Name: porcine as a training module for head and neck microvascular reconstruction
Uploaded: 2018-09-29T13:00:00
Description: Watch this Scientific Journal Video about Porcine As a Training Module for Head and Neck Microvascular Reconstruction at JoVE.com

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 &#38; Future Planning (NRF-2016M3A9E9941746).

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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<ol>
	<li>Chen, C. L., Zenga, J., Roland, L. T., Pipkorn, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complications+of+double+free+flap+and+free+flap+combined+with+locoregional+flap+in+head+and+neck+reconstruction:+A+systematic+review.">Complications of double free flap and free flap combined with locoregional flap in head and neck reconstruction: A systematic review.</a> Head &amp; Neck journal of the Science and Specialties of the Head and Neck. 40 (3), 632-646 (2018).</li><li>Smith, R. K., Wykes, J., Martin, D. T., Niles, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Perforator+variability+in+the+anterolateral+thigh+free+flap:+a+systematic+review.">Perforator variability in the anterolateral thigh free flap: a systematic review.</a> Surgical and Radiologic Anatomy. 39 (7), 779-789 (2017).</li><li>Bauer, F., Koerdt, S., H&#246;lzle, F., Mitchell, D. A., Wolff, K. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Eight+free+flaps+in+24+hours:+a+training+concept+for+postgraduate+teaching+of+how+to+raise+microvascular+free+flaps.">Eight free flaps in 24 hours: a training concept for postgraduate teaching of how to raise microvascular free flaps.</a> British Journal of Oral and Maxillofacial. 54 (1), 35-39 (2016).</li><li>Schoeff, S., Hernandez, B., Robinson, D. J., Jameson, M. J., Shonka, D. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microvascular+Anastomosis+Simulation+Using+a+Chicken+Thigh+Model:+Interval+Versus+Massed+Training.">Microvascular Anastomosis Simulation Using a Chicken Thigh Model: Interval Versus Massed Training.</a> The Laryngoscope. 127 (11), 2490-2494 (2017).</li><li>Bodin, F., Diana, M., Koutsomanis, A., Robert, E., Marescaux, J., Bruant-Rodier, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Porcine+model+for+free-flap+breast+reconstruction+training.">Porcine model for free-flap breast reconstruction training.</a> Plastic and Reconstructive Surgery Journal. 68 (10), 1402-1409 (2015).</li><li>Rodriguez, J. R., Ya&#241;ez, R., Cifuentes, I., Varas, J., Dagnino, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microsurgery+Workout:+A+Novel+Simulation+Training+Curriculum+Based+on+Nonliving+Models.">Microsurgery Workout: A Novel Simulation Training Curriculum Based on Nonliving Models.</a> Plastic and Reconstructive Surgery Journal. 138 (4), 739e-747e (2016).</li><li>Carey, J. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation+of+plastic+surgery+and+microvascular+procedures+using+perfused+fresh+human+cadavers.">Simulation of plastic surgery and microvascular procedures using perfused fresh human cadavers.</a> Plastic and Reconstructive Surgery journal. 67 (2), e42-e48 (2014).</li><li>Chan, W., Niranjan, N., Ramakrishnan, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Structured+assessment+of+microsurgery+skills+in+the+clinical+setting.">Structured assessment of microsurgery skills in the clinical setting.</a> Plastic and Reconstructive Surgery Journal. 63 (8), 1329-1334 (2010).</li><li>Matsumura, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+newly+designed+training+tool+for+microvascular+anastomosis+techniques:+Microvascular+Practice+Card.">A newly designed training tool for microvascular anastomosis techniques: Microvascular Practice Card.</a> Surgical Neurology Journal. 71 (5), 616-620 (2010).</li><li>Kim, W. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tracheal+reconstruction+with+a+free+vascularized+myofascial+flap:+preclinical+investigation+in+a+porcine+model+to+human+clinical+application.">Tracheal reconstruction with a free vascularized myofascial flap: preclinical investigation in a porcine model to human clinical application.</a> Scientific Reports. 7 (1), 10022 (2017).</li></ol>

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,...

