Application of a Microsuction Background Device for Microanastomosis in a Rat Femoral Vessel Model.

SUMMARY: Microvascular anastomoses can be challenging to perform when edematous fluids and blood continuously flood and compromise the field of view. Intermittent irrigation and suctioning disturb workflow, require an assistant, and can increase risk of arterial thrombosis from vessels being drawn into suction drains. The authors developed and patented a novel three-dimensionally printed background device with microfluidic capabilities to provide autonomous, continuous irrigation and suction to optimize operator autonomy and efficiency. The authors tested this in a rat femoral vessel model. Twelve end-to-end anastomoses were performed by two senior microsurgeons [six conventional, six suction-assisted background (SAB)] in a rat femoral artery model. The primary outcome was time taken to complete the anastomosis. Secondary outcomes included the validated Structured Assessment of Microsurgery Skills (SAMS) score and the total number of "wiping" events to obtain field clarity. Each procedure was recorded, and videos were independently rated by two blinded experts using the SAMS score. Time taken to complete the anastomosis was greater in the conventional group compared with the SAB group (741.7 ± 203.1 seconds versus 584 ± 155.9 seconds; P = 0.007). The median SAMS score was lower in the conventional group compared with the SAB group (32.3 ± 1.4 versus 38.3 ± 1.5; P = 0.001). The median number of wiping events was significantly greater in the conventional group compared with the SAB group (13 ± 2.2 versus 1.7 ± 1.2; P < 0.001). The authors show that a novel microfluidic background device allows continuous irrigation and suctioning without the need for an assistant, optimizing the efficiency of the microvascular anastomosis. CLINICAL RELEVANCE STATEMENT: The authors have designed a novel, patented, three-dimensionally printed microsurgical background device that provides continuous irrigation and suction, reduces operative time, and provides better vessel clarity during a microsurgical anastomosis compared to standard background.

Utilising 3D-printed ex vivo biomimetics to improve open reduction and internal fixation (ORIF) simulation training for hand fractures.

Background: Surgery for hand trauma accounts for a significant proportion of the plastic surgery training curriculum. The aim of this article is to create a standardised simulation training module for hand fracture fixation on open reduction and internal fixation (ORIF) techniques for residents in order to create a standardised hand-training framework that universally hones their skill and prepares them for their first encounter in a clinical setting. Methods: A step-ladder approach training using three-dimensional (3D)-printed ex vivo hand biomimetics was employed on a cohort of 15 plastic surgery residents (n = 15). Assessment of skills using a score system (global rating scale) was performed in the beginning and the end of the module by hand experts in our unit. Results: The overall average score of the cohort pre- and post-assessment were 22.08/50 (44.16%) and 41.54/50 (83.08%) respectively. Significant (p < 0.01) difference of improvement of skills was noted on all trainees. All trainees confirmed that the simulated models provided in this module were akin to the patient scenario and noted that it helped them improve their skills with regards to ORIF techniques including improvement of their understanding of the 3D bone topography. Conclusion: We demonstrate a standardised simulation training framework that employs 3D-printed ex vivo hand biomimetics proven to improve the skills of residents and which paves the way to more universal, standardised and validated training across hand surgery. This is, to our knowledge, the first standardised method of simulated training on such hand-surgical cases.Level of Evidence: Not ratable.

Utilization of a 3D Printed Simulation Training Model to Improve Microsurgical Training.

Simulation is integral to the development and maintenance of micro- surgical skills. Several simulation models have been described ranging from bench- top to live animal models. High fidelity models are often burdened by cost and ethical issues limiting widespread implementation. This study aims to determine the feasibility of a microsurgical training platform using the Konjac noodle model. Methods: A prospective cohort study was conducted at our institution. A progressive microsurgical training curriculum was developed. A bespoke three-dimensional printed training platform was produced to enable residents to record training and assessment tasks. Microsurgical skills were blindly assessed before and after completing the training program using the University of Western Ontario Microsurgical Skills Assessment instrument. Results: Plastic surgery residents at various stages of training were recruited (n = 10). A significant improvement in vessel preparation from a pre-training median of 3 (IQR 2 -4) versus a post-training of 4 (IQR 3 -5, P = 0.0035) and suturing with a pre-training median of 3 (IQR 2 -4) versus a post-training of 4 (IQR 3 -5, P = 0.0047) domains of the University of Western Ontario Microsurgical Skills Assessment score was demonstrated after completion of the training program. There was a significant improvement in the global rating score (3 ± 1 versus 5 ± 1, P = 0.0045). Participants felt more confident performing a microsurgical anastomosis following the training program. Conclusion: The use of the Konjac noodle model and video-based assessment using a three-dimensional printed model is an effective teaching tool that improves resident's microsurgical skills.

