduction of chemical signal into mechanical contractile energy, for the most part mediated by calcium. The sarcoplasmic reticulum is the other major component of muscle fiber and is dedicated to calcium storage, liberation and distribution to the fiber, under the influence of action potential propagation. This phenomenon is called excitation-contraction coupling. This paper explores muscle anatomy from its main embryologic stages of development to its histochemical specificity, including its molecular constitution, and details the main morphofunctional relations supporting muscle contraction.

Scanographic features of gastrointestinal stromal tumors.

PURPOSE: To present the scanographic features of gastrointestinal stromal tumor (GIST) and to discuss their differential diagnosis. PATIENTS AND METHODS: A retrospective study of 45 patients who underwent surgery for GIST between January 1990 and March 2006 was performed. RESULTS: Patient age was 64 years on average. The most common symptoms were abdominal pain and gastrointestinal bleeding. Tumors were located in the stomach in 28 patients (body: 19, antrum: 5, fundus: 4), the small intestine in 13 (jejunum: 6, duodenum: 4, ileum: 3), the rectum in two and the small bowel mesentery in two. Computed tomography showed a large (average size: 9.2 cm, range 3.3-30 cm) exophytic extragastric lobulated mass with an associated wall thickening in 35 cases (78%). The pattern was an endoluminal polyp (average size: 3.2 cm, range 2.2-5.5 cm) in eight cases (18%). The two mesenteric stromal tumors (4%) were seen as well-delimited lobulated large masses (3 and 12 cm). The enhancement was peripheral with central hemorrhagic, necrotic and cystic areas in 37 cases (82%). Mucosal ulceration was seen in 18 cases (40%) and ascites in five (11%). Peritoneal spread and liver metastasis were demonstrated in three patients (7%). Calcification, metastatic lymphadenopthy, venous thrombosis or vascular invasion were not seen. CONCLUSION: Scanographic features of GIST can suggest the diagnosis of GIST before surgery.

[Imaging in the diagnosis and the staging of gallbladder tumors]. / Place de l'imagerie dans le diagnostic et le bilan des tumeurs de la vésicule biliaire.

Most of gallbladder tumors are benign. Adenoma, cholesterol polyps, or adenomyomatosis are most frequently typical on ultrasonographic images. All symptomatic lesions must be considered as indications for surgery. It may be difficult to identify precancerous or malignant lesion. Polyps over 1cm are indication for preventive cholecystectomy. In case of suspicious polyp or suspicious wall thickening, endoscopic ultrasonography can be helpful to evaluate local tumoral spread and eliminate differential diagnosis. Unfortunately, diagnosis of gallbladder cancer is often late, when surgical resection can't be curative. Computed tomography and magnetic resonance imaging examinations are then useful for local and metastatic staging.

SimLife a new model of simulation using a pulsated revascularized and reventilated cadaver for surgical education.

INTRODUCTION: Alike becoming a pilot requires competences, acquisition of technical skills is essential to become a surgeon. Halsted's theory on surgical education "See one, do one, and teach one" is not currently compatible with the reality of socio-economic constraints of the operating room, the patient's safety demand and the reduction of residents' work hours. MATERIEL AND METHODS: In all countries, this brings mandatory to simulation education for surgery resident's training. Many models are available: video trainers or pelvi-trainers, computed simulator, animal models or human cadaver… Human cadaveric dissection has long been used to teach surgical anatomy. RESULTS: Surgery on human cadaveric model brings greatest accuracy to the haptic characteristics of surgical procedures. Learning in an appropriate and realistic simulation context increases the level of acquisition of the residents' skills and reduces stress and anxiety when performing real procedures. CONCLUSION: We present a technique of perfusion and ventilation of a fresh human cadaver that restores pulsatile circulation and respiratory movements of the model.

Preoperative detection of hepatic metastases from colorectal cancer: Prospective comparison of contrast-enhanced ultrasound and multidetector-row computed tomography (MDCT).

PURPOSE: The goal of this study was to prospectively compare the sensitivity of contrast-enhanced ultrasound (CEUS) with that of multiphase multidetector-row computed tomography (MDCT) in the preoperative detection of hepatic metastases. MATERIALS AND METHOD: Forty-eight patients, with a mean age of 62years old (range: 43-85years) were prospectively included. All patients underwent CEUS following intravenous administration of 2.4mL of an ultrasound contrast agent (Sonovue(®), Bracco, Milan, Italy) and multiphase MDCT. Intraoperative ultrasound examination (IOUS) was used as the standard of reference. RESULTS: A total of 158 liver metastases were identified by IOUS, 127 by preoperative MDCT (sensitivity; 80.4%) and 102 by CEUS (sensitivity, 64.5%). The 15.9% difference in sensitivity between CEUS and MDCT was statistically significant (P=0.002). There was a disagreement between IOUS and CEUS in 23 patients (47%) and in 13 patients (27%) between IOUS and MDCT. MDCT identified one or more additional metastases in 10 patients (20%) resulting in a change in the surgical strategy. CONCLUSION: Based on an unselected patient cohort and using multiphase MDCT, CEUS is significantly inferior to MDCT for the preoperative detection of hepatic metastases of colorectal cancer.

Irreversible electroporation for locally advanced pancreatic cancer.

Pancreatic adenocarcinoma is one of the solid cancers associated with the poorest prognosis; the only curative treatment remains surgical resection but in most cases, this treatment is not possible because of distant metastasis or local extension. Irreversible electroporation is a new tumor ablation technique, which provides cellular apoptosis without any thermal coagulation effect. This technique helps preserve the ducts, vessels or nerves located in the treatment area. This article reviews the current knowledge regarding the use of electroporation for the treatment of pancreatic adenocarcinoma.

