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Novel and Efficient Synthetic Microvascular Anastomosis Training Model

Microvascular Anastomosis Training Model

International Microsurgery Journal. 2017;1(3):4
DOI: 10.24983/scitemed.imj.2017.00048
Article Type: Idea and Innovation

Abstract

Microsurgery is an essential surgical skill of modern Plastic and Reconstructive Surgery, and it has now well integrated into the practice of many other surgical specialties. With the growing demand of this surgical skill, having a cost-effective training model that is globally accessible is indispensable. This model was made from widely available non-sterile latex gloves with tools and materials that are readily accessible in the laboratory. Similar to other existing latex models, this model is economical and delivers good simulation of the arterial wall elasticity and thickness. It is a suitable model for group training sessions due to its simple construct, where a layperson can be employed for the model setup. Based on our current experience in the training courses, this is a useful bridging model between basic microsurgical exercises and advance microsurgical training with in vitro or in vivo animal models. This non-commercialized model provides a simple platform for trainees to perfect their microanastomosis techniques ethically, systematically, and cost-effectively.

 

Keywords

  • Latex; microanastomosis; microvascular anastomosis; synthetic training model; training model

 

Supplementary Video

Introduction

Microsurgery creates a new frontier in modern surgical practice. Its application has broadened beyond the realm of Plastic and Reconstructive Surgery, and now integrated as part of standard practice in many surgical specialties [1]. From free flap reconstructions to allotransplantation of hands and faces, the development and advancement of microsurgery realizes the grand visions of surgical giants from generations before. Similar to musician training, vigorous and dedicated microsurgery exercise is the only path for its technical perfection. Abundant training models are developed and described in the literature since the birth of microsurgery in 1960s [2]. In vivo animal model is ideal for pre-clinical training, where every facet of microsurgery techniques can be exercised with higher complexity, and the end result of the anastomoses can be observed directly. However, it is a complex model for a novice, and the excess use of live animals for surgical training also raised ethical, economical, and logistic conflicts [3-7]. Many non-animal organic and synthetic models are adopted by microsurgical training centers as their first line training methodology. These models, unlike the in vivo animal models, can be tailored to facilitate targeted exercises, thus trainees can build their technical skills ethically, cost effectively, and systematically [4,5,7]. Among them, latex based models are the most common and has been used for microsurgical training for more than 3 decades [8-13]. The complexity of the model construct varies from 2D flat sheet exercises [8,9] to 3D tubule anastomoses [10-14]. Latex not only simulates arterial lumen well but is also affordable and widely available. This article is aimed to present a novel model based on 3D latex vessel construct for microvascular anastomosis training and compare it with other latex based training models described in the literature.

Method, Material, and Training Model 

The lead author, Dr. Yun-Huan Hsieh, invented the model based on the available resources in Vascularized Composite Allotransplantation Center, Chang Gung Memorial Hospital, Taiwan. Resources required for this exercise set up include a pair of scissors, a latex glove, a rat board with 1 cm hollow cylindrical attachment, Micropore Paper Medical Tape (Micropore, 3M), 10-0 nylon (ETHILON™ 10-0 Nylon Suture), microsurgical instruments, and a table microscope (Carl Zeiss, Germany). The latex glove is transected at the tip and the phalangeal base (Figure 1), creating a finger latex tube. Two strips of Micropore tapes were applied over the mid portion of the finger latex tube, one over the dorsal surface and the other over the ventral surface. The tapes extend and seal over the edge of the latex tube both proximally and distally while the latex tube is in slight extension. Once the inner space is obliterated by the sandwiching technique with the tapes, two tubular structures, the synthetic vessels, are effectively constructed (Figure 2). Its vessel dimension (size) equals to the distance from the edges of the tapes to edges of the finger latex tube (Figure 3). The finger latex tube is then suspended and fixed over the hollow cylindrical attachment of the rat board with Micropore Tapes (Figure 4). The constructed system is positioned under the microscope, with magnification ranges between 20x to 40x. Double microvascular clamps is placed over one of the synthetic vessels, microvascular anastomosis with 10-nylon can begin once the vessel is transected (Figure 5).
 

Figure 1. The latex glove is transected at the tip and the phalangeal base, creating a finger latex tube.

