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Abstract

Introduction

Protocol

Representative Results

Discussion

Acknowledgements

Materials

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Medicine

Porcine As a Training Module for Head and Neck Microvascular Reconstruction

Published: September 29th, 2018

DOI:

10.3791/58104

1Department of Otolaryngology, Head and Neck Surgery, King Abdullah Medical City, 2Department of Otorhinolaryngology, Yonsei University, College of Medicine, 3Severance Biomedical Science Institute, Yonsei University, College of Medicine, 4The George W.Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 5Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine
* These authors contributed equally

Here we present a protocol for the use of the pig superior epigastric artery perforator flap as a learning module for head and neck microvascular reconstruction.

Live models that resemble surgical conditions of humans are needed for training free-flap harvesting and anastomosis. Animal models for training purposes have been available for years in many surgical fields. We used the female (because they are easy to handle for the procedure) Yorkshire pigs for the head and neck reconstruction by harvesting the deep inferior epigastric artery perforator or the superior epigastric artery perforator flap. The anastomosis site (neck skin defect or tracheal wall defect) was prepared via the dissection of the common carotid artery and the internal jugular vein, in which 3.5× loupe magnification was used for anastomosis as we use on human cases in real life. This procedure demonstrates a new training method using a reliable learning model and provides a detailed anatomy in a live scenario. We focused on the ischemia time, harvesting, vessel anastomosis, and designing the flap to fit the defect site. This model improves tissue handling and with the use of proper instruments can be repeated many times so that the surgeon is fully confident before starting the surgery on humans.

Reconstruction following surgery for the head and neck malignant diseases is a difficult procedure associated with significant morbidity. Microvascular free-flap reconstruction has been well established as the standard approach to reconstruction for over 20 years1,2,3. Free-flap transfer plays a significant role in improving the head and neck management in cancer patients and in post-traumatic injuries thereby pushing the boundaries of surgical excision of disease beyond previous techniques, resulting in greater patient quality of life and longer survival rates.css-f1q1l5{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:flex-end;-webkit-box-align:flex-end;-ms-flex-align:flex-end;align-items:flex-end;background-image:linear-gradient(180deg, rgba(255, 255, 255, 0) 0%, rgba(255, 255, 255, 0.8) 40%, rgba(255, 255, 255, 1) 100%);width:100%;height:100%;position:absolute;bottom:0px;left:0px;font-size:var(--chakra-fontSizes-lg);color:#676B82;}

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This study was guided and approved by the Department of Laboratory Animal Resources, Yonsei Biomedical Research Institute, Yonsei University College of Medicine, accredited by the Association for Assessment and Accreditation of Laboratory Animal Care International. This study followed the guidelines for the Care and Use of Laboratory Animals of the Institute of Laboratory Animal Resources Commission on Life Sciences National Research Council. All Pigs were acclimated for One week before the operation.

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We performed the procedure on six pigs: cervical skin defect reconstruction on two pigs, tracheal reconstruction on two pigs, and free flap to test vascular anastomosis device in two pigs. The pigs were monitored for 3 months and there was no clinical sign of neurological deficit.

The mean time for ischemia was 50 min (range, 35-80 min); the time decreased as the procedure was repeated. The mean harvest time of the six pigs was .......

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Significant morbidity and defects can occur in head and neck malignancy patients during surgical management. Microvascular free tissue transfer has become essential for reconstruction in most cases. The viability of the flap is a critical issue, requiring steadiness, precise handling of the pedicle, tactile sensation, visuospatial ability, and excellent operative flow from the surgeon8. To develop these skills, one needs extensive practice with a training model3,.......

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This work was funded and supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (2015R1C1A1A01051907). This work was also supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (NRF-2016M3A9E9941746).

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Name Company Catalog Number Comments
Pigs XP Bio, Seoul, South Korea
Surgical Hair Removal shaver 3M
22 gage catheter B.BRAUN
syring with needle size 18 Jung Rim Medical
Intramuscular alfaxan Careside 10ml/VAL
Intramuscularxylazine Bayer
Intramuscular azaperone Sigma-aldrich 34223
Intramuscular atropine Daewon 0.5mg/A
Intramuscular cefazolin Yuhan 1g
intravenous Ketorolac Hana Pharm 30mg
Swine ansthesia mask DRE 1392
endotracheal cuff tube 6.5 mm SMITH medical 100/150/065
ansthesia Machine Dräger PRIMUS IE
2% lidocaine topical solution Taejoon
vet ointment Pfizer terramycinMisc
eye cover patch Innomed S-universal010S
betadine solution 1%. Korea Pharma
gauze 4*4 First Medical 22*30CM 320S
blade No. 23 Paragon 23
lahey retractor V.Mueller SU3960
kelly tissue scissors SOLCO 05-1990
blade No. 11 Paragon 11
surgical marking pen Aspen Surgical Regular #2750
allis V.Mueller SU4055
tie suture Covidein non-needle
3.5× surgical loupe zeiss eyemag smart
double clamp without frame V.Mueller CH7155
microscissors AESCULAP FD038R
Ringer's lactate Daehan 500ml/1bag
amoxicillin–clavulanate Ilsung 0.6g/V
Meloxicam Samil 7.5mg
propofol Dong Kook 120mg/V
intravenous KCl solution Daehan 20ml/50P
mosquito curved SOLCO 013-0111
mosquito straight SOLCO 05-1050
ethilone 10-0 suture ethicone 10/0W1756
Vicryl 3-0. ethicone 3/0W9890
buprenorphine Hanlim 0.3mg

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  2. Smith, R. K., Wykes, J., Martin, D. T., Niles, N. Perforator variability in the anterolateral thigh free flap: a systematic review. Surgical and Radiologic Anatomy. 39 (7), 779-789 (2017).
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  7. Carey, J. N., et al. Simulation of plastic surgery and microvascular procedures using perfused fresh human cadavers. Plastic and Reconstructive Surgery journal. 67 (2), e42-e48 (2014).
  8. Chan, W., Niranjan, N., Ramakrishnan, V. Structured assessment of microsurgery skills in the clinical setting. Plastic and Reconstructive Surgery Journal. 63 (8), 1329-1334 (2010).
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  10. Kim, W. S., et al. Tracheal reconstruction with a free vascularized myofascial flap: preclinical investigation in a porcine model to human clinical application. Scientific Reports. 7 (1), 10022 (2017).

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