Current status of simulation training in plastic surgery residency programs: A review <s> Animal models <s> Silastic tubes are used as training material for performing microvascular anastomoses. However, silastic texture differs from that of actual blood vessels. In the present work, we evaluate the use of preserved rat arterial segments for training in microvascular anastomoses. One-centimeter-long rat arterial segments were obtained from femoral, carotid, and abdominal arteries, preserved in cold saline solution, and frozen. Trainees performed microvascular anastomoses using the aforementioned material and answered questions about texture, consistency, and wall resistence to the needle, comparing preserved arterial wall and silastic tubes. They were also asked whether the arterial pedicles had a consistency and texture similar to normal vessels, and if they were a more reliable method for practicing microsurgery techniques than synthetic materials. They preferred frozen arterial pedicles over silastic tubes. We conclude that arterial cadaveric segments are a suitable biologic material for microsurgical training. Since they can be obtained from other experiments, this is an effective way to reduce the number of animals bred and sacrificed for teaching purposes. © 2005 Wiley-Liss, Inc. Microsurgery 25:500–501, 2005. <s> BIB001 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Animal models <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> BIB002 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Animal models <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> BIB003 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Animal models <s> Over the past decade, driven by advances in educational theory and pressures for efficiency in the clinical environment, there has been a shift in surgical education and training towards enhanced simulation training. Microsurgery is a technical skill with a steep competency learning curve on which the clinical outcome greatly depends. This paper investigates the evidence for educational and training interventions of traditional microsurgical skills courses in order to establish the best evidence practice in education and training and curriculum design. A systematic review of MEDLINE, EMBASE, and PubMed databases was performed to identify randomized control trials looking at educational and training interventions that objectively improved microsurgical skill acquisition, and these were critically appraised using the BestBETs group methodology. The databases search yielded 1,148, 1,460, and 2,277 citations respectively. These were then further limited to randomized controlled trials from which abstract reviews reduced the number to 5 relevant randomised controlled clinical trials. The best evidence supported a laboratory based low fidelity model microsurgical skills curriculum. There was strong evidence that technical skills acquired on low fidelity models transfers to improved performance on higher fidelity human cadaver models and that self directed practice leads to improved technical performance. Although there is significant paucity in the literature to support current microsurgical education and training practices, simulated training on low fidelity models in microsurgery is an effective intervention that leads to acquisition of transferable skills and improved technical performance. Further research to identify educational interventions associated with accelerated skill acquisition is required. <s> BIB004 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Animal models <s> Background With the increase in minimally invasive approaches to surgical disease and nonoperative management for solid organ injury, the open operative experience of current surgical residents has decreased significantly. This deficit poses a potentially adverse impact on both surgical training and surgical care. Simulation technology, with the potential to foster the development of technical skills in a safe, nonclinical environment, could be used to remedy this problem. In this study, we systematically review the current status of simulation technology in the training of open surgical skills with the aim of clarifying its role and promise in the education of surgical residents. Methods A systematic search of the PubMed database was performed with keywords: “surgical simulation,” “skill,” “simulat,” “surgery,” “surgery training,” “validity,” “surgical trainer,” “technical skill,” “surgery teach,” “skill assessment,” and “operative skill.” The retrieved studies were screened, and additional studies identified by a manual search of the reference lists of included studies. Results Thirty-one studies were identified. Most studies used low fidelity bench models designed to train junior residents in more basic surgical skills. Six studies used complex open models to train senior residents in more advanced surgical techniques. “Boot camp” and workshops have been used by some authors for short periods of intense training in a specialized area, with good results. Conclusions Despite the increasing use of simulation in the technical training of surgical residents, few studies have focused on the use of simulation in the training of open surgical skills. This is particularly true with regard to skills required to competently perform technically challenging open maneuvers under urgent, life-threatening circumstances. In an era marked by a decline in open operative experience, there is a need for simulation-based studies that not only promote and evaluate the acquisition of such less commonly performed techniques but also