 

Figure 2. Two strips of Micropore tapes were applied over the mid portion of the finger latex tube, one over the dorsal surface and the other over the ventral surface. The tapes extend and seal over the edge of the latex tube both proximally and distally while the latex tube is in slight extension. Synthetic vessels (x2), is thus created as the inner space of the finger latex tube is obliterated by the sandwiching technique with Micropore tape.

 

Figure 3. The dimension (size) of the synthetic vessels equals to the distance from the edges of the tapes to edges of the finger latex tube.

 

Figure 4. The finger latex tube is suspended and fixed over the hollow cylindrical attachment of the rat board with Micropore Tapes. 

 

Figure 5. Microvascular anastomosis with 10-nylon can begin once the vessel is transected, and a double clamp is applied. 

 

Figure 6. The completion of anterior wall anastomosis. 

 

Utilization and Experience of Novel Synthetic Microanastomosis Model

Taiwan Society of Reconstructive Microsurgery (TSRM) adopted this model for their Microsurgery Training Courses since 2016. It was a 4-day course, providing basic proficient microsurgical skills for the trainees. In addition to lecturing the basic concepts of microsurgery, trainees were presented with series of tasks including knot-tying exercise between threads of a gauze with 10-0 nylon, simple interrupted suture practice on a suspended flat latex sheet, synthetic vessel microanastomoses (this model), and chicken wing brachial vessel anastomoses. This model required intermediate level of micro-instrument handling as well as proficient suturing techniques. Therefore, it was used as a bridging exercise prior to the actual vascular anastomoses. Although not subjectively measured nor compared, this synthetic microanastomoses model was a beneficial bridging exercise reported by most trainees in the course.

Discussion

Perfection in microvascular anastomosis technique requires devoted training to overcome its hurdles and challenges. The live rat remains to be the gold standard microsurgical training model [1,15-17], it offers adjunctive practice on tissue dissection, adventitial striping, as well as enhancing 3D perception and enabling immediate vessel flow test in addition to microvascular anastomoses exercise [17]. The rising concerns of laboratory animal welfare promotes ingenious ideas into novel training model innovations. Bubble wraps [18], parafilm [19], foliage leaves [20], and gauze [21,22] are commonly used for fundamental microsurgery training. Commercially available training cards with silicon tubes [22], synthetic vessels with polyurethane [3], polytetrafluoroethylene [23], and polyethylene [24,25] are useful models for advanced microsurgical training in attempt to reduce animal usage. Similarly, cryogenic rat or rabbit femoral vessels, carotid vessels, and aorta offer “off the shelf” microvascular anastomosis exercise from the “recycled parts” of the sacrificed animals [26]. These organic and synthetic vessels provide good targeted simulations for vessel anastomoses but unable to offer practice of abovementioned adjunctive exercises. Due to commercialization of the synthetic vessels, and labor intense preparation of the cryogenic vessels, these models are less accessible and are less cost effective to many training centers.

Latex based microvascular anastomosis models have been utilized for more than 3 decades [8-13]. General advantages of using latex for the construct of microvascular anastomosis models include: (1) availability and accessibility of material in all surgical centers and laboratories, (2) economic benefits, and (3) simulation of elasticity and thickness of the arterial wall. The complexity of the described models varies; Awwad [7] and Lee [8] described 2D models for basic microsurgical exercises, comprising basic micro-instrument handling, suture spacing, needle passage, and knot tying in different angles. More complex models are constructed in 3D, resembling authentic “tubule vessels” for microanastomosis training. Guler and Rao [15] described a simple method of tubularization from a latex sheet. They used the cuff of a latex glove, secured over the open ends of a suture box. 2 parallel 10 mm slits were made, creating a central latex strip. Suturing free edges of the latex strips with 10-0 nylon to construct the prefabricated latex tube. This model was further modified by Crosby et al. [16], by creating 2 latex tubes, allowing end to side, side to side anastomosis as well as vein graft practice in addition to end-to-end anastomosis. Kamath [18] demonstrated a method of self-manufacturing 3D latex conduits by dipping a 1 mm K-wire into liquid latex solution, producing a latex tube with 1 mm diameter. Shakeel et al. [19] shares similar passion in utilizing latex conduits for microsurgical training, instead of prefabricating a latex sheet or self-manufacturing latex conduit from its liquid form, they simply use the rim or the sleeve part of a non-sterile glove, employing its hollow rim construct as their model of latex tube. It is a ingenious modification of a latex glove for anastomosis exercise, however, not every glove comprises a hollow rim at its base, thus the model availability is restricted by the brand of the gloves that is used regionally.

