International Residents' Perspectives on Education and Challenges in Microsurgery Training

Objective Microsurgery remains an integral component of the surgical skillset and is essential for a diversity of reconstructive procedures. The apprenticeship also requires overcoming a steep learning curve, among many challenges. The method of microsurgical training differs depending on the countries' regions and resources of their health care system. Methods The Journal of Hand and Microsurgery leadership held an international webinar on June 19, 2021, consisting of a panel of residents from 10 countries and moderated by eminent panelists. This inaugural event aimed to share different experiences of microsurgery training on a global scale, identifying challenges to accessing and delivering training. Results Residents shared various structures and modes of microsurgical education worldwide. Areas of discussion also included microsurgical laboratory training, simulation training, knowledge sharing, burnout among trainees, and challenges for female residents in microsurgical training. Conclusion Microsurgical proficiency is attained through deliberate and continued practice, and there is a strong emphasis globally on training and guidance. However, much remains to be done to improve microsurgical training and start acting on the various challenges raised by residents.Copyright © 2022. Society of Indian Hand & Microsurgeons. All rights reserved.

Inheritance and innovation: maintain academic communications in microsurgery under the normalized prevention and control of COVID-19 pandemics.

Chinese Journal of Microsurgery, based on the premise of doing well in the prevention and control of COVID-19 pandemics, shall keep on driving on the inheritance and innovation, carry forward the spirit of microsurgery, give full play to the advantages of microsurgery technology and improve the level of surgical repair and reconstruction, as well as try new ways for academic communications and give full play to the roles of an academic platform for a professional magazine;Clinical Orthopaedic Microsurgery (internal communication), the internal journal of editorial office, is the "showcase in China" to highlight and disseminate the achievements in microsurgery, focus on the support for the Chinese young microsurgeons who work in the front-line of medical services, provide a platform effectively for the young microsurgeons in China to actively participate in the Sino-English literary exchange, and truly "publish the papers on the land of our motherland".Copyright © 2022 by the authors.

Evaluation of the COVID-19 Infection Rate in the Perioperative Period of Elective Surgeries of the Hand and Microsurgery.

BACKGROUND: After the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic (coronavirus disease 2019 [COVID-19]), the world started reducing the number of elective surgeries to reduce the transmission of the coronavirus. Some priority elective surgeries were performed, and there was no increase in contagion rates due to safety protocols and protection measures. The study aims to present the coronavirus infection rate of elective hand surgeries and microsurgery performed during pandemics. METHODS: A retrospective study evaluating 188 patients submitted to elective surgical procedures. The exclusion criteria were patients infected by COVID-19 before the surgery and patients who submitted to trauma surgery. Only 108 patients were eligible for this study. The mean age was 47.8 years (range: 15 days-81 years). There were 63 females and 45 males. They were divided into 2 groups: outpatient (n = 49) and inpatient (n = 59) procedures. RESULTS: The overall COVID infection rate was 6.48%. The outpatient infection rate was 2.08%, whereas the inpatient infection rate was 10.17% (Student t test: P = .089). The main factor correlated with infection in the postoperative period was the number of postoperative outpatient visits (Student t test: P = .089). No statistical differences were observed between the variables studied, but there was a tendency for patients who submitted to inpatient surgery to get infected by COVID-19 (P = .089). The statistical power was 0.8 (Cohen's d test), showing that large samples are needed to analyze the correlation better. CONCLUSION: We concluded that the safety of performing elective hand surgery during the pandemic remains unclear, and more studies with larger samples are needed.

COVID-19 Associated Micro-Anastomotic Thrombosis After Abdominal Free Tissue Transfer: A Case Report and Literature Review

The hypercoagulable state of COVID-19 infection presents a challenge to microsurgeons. While the American Society of Anesthesiologists recommends deferring surgery for 4–10 weeks for COVID-19-infected patients, little else is known regarding how to mitigate thrombotic complications for patients undergoing free tissue transfer. Here, we present a presumed COVID-19-induced hypercoagulable state in a patient undergoing abdominally based free tissue transfer for breast reconstruction as a brief review of the literature to guide clinical decision making. © 2023 The Author(s).

