一步一步:显微外科培训方法相结合的两个无生命的动物模型

摘要

Here we describe how to set up a small microsurgical practice station and a simple and inexpensive method for the training of microsurgery with non-living animal models.

摘要

The learning of microsurgical techniques and the maintenance of microsurgical skills have been traditionally based on the use of living animals, mainly laboratory rats. This method although extremely valuable can be economically demanding both for the surgeon and the sponsoring institution; it also requires special training facilities that may not always be available or accessible. Furthermore ethical concerns can limit the use of living animals for training purposes. Alternative training methods, such as inert tubes and gloves have not gained popularity among surgeons since they do not offer an experience similar to that of a clinical situation. Non-living animal models include the use of chicken thighs and wings; they offer a practice experience that resembles a clinical situation to a considerable extent. This type of training is relatively cheap and easily available. The microscope and instruments required can be acquired over the internet, and the chicken pieces can be bought at the local supermarket.

This approach allows a motivated trainee to rehearse different types of surgical techniques several times at a reasonable expense, helping to develop or maintain his surgical expertise if more complex facilities are not available. On the current manuscript we describe how to setup a small practice station, how to dissect the specimens, and how to practice both with the chicken thighs and with the chicken wings in a progressive fashion. This approach takes advantage on the versatility of the chicken thigh model and the small size of the chicken wing Brachial artery.

引言

An ample array of training models have been described for the learning and maintenance of both basic and advanced microsurgical skills. These include living animals^1,2, human cadaveric specimens³, inert models^4,5 and non-living animal models^6-9.The Living animal models, specifically those using rats have been extensively used in the teaching of microsurgery ^1,2; and they are considered the current gold standard of training. In spite of their remarkable instructive value, when an intensive or prolonged training is required; economical and ethical concerns can hinder their practical usage.

Cadaveric models³ offer the opportunity to practice in an environment similar to that of the actual clinical situation; they are unfortunately restricted to anatomy labs and similar facilities, a microscope must be available at the lab as well; these models are therefore not widely available. Inert models such as rubber tubes, or gloves^4,5 are cheap, and easily accessible, the required equipment for their application is minimal. The resemblance to a clinical situation is tenuous however; and their application is generally limited to the introductory stages of training, before the trainee starts practicing on rats. To the best of our knowledge Hino⁶ was the first to propose the use of non-living chicken for the development and maintenance of clinical microsurgical skills. His model is based on the extraction and subsequent usage of the chicken brachial artery from commercial chicken wings. This approach does not need institution review board approval, rodent anaesthesia, laboratory technicians or postoperative care.

Following Hino´s description of the chicken wing artery model numerous other nonliving animal models were published. The use of commercial chicken thighs was first suggested by Marsh et al.⁷ who reported the use of the femoral artery, vein and nerve for didactic purposes. This particular model expands the possibilities of training including structures different from the arteries; it permits the trainee to perform a variety of complex procedures such as vein grafts, nerve grafts or fascicular repairs. Jeong et al.⁸ Further studied Marsh’ chicken thigh model and its applications to the teaching of resident doctors. The authors analysed chicken tissue samples histologically and found that it presented similarities to human tissues. The time to perform an anastomosis by the trainee was significantly reduced by practice in their study. They concluded that “the femoral neurovascular bundles of chicken are an appropriate and effective model for teaching and practicing microsurgery”. In 2013 my colleagues and I⁹ published a microsurgical training regimen that combined both the chicken thigh and the chicken wing models; this approach benefits from the versatility of the chicken thighs and from the limited size of the chicken wing artery which can represent more of a challenge than the femoral vessels for the more advanced trainees.

On the current manuscript we describe step by step the process of setting up a microsurgical practice station; the materials required, how to dissect the neurovascular structures of each model and how to effectively apply the training regimen.