In this model, it shares all the advantages as other latex based models. The set up is relatively simple compared with other latex based 3D tubular models. It takes approximately 5 minutes to set up, using widely available tools and materials in a microsurgical lab or an operating theater. As a non-commercialized training model that is simple to construct with materials that are readily accessible, this model can easily be replicated globally. One non-sterile glove consists of 5 finger latex tubes, which equals 5 practice models with total of 10 synthetic vessels. If assuming one surgical glove costs approximately 1 US dollar, the model is estimated to be 20 cents each. Multiple anastomoses can be performed on each synthetic vessel, once the anastomosis is completed, transecting the nearby segment allows direct observation of anastomosis quality, ensuring “vessel inversion” is achieved with each suture. This model does not require any previous microsurgical experience for its setup, thus a layperson can facilitate in the model making process in preparation for a large training session. This model, like all other synthetic models, provides a targeted practice. Although it does not offer exercises in vessel dissection, adventitiectomy, and vascular patency test, it simplifies the anastomosis process by neglecting the need to negotiate with the surrounding tissue during microvascular anastomosis. Negotiating with surrounding soft tissue at the site of microanastomosis can be a source of frustration for a novice trainee. Thus this model may facilitate the confidence building for trainees in pursuing further challenges in in vivo models once their microsurgical technique is matured. The “Vessel Size” in this model is defined as the distance between the edge of the tape and the edge of the finger latex tube. Therefore, the vessel size for the anastomosis exercise is adjustable. The closer the tape to the edge of the tube, the smaller the vessel size it is for the exercise. Suspending the model to a cylindrical structure not only provides the anchorage for the exercise, but also facilitates 3D depth perception training under the microscope. Capturing the posterior wall during microvascular anastomosis is a fatal error, as it leads to inevitable anastomosis failure. In this model, a double clamp can be applied as shown in Figure 6, its application not only closely simulates the actual anastomosis but also allows flipping of the vessel to reveal its posterior wall. With direct examination of suture quality and placement, direct viewing of the lumen from the posterior wall ensures the posterior wall is freed from accidental capturing during anterior wall anastomosis (supplementary video). In addition, this exercise can be oriented in different angle, enabling the practice of microvascular anastomosis in different directions to accomplish the training more comprehensively in preparation of unexpected clinical scenarios. The application of this model is limited by lack of separation of the latex vessel from the trunk of the latex finger tube. Thus this model is inapplicable for end-to-side, side-to-side anastomosis and vein graft training.

Conclusion

We present a novel synthetic vascular model for microanastomosis training. This model is suitable for trainees with intermediate level of microsurgical skills, and useful as a bridging model between simple suturing exercise and in vivo rat vessel anastomosis during pre-clinical training. It is an easy model to construct, using widely available materials. It simulates arterial anastomosis well, and enables direct observation and feedback of the anastomosis quality. This model is non-commercialized, cost effective, and is readily accessible. This model allows the trainee to grow their microsurgical skills ethically, systematically and confidently.

References

 

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Editorial Information

Publication history

Received date: July 31, 2017
Accepted date: November 10, 2017
Published date: December 29, 2017

Copyright

© 2017 The Author (s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0

  1. Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center and Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
  2. Center for Vascularized Composite Allotransplantation, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, and Chang Gung University, Taoyuan, Taiwan
Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center and Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center and Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
Figure 1.jpg
Figure 1. The latex glove is transected at the tip and the phalangeal base, creating a finger latex tube.
Figure 2.jpeg
Figure 2. Two strips of Micropore tapes were applied over the mid portion of the finger latex tube, one over the dorsal surface and the other over the ventral surface. The tapes extend and seal over the edge of the latex tube both proximally and distally while the latex tube is in slight extension. Synthetic vessels (x2), is thus created as the inner space of the finger latex tube is obliterated by the sandwiching technique with Micropore tape.
Figure 3.jpeg
Figure 3. The dimension (size) of the synthetic vessels equals to the distance from the edges of the tapes to edges of the finger latex tube.
Figure 4.jpg
Figure 4. The finger latex tube is suspended and fixed over the hollow cylindrical attachment of the rat board with Micropore Tapes.
Figure 5.jpg
Figure 5. Microvascular anastomosis with 10-nylon can begin once the vessel is transected, and a double clamp is applied.
Figure 6.jpg
Figure 6. The completion of anterior wall anastomosis.

