A Novel Virtual Wet Lab-Using a Smartphone Camera Adapter and a Video Conference Platform to Provide Real-Time Surgical Instruction.

PURPOSE: Proctored surgical instruction has traditionally been taught through in-person interactions in either the operating room or an improvised wet lab. Because of the COVID-19 pandemic, live in-person instruction was not feasible owing to social distancing protocols, so a virtual wet lab (VWL) was proposed and implemented. The purpose of this article is to describe our experience with a VWL as a Descemet membrane endothelial keratoplasty (DMEK) skills-transfer course. This is the first time that a VWL environment has been described for the instruction of ophthalmic surgery. METHODS: Thirteen participant surgeons took part in VWLs designed for DMEK skills transfer in September and October 2020. A smartphone camera adapter and a video conference software platform were the unique media for the VWL. After a didactic session, participants were divided into breakout rooms where their surgical scope view was broadcast live, allowing instructors to virtually proctor their participants in real time. Participants were surveyed to assess their satisfaction with the course. RESULTS: All (100%) participants successfully injected and unfolded their DMEK grafts. Ten of the 13 participants completed the survey. Respondents rated the experience highly favorably. CONCLUSIONS: With the use of readily available technology, VWLs can be successfully implemented in lieu of in-person skills-transfer courses. Further development catering to the needs of the participant might allow VWLs to serve as a viable option of surgical education, currently limited by geographical and social distancing boundaries.

Flexible fibreoptic intubation in swine - improvement for resident training and animal safety alike.

BACKGROUND: Efficient airway management to facilitate tracheal intubation encompasses essential skills in anaesthesiologic and intensive care. The application of flexible fibreoptic intubation in patients with difficult airways has been identified as the recommended method in various international guidelines. However, providing the opportunity to adequately train residents can be challenging. Using large animals for practice during ongoing studies could help to improve this situation, but there is no recent data on fibreoptic intubation in swine available. METHODS: Thirty male German landrace pigs were anesthetized, instrumented and randomized into two groups. The animals were either intubated conventionally using direct laryngoscopy or a single-use flexible video-endoscope. The intervention was carried out by providers with 3 months experience in conventional intubation of pigs and a brief introduction into endoscopy. Intubation attempts were supervised and aborted, when SpO2 dropped below 93%. After three failed attempts, an experienced supervisor intervened and performed the intubation. Intubation times and attempts were recorded and analysed. RESULTS: Flexible fibreoptic intubation showed a significantly higher success rate in first attempt endotracheal tube placement (75% vs. 47%) with less attempts overall (1.3 ± 0.6 vs. 2.1 ± 1.3, P = 0.043). Conventional intubation was faster (42 s ± 6 s vs. 67 s ± 10s, P < 0.001), but showed a higher complication rate and more desaturation episodes during the trial. CONCLUSIONS: Flexible fibreoptic intubation in swine is feasible and appears to be a safer and more accessible method for inexperienced users to learn. This could not only improve resident training options in hospitals with animal research facilities but might also prevent airway complications and needless animal suffering.

Suitability and realism of the novel Fix for Life cadaver model for videolaryngoscopy and fibreoptic tracheoscopy in airway management training.

BACKGROUND: Videolaryngoscopy is increasingly advocated as the standard intubation technique, while fibreoptic intubation is broadly regarded as the 'gold standard' for difficult airways. Traditionally, the training of these techniques is on patients, though manikins, simulators and cadavers are also used, with their respective limitations. In this study, we investigated whether the novel 'Fix for Life' (F4L) cadaver model is a suitable and realistic model for the teaching of these two intubation techniques to novices in airway management. METHODS: Forty consultant anaesthetists and senior trainees were instructed to perform tracheal intubation with videolaryngoscopy and fibreoptic tracheoscopy in four F4L cadaver models. The primary outcome measure was the verbal rating scores (scale 1-10, higher scores indicate a better rating) for suitability and for realism of the F4L cadavers as training model for these techniques. Secondary outcomes included success rates of the procedures and the time to successful completion of the procedures. RESULTS: The mean verbal rating scores for suitability and realism for videolaryngoscopy was 8.3 (95% CI, 7.9-8.6) and 7.2 (95% CI, 6.7-7.6), respectively. For fibreoptic tracheoscopy, suitability was 8.2 (95% CI, 7.9-8.5) and realism 7.5 (95% CI, 7.1-7.8). In videolaryngoscopy, 100% of the procedures were successful. The mean (SD) time until successful tracheal intubation was 34.8 (30.9) s. For fibreoptic tracheoscopy, the success rate was 96.3%, with a mean time of 89.4 (80.1) s. CONCLUSIONS: We conclude that the F4L cadaver model is a suitable and realistic model to train and teach tracheal intubation with videolaryngoscopy and fibreoptic tracheoscopy to novices in airway management training.

