Abstract
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.
References
1.
Ramachandran S, Ghanem AM, Myers SR: Assessment of microsurgery competency – where are we now? Microsurgery 2013; 33:406–415.
2.
Russell WM, Burch RL: The Principles of Humane Experimental Technique. London, Methuen, 1959.
3.
Gross D, Tolba RH: Ethics in animal-based research. Eur Surg Res 2015; 55:43–57.
4.
Pereira S, Tettamanti M: Ahimsa and alternatives – the concept of the 4th R. The CPCSEA in India. ALTEX 2005; 22:3–6.
5.
Handbook: Good Laboratory Practice (GLP): Quality Practices for Regulated Non-Clinical Research and Development, ed 2. Switzerland, World Health Organization, 2009.
6.
Kobayashi E: Present and aspects for cadaver surgical training in Japan (in Japanese). Kyobu Geka 2015; 68:204–211.
7.
Knox AD, Gilardino MS, Kasten SJ, Warren RJ, Anastakis DJ: Competency-based medical education for plastic surgery: where do we begin? Plast Reconstr Surg 2014; 133:702e–710e.
8.
Oltean M, Sassu P, Hellstrom M, Axelsson P, Ewaldsson L, Nilsson AG, Axelsson M: The microsurgical training programme in Gothenburg, Sweden: early experiences. J Plast Surg Hand Surg 2016; 1–6.
9.
Hoyt RF Jr: Clevenger RR, McGehee JA: Microsurgical instrumentation and suture material. Lab Anim (NY) 2001; 30:38–45.
10.
MacDonald JD: Learning to perform microvascular anastomosis. Skull Base 2005; 15:229–240.
11.
VanderKam V: Care of microvascular surgical instruments. Plast Surg Nurs 1999; 19:31–34.
12.
Furka I, Brath E, Nemeth N, Miko I: Conceptions about microsurgical education. What were 5,460 hours of microsurgical basic education enough for? (in Hungarian). Magy Seb 2006; 59:147–151.
13.
Furka I, Brath E, Nemeth N, Miko I: Learning microsurgical suturing and knotting techniques: comparative data. Microsurgery 2006; 26:4–7.
14.
Miko I, Brath E, Furka I: Basic teaching in microsurgery. Microsurgery 2001; 21:121–123.
15.
Kerr B, O’Leary JP: The training of the surgeon: Dr. Halsted’s greatest legacy. Am Surg 1999; 65:1101–1102.
16.
Dumestre D, Yeung JK, Temple-Oberle C: Evidence-based microsurgical skill-acquisition series. Part 1. Validated microsurgical models – a systematic review. J Surg Educ 2014; 71:329–338.
17.
Moulton CA, Dubrowski A, Macrae H, Graham B, Grober E, Reznick R: Teaching surgical skills: what kind of practice makes perfect?: A randomized, controlled trial. Ann Surg 2006; 244:400–409.
18.
Ilie VG, Ilie VI, Dobreanu C, Ghetu N, Luchian S, Pieptu D: Training of microsurgical skills on nonliving models. Microsurgery 2008; 28:571–577.
19.
Meier AH, Rawn CL, Krummel TM: Virtual reality: surgical application – challenge for the new millennium. J Am Coll Surg 2001; 192:372–384.
20.
Erel E, Aiyenibe B, Butler PE: Microsurgery simulators in virtual reality: review. Microsurgery 2003; 23:147–152.
21.
Schoffl H, Froschauer SM, Dunst KM, Hager D, Kwasny O, Huemer GM: Strategies for the reduction of live animal use in microsurgical training and education. Altern Lab Anim 2008; 36:153–160.
22.
Singh M, Ziolkowski N, Ramachandran S, Myers SR, Ghanem AM: Development of a five-day basic microsurgery simulation training course: a cost analysis. Arch Plast Surg 2014; 41:213–217.
23.
