[Historical data on the beginning of the education of the subject "Surgical anatomy and operative techniques" at the time of Founding of the institute in Debrecen •]. / Történeti adatok a "Sebészeti anatómia és mutéttan" tantárgy oktatásának kezdetérol a debreceni intézet megalakulása idején •.

On December 1, 1951, the Institutes of Surgical Anatomy and Operative Techniques were founded in Hungary. In the academic year 1951/1952, only lectures were held for the students, in an increased number of hours during the semester, there was no practical opportunity yet due to the structural organization of the institutes. The actual teaching of the subject only started in the academic year 1952/1953 for the fourth year (semester 8-9) in the form of 1 h of lecture and 2 h of practical training per week, for a total of 40 h per semester. In the second semester, the subject was closed by a final examination. Regarding the institute in Debrecen, the authors present the beginning of teaching the subject based on contemporary documents.

[Historical data on the Founding of Experimental Surgical Section of the Hungarian Surgical Society]. / Történeti adatok a Magyar Sebész Társaság Kísérletes Sebészeti Szekciójának megalakulásáról1.

Following the establishment of the European Society for Surgical Research - ESSR on February 17, 1966 in Nancy/France. After the Re-establishment of Hungarian Surgical Society the organization of the Experimental Surgical Section of the Hungarian Surgical Society also started in October 1966. By January 25, 1967, there were 134 registered members of the Section. Authors present the organisation's letters with the list of applicants with contemporary documents. The Hungarian Experimental Surgical Section held its first congress on September 29-30, 1967 in Debrecen and Hajdúszoboszló.

Experiences with basic microsurgical training programs and skill assessment methods at the University of Debrecen, Hungary.

During the past decades microsurgical training programs together with skill assessment methods had been developing intensively worldwide. Concerning the teaching of basic techniques at various levels, we aimed to summarize the education program types and experiences at our department, in order to define the way of continuity. All in the hope that this summary might contain useful information for other educators as well. About 50 years ago, in the late 1960s, microsurgical basic education had been established in Debrecen. Since the 1990s multilevel education programs have been developed, starting in undergraduate years up to the postgraduate training, residency and continuous medical education programs. In the last three decades about 2,300 participants completed courses, including over 470 residents. The ones who already succeeded microsurgical course as medical students, during residency program could reach better results and skill development. Concluding thoughts, the traditional methods and special experiences are highly important in microsurgical education. The necessary duration and individual training approach are emphasized. Standardization (self and international), comparability, accessibility, providing milestones of microsurgical skills are key factors. Proper feedback and skill assessment (experiences, internationally recognized scores, or combinations) are indispensable, but have to be fitted to the characteristic elements of the course.

Experiences with basic microsurgical training programs and skill assessment methods at the University of Debrecen, Hungary

Abstract During the past decades microsurgical training programs together with skill assessment methods had been developing intensively worldwide. Concerning the teaching of basic techniques at various levels, we aimed to summarize the education program types and experiences at our department, in order to define the way of continuity. All in the hope that this summary might contain useful information for other educators as well. About 50 years ago, in the late 1960s, microsurgical basic education had been established in Debrecen. Since the 1990s multilevel education programs have been developed, starting in undergraduate years up to the postgraduate training, residency and continuous medical education programs. In the last three decades about 2,300 participants completed courses, including over 470 residents. The ones who already succeeded microsurgical course as medical students, during residency program could reach better results and skill development. Concluding thoughts, the traditional methods and special experiences are highly important in microsurgical education. The necessary duration and individual training approach are emphasized. Standardization (self and international), comparability, accessibility, providing milestones of microsurgical skills are key factors. Proper feedback and skill assessment (experiences, internationally recognized scores, or combinations) are indispensable, but have to be fitted to the characteristic elements of the course.

Defining Standards in Experimental Microsurgical Training: Recommendations of the European Society for Surgical Research (ESSR) and the International Society for Experimental Microsurgery (ISEM).

