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 Arch Plast Surg > Volume 41(3); 2014 > Article
Singh, Ziolkowski, Ramachandran, Myers, and Ghanem: Development of a Five-Day Basic Microsurgery Simulation Training Course: A Cost Analysis

### Abstract

The widespread use of microsurgery in numerous surgical fields has increased the need for basic microsurgical training outside of the operating room. The traditional start of microsurgical training has been in undertaking a 5-day basic microsurgery course. In an era characterised by financial constraints in academic and healthcare institutions as well as increasing emphasis on patient safety, there has been a shift in microsurgery training to simulation environments. This paper reviews the stepwise framework of microsurgical skill acquisition providing a cost analysis of basic microsurgery courses in order to aid planning and dissemination of microsurgical training worldwide.

### INTRODUCTION

Since the introduction of microsurgery in the early 1900s, the use of microscopes in the operating theatre has been adopted by many specialties, such as plastic surgery, ophthalmology, urology and maxillo-facial surgery, amongst others [1]. Microsurgery is considered to be one of the most challenging fields of surgery, based on the degree of dexterity and manual skill required by the operator [2]. As such, there can be a significant learning curve in acquisition of microsurgical skill and with the risks to patients in terms of morbidity and even mortality associated with a failed microsurgical anastomosis, coupled with a reduction in training time, a need for training outside of the operating theatre has arisen [3].

### Knot placement/tying principles.apposition of edges, non-dominant hand usage, deformable volumes

This stage of training assumes fundamental skills in manipulation of instruments in a microsurgical field. IIt involves the practice of basic suturing on non-tubular structures, the main models available are latex gloves mounted over a platform to spread out the material and use of a specially made practice card, of similar properties [10]. Both allow straight-line incisions to be made and suturing to be attempted. Although non-sterile latex gloves are easily available, they require mounting and preparation, newer practice cards are available which come ready made. Sharpoint, for example, produce a mounted latex membrane with coloured background, called PracticePak. Table 2 compares the costs of these models.

### Three-dimensional models/completing the anastomosis

When considering the use of three-dimensional (3D) models for anastomosis, most microsurgical courses use live rat models for arterial, venous and nerve repair procedures. However, due to the reasons previously mentioned, such as ethical considerations and hygiene issues, there is a drive towards more realistic non-living synthetic models supported by the development of ever more sophisticated materials. The most basic models available include micro-silicone tubes, such as those used for electrical wire insulation and Gore-Tex (polytetrafluoroethylene) tubes, which, although not actively used in microsurgery, have found use in vascular by-pass surgery [11,12]. Gore-Tex tubes have the advantage that they are believed to behave more like biological vessels than silicone tubes. We also suggest the novel use of intra-venous cannula tubing (Polyurethane) as a useful anastomotic model. Any needle 17 gauge or larger will have a surrounding sheath of at least 1.5 mm internal diameter and so should be suitable, it merely requires removal of the needle and securing the model to a base, facilitated by the wings present on most modern cannulae.
Newer models aim to mimic the handling characteristics of biological tissues more closely, such as synthetic arteries, veins and nerves. Although there are many suppliers, our personal experience has been from SynDaver, based in the United States. They are able to supply vessels comparable to human digital vessels in size and in fascial sleeves to aid mounting onto appropriate models. More sophisticated models include the PracticeRat, which again can mimic artery, vein and nerve and aims to recreate adventitia. The most complex model currently available is the PVC Rat, which although aimed more at research scientists, creates realistic anastomotic experiences in an actual rat model. It also comes with software, which when used in an attached computer, simulates aspects of live animal care, with measures such as temperature, heart rate and respiratory rate displayed on screen. Table 3 summarises the cost for different anastomotic models.

### The biological tissue experience

Biological tissue models can be further divided into non-living and vital examples. The most convenient in terms of purchasing, preparation and cost are chicken vessels. Fresh chicken wings and legs are easily available at local butchers or supermarkets, although prices can vary. Both have been previously published as useful models for microsurgical training [13,14,15,16]. Fresh chicken wings allow arterial anastomosis of the brachial artery, which is comparable in size to a human digital vessel. Fresh chicken legs allow anastomosis of the femoral artery, vein and sciatic nerve.
A commonly used non-living model is cryopreserved rat aorta, which we were able to source locally for $32.36 per 3 to 5 cm segment [17]. This cost was further reduced to$8.07 per 3 to 5 cm segment if the rats were sacrificed following their use in experimental research. We found this model to be particularly useful in the early stages of training, due to an average vessel diameter of 3 to 4 mm. We were also able to obtain freshly killed rat femoral vessels and sciatic nerves. The prices for these can be variable and are very dependent on the number of rats required. The prices include acquisition of the rats and maintenance costs, as well as all handling and shipping costs. The costs for live rat models were similar, however, the course tutor will require a Home Office licence to allow work with live animals. Each candidate will also require a Home Office personal licence for work with live rats over the duration of the course, costs are summarized in Table 4.

### DISCUSSION

Although a variety of microsurgical training courses are currently available, most follow a similar step-wise progression of training models. Day one, typically, involves an introduction to the operating microscope and practice of simple suturing. From this point, simple manipulation tasks are performed on gauze, beads or sewing needles. We found the costs per candidate ranged from 4 cents to $10.6 for these models. However, many can be reused and the costs may represent only initial outlays. In practicing knot placement and tying procedures, a latex practice card provides an ideal model on which to operate. It allows candidates to become proficient at microsurgical suturing on a stable base and represents an integral step before attempting a microvascular anastomosis. It can be easily fashioned by using a latex glove secured firmly, or the latest commercially available versions, such as PracticePak which come pre-made. Prices vary from 7 cents per glove to$38.71 for a branded model.

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