Current status of simulation training in plastic surgery residency programs: A review <s> Cadaver and fresh tissue <s> Although endovascular techniques have achieved widespread acceptance, a suitable model for device development and physician training has not been available. Plastic models of the arterial tree and live animal models have significant limitations. Arterial-to-arterial flow is established in fresh frozen human cadavers after a simple thrombolytic process to achieve a more realistic model for endovascular device testing and training. Circulation can be established through most of the arterial system, including the cerebral, aortoiliac, and extremity vessels. This model offers antegrade flow in human arterial anatomy and has been used successfully for physician training and device development. <s> BIB001 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Cadaver and fresh tissue <s> OBJECT ::: Laboratory training models are essential for developing and refining surgical skills, especially for microsurgery. The closer to live surgery the model is, the greater the benefit. In this paper the authors introduce a cadaver model with unique characteristics: dynamic filling of the cerebral vasculature with colored liquid and clear fluid filling of the arachnoid cisterns. This model is distinctive and has great practical value for training in a wide range of surgical procedures. ::: ::: ::: METHODS ::: Cadaveric heads were prepared for surgical procedures in the following manner: the carotid arteries (CAs) and vertebral arteries (VAs) in the neck were cannulated, as were the internal jugular veins (JVs) on both sides. Two tubes were introduced into the spinal canal and each one was advanced into one of the cerebellopontine angle cisterns. A CA, VA, or both were then connected to a reservoir containing light red fluid and a pressure of 80 to 120 mm Hg and a pulse rate of 60 beats/minute were established using a pump. The JV on the side currently being dissected was connected to a reservoir containing dark red fluid and kept at a pressure between 20 and 40 mm Hg. The remaining vessels were clamped in the neck. The cisternal tubes were connected to a reservoir of clear fluid that was regulated by an adjustable flow. Nine trainees have tested this model on eight specimens by practicing a variety of surgical procedures and maneuvers, including craniotomies; hemostasis; cisternal and vascular dissection; vascular anastomosis and repair; establishment of arterial bypasses; aneurysm creation, dissection, and clipping; management of an aneurysm rupture; intraparenchymal resection such as amygdalohippocampectomy; ventricular endoscopy and third ventriculostomy; cavernous sinus and skull base approaches; and resection of artificial tumors in the basal cisterns. ::: ::: ::: CONCLUSIONS ::: This model mimics the normal human anatomy and dynamic vascular filling found in real surgery and presents it from the training perspective, allowing a wide range of skill development and repeated practice. It provides an alternative model to laboratory animals. It is inexpensive and readily available, and has great value for the acquisition and refinement of surgical skills that are not only specific to neurosurgery, but are applicable to other surgical disciplines. <s> BIB002 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Cadaver and fresh tissue <s> ABSTRACT Purpose: We evaluated the durability of laboratory based technical skills training in urological microsurgery using bench model simulators. Methods and Materials: A total of 50 junior surgery residents (post-graduate years 1 to 3) were recruited to participate in a focused training program in urological microsurgery. Prior to training subjects were randomized to receive hands-on training with bench model simulators (silicone tubing or live rat vas deferens, 40) or didactic training alone (10). Four months following the original training program the technical performance of 18 returning subjects (13 from the bench model and 5 from the didactic training group) was reevaluated using a high fidelity, live animal model (vasovasostomy and rat vas deferens). Outcome measures included blinded, expert assessment of videotaped performance using checklists and global rating scores, and evaluation of anastomotic patency. Results: The retention test checklist (p Conclusions: Laboratory based technical skills training with bench models can lead to a significant retention of technical skill by novice surgeons. Measured performance improvements appear to be durable with time. However, the opportunity for repeat hands-on practice appears to maximize the retention of technical skill. <s> BIB003 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Cadaver and fresh tissue <s> BACKGROUND ::: Although there is growing evidence that practice on bench model simulators can improve the acquisition of technical skill in surgery, the degree to which these models have to approximate real-world conditions (model fidelity) to optimize learning is unclear. Previous research suggests that low-fidelity models may be adequate for novice learners. The purpose of this study was to