Czigany Z, Iwasaki J, Yagi S, Nagai K, Szijarto A, Uemoto S, Tolba RH: Improving research practice in rat orthotopic and partial orthotopic liver transplantation: a review, recommendation, and publication guide. Eur Surg Res 2015; 55:119–138.
24.
Holzen JP, Palmes D, Langer M, Spiegel HU: Microsurgical training curriculum for learning kidney and liver transplantation in the rat. Microsurgery 2005; 25:614–623.
25.
Messaoudi T, Bodin F, Hidalgo Diaz JJ, Ichihara S, Fikry T, Lacreuse I, Liverneaux P, Facca S: Evaluation of a new e-learning platform for distance teaching of microsurgery. Chir Main 2015; 34:109–112.
26.
Nagai K, Yagi S, Uemoto S, Tolba RH: Surgical procedures for a rat model of partial orthotopic liver transplantation with hepatic arterial reconstruction. J Vis Exp 2013;e4376.
27.
Oldani G, Lacotte S, Morel P, Mentha G, Toso C: Orthotopic liver transplantation in rats. J Vis Exp 2012; 65:4143.
28.
Belykh E, Byvaltsev V: Off-the-job microsurgical training on dry models: Siberian experience. World Neurosurg 2014; 82:20–24.
29.
Lannon DA, Atkins JA, Butler PE: Non-vital, prosthetic, and virtual reality models of microsurgical training. Microsurgery 2001; 21:389–393.
30.
Kobayashi E, Haga J: Translational microsurgery. A new platform for transplantation research. Acta Cir Bras 2016; 31:212–217.
31.
Price J, Naik V, Boodhwani M, Brandys T, Hendry P, Lam BK: A randomized evaluation of simulation training on performance of vascular anastomosis on a high-fidelity in vivo model: The role of deliberate practice. J Thorac Cardiovasc Surg 2011; 142:496–503.
32.
Shurey S, Akelina Y, Legagneux J, Malzone G, Jiga L, Ghanem AM: The rat model in microsurgery education: classical exercises and new horizons. Arch Plast Surg 2014; 41:201–208.
33.
Di Cataldo A, La Greca G, Rodolico M, Candiano C, Li Destri G, Puleo S: Experimental models in microsurgery. Microsurgery 1998; 18:454–459.
34.
Chan WY, Matteucci P, Southern SJ: Validation of microsurgical models in microsurgery training and competence: a review. Microsurgery 2007; 27:494–499.
35.
Dumestre D, Yeung JK, Temple-Oberle C: Evidence-based microsurgical skills acquisition series. Part 2. Validated assessment instruments – a systematic review. J Surg Educ 2015; 72:80–89.
36.
Leung CC, Ghanem AM, Tos P, Ionac M, Froschauer S, Myers SR: Towards a global understanding and standardisation of education and training in microsurgery. Arch Plast Surg 2013; 40:304–311.
37.
Ghanem AM, Hachach-Haram N, Leung CC, Myers SR: A systematic review of evidence for education and training interventions in microsurgery. Arch Plast Surg 2013; 40:312–319.
38.
Kolbenschlag J, Gehl B, Daigeler A, Kremer T, Hirche C, Vogt PM, Horch R, Lehnhardt M, Kneser U: Microsurgical training in Germany – results of a survey among trainers and trainees (in German). Handchir Mikrochir Plast Chir 2014; 46:234–241.
39.
Al-Bustani S, Halvorson EG: Status of microsurgical simulation training in plastic surgery: a survey of United States program directors. Ann Plast Surg 2016; 76:713–716.
40.
Goossens DP, Gruel SM, Rao VK: A survey of microsurgery training in the United States. Microsurgery 1990; 11:2–4.
41.
Alzakri A, Al-Rajeh M, Liverneaux PA, Facca S: Courses in microsurgical techniques in France and abroad (in French). Chir Main 2014; 33:219–223.
42.
Di Cataldo A, Puleo S, Rodolico G: Three microsurgical courses in Catania. Microsurgery 1998; 18:449–453.
43.
