Smartphone-Based DIY Home Microsurgical Training with 3D Printed Microvascular Clamps and Japanese Noodles.

We have recently incorporated simple modifications of the konjac flour noodle model to enable DIY home microsurgical training by (i) placing a smartphone on a mug to act as a microscope with at least ×3.5-5 magnification, and (ii) rather than cannulating with a 22G needle as described by others, we have found that cannulation with a 23G needle followed by a second pass with an 18G needle will create a lumen (approximately 0.83 mm) without an overly thick and unrealistic "vessel" wall. The current setup, however, did not allow realistic evaluation of anastomotic patency as the noodles became macerated after application of standard microvascular clamps, which also did not facilitate practice of back-wall anastomoses. In order to simulate the actual operative environment as much as possible, we introduced the use of 3D-printed microvascular clamps. These were modified from its previous iteration (suitable for use in silastic and chicken thigh vessels), and video recordings were submitted for internal validation by senior surgeons. A "wet" operative field where the konjac noodle lumen can be distended or collapsed, unlike other nonliving models, was noted by senior surgeons. With the 3D clamps, the noodle could now be flipped over for back-wall anastomosis and allowed patency testing upon completion as it did not become macerated, unlike that from clinical microvascular clamps. The perceived advantages of this model are numerous. Not only does it comply with the 3Rs of simulation-based training, but it can also reduce the associated costs of training by up to a hundred-fold or more when compared to a traditional rat course and potentially be extended to low-middle income countries without routine access to microsurgical training for capacity development. That it can be utilized remotely also bodes well with the current limitations on face-to-face training due to COVID restrictions and lockdowns.

Microtools: A systematic review of validated assessment tools in microsurgery.

BACKGROUND: Microsurgery is a technically demanding aspect of surgery that is integral to a variety of sub-specialties. Microsurgery is required in high-risk cases where time is limited and pressure is high, so there is increasing demand for skills acquisition beforehand. The aim of this review was to analyse the available literature on validated microsurgical assessment tools. METHODS: Covidence was used to screen papers for inclusion. Keywords included 'microsurgery', 'simulation', 'end-product assessment' and 'competence'. Inclusion criteria specified simulation models which demonstrate training and assessment of skill acquisition simultaneously. Tools which were used for training independently of technical assessment were excluded and so were tools which did not include a microvascular anastomosis. Each assessment tool was evaluated for validity, bias, complexity and fidelity and reliability using PRISMA and SWiM guidelines. RESULTS: Thirteen distinct tools were validated for use in microsurgical assessment. These can be divided into overall assessment and end-product assessment. Ten tools assessed the 'journey' of the operation, and three tools were specifically end-product assessments. All tools achieved construct validity. Criterion validity was only assessed for the UWOMSA1 and GRS.2 Interrater reliability was demonstrated for each tool except the ISSLA3 and SAMS.4 Four of the tools addressed demonstrate predictive validity.4-7 CONCLUSION: Thirteen assessment tools achieve variable validity for use in microsurgery. Interrater reliability is demonstrated for 11 of the 13 tools. The GRS and UWOMSA achieve intrarater reliability. The End Product Intimal Assessment tool and the Imperial College of Surgical Assessment device were valid tools for objective assessment of microsurgical skill.

Development, manufacture and initial assessment of validity of a 3-dimensional-printed bowel anastomosis simulation training model.