研究方案

1.准备:

1. 获得桌面立体显微镜，具有可变3,5- x可45倍放大200毫米的工作距离，55至75mm可变瞳孔间距和一个配件导致环形灯。任何类似的显微镜是足够的，它可以被设置在一个小桌子，是不是非常昂贵。
2. 收集和编写一套显微仪器有两个显微拾音器，一个切除剪刀，一针驱动程序;这是所需要的最低限度，必须考虑到，这些都是实践手段，并且不需要高端品质仪器。
3. 用9/0丝微缝合所有的做法。购买市售鸡大腿或翅膀和食品着色剂在当地的超市。
4. 将20克血管导管用于对鸡的股动脉通畅试验。对于肱动脉，需要更薄的27G的导管。这些可以在当地药剂来获取在互联网上或与设置仪器。买市售注射器注射的食品着色剂。

2.宏观解剖技术:

1. 该方法以股血管很简单。对于鸡大腿，执行钝器解剖技术只是内侧到股骨轴，从骨中分离股骨肌肉并暴露股动脉，静脉和神经。该神经可被进一步分解为不同类型的神经修复做法两个单独分册。
2. 为了纵向向上进入鸡肱动脉的鸡翅，切开皮肤用剪刀，从肩膀到机翼的尖端。观察二头肌和肱三头肌之间运行的动脉。

3.推荐的培训方案:

1. 培训与股动脉。
   注:在训练方案的第一步是用鸡股动脉练习。

1. 放置在显微镜下的片，并启动显微解剖。释放从下面的组织的股动脉;和水平划分它。执行adventicectomy。使用微皮卡和微型剪刀修剪任何adventicia覆动脉管腔。冲洗内腔与普通自来水。记下开始时间
2. 执行端到端吻合。
   1. 开始对相反的操作者侧的动脉的后壁。将第一针;左侧开始，如果工作水平，在下部侧，如果工作垂直。从朝向管腔动脉的外侧通过所述针，然后从腔到动脉的外侧。
   2. 领带针，先执行双结，然后两个单抛出交替方向。完成整个后壁与上述技术。
   3. 开始在右手侧如果正在工作的水平或上侧，如果你是禾rking垂直，放置一个单针从外部向管腔，然后从腔到外部。喜结良缘如上所述。完成前壁重复在3.1.2.2中描述的方法。
   4. 写下最后的时间，这将让你保持一个时间记录，这样你就可以控制你的进展。
      注:笔者喜欢的一种方式了技术;但是任何类型的显微缝线可以排演。值得推荐的是学员完成约25显微外科吻合术以这种方式，才可以尝试其他的临床方案。这些措施包括静脉移植动脉间隙，端到端神经修复，并利用静脉导管的神经差距的治疗。微血管手术的重要技术，可以与该训练方法学是连续或连续缝合，以执行该技术学员收益为3.1.2.1，但施蒂希不琢，继续履行针在无3.1.2.1削减他们üNTIL你完成整个缝合并绑到原来的针在末端。

2. 训练用肱动脉
   1. 将在显微镜下的棋子。完成如上述的股动脉的过程。
      注意:唯一的区别是大小。的肱动脉比股动脉小得多，该吻合是相当多的困难。
3. 通畅试验
   1. 通过交叉吻合平稳20或27G的血管导管，检查所造成的缝合针两种血管壁一起障碍物。
   2. 应用与商业食品着色剂的注射器的血管性导管的末端，并灌注染入动脉来测试喷墨泄漏
   3. 打开动脉纵向以可视化的针，其并行和墙壁的量服食。

结果

作者们chronometered其次，本训练方法，并且已经看见它显著降低吻合次为一股动脉在第三周结束。受训者可以通过检查他的时候，他的通畅百分比和他的线圈的对准控制上他的技术的改进。在这个手稿中描述的系统在图1中被描述，它包括一个桌面显微镜和一组显微仪器。宏观解剖示于图2和3股动脉显微吻合的一个例子示于图4中。图5示出了肱动脉显微吻合。图6示出一个股动脉修复用静脉移植物。通...

讨论

The clinical practice of microsurgery requires a continuous practice and a high level of expertise; it’s applications include free flaps, replantation and revascularization procedures, intracranial – extracranial anastomoses for neurosurgical procedures, peripheral nerve surgery and others. In spite of the wide variety of procedures that require microsurgical techniques, some of them are seldom performed in many centers. The surgeons therefore need sometimes to maintain their skill level rehearsing the surge...

材料

Name	Company	Catalog Number	Comments
Stereomicroscope	Amscope	SM-1BX	Microscope
Led light	Amscope	LED-80S-YA	illumination system
Microsurgical instruments set	Chen hen microsurgical instruments	HC- X803-1	Microsurgical instruments
Microsurgical sutures	S/T microsurgical	9/0 Suture	Sutures