A novel model for hands-on laparoscopic pelvic surgery training on Genelyn-embalmed body: an initial feasibility study.

The human donor body provides a well-accepted ex vivo model for laparoscopic surgical training. Unembalmed, or fresh-frozen, bodies comprise high-fidelity models. However, their short life span and high cost relatively limit the hands-on training benefits. In contrast, soft embalmed body of donors has a relatively longer usability without compromising tissue flexibility. This study reports the initial experience of the utility and feasibility of human donor Genelyn-embalmed body as a novel soft-embalmed cadaveric model for laparoscopic surgical training. An expert laparoscopic surgeon, who organised many fresh-frozen body donor courses, performed deep laparoscopic pelvic dissection and laparoscopic surgical tasks including suturing and electrosurgery on a single Genelyn-embalmed body. The three sessions were performed over a course of 3 weeks. The body was fully embalmed using the Genelyn technique. The technique consisted of a single-point closed arterial perfusion of embalming solution via the carotid artery with no further exposure to or immersion in embalming fluids thereafter. The donor's Genelyn-embalmed body provided a feasible model for laparoscopic surgical training. Initial experience shows evidence of this model being feasible and realistic. There was reproducibility of these qualities across a minimum of 3 weeks in this single-donor study. Initial experience shows that donor's Genelyn-embalmed body provides a novel model for laparoscopic surgical training, which possesses fidelity and is feasible for laparoscopic training. While further studies are needed to validate these findings, this technical note provides perspectives from an expert trainer regarding this model and provides a photographic and videographic atlas of this model's use in laparoscopy.

A Cost-Effective and Reproducible Cadaveric Training Model for Internal Carotid Artery Injury Management During Endoscopic Endonasal Surgery: The Submersible Peristaltic Pump.

BACKGROUND: Internal carotid artery injury (ICAI) represents one of the most challenging complications in endoscopic endonasal neurosurgery and its rarity results in limited opportunities for trainees and surgeons to achieve proficiency in its management. Currently, available models for ICAI have employed costly systems that prevent their widespread use. The objective of this study is to validate an affordable submersible peristaltic pump (SPP)-based model as a reproducible and realistic paradigm for ICAI management training. METHODS: A laceration of the left parasellar internal carotid artery was purposely carried out in 2 human cadaveric heads. A blood substitute was perfused to ensure a perfusion flow of 1 L/min using an affordable SPP. A cohort of 20 neurosurgery and otolaryngology residents, fellows, and attendings were enrolled to evaluate the realism and content validity of the model using a validated 5-grade questionnaire. RESULTS: The model proved to mimic a real intraoperative scenario of ICAI with an expected output flow of 1 L/min. Questionnaire responses reported a realistic experience and the impact of this model on improving trainee surgical coordination and capability to rehearse the most accepted repair technique. The use of a fixed noninjected head allowed the reproducibility of the training session without the additional cost of new fresh-frozen heads. The affordable SPP allowed an impactful reduction of ICAI model training expenses maintaining high realism. CONCLUSIONS: The SPP-based ICAI model with noninjected cadaveric specimens is an affordable and cost-effective system that allows reproducibility and realism. These qualities favor greater adoption in neurosurgery and otolaryngology training curricula.

Evaluation of assumptions in foot and ankle biomechanical models.

BACKGROUND: A variety of biomechanical models have been used in studies of foot and ankle disorders. Assumptions about the element types, material properties, and loading and boundary conditions are inherent in every model. It was hypothesized that the choice of these modeling assumptions could have a significant impact on the findings of the model. METHODS: We investigated the assumptions made in a number of biomechanical models of the foot and ankle and evaluated their effects on the results of the studies. Specifically, we focused on: (1) element choice for simulation of ligaments and tendons, (2) material properties of ligaments, cortical and trabecular bones, and encapsulating soft tissue, (3) loading and boundary conditions of the tibia, fibula, tendons, and ground support. FINDINGS: Our principal findings are: (1) the use of isotropic solid elements to model ligaments and tendons is not appropriate because it allows them to transmit unrealistic bending and twisting moments and compressive forces; (2) ignoring the difference in elastic modulus between cortical and trabecular bones creates non-physiological stress distribution in the bones; (3) over-constraining tibial motion prevents anticipated deformity within the foot when simulating foot deformities, such as progressive collapsing foot deformity; (4) neglecting the Achilles tendon force affects almost all kinetic and kinematic parameters through the foot; (5) the axial force applied to the tibia and fibula is not equal to the ground reaction force due to the presence of tendon forces. INTERPRETATION: The predicted outcomes of a foot model are highly sensitive to the model assumptions.