assess the effect of model fidelity and surgical expertise on the acquisition of vascular anastomosis skill. ::: ::: ::: METHODS ::: Twenty-seven surgical residents participated in this institutional review board-approved study. Junior residents (postgraduate year 1 and 2) and senior residents (postgraduate year 4 or higher) were randomized into two groups: low-fidelity (n = 13) and high-fidelity (n = 14) model training. Both groups were given a 3-hour hands-on training session: the low-fidelity group used plastic models, and the high-fidelity group used human cadaver arms (brachial arteries) to practice graft-to-arterial anastomosis. One week later, all subjects participated in an animal laboratory in which they performed a single vascular anastomosis on a live, anesthetized pig (femoral artery). A blinded vascular surgeon scored candidate performance in the animal laboratory by using previously validated end points, including a checklist and final product analysis score. ::: ::: ::: RESULTS ::: Acquisition of skill was significantly affected by model fidelity and level of training as measured by both the checklist (P = .03) and final product analysis (P = .01; Kruskal-Wallis). Specifically, junior residents practicing on high-fidelity models scored better on the checklist (P = .05) and final product analysis (P = .04). Senior residents practicing on high-fidelity models scored better on final product analysis (P < .05). ::: ::: ::: CONCLUSIONS ::: Training in the laboratory does improve skill when assessed in a realistic setting. Both expertise groups showed better skill transfer from the bench model to live animals when practicing on high-fidelity models. For vascular anastomosis, it is important to provide appropriate model fidelity for trainees of different abilities to optimize the effectiveness of bench model training. <s> BIB004 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Cadaver and fresh tissue <s> SUMMARY ::: Computer-based training simulators have been used extensively, most notably in flight simulation. Over the past 20 years, surgical simulators have been developed, initially for training of minimally invasive surgery and more recently for open surgical simulation. The key effort in today's surgical simulation field is to develop metrics to evaluate how well the skills learned in a simulator translate to improvement in real surgical skills, execution of procedures, and team cooperation in the operating room. The American College of Surgeons has begun implementing a phased approach to introduce simulation in training and education for general surgery. The authors believe that a similar training plan should be mandated for plastic surgery, to take advantage of the use of computers, virtual reality, and simulation in the training of plastic surgery residents and to explore the value of this technology for continuing medical education and maintenance of certification. This article gives a brief background and history of surgical simulation and its technology, followed by a detailed description of the three phases of the American College of Surgeons' plan and how the authors propose that each phase be implemented, with modifications as applicable for trainees in plastic surgery. <s> BIB005 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Cadaver and fresh tissue <s> BACKGROUND ::: Clinical training in operative technique is important to boost self-confidence in residents in all surgical fields but particularly in trauma surgery. The fully trained trauma surgeon must be able to provide operative intervention for any injury encountered in practice. In this report, we describe a novel training model using a human cadaver in which circulation in the major vessels can be simulated to mimic traumatic injuries seen in clinical practice. ::: ::: ::: METHODS ::: Fourteen human cadavers were used for simulating various life-threatening traumatic injuries. The carotid and femoral arteries and the jugular and femoral vein were cannulated and connected to perfusate reservoirs. The arterial reservoir was connected to an intra-aortic balloon pump, which adds pulsatile flow through the heart and major arteries. Fully trained trauma surgeons evaluated the utility of this model for repairing various injuries in the thoracic and abdominal cavity involving the heart, lungs, liver, and major vessels while maintaining emergent airway control. ::: ::: ::: RESULTS ::: Surgeons reported that this perfused cadaver model allowed simulation of the critical challenges faced during operative trauma while familiarizing the student with the operative techniques and skills necessary to gain access and control of hemorrhage associated with major vascular injuries. ::: ::: ::: CONCLUSION ::: In this report, we describe a novel training model that simulates the life-threatening injuries that confront trauma surgeons. An alternative to living laboratory animals, this inexpensive and readily available model offers good educational value for the acquisition and refinement of surgical skills that are specific to trauma surgery. <s> BIB006 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Cadaver and fresh