BACKGROUND: Expectations towards surgeons in modern surgical practice are extremely high with minimal complication rates and maximal patient safety as paramount objectives. Both of these aims are highly dependent on individual technical skills that require sustained, focused, and efficient training outside the clinical environment. At the same time, there is an increasing moral and ethical pressure to reduce the use of animals in research and training, which has fundamentally changed the practice of microsurgical training and research. Various animal models were introduced and widely used during the mid-20th century, the pioneering era of experimental microsurgery. Since then, high numbers of ex vivo training concepts and quality control measures have been proposed, all aiming to reduce the number of animals without compromising quality and outcome of training. SUMMARY: Numerous microsurgical training courses are available worldwide, but there is no general agreement concerning the standardization of microsurgical training. The major aim of this literature review and recommendation is to give an overview of various aspects of microsurgical training. We introduce here the findings of a previous survey-based analysis of microsurgical courses within our network. Basic principles behind microsurgical training (3Rs, good laboratory practice, 3Cs), considerations around various microsurgical training models, as well as several skill assessment tools are discussed. Recommendations are formulated following intense discussions within the European Society for Surgical Research (ESSR) and the International Society for Experimental Microsurgery (ISEM), based on scientific literature as well as on several decades of experience in the field of experimental (micro)surgery and preclinical research, represented by the contributing authors. Key Messages: Although ex vivo models are crucial for the replacement and reduction of live animal use, living animals are still indispensable at every level of training which aims at more than just a basic introduction to microsurgical techniques. Modern, competency-based microsurgical training is multi-level, implementing different objective assessment tools as outcome measures. A clear consensus on fundamental principles of microsurgical training and more active international collaboration for the sake of standardization are urgently needed.

How does practice improve the skills of medical students during consecutive training courses?

PURPOSE:: To follow-up the development of medical students in taking a stitch using two different bench models, and to assess their performance with regards to gender, handedness, prior recreational activities and interest in surgery. METHODS:: The study was performed during the compulsory basic (n=152) and the consecutive elective course (n=27). Students took simple interrupted stitches into synthetic and biopreprate models in the classroom and in the operating room. The time needed for that was measured and the quality was scored, using an OSATS (Objective Structured Assessment of Technical Skill) checklist that had been adapted to our training programs. RESULTS:: Students' performance improved both in time and quality during classes, over the course and compared basic to the elective course, too. No significant difference was found in relation to gender and handedness but certain recreational activities and special interest in surgery led to better results. Operating room environment had a slight negative effect on students' performance. CONCLUSION:: The study could provide objective skill assessment, monitoring has revealed deficiencies and influencing factors. Objective feedback, valid and reliable assessment is important in teaching surgical skills. In addition it may contribute to higher surgical safety later on in the clinical practice.

Changes of red blood cell aggregation parameters in a long-term follow-up of splenectomy, spleen-autotransplantation and partial or subtotal spleen resections in a canine model.

BACKGROUND: Decrease or loss in splenic filtration function may influence the hemorheological state. OBJECTIVE: To follow-up the long-term effects of splenectomy, spleen autotransplantation and spleen resections on red blood cell aggregation in a canine model. METHODS: Beagle dogs were subjected to control (n = 6), splenectomy (SE, n = 4), spleen autotransplantation (AU, Furka's spleen-chip method, n = 8) or partial and subtotal spleen resection (n = 4/each) groups, and followed-up for 18 postoperative (p.o.) months. Erythrocyte aggregation was determined in parallel by light-transmittance aggregometry (Myrenne MA-1 aggregometer) and syllectometry (LoRRca). RESULTS: Erythrocyte aggregation decreased three months after splenectomy, with lower aggregation index and elongated aggregation time. It was more or less associated with relatively lower hematocrit and fibrinogen concentration. However, in autotransplantated animals a relatively higher fibrinogen did not increase the aggregation markedly. Spleen resection resulted in the most controversial red blood cell aggregation findings, and it seems, that the degree of the resection is an influencing factor. CONCLUSIONS: Splenectomy alters erythrocyte aggregation, spleen autotransplantation can be useful to preserve filtration function. However, the degree of restoration shows individual differences with a kind of 'functional periodicity'. Spleen resection controversially influences erythrocyte aggregation parameters. The subtotal resection is supposed to be worse than spleen autotransplantation.

How does practice improve the skills of medical students during consecutive training courses?

Abstract Purpose: To follow-up the development of medical students in taking a stitch using two different bench models, and to assess their performance with regards to gender, handedness, prior recreational activities and interest in surgery. Methods: The study was performed during the compulsory basic (n=152) and the consecutive elective course (n=27). Students took simple interrupted stitches into synthetic and biopreprate models in the classroom and in the operating room. The time needed for that was measured and the quality was scored, using an OSATS (Objective Structured Assessment of Technical Skill) checklist that had been adapted to our training programs. Results: Students' performance improved both in time and quality during classes, over the course and compared basic to the elective course, too. No significant difference was found in relation to gender and handedness but certain recreational activities and special interest in surgery led to better results. Operating room environment had a slight negative effect on students' performance. Conclusion: The study could provide objective skill assessment, monitoring has revealed deficiencies and influencing factors. Objective feedback, valid and reliable assessment is important in teaching surgical skills. In addition it may contribute to higher surgical safety later on in the clinical practice.

