How we do it: the Zurich Microsurgery Lab technique for placenta preparation.

BACKGROUND: Perfused placentas provide an excellent and accessible model for microvascular dissection, microsuturing and microanastomosis training - particularly in the early microsurgical learning curve. This way, a significant amount of live animals can be spared. METHOD: We present the Zurich Microsurgery Lab protocol, detailing steps for obtaining, selecting, cleaning, flushing, cannulating, and preserving human placentas - as well as microsurgical training examples - in a tried-and-true, safe, cost-effective, and high-yield fashion. CONCLUSION: Our technique enables highly realistic microsurgical training (microdissection, microvascular repair, microanastomosis) based on readily available materials. Proper handling, preparation, and preservation of the perfused placenta models is key.

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. Level of Evidence Level V.

Hyperspectral placenta dataset: Hyperspectral image acquisition, annotations, and processing of biological tissues in microsurgical training.

The dataset consists of 101 hyperspectral images of four human placentas and six hyperspectral images of contrast dyes (i.e., indocyanine green and red and blue food colorant) that were captured in the range 515-900 nm, step = 5 nm. The hyperspectral images were manually annotated, delineating the key anatomical structures: arteries, veins, stroma, and the umbilical cord. Standard reference materials were used for flat-field correction. The dataset is instrumental for advancing machine-learning algorithms and automated classification of anatomical structures, particularly the classification of superficial and deep vessels and transparent tissue layers.

A New Model for Basic Microsurgical Nerve Repair Simulation: Making the Most Out of Less.

Microsurgical peripheral nerve repair is a technical and challenging procedure that requires thorough training prior to a real-life operating theater scenario. While the gold standard in training remains training on biological living peripheral nerve specimen, various inanimate models of nerve repair simulation have been described in the past years. The textile elastic band (TEB) obtained from a surgical mask was either covered with a fine silicone sheath or was left bare and was used afterward for end-to-end coaptation. The average diameter of the TEB was 2 mm, similar with the nerves in the distal hand and can be easily crafted out of accessible materials such as a surgical mask and silicone sealant. The silicone that covers the TEB offers more fidelity to the simulation for microsurgical nerve coaptation. The TEB model offers an affordable, available, and easy-to-craft alternative to the existing models for peripheral nerve repair simulation and serves as a good initiation tool before moving on to biological specimens.

A randomized study on the value of self-directed versus traditional mentor-led microsurgical training.

Objective: Analyze efficacy of self-directed resident microvascular training versus a mentor-led course. Study Design: Randomized, single-blinded cohort study. Setting: Academic tertiary care center. Methods: Sixteen resident and fellow participants were randomized into two groups stratified by training year. Group A completed a self-directed microvascular course with instructional videos and self-directed lab sessions. Group B completed a traditional mentor-led microvascular course. Both groups spent equal time in the lab. Video recorded pre and post-course microsurgical skill assessments were performed to assess the efficacy of the training. Two microsurgeons, blinded to participant identity, evaluated the recordings and inspected each microvascular anastomosis (MVA). Videos were scored using an objective-structured assessment of technical skills (OSATS), a global rating scale (GRS), and quality of anastomosis scoring (QoA). Results: The pre-course assessment identified that the groups were well matched with only "Economy of Motion" on the GRS favoring the mentor led group (p = .02). This difference remained significant on the post assessment (p = .02) Both groups significantly improved in OSATS and GRS scoring (p < .05). There was no significant difference in OSATS improvement between the two groups (p = .36) or improvement in MVA quality between groups (p > .99). Time to completion of MVA significantly improved overall by a mean of 8 min and 9 s (p = .005) with no significant difference between post training times to complete (p = .63). Conclusion: Different microsurgical training models have previously been validated as effective methods for improved MVA performance. Our findings indicate that a self-directed microsurgical training model is an effective alternative to a traditional mentor driven models. Level of Evidence: Level 2.

Learning curve and influencing factors of performing microsurgical anastomosis: a laboratory prospective study.