tissue <s> OBJECTIVE ::: To develop and validate a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery. ::: ::: ::: BACKGROUND ::: Simulators have been shown to be viable systems for teaching technical skills outside the operating room; however, integration of simulation training into comprehensive curricula remains a major challenge in modern surgical education. Currently, no curricula have been described or validated for advanced laparoscopic procedures. ::: ::: ::: METHODS ::: This prospective, single-blinded randomized controlled trial allocated 25 surgical residents to receive either conventional residency training or a comprehensive training curriculum for laparoscopic colorectal surgery. The curriculum consisted of proficiency-based psychomotor training on a virtual reality simulator, cognitive training, and participation in a cadaver lab. The primary outcome measure in this study was surgical performance in the operating room. All participants performed a laparoscopic right colectomy, which was video recorded and assessed using 2 previously validated assessment tools. Secondary outcome measures were knowledge relating to the execution of the procedure, assessed with a multiple-choice test, and technical performance on the simulator. ::: ::: ::: RESULTS ::: Curricular-trained residents demonstrated superior performance in the operating room compared with conventionally trained residents (global score 16.0 [14.5-18.0] versus 8.0 [6.0-14.5], P = 0.030; number of operative steps performed 16.0 [12.5-17.5] versus 8.0 [6.0-14.5], P = 0.021; procedure-specific score 71.1 [54.4-81.6] versus 51.1 [36.7-74.4], P = 0.122). Curricular-trained residents scored higher on the multiple-choice test (10 [9-11] versus 7.5 [5.3-7.5], P = 0.047), and outperformed conventionally trained residents in 7 of 8 tasks on the simulator. ::: ::: ::: CONCLUSIONS ::: Participation in a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery results in improved technical knowledge and improved performance in the operating room compared with conventional residency training. Reg. ID#NCT 01371136. <s> BIB007 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Cadaver and fresh tissue <s> BACKGROUND ::: As interest in surgical simulation grows, plastic surgical educators are pressed to provide realistic surgical experience outside of the operating suite. Simulation models of plastic surgery procedures have been developed, but they are incomparable to the dissection of fresh tissue. We evolved a fresh tissue dissection (FTD) and simulation program with emphasis on surgical technique and simulation of clinical surgery. We hypothesized that resident confidence could be improved by adding FTD to our resident curriculum. ::: ::: ::: METHODS ::: Over a 5-year period, FTD was incorporated into the curriculum. Participants included clinical medical students, postgraduate year 1 to 7 residents, and attending surgeons. Participants performed dissections and procedures with structured emphasis on anatomical detail, surgical technique, and rehearsal of operative sequence. Resident confidence was evaluated using retrospective pretest and posttest analysis with a 5-point scale, ranging from 1 (least confident) to 5 (most confident). Confidence was evaluated according to postgraduate year level, anatomical region, and procedure. ::: ::: ::: RESULTS ::: A total of 103 dissection days occurred, and a total of 192 dissections were reported, representing 73 different procedures. Overall, resident predissection confidence was 1.90±1.02 and postdissection confidence was 4.20±0.94 (p<0.001). The average increase in confidence correlated with training year, such that senior residents had greater gains. When compared by anatomical region, confidence was lowest for the head and neck region. When compared by procedure, confidence was lowest for rhinoplasty and face-lift, and highest for radial forearm and latissimus flaps. ::: ::: ::: CONCLUSIONS ::: A high-volume FTD experience was successfully incorporated into the residency program over 5 years. Training with FTD improves resident confidence, and this effect increases with seniority of training. Although initial data demonstrate that resident confidence is improved with FTD, additional evaluation is needed to establish objective evidence that patient outcomes and surgical quality can be improved with FTD. <s> BIB008 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Cadaver and fresh tissue <s> Currently, plastic surgery occupies a negligible component of many undergraduate curricula, and its recognition as a specialty is poorly understood by both medical students and primary care physicians.1,2 One important reason for this is that medical students are seldom exposed to plastic surgery.1,2 Because it is difficult to change the undergraduate curriculum, alternative solutions are required for increased exposure to plastic surgery at the undergraduate level.1,2 ::: ::: To meet that need, we propose training in basic surgical skills pertinent to plastic surgery on an alternative low-fidelity synthetic bench model, prepared with 2.5-mm-thick laminated plates composed of rubber (flattened