A Comparison of Direct Laryngoscopy and Videolaryngoscopy for Endotracheal Intubation by Inexperienced Users: A Pediatric Manikin Study.

OBJECTIVE: Direct laryngoscopy (DL) is the most common technique for endotracheal intubation, whereas videolaryngoscopy provides an indirect view of the glottis without the need to align the oral, pharyngeal, and tracheal axes. The current study compares videolaryngoscopy with DL among experienced and inexperienced users for endotracheal intubation using a pediatric manikin. METHODS: Participants performed DL using Miller and Macintosh laryngoscopes and videolaryngoscopy using CMAC and GlideScope devices on a manikin (SimBaby; Laerdel, Wappingers Falls, NY). Time to endotracheal intubation, number of attempts, and successful intubation within 120 seconds were recorded. RESULTS: Among 31 experienced users, time to endotracheal intubation with the CMAC (20 ± 13 seconds) did not differ from DL with either the Miller (30 ± 28 seconds) or Macintosh (27 ± 23 seconds) laryngoscopes. However, with the GlideScope, time to endotracheal intubation (85 ± 38 seconds) was longer. The results were similar among 12 inexperienced users, as time to endotracheal intubation with the CMAC (61 ± 34 seconds) was comparable with the Miller (72 ± 45 seconds) or Macintosh (72 ± 45 seconds) laryngoscopes but was longer with the GlideScope (118 ± 6 seconds) for each comparison. CONCLUSIONS: The standard straight or curved laryngoscope blades including the CMAC were associated with shorter procedural time and higher success rate when compared with indirect videolaryngoscopy with an unconventional blade design such as the GlideScope in both experienced and inexperienced users. However, the current study demonstrates that results may be influenced by the anatomical design of the manikin.

Surgical training in video-assisted neck surgery-based thyroidectomy using fresh frozen human cadavers.

Endoscopic surgery has been introduced in various surgical fields. Endoscopic surgery requires different skills from open surgery due to the restricted surgical field and difficulty in identifying anatomical structures from certain viewpoints. Therefore, surgeons need to undergo sufficient surgical training before performing such surgery in the clinical setting. We examined the utility of fresh frozen human cadavers for surgical training aimed at introducing video-assisted neck surgery (VANS) at our department. First, we performed surgical training using fresh human cadavers four times. Next, we performed hemi-thyroidectomy with VANS in 5 clinical patients. After the cadaver training and the actual surgery, the surgeons evaluated each step of the surgical procedure using a 3-point scale. In the cadaver training, the scores for steps : creation of a subcutaneous tunnel and lifting up the skin flap and pre-thyroid muscles were higher than other steps. And a tracheal injury occurred as a complication. However, we were able to recognize anatomical structures under the endoscopic view. And it was also useful for confirming the role of surgical staff and simulating the placement of surgical equipment. Surgical training using fresh frozen human cadavers was effective at introducing a new surgical method. J. Med. Invest. 66 : 293-296, August, 2019.

The teaching order of using direct laryngoscopy first may improve the learning outcome of endotracheal incubation: A preliminary, randomized controlled trial.

BACKGROUND: Endotracheal intubation (ETI) is a life-saving procedure taught to medical students. We examined the influence of the order of teaching ETI through direct laryngoscopy (DL) and video laryngoscopy (VL) on learning by measuring the intubation time and learning curve of trainees, in order to explore ways to improve ETI performance. METHODS: Twenty trainees were randomly divided into 2 groups. In the DL-first group, trainees used DL to perform ETI 10 times and then used VL 10 times, while the order was reversed in the VL-first group. Intubation time, number of intubation attempts, the Cormack-Lehane (CL) classification, and adverse events were recorded. The primary outcome was the cumulative summation (CUSUM). The CUSUM equation is defined as (Equation is included in full-text article.), where ct is the cumulative sum. RESULTS: ETI was attempted on 400 patients. The difference in the mean times for the first 10 intubations between the 2 groups was not significant (P > .05). Mean intubation time for second series in the DL-first group was significantly shorter than that of the first series (P < .05), while there were no differences between the 2 series in the VL-first group (P > .05). The mean intubation time in the second series of the DL-first group was shorter than for the first series of the VL-first group (P < .05), while the mean intubation time of the first series by the DL-first group did not differ from the second series by the VL-first group (P > .05). Eighteen attempts were required to achieve an 80% intubation success rate for the DL-first group, while more than 20 attempts were required for the trainees in the VL-first group. CONCLUSION: We consider that teaching trainees DL for tracheal intubation first. CLINICAL TRIAL NUMBER: ChiCTR-OOR-16008364.