Despite being a critical component of any cerebrovascular procedure, acquiring skills in microsurgical anastomosis is challenging for trainees. In this context, simulation models, especially laboratory training, enable trainees to master microsurgical techniques before performing real surgeries. The objective of this study was to identify the factors influencing the learning curve of microsurgical training. A prospective observational study was conducted during a 7-month diploma in microsurgical techniques carried out in the anatomy laboratory of the school of surgery. Training focused on end-to-end (ETE) and end-to-side (ETS) anastomoses performed on the abdominal aorta, vena cava, internal carotid and jugular vein, femoral artery and vein, caudal artery, etc. of Wistar strain rats under supervision of 2 expert anatomical trainers. Objective and subjective data were collected after each training session. The 44 microsurgical trainees enrolled in the course performed 1792 anastomoses (1577 ETE, 88%, vs. 215 ETS, 12%). The patency rate of 41% was independent from the trainees' surgical background and previous experience. The dissection and the temporary clamping time both significantly decreased over the months (p < 0.001). Technical mistakes were independently associated with thrombosis of the anastomoses, as assessed by the technical mistakes score (p < 0.01). The training duration (in weeks) at time of each anastomosis was the only significant predictor of permeability (p < 0.001). Training duration and technical mistakes constituted the two major factors driving the learning curve. Future studies should try and investigate other factors (such as access to wet laboratory, dedicated fellowships, mentoring during early years as junior consultant/attending) influencing the retention of surgical skills for our difficult and challenging discipline.

Microsurgical training using an ex-vivo model: microscope vs 3D exoscope.

Objective: The aim of this study is to evaluate the feasibility of the 3D exoscope in a microvascular anastomosis training setting and compare it with the gold-standard technique using the operating microscope (OM). Methods: Participants were recruited among otorhinolaryngology head and neck surgery (OHNS) residents of two tertiary care hospitals. Trainees were asked to complete 4 microvascular end-to-end anastomoses on chicken thighs with the OM and VITOM 3D exoscope. The performances were scored by experienced microvascular surgeons; an objective evaluation of the anastomosis and a subjective assessment of the workload were conducted. Results: 8 OHNS residents were recruited. Considering the amount of time needed to complete (TTC) the anastomosis, an improvement was shown by all the participants throughout the training program. The objective evaluation of the anastomosis did not show a significant difference. No significant differences were found by analyzing the subjective workload with the different tools. Conclusions: This article represents the first attempt to compare the use of the OM and the 3D exoscope during training for microsurgery. The results of our study demonstrate the noninferiority of microsurgical training obtained using the 3D exoscope compared to that offered by the OM.

Microsurgical training course for clinicians and scientists: a 10-year experience at the Münster University Hospital.

BACKGROUND: Microsurgical techniques are an important part of clinical and experimental research. Here we present our step-by-step microsurgery training course developed at the Münster University Hospital. The goal of this course was to create a short, modular curriculum with clearly described and easy to follow working steps in accordance with the Guidelines for Training in Surgical Research in Animals by the Academy of Surgical Research. METHODS: Over the course of 10 years, we conducted an annual 2.5 day (20 h) microsurgical training course with a total of 120 participants. RESULTS: Prior to the course, 90% of the participants reported to have never performed a microanastomosis before. During the 10 years a total of 84.2% of the participants performed microanastomoses without assistance, 15% required assistance and only 0.8% failed. CONCLUSIONS: Our step-by-step microsurgery training course gives a brief overview of the didactic basics and the organization of a microsurgical training course and could serve as a guide for teaching microsurgical skills. During the 2.5-day curriculum, it was possible to teach, and for participants to subsequently perform a microsurgical anastomosis. The independent reproducibility of the learned material after the course is not yet known, therefore further investigations are necessary. With this step-by-step curriculum, we were able to conduct a successful training program, shown by the fact that each participant is able to perform microvascular anastomoses on a reproducible basis.

Application of a Microsurgical Space Restrictor in Microsurgical Simulation Training.

OBJECTIVE: To investigate the effect of the application of a microsurgical space restrictor in microsurgical simulation training. METHODS: A microsurgical space restrictor that can restrict the operation space was designed and produced. Forty neurosurgery residents with standardized training were selected as the study subjects and were randomly divided into the experimental group (group A) and the control group (group B). Group A was trained using the space restrictor, and group B was trained using the traditional method. The skills and overall performance of the 2 groups of trainees were assessed by the Stanford Microsurgery and Resident Training (SMaRT) scale. The assessment was divided into 2 stages: the unobstructed microsurgery test, and the test with the microsurgical operation space restrictor. RESULTS: In group A, the score for the first stage (A1) was 3.9 ± 0.6, the score for the second stage (A2) was 3.4 ± 0.6, and the score for A1 was better than that for A2 (P = 0.000); in group B, the score for the first stage (B1) was 3.57 ± 0.6, the score for the second stage (B2) was 3.0 ± 0.6, and the score for B1 was better than that for B2 (P = 0.000). Overall, the score for A1 was better than that for B1 (P = 0.046), and the score for A2 was better than that for B2 (P = 0.009). CONCLUSIONS: Microsurgical space restrictor use can improve the effect of microsurgical simulation training and help trainees better master microsurgical operation skills.