BACKGROUND: It is critical that junior residents be given opportunities to practise bowel anastomosis before performing the procedure in patients. Three-dimensional (3D) printing is an affordable way to provide realistic, reusable intestinal simulators. The aim of this study was to test the face and content validity of a 3D-printed simulator for bowel anastomosis. METHODS: The bowel anastomosis simulator was designed and assembled with the use of desktop 3D printers and silicone solutions. The production cost ranges from $2.67 to $131, depending on which aspects of the model one prefers to include. We incorporated input from a general surgeon regarding design modifications to improve the realism of the model. Nine experts in general surgery (6 staff surgeons and 3 senior residents) were asked to perform an anastomosis with the model and then complete 2 surveys regarding face and content validity. Items were rated on a 5-point Likert scale ranging from 1 ("strongly disagree") to 5 ("strongly agree"). RESULTS: The overall average score for product quality was 3.58, indicating good face validity. The average score for realism (e.g., flexibility and texture of the model) was 3.77. The simulator was rated as being useful for training, with an overall average score of 3.98. In general, the participants agreed that the simulator would be a valuable addition to current simulation-based medical education (average score 4.11). They commented that the model would be improved by adding extra layers to simulate mucosa. CONCLUSION: Experts found the 3D-printed bowel anastomosis simulator to be an appropriate tool for the education of surgical residents, based on the model's texture, appearance and ability to undergo an anastomosis. This model provides an affordable way for surgical residents to learn bowel anastomosis. Future research will focus on proving educational efficacy, effectiveness and transfer that can be adapted for laparoscopic anastomosis training, hand-sewing and stapling procedures.

Novel Simulation Model with Pulsatile Flow System for Microvascular Training, Research, and Improving Patient Surgical Outcomes.

BACKGROUND: Simulation allows surgical trainees to acquire surgical skills in a safe environment. With the aim of reducing the use of animal experimentation, different alternative nonliving models have been pursued. However, one of the main disadvantages of these nonliving models has been the absence of arterial flow, pulsation, and the ability to integrate both during a procedure on a blood vessel. In the present report, we have introduced a microvascular surgery simulation training model that uses a fiscally responsible and replicable pulsatile flow system. METHODS: We connected 30 human placentas to a pulsatile flow system and used them to simulate aneurysm clipping and vascular anastomosis. RESULTS: The presence of the pulsatile flow system allowed for the simulation of a hydrodynamic mechanism similar to that found in real life. In the aneurysm simulation, the arterial flow could be evaluated before and after clipping the aneurysm using a Doppler ultrasound system. When practicing anastomosis, the use of the pulsatile flow system allowed us to assess the vascular flow through the anastomosis, with verification using the Doppler ultrasound system. Leaks were manifested as "blood" pulsatile ejections and were more frequent at the beginning of the surgical practice, showing a learning curve. CONCLUSIONS: We have provided a step-by-step guide for the assembly of a replicable and inexpensive pulsatile flow system and its use in placentas for the simulation of, and training in, performing different types of anastomoses and intracranial aneurysms surgery.

The end game - A quantitative assessment tool for anastomosis in simulated microsurgery.

With the move towards simulation based microsurgical training and emphasis on the declining usage of animal models, there is a need for an objective method to evaluate microvascular anastomosis in a non-living, simulated microsurgical training environment. Our aim was to create a validated assessment tool to evaluate the intimal surface of the end product to measure skills acquisition. The intimal surface of 200 anastomoses from 23 candidates and 2 experts were assessed using ImageJ to measure 4 parameters: 1) distance between the distal insertion points, 2) distance between the proximal insertion points, 3) length of sutures placed, 4) number of axes. Using these parameters, a 9-component scoring system was produced based on the hypothesis of the ideal anastomosis having equidistance between the above parameters. The scoring system was devised based on population performance to give a maximum score of 100. The EPIA tool demonstrated its ability to differentiate between seniority from undergraduate to expert. Furthermore, predictive validity was shown by demonstrating skill acquisition between day 3 and 5 of the microsurgery course. The EPIA tool is a valid and feasible method to assess and provide feedback regarding the end product as an adjunct to current scoring systems in simulated microsurgery.