Cumulative sum analysis of learning curve for video-assisted mini-laparotomy partial nephrectomy in renal cell carcinoma.

Video-assisted mini-laparotomy surgery (VAMS), a hybrid of open and laparoscopic surgical techniques, is an important surgical approach in the field of partial nephrectomy. The learning curve for VAMS partial nephrectomy has not been studied to date; we therefore, evaluated this learning curve.We prospectively evaluated 20 consecutive patients who underwent VAMS partial nephrectomy performed by a single surgeon (YEY) between March 2015 and December 2016. The learning curve was evaluated using the cumulative sum method. The measure of surgical performance was composed of 3 parameters (total operation time [Op time], warm ischemic time [WIT], and estimated blood loss [EBL]).Among the 20 patients who underwent VAMS partial nephrectomy, the mean age was 54.6 years. The mean Op time and WIT were 172.5 and 28.8 minutes, respectively. The learning curve for the Op time, WIT, and EBL consisted of 3 unique phases: phase 1 (the first 7 cases), phase 2 (the next 5 to 7 cases), and phase 3 (all subsequent cases). Phase 1 represents the initial learning curve, and the phase 2 plateau represents the period of expert competency. Phase 3 represents when one is competent in VAMS partial nephrectomy.The learning curve for VAMS partial nephrectomy is relatively short and after a learning curve of approximately 7 cases, the surgeon became familiar with VAMS partial nephrectomy; after 12 to 14 cases, the surgeon became competent in this procedure.

LOW-COST SIMULATOR ASSEMBLY FOR 3-DIMENSIONAL VIDEOSURGERY TRAINING.

BACKGROUND: Three-dimensional videosurgery is already a reality worldwide. The trainee program for this procedure should be done initially and preferably in simulators. AIM: Assemble low-cost simulator for three-dimensional videosurgery training. METHODS: The simulator presented here was mounted in two parts, base and glasses. After, several stations can be inserted into the simulator for skills training in videosurgery. RESULTS: It was possible to set up three dimensional (3D) video simulations with low cost. It has proved to be easy to assemble and allows the training surgeon of various video surgical skills. CONCLUSION: This equipment may be used in undergraduate programs and advanced courses for residents and surgeons. The acrylic box allows the visualization of the task executed by the tutor and even by other experienced students.

El anfiteatro endovascular / The endovascular amphitheatre

No disponible

Cumulative sum analysis of the learning curve for video-assisted minilaparotomy donor nephrectomy in healthy kidney donors.

Video-assisted minilaparotomy surgery (VAMS) is a hybrid of open and laparoscopic surgical techniques, so has advantages of both approaches. Here, we examined the learning curve for this procedure.We retrospectively evaluated 50 consecutive patients who underwent VAMS donor nephrectomy performed by a single surgeon (YEY) between March 2015 and March 2016. The learning curve was evaluated using the cumulative sum (CUSUM) method. Measures of surgical performance included total operation time, warm ischemic time, and estimated blood loss.The mean patient age, body mass index, and body surface area were 43.5 years, 23.8 kg/m, and 1.7 m, respectively. The mean operation time and warm ischemic time were 160.0 minutes and 124.4 seconds. The learning curve of total operation time was best modeled as a second-order polynomial with equation CUSUMOT (minutes) = -0.3802 × case number + 20.315 × case number - 41.333 (R = 0.7707). The curve included 3 unique phases: phase 1 (the initial 17 cases), which is the initial learning curve; phase 2 (the middle 23 cases), expert competence, and phase 3 (the subsequent cases), mastery. In terms of warm ischemic time and estimated blood loss, the initial learning was achieved after 16 cases and after 9 to 10 cases, one could achieve competency.The VAMS donor nephrectomy learning curve is shorter than for laparoscopic or robotic hand-assisted donor nephrectomy. Surgeons can become familiar with the procedure and perform it without complications after approximately 16 to 17 operations.