The art of combining neuroanatomy and microsurgical skills in modern neurosurgery.

Neurosurgical training outside the operating room has become a priority for all neurosurgeons around the world. The exponential increase in the number of publications on training in neurosurgery reflects changes in the environment that future neurosurgeons are expected to work in. In modern practice, patients and medicolegal experts demand objective measures of competence and proficiency in the growing list of techniques available to treat complex neurosurgical conditions. It is important to ensure the myriad of training models available lead to tangible improvements in the operating room. While neuroanatomy textbooks and atlases are continually revised to teach the aspiring surgeon anatomy with a three-dimensional perspective, developing technical skills are integral to the pursuit of excellence in neurosurgery. Parapharsing William Osler, one of the fathers of neurosurgical training, without anatomical knowledge we are lost, but without the experience and skills from practice our journey is yet to begin. It is important to constantly aspire beyond competence to mastery, as we aim to deliver good outcomes for patients in an era of declining case volumes. In this article, we discuss, based on the literature, the most commonly used training models and how they are integrated into the treatment of some surgical brain conditions.

Cadaveric Models for Renal Transplant Surgery Education: a Comprehensive Review.

PURPOSE OF REVIEW: To evaluate the utility of cadaveric models for kidney transplant (KT) surgery training. RECENT FINDINGS: Medline® and PubMed® databases were searched for English and Spanish language articles published describing different learning models used in KT formation. We evaluated the use of cadavers preserved by Thiel's embalming method (TEM) as KT simulation models. Students were divided in groups of 4 people: four trainees mentored by an expert in KT surgery. Among the trainees were surgical residents and low-experience surgeons. A total of 39 TEM preserved bodies were used, of which 75 viable renal grafts were obtained. In each cadaver, two complete transplantation processes were performed, each consisting of en bloc nephrectomy with the trunk of aorta and inferior vena cava, bench surgery and perfusion with saline of the organ, and KT surgery. As with any surgical procedure, learning KT surgery is a stepwise process that requires years of dedication. The models available for the surgical simulation of KT surgery allow to practice and achieve dexterity in performing the procedure in a safe and reproducible way. Training on TEM-preserved corpses offers a highly realistic model for the surgical simulation of KT surgery.

Evaluación del conocimiento anátomo-quirúrgico del sistema de la vena cava inferior por médicos residentes de cirugía general / Evaluation of anatomical and surgical understanding of the inferior vena cava system by general surgery interns