Building surgical skills for the ophthalmology trainee in times of a global pandemic

Purpose: The eye surgeon's unique microsurgical skillset is developed over time from repeated and meticulous training on delicate ophthalmic tissue. The impact of COVID-19 on the delivery of regular ophthalmology services has impacted the exposure and available opportunities for skills development in the trainee. Adopting ophthalmic surgery teaching models and simulators as training resources provides solutions to enhance microsurgical skills of the trainee operating in a pandemic. Method(s): A literature search was performed to identify ophthalmic surgery skills training resources. We included prosthetic, harvested produce, non-live animal, and virtual reality and simulation devices. Human cadaveric models were excluded. Result(s): Several established and novel ophthalmic surgery training resources were identified. Low-cost prosthetic models and tissue substitutes are available to develop basic microsurgical and tissue handling skills. Harvested produce, non-live egg, porcine products, and sophisticated virtual reality devices imitate various aspects of ophthalmic tissue to allow simulation of ophthalmic surgery of varying complexity including cataract, corneal, glaucoma, vitreoretinal and strabismus surgeries. The use of ophthalmic skills training devices improved skills of trainee eye surgeons. Conclusion(s): A wide range of ophthalmic surgery training resources are available to both the individual trainee and the training organisation, and provide a wide range of accessible, evidenced solutions to augment surgical skill development not only during the pandemic but also beyond.

Video recording of hand surgeries using a field of view (FOV) matching USB camera module and smartphone in the era of COVID-19.

BACKGROUND: As the online medium has gained in popularity due to the recent coronavirus disease (COVID-19) pandemic, video recording of surgical procedures has become crucial in medical education. Various methods for recording are available but many require professional equipment and experienced personnel. Here, we propose a feasible and acceptable method for video recording of surgeries. METHODS: An M12 mount USB camera, which is based on an Android micro-USB, was utilized. The device was purchased from a website for $32-$40. The camera was mounted between the eyes of the binocular loupes. Surgical procedures were recorded with the camera. The optimal settings were determined according to the types of surgeries. RESULTS: We recorded the following surgical procedures: radial artery superficial palmar branch (RASP) free flap harvest, carpal tunnel release, and free flap operation. The default values were retained for all settings, but the highest image quality (1080 p) was selected with an 8 mm lens. The camera battery was sufficient to record each surgery in its entirety. CONCLUSIONS: The USB camera produced high-quality videos that perfectly matched the surgeon's field of view without the need for additional staff for recording. This low-cost equipment could be widely employed for the recording of educational videos for surgeons, especially in the era of COVID 19.

Minimally Invasive Glaucoma Surgery WetLab: A Follow-Up Needs Assessment Survey for Ophthalmology Residents

Purpose : In 2012 Saheb and Ahmed found that minimally invasive glaucoma surgeries (MIGS) lower intraocular pressure, decrease dependence on medications, and have an excellent safety profile. In 2017 75.5% of glaucoma surgeries performed in the US on Medicare patients 65 years or older in the US were MIGS. A 2020 study surveyed US program directors and found that both didactics and wet labs are used for resident training in MIGS. However, 37% of program directors did not feel that the experience was adequate for independent practice and only 27% felt that MIGS should be an ACGME requirement.<span style='font-size:10.8333px'> </span>Since 2017 Loyola's citywide annual microsurgical wet lab for six Chicago residencies has focused on hands-on training in MIGS to meet the increasing interest amongst residents. During COVID-19, Loyola continued to host our annual wet lab, providing MIGS training virtually. The purpose of this study was to assess residents' perspectives of their current MIGS training and how residents' perspectives have changed since 2017. Methods : In 2017 and 2020 respectively, 31 and 44 residents of 6 Chicago programs attended our wet lab. Residents were given a pre-wet lab survey regarding their interest in MIGS and training satisfaction. The data collected was anonymous and de-identified. In 2017 data was collected in-person on iPads using RedCap software and in 2020 the data was collected remotely using Qualtrics data collection platform. In both wet labs residents performed various MIGS and intraoperative gonioscopy. Results : In 2017 and 2020 respectively, 77% and 81% of residents reported that they were interested or very interested in MIGS. In 2017 32% of residents were satisfied by their MIGS training. In 2020, still only 25% of residents were satisfied by their current MIGS training. Conclusions : Despite widespread use of MIGS in the US and growing interest amongst graduating ophthalmologists, there continues to be a gap between resident interest in MIGS and satisfaction with training during residency. Over the four years, this gap has remained unchanged. A MIGS-based hands-on wet lab experience is one way to improve MIGS training for residents and close the gap between interest and satisfaction with current MIGS resident training.

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.