Peer Review Report: Round 1

Reviewer 1 Comments 
 

  1. Excellent paper. I would put fewer figures just to give the idea of how the model is prepared.
     Reponse Thank you for your kind suggestions. After reviewing the figures, some of them do seem unnecessary and do not provide additional information to clarify the construct of the model. I have reduced the number of figures used, and only keep the most relevant ones for the publication.

Reviewer 2 Comments 

  1. It is better to have a short video for the model set-up.
     ReponseThank you for your review and feedback. I have prepared and uploaded a short video explaining the model set-up in more detail. With the video, the simplicity and practicality of the model can be further highlighted, hoping the model can be more widely utilized.
     
  2. References No.12 & No.15 are not complete.
     Reponse Thank you for checking the reference thoroughly; the above-mentioned references are now corrected.

Reviewer 3 Comments 

Overall, this is an article worthy of publication. I commend the authors for a well-written discussion, but advise them for revisions before publication. Regarding the article "Novel and efficient synthetic microvascular anastomosis training model". The topic of this article is an interesting topic on the tool of education for microsurgery, which firmly connects with the educational prospect of our journal. I commend the authors for a well-written manuscript and providing an innovative approach on how to teach microvascular anastomosis with financial efficiency and safety. I do, however, have a few comments for the authors:

  1. The authors have spent a great deal of time reviewing the literature on the tools used for microvascular education and I commend them for that. However, the details regarding how this method was taught to a microvascular-naive student were not written fully. In particular, in the material and method section, the authors said that this was used as a bridging tool to actual microvascular anastomosis, but did not attempt to quantify the benefits of this tool (such as a questionnaire) or to show some sort of results. If the authors have some type of results to show for this article, then it is recommended. Otherwise, it is difficult for the audience to see the actual benefits of this tool compared to the others. Perhaps, a future study comparing the students who go through this training with those students who don't have this training is recommended to possibly validate the use of this tool.
     ReponseThank you for your kind and thorough feedback. Like most of the microsurgery skill-training courses, the one held by TRSM is a 4-day course, with sequential advancement of the skill training. It starts with full day of lectures introducing basic concepts of instrument setup, handling, and posture positioning for effective microvascular works. It is then followed by basic knot tying exercises including suturing threads of a gauze, 2D latex glove suturing, etc. This model is used when students have achieved adequate hand-eye coordination under the microscope and gained sufficient confidence in instrument holding and basic knot tying. It is used as the final step before animal model was utilized in the course. Therefore, it serves as a bridging tool between synthetic model exercises to microvascular anastomosis in animal models (rats or chicken wings). The model set-up was only taught to the training staffs and was set up for the students for their practice; thus, the course time can be used efficiently. As a bridging model, this model simulates the essential setup of microvascular anastomosis in animals or human. Without the additional surrounding soft tissues that may impede and frustrate microsurgery naïve students, it focuses on suture placements, spacing, vessel edge inversion, and enhances their quality of knot tying on the synthetic vessels (firm but not tight sutures). It is my greatest regret that no formal survey was conducted during the training sessions and the students were not randomized for different training path to show the efficacy of this model. The current feedbacks are based on the direct verbal communication from the students, and are positively received. This format of this paper is aimed to describe the model and compare it with current available training models presented in the literature. It is, however, in my plan to conduct a scientific randomized study on the students who are enrolled for the next training camp to validate the value of the model in microsurgery training.
     