Curva de aprendizado de anastomose arteriovenosa com uso de simulador de baixo custo / Arteriovenous anastomosis learning curve using low cost simulator

Resumo Contexto A redução das dificuldades no aprendizado da técnica cirúrgica levou ao surgimento de ferramentas complementares. Este trabalho descreve a curva de aprendizado dos alunos sujeitos da pesquisa, utilizando um modelo alternativo para a prática de anastomose vascular. Objetivos Avaliar a curva de aprendizado da técnica de anastomose vascular e do desenvolvimento de habilidades manuais a partir da utilização de um modelo experimental de baixo custo. Métodos Este trabalho é um estudo experimental e prospectivo, com a realização de anastomoses vasculares do tipo terminolateral em balões de látex durante cinco fases sucessivas, iniciadas após orientação teórico-prática de uma cirurgiã vascular experiente. Os sujeitos foram seis graduandos do curso de Medicina, do terceiro ao quinto ano, da Universidade Federal da Paraíba (UFPB), João Pessoa, Paraíba, Brasil. A interpretação do material coletado acerca da qualidade das anastomoses e do tempo utilizado seguiu a análise de agrupamento. Resultados Houve redução do tempo de realização das anastomoses de todos os alunos, com diferença estatística da fase 1 quando comparada às fases 4 e 5, bem como tendência crescente no índice de qualidade ao longo das fases. Porém, não foi detectada diferença estatística a partir do teste de Friedman, apropriado para dados com nível de mensuração ordinal (escala de 1 a 5 na avaliação da qualidade). Conclusões O modelo de treinamento utilizado foi efetivo para incremento do aprendizado dessa técnica, acreditando-se que amostras de maior tamanho ou com maior número de fases em trabalhos futuros poderiam demonstrar redução do tempo associada a melhora da qualidade da anastomose realizada com significância estatística.

Abstract Background In order to reduce difficulties with learning surgical techniques, supplementary tools for training were developed. This paper describes the learning curve followed by student volunteer research subjects who used an alternative model for practicing vascular anastomosis. Objectives To evaluate the vascular anastomosis technique learning curve and development of manual skills using a low-cost experimental model. Methods Experimental and prospective study using end-to-side vascular anastomosis in latex balloons over five successive phases, initiated after theoretical and practical guidance given by experienced vascular surgeon. The study subjects were six undergraduate medical students from Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brazil, in their third to fifth years of the course. Cluster analysis was used to interpret the data collected on the quality of anastomoses and the time taken. Results The time taken to perform anastomosis reduced for all students, with statistical differences from phase 1 compared to phases 4 and 5. There was also a trend to increasing scores on the quality index as the phases progressed. However, no statistical differences were detected using the Friedman test, which is appropriate for data measured with ordinal levels (quality was assessed on a scale of 1 to 5). Conclusions It was found that the training model used was effective for increasing learning of this technique. It is believed that future studies with larger samples or a higher number of phases could demonstrate both reduced time and improved quality of the anastomoses performed with statistical significance.

Design and Validation of a Low-Cost, High-Fidelity Model for Urethrovesical Anastomosis in Radical Prostatectomy.

OBJECTIVE: We sought to develop and validate a low-cost, high-fidelity robotic surgical model for the urethrovesical anastomosis component of the robot-assisted laparoscopic radical prostatectomy. MATERIALS AND METHODS: A novel simulation model was constructed using a 3D-printed model of the male bony pelvis from CT scan data and silicone molds to recreate the soft tissue aspects. Using a da Vinci Si surgical robot, urology faculty and trainees performed simulated urethrovesical anastomosis. Each participant was given 12 minutes to complete the simulation. A survey established face validity, content validity, and acceptability. Simulation runs were evaluated by three blinded reviewers. The anastomosis was graded by two reviewers for suture placement accuracy and anastomosis quality. These factors were compared with robotic experience to establish construct validity. RESULTS: Twenty participants took part in the initial validation of this model. Groups were defined as experts (surgical faculty), intermediate (fellows and chief residents), and novices (junior residents). Likert scores (1-5 scale, top score 5) examining face validity, content validity, and acceptability were 3.49 ± 0.43, 4.15 ± 0.23, and 4.02 ± 0.19, respectively. Construct validity was excellent based on the model's ability to stratify groups. All evaluated metrics were statistically different between the three levels of training. Total material cost was $2.50 per model. CONCLUSIONS: We developed a novel low-cost robotic simulation of the urethrovesical anastomosis for robot-assisted radical prostatectomy. The model discerns robotic skill level across all levels of training and was found favorable by participants showing excellent face, content, and construct validities.

