Name: step by step: microsurgical training method combining two nonliving animal models
Uploaded: 2015-05-09T14:00:00
Description: Watch this Scientific Journal Video about Step By Step: Microsurgical training method combining two nonliving animal models at JoVE.com

The authors have no acknowledgements.

1. Preparation:
<ol>
	<li>Obtain a tabletop stereo microscope, with a variable 3,5 x to 45x zoom, 200 mm working distance, 55 to 75 mm variable inter-pupillary distance and an accessory led ring light. Any similar microscope is adequate, it can be set up on a small table and is not extremely expensive.</li>
	<li>Gather and prepare a set of microsurgical instruments with two microsurgical pickups, one dissecting scissor, and one needle-driver; this is the minimum required, it must be taken into account that these are pr...

<ol>
	<li>Lee, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Historical+events+on+development+of+experimental+microsurgical+organ+transplantation.">Historical events on development of experimental microsurgical organ transplantation.</a> Yonsei Med J. 45 (6), 1115-1120 (2004).</li><li>Shurey, S., Akelina, Y., Legagneux, J., Malzone, G., Jiga, L., Ghanem, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+rat+model+in+microsurgery+education:+classical+exercises+and+new+horizons.">The rat model in microsurgery education: classical exercises and new horizons.</a> Arch Plast Surg. 41 (3), 201-208 (2014).</li><li>Olabe, J., Olabe, J., Sancho, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Human+cadaveric+infusi&#243;n+model+for+neurosurgical+training.">Human cadaveric infusi&#243;n model for neurosurgical training.</a> Surg Neurol. 72, 700-702 (2009).</li><li>Peled, I. J., Kaplan, H. Y., Wexler, M. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microsilicone+anastomoses.">Microsilicone anastomoses.</a> Ann Plast Surg. 10 (4), 331-332 (1983).</li><li>Gluer, N. M., Rao, G. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Canniesburn+&#8220;ever-ready&#8221;+model+to+practise+microsurgery.">Canniesburn &#8220;ever-ready&#8221; model to practise microsurgery.</a> Br J Plast Surg. 43 (3), 381-382 (1990).</li><li>Hino, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Training+in+microvascular+surgery+using+a+Chicken+wing+artery.">Training in microvascular surgery using a Chicken wing artery.</a> Neurosurgery. 52 (6), 1495-1498 (2003).</li><li>Marsh, D. J., Norton, S. E., Mok, J., Patel, H. D., Chen, H. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microsurgical+training+the+Chicken+thigh+model.">Microsurgical training the Chicken thigh model.</a> Ann Plast Surg. 59 (3), 355-356 (2007).</li><li>Jeong, H. S., Moon, M. S., Kim, H. S., Lee, H. K., Yi, S. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microsurgical+training+with+fresh+chicken+legs+and+their+histological+characteristics.">Microsurgical training with fresh chicken legs and their histological characteristics.</a> Ann Plast Surg. 70 (1), 57-61 (2013).</li><li>Couceiro, J., Ozyurekoglu, T., Sanders, S., Tien, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microsurgical+training+regimen+with+nonliving+chicken+models.">Microsurgical training regimen with nonliving chicken models.</a> Microsurgery. 33 (3), 251-252 (2013).</li><li>Phoon, A. F., Gumley, G. J., Rtshiladze, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microsurgical+training+using+a+pulsatile+membrane+pump+and+chicken+thigh:+A+new,+realistic,+practical,+nonliving+educational+model.">Microsurgical training using a pulsatile membrane pump and chicken thigh: A new, realistic, practical, nonliving educational model.</a> Plast Reconstr Surg. 126 (5), 278e-279e (2010).</li><li>Zhou, Y., Gu, X., Xiang, J., Qian, S., Chen, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comparative+study+on+suture+versus+cuff+anastomosis+in+mouse+cervical+cardiac+transplant.">A comparative study on suture versus cuff anastomosis in mouse cervical cardiac transplant.</a> Exp Clin Transplant. 8 (3), 245-249 (2010).</li></ol>

The clinical practice of microsurgery requires a continuous practice and a high level of expertise; it&#8217;s applications include free flaps, replantation and revascularization procedures, intracranial &#8211; 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...

An ample array of training models have been described for the learning and maintenance of both basic and advanced microsurgical skills. These include living animals1,2, human cadaveric specimens3, inert models4,5 and non-living animal models6-9.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 gloves4,5 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&#180;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&#8217; 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 &#8220;the femoral neurovascular bundles of chicken are an appropriate and effective model for teaching and practicing microsurgery&#8221;. 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.

<table border="0" cellpadding="0" cellspacing="0" width="765">
	<tbody>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Name of Material/ Equipment</td>
			<td style="width:243px;">Company</td>
			<td style="width:119px;">Catalog Number</td>
			<td style="width:187px;">Comments/Description</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">Stereomicroscope</td>
			<td style="width:243px;">Amscope</td>
			<td style="width:119px;">SM-1BX</td>
			<td>Microscope</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">Led light</td>
			<td style="width:243px;">Amscope</td>
			<td style="width:119px;">LED-80S-YA</td>
			<td>illumination system</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Microsurgical instruments set</td>
			<td style="width:243px;">Chen hen microsurgical instruments</td>
			<td style="width:119px;">HC- X803-1</td>
			<td>Microsurgical instruments</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">Microsurgical sutures</td>
			<td style="width:243px;">S/T microsurgical</td>
			<td style="width:119px;">9/0 Suture</td>
			<td>Sutures</td>
		</tr>
	</tbody>
</table>

step by step: microsurgical training method combining two nonliving animal models

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.

The authors have chronometered their times with the present training method and have seen it to significantly reduce the anastomosis times for a femoral artery at the end of the third week. The trainee can control the improvements on his technique by checking his times, his patency percentages and the alignment of his stitches. The system described in this manuscript is depicted in Figure 1 it includes a tabletop microscope and a set of microsurgical instruments. The macroscopic dissections are shown in Figures 2 and 3. ...

Watch this Scientific Journal Video about Step By Step: Microsurgical training method combining two nonliving animal models at JoVE.com

Step By Step: Microsurgical training method combining two nonliving animal models

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.

The learning of microsurgical techniques and the maintenance of microsurgical skills have been traditionally based on the use of living animals, mainly ...

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