  2. The biggest reason for using a latex glove with two layers is to simulate the hollow arterial lumen of a vessel, and to prevent back wall suturing when performing the actual anastomosis. How do the authors show after a repair that no back wall suturing occurred? Please explain.
     Reponse I completely agree with this statement, and I believe that pictures are difficult to show it well. One of the major advantages of having a 3D luminal construct for anastomosis training is that the trainee is able to learn and avoid capturing the back wall during the anastomosis. Capturing the back wall during anterior wall anastomosis can be prevented if the tip of the needle is visualized constantly while the posterior wall remains well separated from its anterior wall (usually with tips of micro-forceps). A thorough examination of the lumen from the posterior wall directly is the final crucial step to ensure that the back wall remains separated after the anastomosis. With the application of double clamp, we can flip the synthetic vessel, revealing its lumen from the view of the posterior wall. This final examination serves as the final checkpoint confirming that the back wall is not captured at any stage of the exercise. I have incorporated this point in the revised manuscript, and I have prepared a special section in the supplementary video showing the importance of lumen examination from the view of posterior wall, to ensure that the back wall is free from capturing.
     
  3. In the "Utilization and experience of this novel synthetic microanastomosis model" section, the author is describing the experiences of this model being used in a teaching exercise. Please change the paragraph to past tense as it is describing an event that has already happened.
     Reponse All the appropriate verbs in this paragraph were changed to past tense as you kindly suggested.
     
  4. Figure 5b seems to be a bit redundant as compared to figure 5a. Please explain in more detail what figure 5b is for, or otherwise I recommend combining these two figures, or perhaps removing figure 5b.
     Reponse After carefully reviewing the photos and the sequence of storytelling, I agree that the combined use of figure 5a and 5b does not appear to be logically sound. My initial intention of showing both figure 5a and 5b is to give a macro and micro view of the setup while showing that the model is suspended. This idea appeared to be complex and illogical, especially, in the presence of double clamp in figure 5a, when it simply shows too many ideas in one photo and thus may confuse the reader. Therefore, with your permission, I would prefer to remove figure 5a instead of 5b, as figure 5b clearly shows that the model is suspended for 3D perception training under the microscope, whereas figure 5a is merely a magnified, yet a confused, view of the same setup. Similarly, I have also removed the initial figure 2 and figure 7a. I believe that these changes will enhance the reading flow without being misguided. The figure legends were changed accordingly and the revised version will be resubmitted. Thanks again for a great suggestion.
     
  5. For some reason, the manuscript that I see shows the figures section with erroneous figure labelling. For example, it says figure 5b for the 6th figure, and figure 6 for the 7th figure. Can the journal or the authors please try to correct this?
     ReponseThe error might have occurred during the submission process, as I was using 2 sub figures for 1. With the adjustments of my figures, this problem should have been resolved. Thank you for ensuring the correct figure submission and its quality.
     

Peer Review Report: Round 2

Reviewer 1 Comments 
 

  1. The objective of this article is very concise and clear. Literature review is thorough. The step described in figure 2 is not clear. I was forced to imagine how one can make two sides of the gloves digit stick to each other by taping from outside when nothing is holding it from inside? Is the tape taken both proximally and distally and taped together? I hope the author can make it clear. Rest of the things are clear. Some of the pictures were redundant in the original manuscript; thank you for removing them. Some grammatical errors are noticed and mentioned below.
    1. Method, material, and training model: in second paragraph, 2 strips of Micropore are tapped.... please replace "2" with "Two" and tapped or taped? Please change "(Figure 2) Its vessel width (size) ..." diameter is a better word. Please mention. 
    2. in Discussion: in 10th line, change "advance" to "advanced", in 3rd paragraph (6th page), "Capturing the posterior wall during microvascular anastomosis is a fetal error".... change "fetal" to "fatal"

     ReponseThank you for your kind review and suggestions. I have paraphrased my idea into the following, for figure 2. “Two strips of Micropore tapes were applied over the mid portion of the finger latex tube, one over the dorsal surface and the other over the ventral surface. The tapes extend and seal over the edge of the latex tube, both proximally and distally, while the latex tube is in slight extension. Synthetic vessel (x2), thus created as the inner space of the finger latex tube, is obliterated by the sandwiching technique with Micropore tape.” I have revised it in both the manuscript and the figure legends to clarify my idea and hoping to explain it better for the reader. Thank you for proof reading my work, ensuring high quality writing achieved before publication. All my errors are corrected accordingly.