A simple and novel technique for training in microvascular suturing in a rat model.

BACKGROUND: Though microvascular clamps are widely used for anastomosis training, there still have several shortcomings, including the bulging, expensiveness and unavailability due to sterilization. The aim of this study is to introduce a simple and novel microvascular training model without use of microvascular clamps. METHODS: Femoral vessels of Sprague Dawley rats training model were used to evaluate the usefulness of 4-0 silk as a slipknot for performing arterio-arterial and veno-venous microvascular anastomoses. A total of 12 Sprague Dawley rats were randomly assigned to either slipknot group or vascular clamp group. We also assess other endpoints, including ischemic time, patency rate, and clinical features. An additional histological study was performed to compare their immediate traumatic effects on vessel wall. RESULTS: There was no ischemic change or congestive sign in the lower limb after microvascular anastomosis. The total warm ischemic time for the vascular anastomosis was not significantly different. We performed the patency test immediately after microvascular anastomosis and one week after surgery. No intraoperative vascular bleeding was found during these procedures and no thrombosis occurred postoperatively. The histologic damages to occluded area were not significantly different in both groups. CONCLUSION: We demonstrate a microsurgical suture technique performed without any vascular clamp on a rat model. This rat model was designed for training in the technique of microvascular anastomosis. Compared with microvascular clamps, silk slipknot is a cheap, easily available, less space-occupying technique while performing microvascular anastomoses training. This preliminary study provides a simple and effective alternative method for microvascular anastomosis training.

Surgeons see anatomical structures faster and more accurately compared to novices: Development of a pattern recognition skill assessment platform.

BACKGROUND: This study aimed to identify differences in pattern recognition skill among individuals with varying surgical experience. METHODS: Participants reviewed laparoscopic cholecystectomy videos of various difficulty, and paused them when the cystic duct or artery was identified to outline each structure on the monitor. Time taken to identify each structure, accuracy and work load, which was assessed using the NASA-Task Load Index (TLX), were compared among the three groups. RESULTS: Ten students, ten residents and eight attendings participated in the study. Attendings identified the cystic duct and artery significantly faster and more accurately than students, and identified the cystic artery faster than residents. The NASA-TLX score of attendings was significantly lower than that of students and residents. CONCLUSIONS: Attendings identified anatomical structures faster, more accurately, and with less effort than students or residents. This platform may be valuable for the assessment and teaching of pattern recognition skill to novice surgeons. SHORT SUMMARY: Accurate anatomical recognition is paramount to proceeding safely in surgery. The assessment platform used in this study differentiated recognition skill among individuals with varing surgical experience.

Crowdsourced Assessment of Inanimate Biotissue Drills: A Valid and Cost-Effective Way to Evaluate Surgical Trainees.

OBJECTIVE: Providing feedback to surgical trainees is a critical component for assessment of technical skills, yet remains costly and time consuming. We hypothesize that statistical selection can identify a homogenous group of nonexpert crowdworkers capable of accurately grading inanimate surgical video. DESIGN: Applicants auditioned by grading 9 training videos using the Objective Structured Assessment of Technical Skills (OSATS) tool and an error-based checklist. The summed OSATS, summed errors, and OSATS summary score were tested for outliers using Cronbach's Alpha and single measure intraclass correlation. Accepted crowdworkers then submitted grades for videos in 3 different compositions: full video 1× speed, full video 2× speed, and critical section segmented video. Graders were blinded to this study and a similar statistical analysis was performed. SETTING: The study was conducted at the University of Pittsburgh Medical Center (Pittsburgh, PA), a tertiary care academic teaching hospital. PARTICIPANTS: Thirty-six premedical students participated as crowdworker applicants and 2 surgery experts were compared as the gold-standard. RESULTS: The selected hire intraclass correlation was 0.717 for Total Errors and 0.794 for Total OSATS for the first hire group and 0.800 for Total OSATS and 0.654 for Total Errors for the second hire group. There was very good correlation between full videos at 1× and 2× speed with an interitem statistic of 0.817 for errors and 0.86 for OSATS. Only moderate correlation was found with critical section segments. In 1 year 275hours of inanimate video was graded costing $22.27/video or $1.03/minute. CONCLUSIONS: Statistical selection can be used to identify a homogenous cohort of crowdworkers used for grading trainees' inanimate drills. Crowdworkers can distinguish OSATS metrics and errors in full videos at 2× speed but were less consistent with segmented videos. The program is a comparatively cost-effective way to provide feedback to surgical trainees.