Inheritance and innovation: maintain academic communications in microsurgery under the normalized prevention and control of COVID-19 pandemics

Chinese Journal of Microsurgery, based on the premise of doing well in the prevention and control of COVID-19 pandemics, shall keep on driving on the inheritance and innovation, carry forward the spirit of microsurgery, give full play to the advantages of microsurgery technology and improve the level of surgical repair and reconstruction, as well as try new ways for academic communications and give full play to the roles of an academic platform for a professional magazine;Clinical Orthopaedic Microsurgery (internal communication), the internal journal of editorial office, is the "showcase in China" to highlight and disseminate the achievements in microsurgery, focus on the support for the Chinese young microsurgeons who work in the front-line of medical services, provide a platform effectively for the young microsurgeons in China to actively participate in the Sino-English literary exchange, and truly "publish the papers on the land of our motherland". © 2022 by the authors.

Single Centre experience with the Superficial Circumflex Iliac artery Perforator (SCIP) flap for traumatic limb defects: A Case-Series for First year as a regional major trauma network during a global pandemic

Introduction;The free superficial circumflex iliac artery perforator (SCIP) flap evolved from the traditional groin flap, conferring numerous advantages. The thin nature of the flap avoids the need for secondary revisions and debulking procedures, particularly pertinent when theatre capacity was limited during the COVID-19 pandemic. We present a series reporting our centre’s first year experiences undertaking SCIP flap reconstruction for traumatic limb injuries following the establishment of our regional major trauma network. Materials and methods;A retrospective analysis of all patients treated for traumatic limb defects in our centre was undertaken between September 2020 to September 2021. Data was collected on patient demographics, injury, flap dimensions and flap survival. Results;Ten patients (M:F 1:1, mean age 45 years) with traumatic limb defects were reconstructed with SCIP flaps performed by the senior authors. All had sustained open fractures. Nine had lower limb defects, most commonly at the medial ankle, one had a volar wrist defect with a devascularised hand. The mean flap dimension was 6.3x14.5cm. All were anastomosed end-to-side to the recipient artery except one end-to-end anastomosis to a posterior tibial artery perforator using super-microsurgery. There was 100% flap survival. Complications consisted of one flap suffering <10% tip necrosis requiring debridement and small skin graft. Conclusion, The SCIP flap provides reliable, thin and pliable tissue without the need for secondary flap revisions and should be considered in the armamentarium of the reconstructive surgeon in extremity trauma reconstruction, particularly in the current environment surrounding the global pandemic.

The benefits of dual-consultant operating in complex breast reconstruction: A retrospective cohort comparison study.

BACKGROUND: Dual-consultant operating (DCO) has been introduced in a multitude of surgical specialities. This retrospective cohort comparison study seeks to delineate any benefits DCO may confer on list utilisation, patient safety and training opportunities. METHODS: A retrospective cohort comparison of all free-flap breast reconstruction cases conducted at a single centre by five consultant plastic surgeons in the period May 2016-May 2020. RESULTS: A total of 281 patient records were used for analysis; 146 cases were dual consultants compared with 135 single consultants, representing 186 and 158 free flaps, respectively. Patient demographics were near identical in terms of patient age, BMI and ASA grade. Operating times were significantly reduced for both unilateral (mean reduction 59.49 min) and bilateral cases (mean reduction 38.14 min) with the presence of dual consultants. The mean length of stay for dual-consultant cases was on average 0.35 days less than for single consultant cases (p = 0.04). Dual-consultant case complications were less severe than those of single consultant cases (mean Clavien-Dindo severity 1.35 vs 0.96, p = 0.05). The rates of trainee one-to-one consultant training were increased in dual-consultant cases when preparing vessels (0.08 vs 0.35, p=<0.01) and performing anastomosis (0.63 vs 0.77, p = 0.03). CONCLUSIONS: DCO for complex breast reconstruction confers significant benefits to operating time, list utility and patient safety whilst protecting training opportunities for trainees. Plastic surgery departments looking to redesign services in the post-SARS-CoV-19 era should consider its adoption into their enhanced recovery protocols.

Investigation of Objectivity in Scoring and Evaluating Microvascular Anastomosis Simulation Training.