MicroSUCI: A Microsurgical Background That Incorporates Suction Under Continuous Irrigation.

The microsurgical anastomosis is integral to the success of autologous-free tissue transfer. Successful performance of this procedure relies strongly on operator dexterity, which can be made more challenging when blood and edematous fluids obscure the field of view. Workflow is impeded by intermittent irrigation and suctioning, necessitating presence of an assistant, with risk of arterial thrombosis, from vessels being drawn into suction drains. To negate these current disadvantages and minimize the barrier of entry to microvascular operations, we designed, manufactured, and patented a novel three-dimensional printed microsurgical background device with microfluidic capabilities that allow continuous suction and irrigation as well as provide platforms that enable multiangle retraction to facilitate operator autonomy. This was validated in an ex vivo model, with the device found to be superior to the current standard. We believe that this will have major applicability to the improvement of microsurgeon.

Smartphone-Based DIY Home Microsurgical Training with 3D Printed Microvascular Clamps and Japanese Noodles.

We have recently incorporated simple modifications of the konjac flour noodle model to enable DIY home microsurgical training by (i) placing a smartphone on a mug to act as a microscope with at least ×3.5-5 magnification, and (ii) rather than cannulating with a 22G needle as described by others, we have found that cannulation with a 23G needle followed by a second pass with an 18G needle will create a lumen (approximately 0.83 mm) without an overly thick and unrealistic "vessel" wall. The current setup, however, did not allow realistic evaluation of anastomotic patency as the noodles became macerated after application of standard microvascular clamps, which also did not facilitate practice of back-wall anastomoses. In order to simulate the actual operative environment as much as possible, we introduced the use of 3D-printed microvascular clamps. These were modified from its previous iteration (suitable for use in silastic and chicken thigh vessels), and video recordings were submitted for internal validation by senior surgeons. A "wet" operative field where the konjac noodle lumen can be distended or collapsed, unlike other nonliving models, was noted by senior surgeons. With the 3D clamps, the noodle could now be flipped over for back-wall anastomosis and allowed patency testing upon completion as it did not become macerated, unlike that from clinical microvascular clamps. The perceived advantages of this model are numerous. Not only does it comply with the 3Rs of simulation-based training, but it can also reduce the associated costs of training by up to a hundred-fold or more when compared to a traditional rat course and potentially be extended to low-middle income countries without routine access to microsurgical training for capacity development. That it can be utilized remotely also bodes well with the current limitations on face-to-face training due to COVID restrictions and lockdowns.

Educational impact of a novel cleft palate surgical simulator: Improvement in surgical trainees' knowledge and confidence.

BACKGROUND: Trainees' experience in cleft surgery is limited due to the high-risk nature of the surgery and centralization of cleft care. Simulation training allows trainees to learn complex surgical tasks whilst ensuring patient safety. Existing cleft surgical simulators are over-simplified or prohibitively expensive. In this article, we show the development and application of a high-fidelity yet cost-effective simulator for cleft palate repair. METHODS: Skeletal elements were obtained through high-resolution scanning of a pathologic specimen, 3-dimensional printed, and then molded in plastic. Soft tissue components were formed through molding layers of silicone. The simulator was tested by 26 United Kingdom (UK) specialty trainees who performed a vomerine mucosal flap and intra-velar veloplasty in a 1-hour workshop. Pre- and post-simulation questionnaires assessing cleft knowledge and surgical confidence were compared for statistical significance. RESULTS: The simulator had high acceptability: 23/26 participants confirmed that the simulation training was a valuable learning experience. Baseline experience of cleft palate surgery was low: 24 participants had never performed any part of the procedure before. Following the workshop, mean knowledge score increased by 38%, and confidence by 53%. The paired T-test demonstrated that observed improvements in both knowledge and confidence were statistically significant (p<0.001). CONCLUSIONS: Simulation training is increasingly recognized as a crucial component of improving patient safety. Our new cost-effective cleft palate simulator has high acceptability and is a powerful educational tool that is effective in improving cleft palate surgical knowledge and confidence across all grades of surgical trainees.

Implementing mindfulness meditation in hand surgery training: a feasibility study.

