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Validation of a Microsurgical Skills Laboratory: A New Paradigm to Train Microsurgery
Gregory E. Lakin, MD, John A. Girotto, MD, MMA, FAAP, FACS, Jacob M. Bloom, M.D., M.S., Raul H. Herrera, M.D., Howard N. Langstein, M.D..
Division of Plastic and Reconstructive Surgery, University of Rochester School of Medicine, Rochester, NY, USA.
PURPOSE: In accordance with the Hippocratic Oath, "First do no harm", surgical education has evolved to include training in simulation and skills labs to prepare for operating safely on patients. Skills labs are now widely used in the training of surgical residents in many specialties. Until now a checklist of microsurgical competencies in the skills laboratory setting has yet to be defined. In this prospective blinded study, we develop a checklist of specific competencies to assess basic microsurgical skills of plastic surgery residents using a chicken thigh model.
METHODS: Plastic surgery residents from various levels of training (n=7) participated in this study which was conducted in the Department of Surgery surgical skills laboratory. Materials included instructional manuals and DVD, operating room microscope, microsurgery instruments, 9-0 nylon sutures, synthetic gloves, and food-grade chicken thighs. Experienced microsurgeons watched the videos in a blinded manner to evaluate time and performance before and after practicing on synthetic gloves and chicken femoral arteries. Time was defined from when the needle was grabbed by the needle driver to the last suture cut with scissors. A modified validated task specific checklist (maximum score 15-points) included: vessel oriented correctly (no twisting), single attempt at picking up needle before 80% of bites, needle loaded in middle third of needle 80% of the bites, single attempt at needle passage 80% of bites, follow through on curve of needle on entrance on 80% of bites, follow through on curve of needle on exit on 80% of bites, minimal damage with forceps, uses forceps to handle needle, suture spacing equally apart from eachother, equal bites on each side 80% of bites, square knots, minimum three throws on knots, apposition without excessive tension on sutures, patency test, no backwalling. A global rating scale contained five variables ranked on a Likert scale from 1-5 (maximum score 25-points): respect for tissue, time and motion, instrument handling, suture handling, and flow of operation. The student’s t-test was used to determine statistical significance (P<0.05 was considered significant).
RESULTS: Efficiency and quality of microsurgical skills (minimal damage with forceps, no backwalling) improved for all levels of residents, but were statistically significant among the most junior residents tested at the PGY-3 level (P=0.04). The chief residents had a statistically significant improvement in their time to complete suturing from 14min47sec to 12min45sec (P = 0.0034) and a noticeable improvement in economy of motion.
CONCLUSION: This study emphasizes the value of simulation and establishment of competency in microsurgery. It is the first to establish a checklist of specific microsurgical skills lab competencies. Furthermore, we demonstrate that the inexpensive chicken thigh model is an effective tool for training microsurgery. These standardized checklists and rating scales can be used as instruments to measure progress and can be included in the resident’s academic record. While this was performed in a dedicated surgical skills laboratory, training could be done in a non-laboratory setting. These competencies can be used in other animal models as well as in the clinical arena.
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