The increase in minimally invasive surgery has led to a decrease in surgical experience. To date, there is only limited research examining whether skills are evaluated objectively and equally in simulation training, especially in microsurgery. The purpose of this study was to analyze the objectivity and equality of simulation evaluation results conducted in a contest format. A nationwide recruitment process was conducted to select study participants. Participants were recruited from a pool of qualified physicians with less than 10 years of experience. In this study, the simulation procedure consisted of incising a 1 mm thick blood vessel and suturing it with a 10-0 thread using a microscope. Initially, we planned to have the neurosurgical supervisors score the simulation procedure by direct observation. However, due to COVID-19, some study participants were unable to attend. Thus requiring some simulation procedures to be scored by video review. A total of 14 trainees participated in the study. The Cronbach's alpha coefficient among the scorers was 0.99, indicating a strong correlation. There was no statistically significant difference between the scores from the video review and direct observation judgments. There was a statistically significant difference (p <0.001) between the scores for some criteria. For the eight criteria, individual scorers assigned scores in a consistent pattern. However, this pattern differed between scorers indicating that some scorers were more lenient than others. The results indicate that both video review and direct observation methods are highly objective techniques evaluate simulation procedures.

Impact of the COVID-19 pandemic on the stage and the type of surgical treatment of laryngeal cancer.

PURPOSE: Changes in the entire health care system during COVID-19 epidemic have affected the management of patients with head and neck cancer and posed several clinical challenges for ENT surgeons. Therefore, the present study aimed to investigate the effect of COVID-19 on the stage and the type of surgical treatments used in laryngeal cancer (including total laryngectomy, supracricoid partial laryngectomy (SCPL) and transoral laser microsurgery (TLM)) and also to compare the results of April 2020 to April 2021 with the previous year. MATERIALS AND METHODS: This cross-sectional study was performed on all patients with a diagnosis of laryngeal cancer who underwent surgery in the tertiary care center from April 2020 to April 2021 and the year before the pandemic in the same time. Demographic, cancer stage, and treatment data of all patients were recorded and analysis in two groups. RESULTS: Patients referred at the time of the virus outbreak; 111 were male and 5 were female, and in the group of patients referred before COVID-19, 90 were male and 12 were female. The type of surgical treatment of laryngeal cancer, mean time elapsed from sampling to surgery, stage of disease and mean tumor volume was statistically significant differences in patients before and during the outbreak. CONCLUSION: Patients who referred for diagnosis and treatment at the time of COVID-19 outbreak had more advanced stages of the disease and also the tumor volume was higher in them than patients who had referred before the outbreak. It is necessary to provide new solutions, education and treatment management for patients with laryngeal cancer in such pandemics.

Youtube as in information source for microsurgical training: A systematic review of video content

Aim: The COVID-19 pandemic has resulted in fewer physical microsurgical training opportunities, forcing trainees to seek virtual alternatives. As one of the largest video-sharing platforms globally, YouTube is increasingly being used to provide educational content. With additional emphasis placed on these videos, there will likely have an impact on training progression further down the line. This research aims to evaluate YouTube video content as a microsurgical training information source. Method: We searched Youtube.com for videos demonstrating and teaching microsurgical techniques. Search terms included 'microsurgical', 'teaching', 'anastomosis' and 'flap'. All videos of neurosurgical nature were excluded. Thirty-one videos were evaluated using nine criteria and using a modified GQS score. To reduce duplication, included videos were limited to two from one source. Results: Initial results show 79% of the videos were GQS Score 4/5 and therefore of good quality, despite only 38.7% featuring human procedures. 82.8% of the videos found were from medical websites, with most generated from three independent sources. The highly-scoring YouTube videos tended to have an audio voice-over or subtitles and clearly described the instruments and materials used. Conclusions: The results demonstrated that high-quality videos are easily accessible on YouTube and deemed useful as educational tools. However, trainees should be aware that varied sources provide videos that range in quality;and the learning acquired may not directly correspond to learning objectives set out by governing bodies and is unlikely to be comparable to real-life observation in theatre. Overall, evidence for the current educational value of YouTube for microsurgical techniques is somewhat limited.

Impact of COVID -19 Pandemic on Plastic Surgery Practices in a Tertiary Care Set Up in Southern India.