Background: Surgery can be stressful, requiring decision-making and performance under pressure. The COVID-19 pandemic has further challenged surgeons' well-being and training. Excess stress adversely affects well-being, technical and non-technical performance, and, by extension, patient care. Little emphasis has been placed on interventions to improve individual surgeons' stress resilience despite mindfulness training being robustly linked to resilience, well-being, and improved executive function and performance. This feasibility study aimed to evaluate the effect and acceptability of a mindfulness meditation session on a group of surgical trainees during a hand fracture fixation course. Methods: All participants of a single-day hand fracture fixation course were invited to take part in the study, and randomised into two groups. The intervention group experienced a 10-min guided meditation session before their assessment, while the control group did not. Basic demographics, inherent 'trait' mindfulness, change in mood, and perceived acceptability were compared between the two groups. Results: The 17 participants were demographically similar, as were their self-reported mood scores until after the meditation, where they diverged significantly (p < .01, t-test), with the meditation group feeling more relaxed and calm. Meditation as an intervention was considered largely acceptable. Conclusions: Mindfulness meditation is established in improving stress resilience, relevant to surgeon well-being, performance, and patient care. This feasibility study suggests benefit and acceptability, and potential for further research in designing a targeted programme for surgeons, to reduce stress sensitivity, and improve performance, joy, and well-being within surgical training.Level of evidence: Level III, Therapeutic study. Supplementary Information: The online version contains supplementary material available at 10.1007/s00238-022-01962-1.

Utilisation of a 3D printed ex vivo flexor tendon model to improve surgical training.

BACKGROUND: Surgery for hand trauma accounts for a significant proportion of the plastic surgery trainee activity. The aim of this article is to create a standardised simulation training module for flexor tendon repair techniques for residents prior to their first encounter in the clinical setting. METHODS: A step-ladder approach flexor tendon repair training with four levels of difficulty was conducted using a three-dimensional (3D) printed anatomical simulation model and a silicone tendon rod on a cohort of 28 plastic surgery Senior House Officers (SHOs) of various stages in their training (n=28). Assessment of knowledge (online questionnaire) and practical skills using validated score systems (global rating scale and task specific score) was performed at the beginning and end of the module by hand experts of our unit. RESULTS: The overall average knowledge-based scores of the cohort pre- and post-assessment were 1.48/5 (29.6%) and 3.56/5 (71.5%), respectively. The overall average skills-based scores of the cohort pre- and post-assessments were 3.05/5 (61%) and 4.12/5 (82.5%), respectively. Significant (p<0.01) difference of improvement of knowledge and skills was noted on all trainees. All trainees confirmed that the training module improved their confidence with flexor tendon repair. CONCLUSION: We demonstrate a standardised simulation training framework that employs a 3D printed flexor tendon simulation model proven to improve the skills of residents especially during their early learning curve and which paves the way to a more universal, standardised and validated training across hand surgery.

3D Printed Chest Wall: A Tool for Advanced Microsurgical Training Simulating Depth and Limited View.

The deep inferior epigastric perforator (DIEP) flap has become the free flap of choice for autologous breast reconstruction. However, anastomoses of DIEP pedicles to internal mammary vessels in the chest wall are difficult due to restricted access and the depth of the vessels. Successful performance of such demanding procedures necessitates advanced requirements for microsurgical training models. The current chicken thigh model has been used to acquire microsurgical skills, allowing early learning curve trainees to practice repeatedly in inconsequential environments. Despite the increasing use of this model for training purposes, the resemblance to a clinical environment is tenuous. Such models should include anastomosis practice within the depth where the recipient vessels are located. To address this, we developed a three-dimensional (3D) printed chest wall as an addition to the current chicken thigh model, which reliably mimics the complexity of the anastomosis performed during DIEP breast reconstruction. This form of rapid prototyping facilitates a newfound ability for early learning curve trainees to exercise end-to-end anastomoses on vessels located with variable depths. Our enhancement of the current chicken thigh model is simple, cost-effective and offers a significantly more realistic resemblance to a clinical situation.

Open reduction and internal fixation of metacarpal fractures using a thermoplastic splint as a surgical instrument.

Adequate positioning of the hand is a critical step in hand fracture operative repair that can impact both the clinical outcome and the efficiency of the operation. In this paper, we introduce the use of a thermoplastic splint with an added thumb stabilizing component as a means to increase the surgeon's autonomy and to streamline the patient care pathway. The thermoplastic splint is custom fabricated preoperatively by the specialist hand therapist. The splint is used prior, during, and post operation with minimal modification. The thumb component assists maintaining the forearm in a stable pronated position whilst drilling and affixing metal work. This is demonstrated in the video of removal of metal work and open reduction and internal fixation of a metacarpal fracture.