Las lesiones de vena cava inferior (VCI) han sido descritas como la lesión vascular abdominal mas frecuente encontradas en los centros de trauma. Puede lesionarse entre la supra e infrarrenal; y en el caso de lesión retrohepática, se asocia con alta mortalidad. En heridas penetrantes conllevan una elevada mortalidad. Hasta un 50 % de los individuos que experimentan estas lesiones muere antes de llegar al hospital; y la tasa de mortalidad entre los que llegan con vida a un centro de trauma varía entre 20­57 %. Se evaluaron a 12 cirujanos en formación, respecto de los conocimientos anatómicos del sistema de la VCI y sus relaciones, con material cadavérico formalizado mediante listas de verificación (Abril/2014). Luego de un período de entrenamiento mediante la disección anatómica de 10 cadáveres formolizados (Mayo/2014-Agosto/2014); se realizó una nueva evaluación de los médicos residentes de cirugía general en formación mediante listas de verificación, con material cadavérico fresco (Septiembre/2014). Durante la primera evaluación la vena iliaca común derecha e izquierda, fueron identificadas por 8 (66,66 %) residentes. Siete (58,33 %) mencionaron los segmentos de la VCI en intratorácico y abdominal. Seis (85,71 %) mencionaron la porción intrapericárdica y uno (14,29 %) la porción extrapericárdica. La porción o segmento subduodenal fue identificado como subhepático por siete (58,33 %) residentes; y solo dos (16,66 %) mencionaron los segmentos subduodenal, retroduodenopancreático y supraduodenopancreático como parte del segmento subhepático. Tres (25 %) no mencionaron los diferentes segmentos de la VCI (abdominal). El segmento retrohepático fue identificado por ocho (66,66 %). Durante la segunda evaluación la vena iliaca común derecha e izquierda, fueron identificadas por todos los residentes. Once (91,66 %) mencionaron los segmentos de la VCI en intratorácico y abdominal, además de la porción intrapericárdica y la porción extrapericárdica. El segmento subduodenal fue identificado como subhepático por dos (16,66 %) residentes; y nueve (75 %) mencionaron los segmentos subduodenal, retroduodenopancreático y supraduodenopancreático como parte del segmento subhepático. El segmento retrohepático fue identificado por once (91,66 %) residentes. La observación y disección anatómica de la VCI en material cadavérico durante la formación del cirujano general, brinda un importante método de enseñanza, capacitación y entrenamiento hacia el reconocimiento de las diferentes estructuras anatómicas de la región, pudiendo luego ser aplicado en cirugía. La metodología de supervisión y evaluación mediante listas de verificación, por médicos especialistas, es una opción a agregar a los programas de formación para mejorar el proceso de educación.

Injuries in the inferior vena cava (IVC) have been described as the most common vascular abdominal injury found in trauma. The injury may present between the suprarenal and the infrarenal; in the case of retrohepatic injuries, it is associated with a high mortality rate. In a penetrating wound, high mortality rates are reported. Up to 50% of the individuals who experience these injuries die before getting to the hospital, and the mortality rate among those who get to a healthcare facility alive, ranges from 20 to 57 %. The study involved the evaluation of 12 trainee surgeons concerning anatomical understanding of the inferior vena cava system and related areas, using corpses subject to 10 % formol via checklists (April 2014). After a training period with anatomical dissection of 10corpses subject to 10 % formol (May 2014-August 2014), the general surgery interns were reassessed via checklists using fresh corpses fresco (September 2014). During the first evaluation, the right and left common iliac vein were identified by 8 (66.66 %) interns: 7 (58.33 %) mentioned the segments of the IVC in the intrathoracic and abdominal area; 6 (85.71 %) referred to the intrapericardial portion, and 1 (14.29 %) mentioned the extrapericardial portion. The subduodenal portion or segment was identified as subhepatic by 7 (58.33 %) interns, and only 2 (16.66 %) referred to the subduodenal, retroduodenopancreatic and supraduodenopancreatic segments as part of the subhepatic segment. 3 (25 %) failed to mention the various segments of the (abdominal) IVC. The retrohepatic segment was identified by 8 (66.66 %) interns. During the second evaluation, the right and left common iliac vein were identified by 12 (100 %) interns: 11 (91.66 %) mentioned the segments of the inferior vena cava in the intrathoracic and abdominal areas; 11 (91.66 %) interns referred to the intrapericardial and the extrapericardial portions. The subduodenal segment was identified as subhepatic by 2 (16.66 %) interns, and 9 (75 %) of them mentioned the subduodenal, retroduodenopancreatic and supraduodenopancreatic segments as part of the subhepatic segment. The retrohepatic segment was identified by 11 (91.66 %) interns. Observation and anatomical dissection of the IVC in corpses when training a general surgeon provides a major teaching and training method to recognize the different anatomical structures of the area, for subsequent its application to surgery. The supervision and evaluation methodology consisting of the use of checklists by specialist physicians is an option that should be added to training programs in order to improve the educational process.