Comparative erythrocyte deformability investigations by filtrometry, slit-flow and rotational ektacytometry in a long-term follow-up animal study on splenectomy and different spleen preserving operative techniques: Partial or subtotal spleen resection and spleen autotransplantation.

BACKGROUND: Partial or subtotal spleen resection or spleen autotransplantation can partly preserve/restore the splenic filtration function, as previous studies demonstrated. OBJECTIVE: For better evaluation and follow-up of the various spleen-preserving operative techniques' effectiveness versus splenectomy, a composite methodological approach was applied in a canine experimental model. METHODS: Beagle dogs were subjected to control (n = 6), splenectomy (SE, n = 4), partial and subtotal spleen resection (n = 4/each) or spleen autotransplantation groups (AU, Furka's spleen-chip method, n = 8). The follow-up period was 18 postoperative (p.o.) months. Erythrocyte deformability was determined in parallel by bulk filtrometry (Carat FT-1 filtrometer), slit-flow ektacytometry (RheoScan D-200) and rotational ektacytometry (LoRRca MaxSis Osmoscan). RESULTS: By filtrometry, relative cell transit time increased in the SE group (mostly in animal Nr. SE-3), showing the highest values on the 3rd, 9th and in 18th p.o. months. Elongation index values decreased in this group (both by slit-flow and rotational ektacytometers). In general, AU and two resection groups' values were lower versus control and higher than in SE. CONCLUSIONS: Forasmuch in the circulation both elongation by shear stress and filtration occur, these various erythrocyte deformability testing methods together may describe better the alterations. Considering the possible complications related to functional asplenic-hyposplenic conditions, individual analysis of cases is highly important.

Usage of ultraviolet test method for monitoring the efficacy of surgical hand rub technique among medical students.

BACKGROUND: Adequate hand movements are essential in surgical hand rub, so it is important for medical students to learn it correctly. To assess its efficacy, we aimed to use ultraviolet (UV) light test after applying fluorescent solution. METHODS: Digital images of the hands of 253 medical students were analyzed during "Basic Surgical Techniques" course on the 10th (Survey 1) and 14th (Survey 2) week of the curriculum to check the process and the skills development. The last step of the surgical hand rub was performed with a fluorescent solution, and then the hands were placed under UV light. Photographs were taken and analyzed. Every uncovered area was considered an error. Number and the localization of missed spots and its extent was determined. For evaluation, palmar (P) and dorsal (D) sides of the hands were divided into regions of interest (1-distal phalanxes, 2-thumb and first metacarpus, 3-second to fifth fingers, and 4-second to fifth metacarpals). RESULTS: Various magnitude and number of failure occurred in 123 (48.61%) students in survey 1 and in 65 (25.69%) in survey 2. The most frequent sites of the missed spots were D/2 and P/4 region in survey 1 and D/1 and P/4 in survey 2. There was an improvement seen in survey 2, as shown by a decrease in the number and extent of missed spots. Right-handed students made fewer mistakes on their nondominant hands than left-handed students (n = 23) did. DISCUSSION: The method was suitable to monitor the efficacy of surgical hand rub technique and identify the mistakes and the critical sites. The main advantage of the UV test was the immediate feedback, which resulted in a distinct improvement. CONCLUSION: Applying the UV test to the medical education and training may contribute to improvement in the compliance and the efficacy of the technique of surgical hand rub among the students.

Effects of various drugs (flunixin, pentoxifylline, enoxaparin) modulating micro-rheological changes in cerulein-induced acute pancreatitis in the rat.

Previously we have investigated the cerulein-induced acute pancreatitis and provided data on its micro-rheological impact in the rat. We hypothesized that non-steroid anti-inflammatory agent flunixin, the xanthine-derivate pentoxifylline and the low molecular weight heparin enoxaparin may have various beneficial effects improving microcirculatory and rheological parameters. In female rats, under general anesthesia, 10 µg/kg cerulein s.c. was administered and 2 hours afterwards microcirculation was tested by laser Doppler flowmetry on the tongue and after performing laparotomy on the small intestine, liver and pancreas prior to terminal blood sampling. From blood samples hematological parameters, blood pH, lactate concentration, erythrocyte deformability, osmoscan parameters and erythrocyte aggregation were tested. Compared to normal control in acute pancreatitis group we found severe deterioration in tissue microcirculation together with impaired erythrocyte deformability and enhanced aggregation, accompanied by acidic pH and increasing lactate concentration. Improvement was found when using flunixin (s.c.), pentoxifylline (i.p.) or enoxaparin (s.c.). These drugs could partly improve the blood flux on the surface of the investigated organs, and the flunixin had the most expressed improving effects on micro-rheological parameters. Surprisingly, the improving effect of pentoxifylline on micro-rheological parameters was not obvious (red blood cell deformability did not improved better than in the other treated groups), however, microcirculatory parameters improved.

