[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.

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.

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.

Development of a program for teaching practical skills in visceral and digestive surgery by simulation.

Up until 2013 in France, practical training for DES/DESC (advanced level) residents in visceral and digestive surgery was not standardized. Since 2017, the third cycle of medical studies has been restructured around three major thematic axes: academic knowledge, and technical and non-technical skills. The curriculum now includes a practical training program by means of simulation outside the operating theater, and it is structured, uniformized and standardized nationwide. Development of this training program is derived from the deliberations of a national consensus panel working under the umbrella of the French college of visceral and digestive surgery, program presenting a training guide to all future surgeons in the specialty. Four consensus conference sessions bringing together an eight-member commission have led to the drafting of a "Resident's manual for practical teaching in visceral and digestive surgery". As a reference document, the manual details in 272 pages the objectives (phase I), the learning resources for each skill (phase II) and, lastly, the means of evaluation for the cornerstone phases as well as the in-depth phases of an advanced degree (DES) in visceral and digestive surgery. As a complement to the manual, we have conducted a review of the structuring and implementation of the program as of November 2017 on a nationwide scale; the conclusions of the review are detailed at the end of this article.

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.

[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.

Contribution of minimally invasive bone augmentation to primary stabilization of the osteosynthesis of Schatzker type II tibial plateau fractures: Balloon vs bone tamp.

BACKGROUND: Schatzker type II tibial plateau fractures necessitate the least invasive treatment possible. Arthroscopic reduction by bone tamp followed by osteosynthesis is the current gold standard for this type of tibial plateau fracture. The objective of this study was to compare this technique to anterior approach tuberoplasty with balloon reduction. The comparison criteria were residual articular step off, metaphyseal cavity volume formed during reduction, and mechanical strength to separation and to depression displacement. METHODS: Fractures were created on 12 human cadaveric tibiae and reduced by a minimally invasive approach in six specimens by a balloon, and by bone tamp in the six others. Articular step off and metaphyseal-epiphyseal cavity volume were measured by TDM. Mechanical tests were performed up to assembly failure to characterize structural strength. Secondary displacements, fracture depression displacement and separation were measured by optical methods. FINDINGS: There was no significant difference in step off measurement after balloon reduction or bone tamp (0.29 cm vs 0.37 cm; p = 0.06). The cavity volume formed by balloon reduction was significantly smaller than the volume created by bone tamp reduction (0.45 cm3 vs 5.12 cm; p = 0.002). The compressive load required for assembly failure was significantly greater in the balloon group than in the bone tamp group (1210.17 N vs 624.50 N; p = 0.015). INTERPRETATION: There exists a correlation between load to failure of the assembly frame and the metaphyseal volume required for bone fracture reduction. The minimally invasive balloon technique has fewer negative effects on the osseous stock, thereby enabling better primary structural strength of the fracture.

Biomechanical cadaveric comparison of patellar ligament suture protected by a steel cable versus a synthetic cable.

BACKGROUND: Purpose and hypothesis: Patellar ligament rupture is a rare disabling pathology requiring a surgical ligament suture protected by a frame. The gold standard is the steel cable, but its rigidity and the necessity of a surgical re-intervention for its removal render it unsatisfactory. The objective of this paper is to quantify the mechanical protection provided by the terylene® in comparison with steel. METHODS: Twenty-four knees of 12 fresh frozen cadaveric subjects were divided into 2 homogeneous groups (terylene and steel) of 12 knees (mean age = 69.3 years). Proximal ligament repair was performed according to a three-tunnel transosseous reinsertion technique. Mechanical tests were performed in flexion to simulate movement of the knee. The interligament gap and the amplitude angulation of the knee were measured by a system of extensometer and optical goniometer. Mechanical analysis permitted calculation of flexion amplitude for a ligament gap of 1 and 2 mm taking as initial angle the adjusting angle of pretension of the protection frame. Study of deformations of frames was performed. Statistical analysis was performed with a Wilcoxon Mann Whitney test. RESULTS: There is no significant difference in protection of the ligament suture between the "terylene" and "steel" groups. Mean flexion amplitudes (mΔF) show no significant differences between the 2 groups for a distension of the suture of 1 mm (m ΔF terylene1 = 4.74 °; mΔF steel1 = 5.91°; p = 0.198) and 2 mm (mΔF terylene2 = 8.71°; mΔF steel2 = 10.41°; p = 0.114). Elastic deformation of terylene was significantly greater than that of steel (p = 0.0004). CONCLUSION: Suture protection of the patellar ligament by a terylene wire is not significantly different from that provided by steel frame. The elastic properties of terylene and absence of a need for re intervention to secure its removal lead us towards its use in acute ruptures of the patellar ligament. The main limits involve the properties of the chain extenders with no contraction/muscle shortening and partial dehydration of tendons and ligaments and the mean age of 69.3 years. Level 5.