Studinger RM, Bradford MM, Jackson IT: Microsurgical training: is it adequate for the operating room? Eur J Plast Surg 2005; 28:91–93.
44.
Christensen TJ, Anding W, Shin AY, Bishop AT, Moran SL: The influence of microsurgical training on the practice of hand surgeons. J Reconstr Microsurg 2015; 31:442–449.
45.
Atkins JL, Kalu PU, Lannon DA, Green CJ, Butler PE: Training in microsurgical skills: does course-based learning deliver? Microsurgery 2005; 25:481–485.
46.
Kalu PU, Atkins J, Baker D, Green CJ, Butler PE: How do we assess microsurgical skill? Microsurgery 2005; 25:25–29.
47.
Satterwhite T, Son J, Carey J, Zeidler K, Bari S, Gurtner G, Chang J, Lee GK: Microsurgery education in residency training: validating an online curriculum. Ann Plast Surg 2012; 68:410–414.
48.
Odobescu A, Moubayed SP, Harris PG, Bou-Merhi J, Daniels E, Danino MA: A new microsurgical research model using Thiel-embalmed arteries and comparison of two suture techniques. J Plast Reconstr Aesthet Surg 2014; 67:389–395.
49.
Ghanem AM, Al Omran Y, Shatta B, Kim E, Myers S: Anastomosis lapse index (ALI): a validated end product assessment tool for simulation microsurgery training. J Reconstr Microsurg 2016; 32:233–241.
50.
Harden RM, Stevenson M, Downie WW, Wilson GM: Assessment of clinical competence using objective structured examination. Br Med J 1975; 1:447–451.
51.
Ananthakrishnan N: Objective structured clinical/practical examination (OSCE/OSPE). J Postgrad Med 1993; 39:82–84.
52.
Grober ED, Hamstra SJ, Wanzel KR, Reznick RK, Matsumoto ED, Sidhu RS, Jarvi KA: The educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures. Ann Surg 2004; 240:374–381.
53.
Regehr G, MacRae H, Reznick RK, Szalay D: Comparing the psychometric properties of checklists and global rating scales for assessing performance on an OSCE-format examination. Acad Med 1998; 73:993–997.
54.
Martin JA, Regehr G, Reznick R, MacRae H, Murnaghan J, Hutchison C, Brown M: Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 1997; 84:273–278.
55.
Schueneman AL, Pickleman J, Hesslein R, Freeark RJ: Neuropsychologic predictors of operative skill among general surgery residents. Surgery 1984; 96:288–295.
56.
Grober ED, Hamstra SJ, Wanzel KR, Reznick RK, Matsumoto ED, Sidhu RS, Jarvi KA: Laboratory based training in urological microsurgery with bench model simulators: a randomized controlled trial evaluating the durability of technical skill. J Urol 2004; 172:378–381.
57.
Grober ED, Hamstra SJ, Wanzel KR, Reznick RK, Matsumoto ED, Sidhu RS, Jarvi KA: Validation of novel and objective measures of microsurgical skill: hand-motion analysis and stereoscopic visual acuity. Microsurgery 2003; 23:317–322.
58.
Ezra DG, Aggarwal R, Michaelides M, Okhravi N, Verma S, Benjamin L, Bloom P, Darzi A, Sullivan P: Skills acquisition and assessment after a microsurgical skills course for ophthalmology residents. Ophthalmology 2009; 116:257–262.
59.
Temple CL, Ross DC: A new, validated instrument to evaluate competency in microsurgery: the University of Western Ontario Microsurgical Skills Acquisition/Assessment instrument (outcomes article). Plast Reconstr Surg 2011; 127:215–222.
60.
Chan W, Niranjan N, Ramakrishnan V: Structured assessment of microsurgery skills in the clinical setting. J Plast Reconstr Aesthet Surg 2010; 63:1329–1334.
61.
Selber JC, Chang EI, Liu J, Suami H, Adelman DM, Garvey P, Hanasono MM, Butler CE: Tracking the learning curve in microsurgical skill acquisition. Plast Reconstr Surg 2012; 130:550e–557e.