Using GoPro to Give Video-Assisted Operative Feedback for Surgery Residents: A Feasibility and Utility Assessment.

OBJECTIVE: As an adjunct to simulation-based teaching, laparoscopic video-based surgical coaching has been an effective tool to augment surgical education. However, the wide use of video review in open surgery has been limited primarily due to technological and logistical challenges. The aims of our study were to (1) evaluate perceptions of general surgery (GS) residents on video-assisted operative instruction and (2) conduct a pilot study using a head-mounted GoPro in conjunction with the operative performance rating system to assess feasibility of providing video review to enhance operative feedback during open procedures. DESIGN: GS residents were anonymously surveyed to evaluate their perceptions of oral and written operative feedback and use of video-based operative resources. We then conducted a pilot study of 10 GS residents to assess the utility and feasibility of using a GoPro to record resident performance of an arteriovenous fistula creation with an attending surgeon. Categorical variables were analyzed using the chi-square test. SETTING: Academic, tertiary medical center. PARTICIPANTS: GS residents and faculty. RESULTS: A total of 59 GS residents were anonymously surveyed (response rate = 65.5%). A total of 40% (n = 24) of residents reported that structured evaluations rarely or never provided meaningful feedback. When feedback was received, 55% (n = 32) residents reported that it was only rarely or sometimes in regard to their operative skills. There was no significant difference in surveyed responses among junior postgraduate year (PGY 1-2), senior (PGY 3-4), or chief residents (PGY-5). A total of 80% (n = 8) of residents found the use of GoPro video review very or extremely useful for education; they also deemed video review more useful for operative feedback than written or communicative feedback. An overwhelming majority (90%, n = 9) felt that video review would lead to improved technical skills, wanted to review the video with the attending surgeon for further feedback, and desired expansion of this tool to include additional procedures. CONCLUSIONS: Although there has been progress toward improving operative feedback, room for further improvement remains. The use of a head-mounted GoPro is a dynamic tool that provides high-quality video for operative review and has the potential to augment the training experience of GS residents. Future studies exploring a wide array of open procedures involving a greater number of trainees will be needed to further define the use of this resource.

Low-cost simulator assembly for 3-dimensional videosurgery training / Montagem de simulador de baixo custo para treinamento de videocirurgia em três dimensões

ABSTRACT Background: Three-dimensional videosurgery is already a reality worldwide. The trainee program for this procedure should be done initially and preferably in simulators. Aim: Assemble low-cost simulator for three-dimensional videosurgery training. Methods: The simulator presented here was mounted in two parts, base and glasses. After, several stations can be inserted into the simulator for skills training in videosurgery. Results: It was possible to set up three dimensional (3D) video simulations with low cost. It has proved to be easy to assemble and allows the training surgeon of various video surgical skills. Conclusion: This equipment may be used in undergraduate programs and advanced courses for residents and surgeons. The acrylic box allows the visualization of the task executed by the tutor and even by other experienced students.

RESUMO Racional: A videocirurgia em três dimensões já é realidade no cenário atual. O treinamento dessa habilidade deve ser feito inicialmente e preferencialmente em simuladores. Objetivo: Montar simulador de baixo custo para treinamento de videocirurgia em três dimensões. Métodos: O simulador aqui apresentado foi montado em duas partes, base e óculos. Após montagem, podem ser inseridas estações diversas no simulador para treinamento de habilidades em videocirurgia. Resultados: Foi possível montar simuladores de videocirurgia em 3D com custo baixo. Ele apresentou-se ser de fácil montagem permitindo o treinamento de várias habilidades videocirúrgicas. Conclusão: Este equipamento pode ser utilizado tanto em cursos básicos para a graduação quanto para avançados destinados a residentes e cirurgiões. A caixa de acrílico permite a visualização da tarefa executada pelo orientador/tutor e por outros alunos.

[Training course transanal total mesorectal excision (TaTME) : Concept and establishment of a training course for safe application]. / Trainingskurs transanale totale mesorektale Exzision (TaTME) : Konzept und Realisation eines Trainingskurses zur sicheren Anwendung.