Endogenous and Exogenous Factors Affecting the Surgical Technique (Review).

In this review, we analyzed essential factors affecting precise manual movements in microsurgery described in the medical literature. The search for publications in English and Russian languages was conducted in the PubMed database without limitation by the date of publication. The search was carried out according to the following descriptors: surgical procedures, dexterity, microsurgery, caffeine, alcohol, nicotine, physical exercise, sleep deprivation, posture. Only randomized and cohort studies involving doctors and students with surgical specialties were included in the analysis. We did not include papers in which only psychological (non-motor) aspects were studied. Due to the limited number of publications meeting the inclusion criteria and conflicting results in some of them, the presented review does not allow us to formulate unambiguous conclusions and recommendations. Further studies (deep and fundamental) of endogenous and exogenous factors affecting the microsurgical technique are needed.

An Affordable Stereomicroscope for Microsurgery Training with Fluorescence Mode.

BACKGROUND: Laboratory training is a very important step on the development of the skills necessary for a neurosurgeon. This can be achieved using animal models and surgical microscopes or stereomicroscopes. Methods, like the use of fluorescein, increase the lifelike situation and allow anyone to assess the patency of an anastomosis and improve the quality of this training. METHODS: We report the use of a stereomicroscope with white light and a fluorescence mode used to perform dissection of small arteries and anastomosis using a chicken wing model. Using an affordable device, we could perform fluorescein videoangiography to asses the patency of those anastomosis and improve the quality of the training skills in microsurgery. RESULTS: The stereomicroscope is a useful tool for laboratory training and can be used as a substitute of a surgical microscope for microsurgery training. The fluorescence mode allowed us to perform fluorescein videoangiography with very a good quality of image. CONCLUSIONS: Microsurgery training is important part in the life of any neurosurgeon. Using a stereomicroscope with a fluorescence mode is an affordable method that can be reproduced in any laboratory in the world.

The Role of Low-Cost Microsurgical Training Models and Experience with Exercises Based on a Bovine Heart.

BACKGROUND: Microscopic training is essential for development of neurosurgical skills. A range of models is reported in the literature for this purpose, including live animals, exvivo, and synthetic material. Among the factors involved in selection and development of a training station, cost is a decisive one. METHODS: We present a low-cost model to practice microvascular anastomoses using a bovine heart and an artificial perfusion system. We also present a brief review of laboratory models for microsurgical training, focusing on the costs and reproducibility of the different options. RESULTS: Exvivo models are a great bridging point between nonbiologic and living animal training models. These models have major similarities to human vessels, such as lumen size and malleability of the arteries. The bovine heart model allowed the residents to gain confidence in handling vascular tissue in a microscopic environment. CONCLUSIONS: Although these models do not resemble anatomic landmarks in the human brain, the bovine heart model allowed the residents to gain confidence in handling vascular tissue in a microscopic environment.

Microsurgical vasectomy reversal: contemporary techniques, intraoperative decision making, and surgical training for the next generation.

Men seeking fertility after elective sterilization can be treated with a wide array of interventions. Reconstruction of the reproductive tract remains the gold standard and most cost-effective option for the appropriately selected candidate. In the following review, the treatment algorithm for men desiring vasectomy reversal is outlined. Specifically, the current evidence basis for preoperative evaluation, intraoperative decision making, postsurgical management, and emerging advances to optimize outcomes will be discussed. Finally, the important role of microsurgical training and how the field can improve quality of care will be reviewed.