62.
Satterwhite T, Son J, Carey J, Echo A, Spurling T, Paro J, Gurtner G, Chang J, Lee GK: The Stanford microsurgery and resident training (SMaRT) scale: validation of an on-line global rating scale for technical assessment. Ann Plast Surg 2014; 72(suppl 1):S84–S88.
63.
Hori T, Nguyen JH, Zhao X, Ogura Y, Hata T, Yagi S, Chen F, Baine AM, Ohashi N, Eckman CB, Herdt AR, Egawa H, Takada Y, Oike F, Sakamoto S, Kasahara M, Ogawa K, Hata K, Iida T, Yonekawa Y, Sibulesky L, Kuribayashi K, Kato T, Saito K, Wang L, Torii M, Sahara N, Kamo N, Sahara T, Yasutomi M, Uemoto S: Comprehensive and innovative techniques for liver transplantation in rats: a surgical guide. World J Gastroenterol 2010; 16:3120–3132.
64.
Starkes JL, Payk I, Hodges NJ: Developing a standardized test for the assessment of suturing skill in novice microsurgeons. Microsurgery 1998; 18:19–22.
65.
Jin H, Huang H, Dong W, Sun J, Liu A, Deng M, Dirsch O, Dahmen U: Preliminary experience of a PDCA-cycle and quality management based training curriculum for rat liver transplantation. J Surg Res 2012; 176:409–422.
66.
Reiley CE, Lin HC, Yuh DD, Hager GD: Review of methods for objective surgical skill evaluation. Surg Endosc 2011; 25:356–366.
67.
Van Nortwick SS, Lendvay TS, Jensen AR, Wright AS, Horvath KD, Kim S: Methodologies for establishing validity in surgical simulation studies. Surgery 2010; 147:622–630.
68.
Saleh GM, Voyatzis G, Hance J, Ratnasothy J, Darzi A: Evaluating surgical dexterity during corneal suturing. Arch Ophthalmol 2006; 124:1263–1266.
69.
Saleh GM, Gauba V, Sim D, Lindfield D, Borhani M, Ghoussayni S: Motion analysis as a tool for the evaluation of oculoplastic surgical skill: evaluation of oculoplastic surgical skill. Arch Ophthalmol 2008; 126:213–216.
70.
Grober ED, Roberts M, Shin EJ, Mahdi M, Bacal V: Intraoperative assessment of technical skills on live patients using economy of hand motion: establishing learning curves of surgical competence. Am J Surg 2010; 199:81–85.
71.
Shah A, Rowlands M, Patel A, Fusi S, Salomon J: Ubersense: using a free video analysis app to evaluate and improve microsurgical skills. Plast Reconstr Surg 2014; 134:338e–339e.
72.
McGoldrick RB, Davis CR, Paro J, Hui K, Nguyen D, Lee GK: Motion analysis for microsurgical training: objective measures of dexterity, economy of movement, and ability. Plast Reconstr Surg 2015; 136:231e–240e.
73.
Harada K, Morita A, Minakawa Y, Baek YM, Sora S, Sugita N, Kimura T, Tanikawa R, Ishikawa T, Mitsuishi M: Assessing microneurosurgical skill with medico-engineering technology. World Neurosurg 2015; 84:964–971.
74.
Wanzel KR, Hamstra SJ, Anastakis DJ, Matsumoto ED, Cusimano MD: Effect of visual-spatial ability on learning of spatially-complex surgical skills. Lancet 2002; 359:230–231.
75.
Murdoch JR, Bainbridge LC, Fisher SG, Webster MH: Can a simple test of visual-motor skill predict the performance of microsurgeons? J R Coll Surg Edinb 1994; 39:150–152.
76.
Horváth A, Valalik I, Csokay A: Suture of minimal-diameter vessels using fingertip support technique. J Hand Microsurg 2013; 5:44–45.
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