Simultaneous investigation of hemodynamic, microcirculatory and arterio-venous micro-rheological parameters in infrarenal or suprarenal aortic cross-clamping model in the rat.

We aimed to investigate hemodynamic, microcirculatory and hemorheological consequence of infrarenal or suprarenal aortic cross-clamping (IRAXC, SRAXC) in the rat. We hypothesized that the magnitude of the changes are different. Twenty-one male rats were randomized into Control, IRAXC or SRAXC groups. Under anesthesia the right carotid artery was cannulated for monitoring heart rate and mean arterial pressure, then median laparotomy was performed. In AXC groups the abdominal aorta and the caudal caval vein were atraumatically clamped for 60 minutes below or above the renal vessels. Before and just after the ischemia, in the 30th and 60th minutes of the reperfusion besides hemodynamic test, laser Doppler flowmetry was used on the liver's, small-intestine's and the kidney's surface, then arterial (cannulated carotid artery) and venous (lateral tail vein) blood samples were taken for determining hematological, acid-base, erythrocytes' deformability, osmoscan and aggregation parameters. We found that when hemodynamic changes were prominent, microcirculatory or hemorheological parameters did not show such large differences. However, every parameter changed in various manners, showing more or less differences between IRAXC and SRAXC groups. Although the largest deviations were observable in SRAXC group, the acid-base and hemodynamic alterations were much more expressed than the micro-rheological ones. Further investigations of in vivo relations-correlations of changes in hemodynamic, microcirculatory, metabolic and hemorheological factors need further studies providing simultaneous monitoring possibilities.

Comparative osmotic gradient ektacytometry data on inter-species differences of experimental animals.

It is known that red blood cell deformability may show colorful inter-species differences, influenced by inner viscosity, cell membrane viscosity, morphology and surface-volume ratio of the erythrocytes. It is also well-known that the cell volume is changing depending on the micro-environmental osmolarity. These changes can be well observable using osmotic gradient ektacytometry (osmoscan). Interestingly, there is a lack of base and comparative osmoscan data regarding the experimental/laboratory animal species. In this study mouse, rat, canine and porcine blood samples were analyzed using a LoRRca MaxSis Osmoscan ektacytometer. The highest elongation index values were found in mouse, typically above shear stress of 1 Pa. Some lower values than these were shown in rat and more lower in canine, while the lowest values were detected in porcine, typically above 3-5 Pa. The optimal osmolarity point value, so the measurable maximal EI osmolarity was in a wide range among the species. While the lowest values were detected in canine, the highest ones in porcine and mouse, the rat values were in between. Further analysis and wider comparison of the osmotic gradient ektacytometry may contribute to the better understanding of the erythrocyte micro-rheological properties, their induced changes and inter-species differences.

Testicular ischemia-reperfusion may alter micro-rheological parameters in laboratory rats.

Ischemia-reperfusion-caused hemorheological alterations have been widely studied but the effect of testicular ischemia-reperfusion has not so far. In this study 14 Sprague-Dawley rats were involved. In the ischemia-reperfusion group under general anaesthesia the left testis was explored by opening the scrotum then the deferent duct and vasculature were clamped for 30 minutes. Testicular microcirculation was monitored by laser Doppler flowmetry. The right testis was untouched. In the control group: only anaesthesia was induced. Blood sampling occurred before and after ischemia, at the 60th minute of reperfusion and on the 1st postoperative day for determining hematological parameters (microcell-counter), erythrocyte deformability (slit-flow ektacytometer) and erythrocyte aggregation (light-transmission aggregometer). After the last blood sampling, testicles were removed for histological examination. Hematological parameter changes reflected inflammatory response. Erythrocyte deformability showed a worsening already at the 60th minute of reperfusion compared to base and control values. By the 1st postoperative day further decrease was observed. Erythrocyte aggregation significantly enhanced with great magnitude versus base and control values (p < 0.001). However, conventional histological examinations did not show marked testicular injury. The experienced changes can attract attention to the testicular ischemia-reperfusion causing significant effects on hemorheological parameters, which can lead to further harmful microcirculatory consequences.

Hemorheological changes in ischemia-reperfusion: an overview on our experimental surgical data.