Objective assessment of robotic suturing skills with a new computerized system: A step forward in the training of robotic surgeons.

INTRODUCTION: The purpose of this study was to assess robot-assisted suturing skills on a laparoscopic intestinal anastomosis model by using a novel computerized objective assessment system. METHODS: This study compared the suturing skills of 13 surgically naïve participants on an artificial intestinal anastomosis model that mimics real tissue. Each examinee sutured using da Vinci robot assistance under 2-D and 3-D visualization and with conventional laparoscopy (CL). Pressure-measuring and image-processing devices were employed to quantitatively evaluate suturing skills. Five unique criteria were used to evaluate the skills of participants. RESULTS: Suturing under 3-D visualization (P < 0.01) and with CL (P < 0.05) were significantly faster than under 2-D visualization. Sutures placed under 3-D (P < 0.05) and 2-D (P < 0.01) visualization had significantly better suture tension than those placed with CL, which did not meet acceptable values for suture tension. Sutures placed with CL had significantly better air pressure leakage than those placed under 2-D visualization (P < 0.05), which did not meet acceptable values for air pressure leakage and wound opening area. One participants failed to achieve full-thickness sutures with 2-D, two participants with CL, and one participant with 3-D. CONCLUSION: Using 3-D vision is necessary for complex maneuvering during robot-assisted minimally invasive surgery. Our quantitative assessment system is useful for evaluating the skill acquisition of surgeon-trainees undergoing robotic surgery training.

Interview Scores Correlate with Fellow Microsurgical Skill and Performance.

BACKGROUND: The interview process for surgical trainees aims to select those individuals who will perform best during training and have the greatest potential as future surgeons. The objective of this study was to evaluate the relationship between criteria assessed at interview, technical skills, and performance, for the first time, to optimize the selection process for a Microsurgery fellowship. METHODS: Twenty microsurgery fellows in three consecutive annual cohorts at a single academic center were prospectively evaluated. At interview, subjects were scored for multiple standardized domains. At the start and at end of the fellowship, microsurgical technical skill was assessed both in the laboratory and operating room (OR) using a validated assessment tool. At the end of the fellowship, there was a final evaluation of performance. RESULTS: At the start, microsurgical skill significantly correlated with almost all domains evaluated at interview, most closely with prior plastic surgery training experience. At the end of the fellowship, skill level improved in all trainees, with the greatest improvement made by the lowest ranked and skilled trainees. The highest ranked trainees, however, made the greatest improvement in speed. CONCLUSIONS: The results of this study, for the first time, validate the current interview process to correctly select the highest performing and most skilled candidates and support the effectiveness of a 1-year microsurgical fellowship in improving microsurgical skill in all trainees, irrespective of their initial ability. The importance of valuing the relative quality of prior training and experience at selection is also highlighted.

Novel Dry-Lab Training Method for Totally Endoscopic Coronary Anastomosis: A Pilot Study.