[Torsion of the spleen in children]. / Volvulus splénique chez l'enfant.

The wandering spleen is caused by congenital absence of fixating ligaments or abnormally long ligaments. It is an uncommon clinical entity, which rarely affects children. The clinical presentation of wandering spleen is variable, but the most dangerous complication is splenic torsion. A 7 year-old boy presented with abdominal pain and vomiting. The abdominal ultrasound scan discovered spleen ischemia. Volvulus of the spleen was evoked. Laparotomy was carried out and the patient underwent splenectomy. In this case the anatomical means of spleen fixity were absent. Because wandering spleen is uncommon in the paediatric population, a heightened awareness of the condition is required for accurate diagnosis and appropriate management. The treatment of choice is splenopexy, while if splenic necrosis is present, splenectomy is required.

Primary versus secondary delayed gastric emptying (DGE) grades B and C of the International Study Group of Pancreatic Surgery after pancreatoduodenectomy: a retrospective analysis on a group of 132 patients.

Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PDD) significantly contributing to post-operative morbidity. Clinical risk factors for DGE occurrence after PDD remain controversial. From January 2004 to December 2011, a total of 132 patients underwent PDD for either malignancies (73.5%) or benign diseases (26.5%) in one single universitary center. Post-operative mortality and morbidity were, respectively, 3 and 44.7%. DGE has been defined in accordance with the International Study Group of Pancreatic Surgery (ISGPS) classification. DGE was distinguished in primary or secondary. Factors associated with grades B and C of DGE, based on severity and clinical impact, were assessed by means of univariate and multivariate analysis. Thirty-eight patients (28.8%) had clinical DGE grade B or C. Post-operative complications (pancreatic fistula and/or hemorrhage or anastomotic leak) were reported in 25 out of the 38 patients (65.8%, secondary DGE), while in 13 patients it was not associated to any other complication (34.2%, primary DGE). Post-operative complications (pancreatic fistula and hemorrhage) appeared to be the most important predictive factor for Grade B or C DGE.

Biomechanical study of dynamic changes in L4-L5 foramen surface area in flexion and extension after implantation of four interspinous process devices.

BACKGROUND: Lumbar spinal stenosis is a major public health issue. Interspinous devices implanted using minimally invasive techniques may constitute an alternative to the reference standard of bony decompression with or without intervertebral fusion. However, their indications remain unclear, due to a paucity of clinical and biomechanical data. Our objective was to evaluate the effects of four interspinous process devices implanted at L4-L5 on the intervertebral foramen surface areas at the treated and adjacent levels, in flexion and in extension. MATERIALS AND METHOD: Six fresh frozen human cadaver lumbar spines (L2-sacrum) were tested on a dedicated spinal loading frame, in flexion and extension, from 0 to 10 N·m, after preparation and marking of the L3-L4, L4-L5, and L5-S1 foramina. Stereoscopic 3D images were acquired at baseline then after implantation at L4-L5 of each of the four devices (Inspace(®), Synthes; X-Stop(®), Medtronic; Wallis(®), Zimmer; and Diam(®), Medtronic). The surface areas of the three foramina of interest were computed. RESULTS: All four devices significantly opened the L4-L5 foramen in extension. The effects in flexion separated the devices into two categories. With the two devices characterized by fixation in the spinous processes (Wallis(®) and Diam(®)), the L4-L5 foramen opened only in extension; whereas with the other two devices (X-Stop(®) and Inspace(®)), the L4-L5 foramen opened not only in extension, but also in flexion and in the neutral position. None of the devices implanted at L4-L5 modified the size of the L3-L4 foramen. X-Stop(®) and Diam(®) closed the L5-S1 foramen in extension, whereas the other two devices had no effect at this level. CONCLUSION: Our results demonstrate that interspinous process devices modify the surface area of the interspinous foramina in vitro. Clinical studies are needed to clarify patient selection criteria for interspinous process device implantation. LEVEL OF EVIDENCE: Level IV. Investigating an orthopaedic device.

Renoprotective effects of trimetazidine against ischemia-reperfusion injury and cold storage preservation: a preliminary study.

BACKGROUND: Initial ischemia-reperfusion injury is associated with organ retrieval, storage, and transplantation adversely affects early graft function and influences the development of chronic graft dysfunction. We have recently shown that the protective agent trimetazidine (TMZ) added to preservation solutions: Euro-collins (EC) and University of Wisconsin (UW) was efficient to protect kidneys from ischemia-reperfusion injury in an isolated perfused kidney model. We extended these observations to investigate the role of this drug in the development and progression of organ dysfunction in the autotransplant pig kidney model. METHODS: Five experimental groups were studied. After 48-hr cold preservation, autotransplantation and immediate controlateral nephrectomy was then performed in group EC (EC+placebo (n=8), EC+TMZ (n=8), UW+placebo (n=7), and (UW+TMZ) (n=7) and compared with control group (uninephrectomized, n=4) during 14 days. Blood and urine samples were collected for the measurement of creatinine and blood urea nitrogen on postoperative days 1, 3, 5, 7, 11, and 14. Histological analysis was performed after reperfusion and at day 14. RESULTS: Survivals were 100% in group B and D versus 42% in group A and 57% in group C. Urine production occurred earlier after autotransplantation from TMZ preserved kidneys than in placebo preserved groups. Peak creat and blood urea nitrogen was significantly greater in groups B and D than in groups A and C. TMZ was also efficient both to reduce ischemia-reperfusion injury and to decrease cellular infiltration. CONCLUSION: These results support the beneficial effect of TMZ against ischemia-reperfusion injury and its early effects on grafts in the form of delayed graft function and decreased graft survival. In addition, TMZ reduces inflammatory cellular infiltration in the renal parenchyma.