determine the efficacy with which they can be transferred from a simulated environment to a patient in an operating room. <s> BIB005 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Animal models <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> BIB006 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Animal models <s> The widespread use of microsurgery in numerous surgical fields has increased the need for basic microsurgical training outside of the operating room. The traditional start of microsurgical training has been in undertaking a 5-day basic microsurgery course. In an era characterised by financial constraints in academic and healthcare institutions as well as increasing emphasis on patient safety, there has been a shift in microsurgery training to simulation environments. This paper reviews the stepwise framework of microsurgical skill acquisition providing a cost analysis of basic microsurgery courses in order to aid planning and dissemination of microsurgical training worldwide. <s> BIB007 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Animal models <s> In the last three decades, simulation has become a key tool in the training of doctors and the maintenance of patient safety. Simulation offers an immersive, realistic way of learning technical skills. Recent changes to the training schemes in many surgical specialities mean that the hours spent working between senior house officer and consultant have been reduced. This, combined with other pressures (such as reduced operating hours), means that surgery has moved away from its traditional apprenticeship model and toward a competency-based one. Simulation can be a standardized and safe method for training and assessing surgeons. Use of simulation for training has become significant alongside the development of laparoscopic techniques, and evidence suggests that skills obtained in simulation are applicable in real clinical scenarios. Simulation allows trainees to make mistakes, to ask the "what if?" questions, and to learn and reflect on such situations without risking patient safety. Virtual reality simulators have been used to allow experts to plan complicated operations and assess perioperative risks. Most recently, fully immersive simulations, such as those with whole theater teams involved, and patient-centered simulations allow development of other key skills aside from purely technical ones. Use of simulation in isolation from traditional teaching methods will furnish the surgeon in training with skills, but the best time and place to use such skills comes only with experience. In this article we examine the role of simulation in surgical training and its impact in the context of reduced training time. <s> BIB008 </s> Current status of simulation training in plastic surgery residency programs: A review <s> Animal models <s> 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. <s> BIB009
In recent years, there has been a shift away from animal models for surgical training due to ethical concerns regarding their use BIB003 BIB002 BIB004 BIB008 BIB005  . Still, many argue that practice on live or cryopreserved animals provide transferrable skills to the OR. Traditionally, training involved didactic models in which different materials were used (e.g., surgical gloves, surgical gauze, and silastic tubes). However, none of these models compared to rat aortas on account of differences in softness and resistance to the needle BIB001 . Rat vessels are heavily used in contemporary microsurgery training, specifically for practicing anastomoses BIB009 BIB006 . Many institutions implement 5-day training courses to evaluate residents on their ability to anastomose rat aortas BIB009 BIB007 . Cryopreserved rat aortas are rather inexpensive, easy to obtain, and eliminate ethical issues regarding the use of live animals BIB005  . To evaluate resident ability to perform anastomoses and measure transferability to the OR, Ghanem et al. BIB009 developed the Anastomosis Lapse Index (ALI). The ALI scores anastomoses based on 10 common mistakes: line disruption, partial thickness stitch, unusually large bites causing infoldment, oblique stitch causing tissue distortion, tight sutures causing strangulation of edges, vessel tear, thread in lumen, gap that is more than two ideal spacing, internal valve/large flap, caught back wall or sidewall. Construct validity was carried out by comparing scores between participants of varying skills and experience; validating ALI as a method to evaluate and predict transfer of microsurgical skills to the OR BIB009 . To measure resident competency prior to clinical application, the development of a simple, valid, and objective low cost assessment method would prove extremely valuable. Use of animal models is not new to surgical training, but the ability to measure skill acquisition and predict the extent to which they are clinically transferable provides additional impetus for their use as a training method BIB003 BIB002 BIB004 BIB008 BIB005  . The cost of training programs is minimized by the use of cryopreserved specimen, and the texture, size, and recoil of vessels is close enough to humans to facilitate realistic experiences. This aspect of realism puts animal models ahead of synthetic or virtual based training; however, ethical concerns regarding the use of animals persist as a major deterrent. Still, animal models remain useful for practicing microsurgical and suturing skills, and cryopreserved models predominate among current residency programs. A resident uses a synthetic model to practice breast reconstruction at NYU Langone Health.