pure polyvinyl chloride) reinforced with mesh (polyester and cotton) (Emborrachado or Rubberised Line; Kelson's Industria e Comercio S.A., Rio de Janeiro, Brazil). Generally, these plates are used in the manufacture of decorative objects such as handpainted rugs and are readily purchased at craft stores (eg, Sonalk Representacoes Ltda, Sa Paulo, Brazil, and ANMAG Representacoes Ltda, Rio de Janeiro, Brazil). This synthetic material can also be purchased and shipped anywhere in the world through … <s> BIB009 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Cadaver and fresh tissue <s> Summary Introduction Surgical simulation models are often limited by their lack of fidelity, which hinders their essential purpose, making a better surgeon. Fresh cadaveric tissue is a superior model of simulation owing to its approximation of live tissue. One major unresolved difference between dead and live tissue is perfusion. Here, we propose a means of enhancing the fidelity of cadaveric simulation through the development of a perfused cadaveric model whereby simulation is further able to approach life-like surgery and teach one of the more technically demanding skills of plastic surgery: microsurgery. Method Fresh tissue human cadavers were procured according to university protocol. Perfusion was performed via cannulation of large vessels, and arterial and venous pressure was maintained by centrifugal circulation. Skin perfusion was evaluated with incisions in the perfused regions and was evaluated using indocyanine green angiography. Surgical simulations were selected to broadly evaluate applicability to plastic surgical education. Result Surgical simulation of 38 procedures ranging in complexity from skin excisions to microsurgical cases was performed with high priority given to the accurate simulation of clinical procedures. Flap dissections included perforator flaps, muscle flaps, and fasciocutaneous flaps. Effective perfusion was noted with ICG angiography and notable bleeding vessels. Microsurgical flap transfer was successfully performed. Conclusion We report the establishment of a high fidelity surgical simulation using a perfused fresh tissue model in a realistic environment akin to the operating room. We anticipate utilization of this model prior to entering the operating room will enhance surgical ability and offer a valuable resource in plastic surgical education. <s> BIB010
Many of the simulation models formerly discussed are limited by their lack of fidelity, which hinders their ability to facilitate surgical competence. Starting in medical school, the use of cadavers is a long standing practice utilized in all levels of medical training BIB005 BIB007 . With human anatomy and physical attributes accurately represented, anatomical variation is also present, thereby challenging trainees to learn and work within these disparities BIB005 BIB003 BIB004 . Nonetheless, cadavers still lack physiological perfusion, the simulation of which has been accomplished and proven effective in the context of vascular, neurological, and trauma surgical procedures BIB010 BIB002 BIB006 BIB001 . Perfused cadaver utilization in plastic surgery training was explored by Carey et al. BIB010 , in a study that sought to improve the fidelity of cadavers used in microsurgical training. Regional perfusion maintained by a centrifugal circulation was administered directly to proximal vessels of extremity or neck, with full cadaveric pressurization performed via the femoral artery. Arterial pressure could be adjusted based on the procedure at hand, allowing for accurate replication of the physiologic conditions experienced in live surgery. Cutaneous bleeding was confirmed with 11 procedures being taught to residents BIB010 . Recreation of techniques in an environment which mimics actual surgery has been a long standing feat. By perfusing cadavers to establish physiological conditions, realistic simulation and use of instruments provides the opportunity to train residents on a high fidelity model that facilitates the acquisition of transferrable skills. In a study by Sheckter et al. BIB008 incorporation of this model into residency training programs resulted in significant increases in confidence levels for all procedures among all resident training levels. Residents were required to attend weekly dissections related to their current rotation, each of which included a lab manager, surgical technician, and attending physician. Although costing over $53,000, the curriculum overcame major hurdles in increasing resident confidence over a 5-year trial period. As an alternative to the use of cadavers and as a method to cut costs, many institutions use freshly excised tissue following surgeries such as abdominoplasty and body contouring. This limits practice to specific techniques as opposed to procedures, but can be very useful for teaching competence in surgical tools  BIB009 . Concern over the use of cadavers is commonplace in regards to their potential to become reservoirs for communicable disease. Despite this fear and the high cost of use, cadavers and fresh tissue models provide the closest replications of live surgery.