OBJECTIVE: We describe our original dry-lab training system for nonrobotic and beating heart endoscopic coronary artery anastomosis. METHODS: All the materials used for this training were commercially available. We selected a boxed machine, which can produce pulsatile movements of artificial vessels, and on its roof, we installed a two-dimensional home video camera and a monitor. A multiple-holed plate was placed in front of the machine, and through these holes, a trainee inserted endoscopic surgical instruments and anastomosed the artificial vessels by running fashion while watching the monitor. This training program has four stages. During the first stage, a trainee has to demonstrate mastery in conducting a conventional off-pump coronary artery anastomosis without assistance. The second stage is the "nonbeating" version, and the third stage is the "beating" version with the model mentioned previously. After a trainee gets accustomed to the third stage, the original artificial vessel is replaced with an extremely fragile one, and this is the fourth stage. Our trainee conducted one hundred fourth-stage anastomoses and each procedure was recorded with the video camera. We analyzed several factors from the videos and evaluated the efficacy of the training method. We compared the outcomes of the first 50 consecutive anastomoses with the following 50 ones and described the learning curves. RESULTS: The comparison showed a significant decrease in anastomotic time and vessel injury. We considered the quality of anastomosis acceptable after 47 anastomoses, and anastomotic time fell below 15 minutes at the 81st training at the fourth stage. CONCLUSIONS: Our dry-lab system might be an effective training method for endoscopic coronary anastomosis.

Robotic Pancreatoduodenectomy Biotissue Curriculum has Validity and Improves Technical Performance for Surgical Oncology Fellows.

OBJECTIVE: Obtaining the proficiency on the robotic platform necessary to safely perform a robotic pancreatoduodenectomy is particularly challenging. We hypothesize that by instituting a proficiency-based robotic training curriculum we can enhance novice surgeons' skills outside of the operating room, leading to a shorter learning curve. DESIGN: A biotissue curriculum was designed consisting of sewing artificial organs to simulate a hepaticojejunostomy (HJ), gastrojejunostomy (GJ), and pancreaticojejunostomy (PJ). Three master robotic surgeons performed each biotissue anastomosis to assess validity. Using video review, trainee performance on biotissue drills was evaluated for time, errors and objective structured assessment of technical skills (OSATS) by 2 blinded graders. SETTING: This study is conducted at the University of Pittsburgh Medical Center (Pittsburgh, PA), a tertiary care academic teaching hospital. PARTICIPANTS: In total, 14 surgical oncology fellows completed the biotissue curriculum. RESULTS: Fourteen fellows performed 196 anastomotic drills during the first year: 66 (HJ), 64 (GJ), and 66 (PJ). The fellows' performances were analyzed as a group by attempt. The attendings' first attempt outperformed the fellows' first attempt in all metrics for every drill (all p < 0.05). More than 5 analyzed attempts of the HJ, there was improvement in time, errors, and OSATS (all p < 0.01); however, no metric reached attending performance. For the GJ, time, errors, and OSATS all improved more than 5 attempts (all p < 0.01), whereas only errors and OSATS reached proficiency. For the PJ, errors and OSATS both improved over attempts (p < 0.01) and reached proficiency; however, time did not statistically improve nor reach proficiency. The graders scoring correlated for errors and OSATS (p < 0.0001). CONCLUSION: A pancreatoduodenectomy biotissue curriculum has face and construct validity. The curriculum is feasible and improves errors and technical performance. Time is the most difficult technical parameter to improve. This curriculum is a valid tool for teaching robotic pancreatoduodenectomies with established milestones for reaching optimum performance.

Basic Cardiac Surgery Skills on Sale for $22.50: An Aortic Anastomosis Simulation Curriculum.