PolliRS: A 3D-printed Pollicization Retractor System that Improves Access and Autonomy during the Surgical Procedure.

We demonstrate the design, manufacture, and deployment of the first custom-made 3-dimensional (3D)-printed hand retractor for the pollicization procedure. Radiological images of the patient's hand were taken preoperatively to measure anatomical dimensions and guide the design of the device in a patient-precise manner. The 3D-printed, sterilizable, device was autoclaved and successfully used on a patient that underwent a pollicization procedure in our unit. The radiolucency of the device and the fluency enabled by the ability to exchange between different positions demonstrated the potential of this device in increasing the overall autonomy afforded to the lead-surgeon during the operation and demonstrated the potential of rapid-prototyping techniques such as 3D printing for producing patient-precise tools on-the-fly that taken account the specific needs of the patient.

Three-dimensional Printed Customized Adjustable Mallet Finger Splint: A Cheap, Effective, and Comfortable Alternative.

Mallet finger deformity is a common and debilitating injury of the fingertip, accounting for 10% of all tendon and ligament injuries. It involves a disruption of the terminal extensor mechanism of the distal phalanx. Patients can experience significant pain and swelling of the fingertip and have significant morbidity without treatment. Nonoperative treatment using joint immobilization with splints is the mainstay of management. Traditionally, prefabricated and thermoplastic splints have been utilized; however, issues with comfort and skin complications such as maceration can lead to patient noncompliance and eventually, poor outcomes. To address this, we demonstrate our experience with the design, manufacture, and application of individualized 3D printed mallet finger splints. The splints were found to provide advantages akin to traditional thermoplastic splints, with the addition of being low cost, easy to manufacture, and environmentally friendly.

A Standardized Hand Fracture Fixation Training Framework using Novel 3D Printed Ex Vivo Hand Models: Our Experience as a Unit.

Surgery for hand trauma accounts for a significant proportion of the plastic surgery training curriculum. The aim of this study was to create a standardized simulation training module for hand fracture fixation with Kirschner wire (K-wire) techniques for residents to create a standardized hand training framework that universally hones their skill and prepares them for their first encounter in a clinical setting. METHODS: A step-ladder approach training with 6 levels of difficulty on 3-dimensional (3D) printed ex vivo hand biomimetics was employed on a cohort of 20 plastic surgery residents (n = 20). Assessment of skills using a score system (global rating scale) was performed in the beginning and at the end of the module by hand experts of our unit. RESULTS: The overall average scores of the cohort before and after assessment were 23.75/40 (59.4%) and 34.7/40 (86.8%), respectively. Significant (P < 0.01) difference of improvement of skills was noted on all trainees. All trainees confirmed that the simulated models provided in this module were akin to the patient scenario and noted that it helped them improve their skills with regard to K-wire fixation techniques, including improvement of their understanding of the 3D bone topography. CONCLUSIONS: We demonstrate a standardized simulation training framework that employs 3D printed ex vivo hand biomimetics proved to improve the skills of residents and that paves the way to more universal, standardized and validated training across hand surgery. This is, to our knowledge, the first standardized method of simulated training on such hand surgical cases.

A Novel Customized 3D Printed Arm Stand Improving Skin Preparation Efficiency in Hand Surgery.

Patient preparation for hand surgery often necessitates skin preparation via the use of an assistant to hold the arm to be operated on in mid-air while disinfectant is applied. This study introduces a three-dimensional printed arm stand that decreases dead time during skin preparation, while also enabling the more efficient use of an assistant. The arm stand devices were customized on the anatomy of the patients and then successfully used on patients having general or regional anesthesia. A practical, reusable, and effective three-dimensional printed arm stand has been developed and applied on both adult and pediatric patients. We have found the bespoke device to be beneficial in terms of reducing theater dead time and overall costs, while increasing the efficiency of an upper limb operating theater list. The rapid prototyping cycle afforded by 3D printing renders this technology a valuable tool for developing medical devices with patient-precise dimensions.

Three-dimensional Printed Microvascular Clamps: A Safe, Cheap, and Effective Instrumentation for Microsurgery Training.

Microsurgical training involves practice in ex vivo models during the early learning curve, and poor instrument handling by the inexperienced microsurgeons can cause damage to microsurgical instrumentation or clamps, which is particularly costly. To address this, we demonstrate the development, design, manufacturing, and application of 3 different types of 3-dimensional printed microvascular clamps in an ex vivo simulation training model. This report provides evidence of a low-cost and easily accessible device that facilitates the process of microsurgical training. The clamps were found to provide advantages akin to normal stainless-steel microvascular clamps in training settings.