Abstract
Supplemental education is desirable for neurosurgical training, and the use of human cadaver specimen and virtual reality models is routine. An in vivo porcine training model for cranial neurosurgery was introduced in 2005, and our recent experience with this unique model is outlined here. For the first time, porcine anatomy is illustrated with particular respect to neurosurgical procedures. The pros and cons of this model are described. The aim of the course was to set up a laboratory scenery imitating an almost realistic operating room in which anatomy of the brain and neurosurgical techniques in a mentored environment free from time constraints could be trained. Learning objectives of the course were to learn about the microsurgical techniques in cranial neurosurgery and the management of complications. Participants were asked to evaluate the quality and utility of the programme via standardized questionnaires by a grading scale from A (best) to E (worst). In total, 154 residents have been trained on the porcine model to date. None of the participants regarded his own residency programme as structured. The bleeding and complication management (97 %), the realistic laboratory set-up (89 %) and the working environment (94 %) were favoured by the vast majority of trainees and confirmed our previous findings. After finishing the course, the participants graded that their skills in bone drilling, dissecting the brain and preserving cerebral vessels under microscopic magnification had improved to level A and B. In vivo hands-on courses, fully equipped with microsurgical instruments, offer an outstanding training opportunity in which bleeding management on a pulsating, vital brain represents a unique training approach. Our results have shown that education programmes still lack practical training facilities in which in vivo models may act as a complementary approach in surgical training.
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Gilberto K.K. Leung, Hong Kong
Regelsberger et al. reported their experiences with resident training in microsurgical techniques using an in vivo porcine model. This is an important development in surgical training. The authors provided a detailed comparison between porcine and human cranial anatomy which is useful for those in the process of designing similar programmes. This platform can readily be expanded to include other intra-operative scenarios such as accidental major vascular injuries, intracerebral haemorrhages, unexpected brain swelling and so on. That would enable the trainers to employ the approach used in other programmes such as the Definitive Surgical Trauma Care (DSTC) course, in which participants are challenged by and trained to deal with situations where ‘things do not work according to plan’. The authors also reported the participants’ post-course subjective evaluations. It would be interesting to obtain, in addition, feedbacks and assessments from their supervisors back in their home units. The limitations of this training model include the costs and logistics for setting up such an elaborate workshop. When available, this platform would be an invaluable supplement to existing computer simulation and cadaveric dissection courses.
Ulrich Sure, Essen, Germany
This is a very nice and important paper on a novel porcine in vivo model for cranial micro-neurosurgery. The authors have to be congratulated for their work and the evaluation of this unique training model.
As the authors state, ‘microscopic surgery and bleeding management of a pulsating brain are particularly challenging’. By this model, ‘training can be given using an in vivo set-up in a step-by-step manner in a calm and patient setting. Suctioning while bleeding, handling the microscope, changing the instruments and decision-making in the in vivo model are as complex as in clinical practice’ and are trained on a living brain. It is also correctly claimed that ‘the legal systems of many European and North American countries demonstrate extreme sensitivity regarding medical errors, without considering the steep learning curve associated with the vast majority of surgical and particularly neurosurgical procedures. At the same time, structural problems arise with an increasing number of residents and further requirements on educational objectives. Therefore, restricted teaching may be particularly true for smaller units with a high number of residents.’
Of course, economic pressure and working directives may influence a non-structured training programme negatively as suggested by the authors; however, according to the discussion that I had with a number of residents, a major lack in university and teaching hospitals is that too many institutions teach too many residents and thus a single doctor often receives too restricted teaching. This holds particularly true for smaller departments with a higher number of residents. In these, the residents are unsatisfied with training and usually may not be trained appropriately within 6 years of residency. This reflects a structural and political problem which is particularly unique in Germany and a few other European countries. Too many residents are trained sometimes with a questionable quality, which evokes a number of further severe problems not discussed in the paper. Unfortunately, these mainly socioeconomic problems cannot be solved by the presented porcine training model. However, this beautiful model redounds a reasonable and structured teaching model for microsurgery on living brains to the medical literature.
Tarek A Rayan, Fady T Charbel, Chicago, USA
This article is one of many emerging studies discussing the topic of supplemental surgical education. Structuring of surgical education is of major interest and is of a high impact on future skill levels of graduating surgical residents.
The present situation in surgical education is undergoing huge changes as a result of reduction of work hours, current trends committed to patient safety and linking reimbursements with clinical outcomes and economic pressures.
In neurosurgery, procedures are characterized by technically sophisticated procedures requiring years of training to minimize morbidity to patients. Therefore, improving training and education is of paramount importance to both the neurosurgeons and their patients. That said, we find that most residents are unsatisfied with their surgical training. Reasons for that include unstructured programmes, competition, low caseloads and time constraints.
From this ordeal, the importance of supplemental surgical education emerges, allowing a realistic environment for training that would not affect patient outcome.
The authors revaluate their unique training model using an in vivo porcine model for training in cranial neurosurgery. In comparison to their previous study in 2009, there is a significant increase in number of participants in their hands-on courses (from 24 to 154), reaffirming the growing need and importance of this kind of training.
The in vivo porcine models provide a realistic environment for training on the operating microscope and handling a pulsatile and bleeding brain, a situation that regular cadaveric dissection courses do not provide.
The authors nicely include in their article a brief anatomy of the porcine model and explain the similarities and differences one would expect to find performing the craniotomy and handling brain tissue for dissection.
They clearly outline the drawbacks of this model to include small-sized exposures and failure of endoscopic procedures due to small brain and ventricular sizes.
These courses require lab structuring with complete adherence to animal anaesthesia, care and handling guidelines making them more expensive and require the need for institutional experiences. In comparison to less expensive and smaller animal models, it still provides the most realistic imitation to daily situations met in the operating room.
Results of our studies discussing surgical simulators like immersive technology and virtual reality models proved to improve operating room performance for our residents. That said, they probably would not replace hands-on training models allowing the unique experience of soft tissue handling, suctioning and haemostasis with the application of microsurgical techniques not often practised by residents.
The authors also state that in vivo porcine models are inferior for vascular training, better performed on rats or chicken wings. Also, cranial base structures can only be reached by extensive brain resection and with a number of cranial approaches not comparable to surgery in humans.
This article reaffirms the growing recognition of the importance of supplemental surgical education in this era of modern surgery, especially in sophisticated high-risk procedures like neurosurgery. In vivo porcine training models provide a unique experience that imitates real situations in daily neurosurgery procedures. That said, it does not replace other models for training as cadaveric dissection for skull base exposures or models used to perform cerebrovascular procedures.
Jan Regelsberger and Sven Eicker contributed equally to the manuscript.
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Regelsberger, J., Eicker, S., Siasios, I. et al. In vivo porcine training model for cranial neurosurgery. Neurosurg Rev 38, 157–163 (2015). https://doi.org/10.1007/s10143-014-0572-4
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DOI: https://doi.org/10.1007/s10143-014-0572-4