BACKGROUND: Current resident and student duty-hour restrictions necessitate efficient training, which may be aided by simulation. Data on the utility of low-cost simulation in cardiothoracic surgery are scant. We evaluated the effect and value of a low-cost, low-fidelity aortic anastomosis simulation curriculum. METHODS: Twenty participants (11 medical students, 9 residents) completed an aortic anastomosis on a porcine heart as a pretest. Participants were then provided access to a 14-minute online video created by a cardiac surgeon and given a low-cost task trainer for self-directed practice. Five weeks later, participants performed another aortic anastomosis on a porcine heart as a posttest. Pretest and posttest performances were filmed, deidentified, and graded blindly and independently by two cardiac surgeons using a standardized assessment tool (perfect score, 110; passing score, 58 or higher). Participants were surveyed anonymously after the posttest. RESULTS: The mean (SD) aortic anastomosis performance score improved significantly from pretest (53.3 [25.3]) to posttest (83.6 [15.3]; p < 0.001). Pass rates also improved significantly (35% versus 95%, p < 0.001). Medical students' scores improved most (p = 0.01). All 20 participants reported improved confidence in performing the task, and 18 believed that the online video was essential to better performance. The cost of the curriculum totaled $22.50 per participant, with 6 hours of total staff time required for assessment. CONCLUSIONS: An aortic anastomosis training and simulation curriculum improves the skills of student and resident trainees with minimal expense and staff time commitment. Such a curriculum may be of great value to both cardiothoracic training programs and their trainees.

Anastomosis Lapse Index (ALI): A Validated End Product Assessment Tool for Simulation Microsurgery Training.

BACKGROUND: Over the last decade, simulation has become a principal training method in microsurgery. With an increasing move toward the use of nonliving models, there is a need to develop methods for assessment of microvascular anastomosis skill acquisition substituting traditional patency rate. The authors present and validate a novel method of microvascular anastomosis assessment tool for formative and summative skills competency assessment. METHODS: In this study, 29 trainees with varying levels of experience in microsurgery undertook a 5-day microsurgery course. Two consecutive end-to-end microvascular anastomoses of cryopreserved rat aortas performed on day 3 and day 5 of the course were longitudinally split and photographed for randomized blinded qualitative evaluation. Four consecutive anastomoses by two experienced microsurgeons were analyzed as expert controls. Errors potentially leading to anastomotic leak or thrombosis were identified and logged. Statistical analysis using the Kruskal-Wallis analysis of variance (ANOVA) and a two-way repeated measure ANOVA was used to measure construct and concurrent validity, respectively. RESULTS: A total of 128 microvascular anastomoses were analyzed for both student and control groups. Ten errors were identified and indexed. There was a statistically significant difference detected between average errors per anastomosis performed between groups (p < 0.05). Average errors per anastomosis was statistically decreased on day 5 of the course compared with day 3 (p < 0.001). CONCLUSION: Evaluation of anastomosis structural patency and quality in nonliving models is possible. The proposed error list showed construct and predictive validity. The anastomosis lapse index can serve as a formative and summative assessment tool during microvascular training.

Experience report on teaching surgical technique without animal use.

PURPOSE: To report the experience of the school in implementing the 3 Rs replace, reduce and refine; showing time and assembling cost of the experimental models used in the teaching of Surgical Technique and Experimental Surgery. METHODS: Assembly time and costs of models: grafts and flaps performed in pork belly, model of intestinal anastomosis and jejunostomy done in Bahiana box and black box model for training videosurgery. RESULTS: Average time and cost estimate: ten minutes-pork belly, cost $ 6.00 per kilogram; two minutes-Bahiana box, cost $ 27.2; Black box-3.6 hours for manufacturing, cost $ 100.00. The repetition of each practice the cost is $ 3.20 for Bahiana box and at no cost to the black box. CONCLUSION: The experimental models presented are easily reproducible and of low cost.

Experience report on teaching surgical technique without animal use

PURPOSE: To report the experience of the school in implementing the 3 Rs replace, reduce and refine; showing time and assembling cost of the experimental models used in the teaching of Surgical Technique and Experimental Surgery. METHODS: Assembly time and costs of models: grafts and flaps performed in pork belly, model of intestinal anastomosis and jejunostomy done in Bahiana box and black box model for training videosurgery. RESULTS: Average time and cost estimate: ten minutes-pork belly, cost $ 6.00 per kilogram; two minutes-Bahiana box, cost $ 27.2; Black box-3.6 hours for manufacturing, cost $ 100.00. The repetition of each practice the cost is $ 3.20 for Bahiana box and at no cost to the black box. CONCLUSION: The experimental models presented are easily reproducible and of low cost. .