BACKGROUND: In recent years the video endoscopy-assisted transanal approach to total mesorectal excision (TME) combined with the conventional laparoscopic technique was developed as an alternative indication for treatment of low rectal cancer (TaTME). OBJECTIVE: The concept and results of the first German TaTME hands-on cadaver course with subsequent live surgery are presented. MATERIAL AND METHODS: The 2­day training course was structured into an anatomical and a clinical surgery part. The participants could learn from basics to live surgery and shared their experiences during presentations about currently available data, rationale and technique of TaTME with special emphasis on technical failures and pitfalls. The supervised simulator training and TaTME exercises at three cadaver work stations were proctored by experienced surgeons. On day 2 the participants observed two cases of TaTME at the moderated live surgery session. RESULTS: The step-up learning curve for the transanal approach could be clearly observed in each team from warm-up to hands-on training sessions. In the practical session the participants could train the milestones of the transanal approach on cadavers, including the pitfalls. Finally, the participants observed live surgery on two patients with low rectal tumors on day 2 of the course. CONCLUSION: A step-up training course on cadavers is indispensable regarding implementation of techniques, such as TaTME into clinical practice. Coordinated clinical guest demonstrations provide translation of theoretical basic principles and practical skills from the cadaver course to real patient treatment. Participants should be encouraged to report their cases to registered trials or registries.

[Educational suitability of endotracheal intubation using a video-laryngoscope].

PURPOSE: The purpose of this study is to determine the educational suitability of the video-laryngoscope in teaching endotracheal intubation to students. METHODS: Medical students participated in a course on the use of a Macintosh direct laryngoscope and McGrath MAC videolaryngoscope for intubation. The course comprised a 1-hour lecture and 30 minutes of practice on a manikin. After the course, in each of the three simulated patient scenarios-normal airway, cervical spine fixation, and tongue edema-time to intubate, success rate, and chance of complications were measured. A questionnaire was administered before and after the course to determine thesuitability of intubation by video-laryngoscope for a medical education course. Also, changes in the perception and stance on the video-laryngoscope were evaluated. RESULTS: Time to intubate decreased as attempts were repeated. The first-attempt success rate in the cervical spine fixation scenario was higher using the video-laryngoscope (p=0.028). Rates if tooth injury were lower in the cervical spine fixation (p=0.005) andtongue edema scenarios (p=0.021) using the video-laryngoscope. Based on the questionnaires, students responded positively with regard to their knowledge of the video-laryngoscope, its practical value, and its suitability for medical education (p<0.001). Also,the preference for the video-laryngoscope was greater (p=0.044). Students felt that repeated attempts and feedback on intubation were helpful. CONCLUSION: The students' evaluations and surveys showed positive results to intubation by video-laryngoscope. Thus, based on its suitability for medical education it is reasonable to consider learning intubation using the video-laryngoscope.

Experience report on teaching surgical technique without animal use.

PURPOSE: To report the experience of the school in implementing the 3 Rs replace, reduce and refine; showing time and assembling cost of the experimental models used in the teaching of Surgical Technique and Experimental Surgery. METHODS: Assembly time and costs of models: grafts and flaps performed in pork belly, model of intestinal anastomosis and jejunostomy done in Bahiana box and black box model for training videosurgery. RESULTS: Average time and cost estimate: ten minutes-pork belly, cost $ 6.00 per kilogram; two minutes-Bahiana box, cost $ 27.2; Black box-3.6 hours for manufacturing, cost $ 100.00. The repetition of each practice the cost is $ 3.20 for Bahiana box and at no cost to the black box. CONCLUSION: The experimental models presented are easily reproducible and of low cost.

Experience report on teaching surgical technique without animal use

PURPOSE: To report the experience of the school in implementing the 3 Rs replace, reduce and refine; showing time and assembling cost of the experimental models used in the teaching of Surgical Technique and Experimental Surgery. METHODS: Assembly time and costs of models: grafts and flaps performed in pork belly, model of intestinal anastomosis and jejunostomy done in Bahiana box and black box model for training videosurgery. RESULTS: Average time and cost estimate: ten minutes-pork belly, cost $ 6.00 per kilogram; two minutes-Bahiana box, cost $ 27.2; Black box-3.6 hours for manufacturing, cost $ 100.00. The repetition of each practice the cost is $ 3.20 for Bahiana box and at no cost to the black box. CONCLUSION: The experimental models presented are easily reproducible and of low cost. .