Blood vessel occlusions of various origin, depending on the duration and extension, result in tissue damage, causing ischemic or ischemia-reperfusion injuries. Necessary surgical clamping of vessels in vascular-, gastrointestinal or parenchymal organ surgery, flap preparation-transplantation in reconstructive surgery, as well as traumatological vascular occlusions, all present special aspects. Ischemia and reperfusion have effects on hemorheological state by numerous ways: besides the local metabolic and micro-environmental changes, by hemodynamic alterations, free-radical and inflammatory pathways, acute phase reactions and coagulation changes. These processes may be harmful for red blood cells, impairing their deformability and influencing their aggregation behavior. However, there are still many unsolved or non-completely answered questions on relation of hemorheology and ischemia-reperfusion. How do various organ (liver, kidney, small intestine) or limb ischemic-reperfusionic processes of different duration and temperature affect the hemorheological factors? What is the expected magnitude and dynamics of these alterations? Where is the border of irreversibility? How can hemorheological investigations be applied to experimental models using laboratory animals in respect of inter-species differences? This paper gives a summary on some of our research data on organ/tissue ischemia-reperfusion, hemorheology and microcirculation, related to surgical research and experimental microsurgery.

Early micro-rheological consequences of single fraction total body low-dose photon irradiation in mice.

Despite of the studies on widespread biological effects of irradiation, surprisingly only little number of papers can be found dealing with its in vivo hemorheological impact. Furthermore, other studies suggested that low-dose irradiation might differ from high-dose in more than linear ways. On Balb/c Jackson female adult mice hematological and hemorheological impacts of total body irradiation were investigated 1 hour following 0.002, 0.005, 0.01, 0.02, 0.05 and 0.1 Gy dose irradiation. In case of 0.01 Gy further groups were analyzed 30 minutes, 2, 4, 6, 24 and 48 h after irradiation. According to the results, it seems that the dose-dependent changes of blood micro-rheological parameters are not linear. The irradiation dose of 0.01 Gy acted as a point of 'inflexion', because by this dose we found the most expressed changes in hematological parameters, as well as in red blood cell aggregation, deformability and osmoscan data. The time-dependent changes showed progressive decrease in pH, rise in lactate concentration, further decrease in erythrocyte aggregation index and deformability, with moderate shifting of the optimal osmolarity point and modulation in membrane stability. As conclusion, low-dose total body irradiation may cause micro-rheological changes, being non-linearly correlated with the irradiation dose.

[Trocar site herniation (TSH) following laparoscopic cholecystectomy: incidence, pathogenesis, and prevention -- animal study]. / A trokárok helyén kialakult hasfali sérvekrol (Trocar Site Hernia) laparoscopos cholecystectomia után: incidencia és megelozés -- állatkísérletes tanulmány.

INTRODUCTION: In 1968 R. E. Fear first reported a trocar site hernia (TSH) in his large series on laparoscopy. Currently, the incidence of TSH is estimated to be 0.65-2.80%. Ports ≥10-mm are usually closed, but ports of the 5-mm trocars are always left open, which may lead to herniation. MATERIAL AND METHODS: Authors guided teaching courses for hands-on animal laparoscopic cholecystectomy (LC) operations, where trainees performed LC-s on 60 animals. Two and four weeks following the operations the animals underwent second look laparoscopy to detect adhesion formation. RESULTS: Trocar site herniation was observed, and in 20% of the animals herniation was found. 70% of the hernias were situated in the 5-mm ports and 30% in the 10-mm ports. CONCLUSION: Port sites should be closed to prevent the formation of TSH. Attention should be payed on the closure of 5-mm trocar sites as well.

A modified microsurgical model for end-to-side selective portacaval shunt in the rat. Intraoperative microcirculatory investigations.

PURPOSE: To investigate the intraoperative microcirculatory changes of the affected organs (small bowel, liver and kidney) during the making of a modified selective portacaval (PC) shunt. METHODS: On ten anaesthetized Sprague-Dawley rats the selective end-to-side mesocaval anastomosis was performed, where only the rostral mesenteric vein is utilized and the portal vein with the splenic vein are left intact. Morphometric and microcirculatory investigations using a LDF device determining flux units (BFU) were carried out. RESULTS: After completing the shunts the microcirculatory flux values did not recover in the same manner on the surface of the small intestine, the liver or the kidney. BFU values showed deterioration in the small intestine and in the liver (p<0.001). During the reperfusion the BFU values improved, but not in the same manner. The small intestine values left behind the kidney and liver data. CONCLUSIONS: Technically, the advantages of the models include the selective characteristic, the mesocaval localization and the relatively easy access to those vessels. However, its major disadvantage is the time needed for positioning the vessels without coiling or definitive stretching. Intraoperative LDF may provide useful data on the microcirculatory affection of the organs suffering from hypoperfusion or ischemia during creating the shunts.