BACKGROUND: The COVID-19 pandemic has modified the way, plastic surgeons treat their patients. This article depicts how we as a plastic surgery department in a tertiary care setup handled the pandemic with an emphasis on infection control policy. METHODS: Data was collected from hospital records and quality assurance cell from March 21, 2020 to June 19, 2020 in terms of patient triaging, consultations, perioperative protocols, duty rosters, and academic activities. The changes on these with the impact of COVID-19 were studied with the same period of previous year. RESULTS: Outpatient clinics were closed and emergency consultations were reduced. Number of consultations reduced from 2591 to 75 and surgeries from 320 to 46 during the same period in 2019 and 2020 respectively. Though tele-consultations were helpful, the overall benefits were subpar. Emergency services continued with the guidelines of institute's infection control committee, such as area specific personal protective equipment, allotment of operating rooms, minimizing the crowd in operating room. There was some compromise in using accessories for microsurgical procedures. Duty rosters were designed to maintain uninterrupted services. Academic activities were continued with virtual platforms. CONCLUSION: Adequate preparation of health care setup and nation-wide lockdown has helped to handle emergency cases and in reduction of trauma-surgeries respectively. Though there were obstacles for some patients in accessing health care, our institutional response made us to render maximum possible care. Advancements in virtual platform helped in consultations and academics. Delayed conservative approach was used in most cases at the expense of cosmetic compromise.

Microsurgical autologous breast reconstruction in the midst of a pandemic: A single-unit COVID-19 experience.

INTRODUCTION: COVID-19 has disrupted the provision of breast reconstructive services throughout the UK. Autologous free flap breast reconstruction was restarted in our unit on 3 June 2020. We aimed to compare the unit's performance of microsurgical autologous breast reconstruction in the "post-COVID" period compared with the exact time period in the preceding year. METHODS: We retrospectively reviewed prospectively collected data in the "pre-COVID" (from 3 June 2019 to 31 December 2019) and "post-COVID" period (from 3 June 2020 to 31 December 2020). Patient demographics included age, body mass index, co-morbidities, Anaesthesiologists (ASA) grade and smoking status. Surgical factors included neoadjuvant chemotherapy, previous chest wall radiotherapy, unilateral or bilateral reconstruction, reconstruction timing, number of pedicles, contralateral symmetrisation and other procedures. dependant variables were ischaemic time, operative time, mastectomy weight, flap weight, length of stay, return to theatre and complication rates. The number of trainers and trainees present in theatre was recorded and analysed. RESULTS: Fewer DIEP flaps were performed in the "post-COVID" period (45 vs. 29). No significant difference was observed in mastectomy resection weight, but flap weight was significantly increased. No significant difference was found in ischaemic time as well. The postoperative length of stay was significantly reduced. No significant difference was found in rates of return to theatre, unplanned admission, infection, haematoma, seroma or wound dehiscence. No cases of venous thromboembolism or flap failures were recorded. The mean number of trainers and trainees, and the trainee-to-trainer ratio was not found to be significantly different between cohorts. CONCLUSION: Although fewer cases were performed, autologous breast reconstruction was safely delivered throughout the COVID-19 pandemic in the first wave without affecting training.

Superiority of living animal models in microsurgical training: beyond technical expertise.

BACKGROUND: Many studies are investigating the role of living and nonliving models to train microsurgeons. There is controversy around which modalities account for the best microsurgical training. In this study, we aim to provide a systematic literature review of the practical modalities in microsurgery training and compare the living and nonliving models, emphasizing the superiority of the former. We introduce the concept of non-technical skill acquisition in microsurgical training with the use of living laboratory animals in the context of a novel proposed curriculum. METHODS: A literature search was conducted on PubMed/Medline and Scopus within the past 11 years based on a combination of the following keywords: "microsurgery," "training," "skills," and "models." The online screening process was performed by two independent reviewers with the Covidence tool. A total of 101 papers was identified as relevant to our study. The protocol was reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: Living models offer the chance to develop both technical and non-technical competencies (i.e., leadership, situation awareness, decision-making, communication, and teamwork). Prior experience with ex vivo tissues helps residents consolidate basic skills prior to performing more advanced techniques in the living tissues. Trainees reported a higher satisfaction rate with the living models. CONCLUSIONS: The combination of living and nonliving training microsurgical models leads to superior results; however, the gold standard remains the living model. The validity of the hypothesis that living models enhance non-technical skills remains to be confirmed.Level of evidence: Not ratable.

Microsurgery in the era of COVID-19.

The COVID-19 pandemic has presented new challenges to microsurgeons. The virus is highly transmissible, with increased risk during operations that involve the aerodigestive tract. It is important to be able to identify high-risk operations and scenarios to guide management decisions and selection of personal protective equipment. Preoperative testing is a key element in identifying high-risk scenarios, and preoperative testing protocols are essential to maintaining safety in the COVID-19 era. Because COVID-19 can be transmitted via the conjunctiva, adaptations to loupes and microscopes are necessary to safely perform microsurgery in high-risk scenarios. We outline a potential risk stratification algorithm, as well as precautions for each scenario. Potential areas for innovation are also discussed.