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.

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.

French intensive training course in laparoscopic surgery (HUGOFirst) on live porcine models: Validation of a performance assessment scale and residents' satisfaction in a prospective study.

INTRODUCTION: Simulation as a method for practical teaching of surgical residents requires objective evaluation in order to measure the student's acquisition of knowledge and skills. The objectives of this article are to publish our evaluation and validation grids and also the measure of student satisfaction. METHOD: A teaching platform based on practical exercises with a porcine model was created in 2009 at seven French University Hospitals. Three times a year, 31 Diplôme d'Études Spécialisées Complémentaires (DESC) surgical residents underwent timed assessment of the performance of five surgical tasks: trocar insertion (trocars) testing the convergence of instruments (convergence), intra-corporeal knot tying (knots), running of the small intestine to find a lesion (exploration), and performance of a running suture closure of the peritoneum (closure). Two experts evaluated performances prospectively on grid score sheets specifically designed and validated for these exercises. We measured time, scores on a rating scale, and the interest and satisfaction of the residents. RESULTS: Data for 31 residents between May 2011 and March 2012 were analyzed. Rating scales were statistically validated and correlated (Kappa correlation coefficient K>0.69) for each task. The performance times of the most experienced residents decreased significantly for all tasks except for small bowel exploration (P=0.2). After four sessions, times were significantly improved with better quality (fewer errors and higher average scores [>88%]), regardless of the residents' experience. Of the participants, 92% were satisfied, 86% thought that the sessions improved their technical skills and 74% thought it had a favorable impact on their clinical practice. CONCLUSION: This study shows that the performance of surgical techniques can be improved through simulation, that HUFEG grids are valid, and that this teaching program is popular with surgical residents.

Appropriate dosing of sugammadex to reverse deep rocuronium-induced neuromuscular blockade in morbidly obese patients.

In morbidly obese patients, the speed of reversal of neuromuscular blockade with sugammadex based on ideal body weight is still matter of debate. In this single-center, randomised, double-blinded study, neuromuscular blockade was monitored in 50 patients using acceleromyography at the adductor pollicis. At the end of surgery with deep rocuronium-induced neuromuscular blockade, patients randomly received sugammadex 4 mg.kg(-1) (high dose group), 2 mg.kg(-1) (middle dose group), or 1 mg.kg(-1) (low dose group) of ideal body weight. After administration of the first dose of sugammadex, the mean (SD) recovery time (censored at 600 s) from deep neuromuscular blockade was significantly shorter (p < 0.001) in the high-dose group (n = 14; 255 (63) s) vs the middle-dose group (n = 13; 429 (102) s), or low-dose group (n = 4; 581 (154) s). Success rate from neuromuscular blockade reversal defined by a train-of-four ≥ 0.9 within 10 min after sugammadex administration, were 93%, 77% and 22% for these high, middle and low-dose groups respectively (p < 0.05 vs low-dose group). In morbidly obese patients, 4 mg.kg(-1) of ideal body weight of sugammadex allows suitable reversal of deep rocuronium-induced neuromuscular blockade. Monitoring remains essential to detect residual curarisation or recurarisation.

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.

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.

Parastomal hernia.

Despite advances in surgery including new prosthetic materials and the advent of laparoscopy, the treatment of parastomal hernias remains a challenge for the surgeon. This is mainly due to the very high recurrence rate. Adequate management requires preoperative multidisciplinary consultation to offer the most appropriate surgical solution to each patient. We propose a review of current knowledge about this complication.

Pre-duodenal portal vein in polysplenia syndrome: clinical effects and surgical application.

UNLABELLED: STATING BACKGROUND: Pre-duodenal portal vein (PPV) is a rare congenital anomaly, usually asymptomatic and thus detected only incidentally in adults. It is often associated with other anomalies which can be included into polysplenic syndrome. METHODS: In this case, a 56-year-old-female was admitted for a degenerative ampullome. The preoperative work-up shows a PPV vein, the absence of inferior vena cava retro-hepatic and the presence of an anastomosis between the inferior vena cava and the azygos system and a complete common mesentery. DISCUSSION: Such a discovery is often incidental and of little import; however, it takes on major importance for surgeons because the accidental damage of PPV can lead to serious consequences. CONCLUSION: The aim of this study, based on the embryology of the portal vein focused on a rare anomaly to keep it in mind because this anomaly in case of digestive surgery may need to adjust surgical techniques.

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.