Entrenamiento básico de microcirugía. Centro de Cirugía Experimental, Instituto de Ciencias Básicas y Preclínicas "Victoria de Girón" / Basic microsurgery training. Center for Experimental Surgery, "Victoria de Girón" Institute of Basic and Pre-Clinical Sciences

Introducción: Las técnicas microquirúrgicas son hoy enormemente aplicadas en el mundo en diferentes especialidades quirúrgicas. El centro, desde la década del 90, comenzó a impartir los entrenamientos de microcirugía vascular y nerviosa a especialistas y residentes nacionales y extranjeros respectivamente. Objetivo: Evaluar los resultados del entrenamiento de microcirugía que se imparte en el Centro de Cirugía Experimental de la Facultad de Medicina Victoria de Girón. Material y métodos: Se realizó un estudio longitudinal retrospectivo para evaluar el programa que se oferta. El entrenamiento está dividido en tres partes fundamentales: Parte teórica; prácticas en un simulador de látex; sutura termino-terminal de intestino delgado sobre la rata y, por último, el desarrollo de las técnicas básicas microquirúrgicas para un total de 90 horas. La matricula total en el período fue de 203 cursistas a quienes se les aplicó una encuesta al finalizar el entrenamiento; se midió además el tiempo de realización de la anastomosis y la permeabilidad vascular para calificarlos de Mal, Bien y Excelente al concluir. Resultados: En general fueron satisfactorios en 90 por ciento de los estudiantes sobre todo aquellos que poseen o estudian una especialidad quirúrgica, quienes presentaron mejores habilidades en un corto período que aquellos que no practicaban la cirugía reduciendo el tiempo de realización de las anastomosis y obteniendo una buena permeabilidad vascular. Conclusiones: El entrenamiento básico de microcirugía implementado constituye una útil herramienta para que los educandos desarrollen las habilidades necesarias para poder acometer con éxito las prácticas microquirúrgicas en la clínica quirúrgica(AU)

Introduction: Microsurgical techniques are currently applied in different surgical specialties worldwide. During the 90´s, our center began to implement vascular and nerve microsurgery trainings to specialists and national and foreign residents, respectively. Objective: To evaluate the results of microsurgery training that it is taught in the Center for Experimental Surgery at Victoria de Girón Institute of Basic and Pre-Clinical Sciences. Material and methods: A retrospective longitudinal study was carried out to evaluate the microsurgery training program. The training was divided into three main parts: theoretical lessons; practices upon the latex simulator; end-to-end anastomosis of small intestine on the rat; and finally, the development of basic microsurgical techniques on different vascular structures (abdominal aorta and vein) and the sciatic nerve of the rat, for a total of 90 hours of training. The total enrollment during the mentioned period was 203 students to whom a survey was applied at the end of the training; also, the time of realization of anastomosis and the vascular permeability were measured and evaluated as Bad, Good, and Excellent. Results: The results were satisfactory in general, but 90 percent of students that were carrying out their studies of a surgical specialty showed better skills in a shorter period than those that didn't practice surgery, demonstrating a less time-consuming exercise in the realization of vessel anastomosis and obtaining a good vascular permeability in this group. Conclusions: This teaching method constitutes a useful tool so that the students develop the necessary skills to carry out microsurgical practices in clinical surgery successfully(AU)

Virtual Reality Glasses and "Eye-Hands Blind Technique" for Microsurgical Training in Neurosurgery.

OBJECTIVE: Microsurgical skills and eye-hand coordination need continuous training to be developed and refined. However, well-equipped microsurgical laboratories are not so widespread as their setup is expensive. Herein, we present a novel microsurgical training system that requires a high-resolution personal computer screen, smartphones, and virtual reality glasses. METHODS: A smartphone placed on a holder at a height of about 15-20 cm from the surgical target field is used as the webcam of the computer. A specific software is used to duplicate the video camera image. The video may be transferred from the computer to another smartphone, which may be connected to virtual reality glasses. RESULTS: Using the previously described training model, we progressively performed more and more complex microsurgical exercises. It did not take long to set up our system, thus saving time for the training sessions. CONCLUSION: Our proposed training model may represent an affordable and efficient system to improve eye-hand coordination and dexterity in using not only the operating microscope but also endoscopes and exoscopes.

A Portable Training Model for Deep Bypass Surgery.

INTRODUCTION: Deep bypass surgery remains a challenging operative procedure. For novice trainees, there is a high barrier to improving the microsurgical skills needed for this procedure because of the relatively low number of cases and the high cost of microsurgical instruments. Here, the authors introduce a training model that includes highly accessible devices and does not require a microscope. MATERIALS AND METHODS: The surgical environment consisted of two 15.5-cm straight serrated forceps with a 1-mm tip width (Medicon, Tuttlingen, Germany), 9-cm curved iris scissors (Medicon), 4-0 black silk suture, gauze, and a 15 × 10.5 × 3.5-cm-sized box with a transparent cover. These materials are affordable even in low-income countries. PROCEDURE: To understand and learn the hand positioning used in the deep surgical field, suturing practice was performed as follows: the forceps and a needle were placed in a slanted position, with hand position maintained at a 50° angle between the 2 forceps. This was also performed above the desk, without wrist support. CONCLUSIONS: Our training system will be helpful, especially for deep bypass surgery, since training with similar muscle effort and fatigue can improve surgical skills. This system is economic, highly accessible, and available even for portable training.

An Affordable Microsurgical Training System for a Beginning Neurosurgeon: How to Realize the Self-Training Laboratory.

OBJECTIVE: To provide detailed information about how to realize a self-training laboratory with cost-effective microsurgical instruments, especially pertinent for the novice trainee. METHODS: Our training model is designed to allow the practice of the microsurgery skills in an efficient and cost-effective manner. A used stereoscopic microscope is prepared for microsurgical training. A sufficient working distance for microsurgical practice is obtained by attaching an auxiliary objective lens. The minimum instrument list includes 2 jeweler's forceps, iris scissors, and alligator clips. The iris scissors and alligator clip provide good alternatives to micro-scissors and microvascular clamp. RESULTS: The short time needed to set up the microscope and suture the gauze with micro-forceps makes the training model suitable for daily practice. It takes about 15 minutes to suture 10 neighboring fibers of the gauze with 10-0 nylon; thus, training can be completed more quickly. CONCLUSIONS: We have developed an inexpensive and efficient micro-anastomosis training system using a stereoscopic microscope and minimal micro-instruments. Especially useful for novice trainees, this system provides high accessibility for microsurgical training.

Microsurgical skill acquisition in a one-day introductory course with performance evaluation using software-assisted scoring system.

BACKGROUND: Recent emphasis on microsurgical skill acquisition at an earlier stage of plastic surgery training has seen a shift toward objective competence-based assessment. Yet no objective measures of spacing or alignment exist, with few validated models that assess ability. The authors propose a novel software analysis scoring system to objectively measure spacing, alignment and the overall improvement in a 1-day, introductory course setting. METHODS: Images of standard 4-mm latex strips that had been sutured by participants using the Microtrainer system were uploaded onto calibrated, online software. Sutures were analysed with regard to spacing, alignment and density. From these measurements, a total score was calculated, one on initial assessment at the course beginning (Score 1) and another on final assessment at the course end (Score 2), thereby facilitating measurement of the overall improvement. RESULTS: A total of 38 microsurgical anastomoses from 19 participants ranging from postgraduate years 1-7 were analysed. Seventeen participants had no previous experience of microsurgery. The mean average Score 1 of participants was -2 (range -12 to +22) and Score 2 was 22 (range +12 to +32), thus showing a significant improvement in candidate ability throughout the course of the day (p < 0.0001). CONCLUSIONS: Microtrainer system software analysis provides a novel, reliable, and consistent objective assessment for surgical trainees at all stages of training, without risk to patients. It has an associated cost for the initial setup, yet is timely, repeatable and can efficiently demonstrate progress in a 1-day course setting.

Microsurgical training model for residents to approach to the orbit and the optic nerve in fresh cadaveric sheep cranium.

BACKGROUND: Neurosurgery and ophthalmology residents need many years to improve microsurgical skills. Laboratory training models are very important for developing surgical skills before clinical application of microsurgery. A simple simulation model is needed for residents to learn how to handle microsurgical instruments and to perform safe dissection of intracranial or intraorbital nerves, vessels, and other structures. MATERIALS AND METHODS: The simulation material consists of a one-year-old fresh cadaveric sheep cranium. Two parts (Part 1 and Part 2) were designed to approach structures of the orbit. Part 1 consisted of a 2-step approach to dissect intraorbital structures, and Part 2 consisted of a 3-step approach to dissect the optic nerve intracranially. RESULTS: The model simulates standard microsurgical techniques using a variety of approaches to structures in and around the orbit and the optic nerve. CONCLUSIONS: This laboratory training model enables trainees to gain experience with an operating microscope, microsurgical instruments and orbital structures.