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 rates1,2,3. The various flaps for reconstruction include rotational, graft, and free flaps.
The role of free flaps in the head and neck reconstruction has expanded. It is the most difficult flap to work with, requiring skilled and delicate handling. Flap failure is a catastrophic event, with significant morbidity4,5. Thus, considerable training time is required to develop the precision necessary for the successful surgical outcomes3,4,5,6,7,8,9. The steep learning curve associated with such a surgery can influence the outcome for patients and affect treatment management3,4,5,6,7,8,9. To reduce the training time and learning curve for new surgeons, a training model is needed that mimics human biology and provides similar surgical field conditions8.
The goal of this study is to show the visibility of Porcine as a good training module for the head and neck microvascular reconstruction resembling the human case with improved skills in the active fashion.
This study investigated the use of a porcine model for training new colleagues in the head and neck microvascular reconstruction for free-flap transfer to provide a cost-effective and less stressful supplement to the clinical field training with reliably similar features for free-flap procedures. Pigs have been used for many studies and as teaching models for various surgical reconstructions, e.g., breast reconstruction;5 however, pigs have never been used for head and neck reconstruction except in our study for tracheal reconstruction due to tracheal stenosis10.
The idea was started after Frederic Bodin7, who describe the similar flap for breast reconstruction. The main advantage for the study over the other module of microvascular training is the active livening module with a real immediate result of the procedure.

<table>
	<tbody>
		<tr>
			<td>Pigs XP Bio, Seoul, South Korea</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical Hair Removal shaver</td>
			<td>3M</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>22 gage catheter</td>
			<td>B.BRAUN</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>syring with needle size 18</td>
			<td>Jung Rim Medical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Intramuscular alfaxan</td>
			<td>Careside</td>
			<td></td>
			<td>10ml/VAL</td>
		</tr>
		<tr>
			<td>Intramuscularxylazine</td>
			<td>Bayer</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Intramuscular azaperone</td>
			<td>Sigma-aldrich</td>
			<td></td>
			<td>34223</td>
		</tr>
		<tr>
			<td>Intramuscular atropine</td>
			<td>Daewon</td>
			<td></td>
			<td>0.5mg/A</td>
		</tr>
		<tr>
			<td>Intramuscular cefazolin</td>
			<td>Yuhan</td>
			<td></td>
			<td>1g</td>
		</tr>
		<tr>
			<td>intravenous Ketorolac</td>
			<td>Hana Pharm</td>
			<td></td>
			<td>30mg</td>
		</tr>
		<tr>
			<td>Swine ansthesia mask</td>
			<td>DRE</td>
			<td></td>
			<td>1392</td>
		</tr>
		<tr>
			<td>endotracheal cuff tube 6.5 mm</td>
			<td>SMITH medical</td>
			<td></td>
			<td>100/150/065</td>
		</tr>
		<tr>
			<td>ansthesia Machine</td>
			<td>Dr&#228;ger</td>
			<td></td>
			<td>PRIMUS IE</td>
		</tr>
		<tr>
			<td>2% lidocaine topical solution</td>
			<td>Taejoon</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>vet ointment</td>
			<td>Pfizer</td>
			<td></td>
			<td>terramycin<img alt="Misc" src="/files/ftp_upload/58104/58104misc1.jpg" /></td>
		</tr>
		<tr>
			<td>eye cover patch</td>
			<td>Innomed</td>
			<td></td>
			<td>S-universal010S</td>
		</tr>
		<tr>
			<td>betadine solution 1%.</td>
			<td>Korea Pharma</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>gauze 4*4</td>
			<td>First Medical</td>
			<td></td>
			<td>22*30CM 320S</td>
		</tr>
		<tr>
			<td>blade No. 23</td>
			<td>Paragon</td>
			<td></td>
			<td>23</td>
		</tr>
		<tr>
			<td>lahey retractor</td>
			<td>V.Mueller</td>
			<td></td>
			<td>SU3960</td>
		</tr>
		<tr>
			<td>kelly tissue scissors</td>
			<td>SOLCO</td>
			<td></td>
			<td>05-1990</td>
		</tr>
		<tr>
			<td>blade No. 11</td>
			<td>Paragon</td>
			<td></td>
			<td>11</td>
		</tr>
		<tr>
			<td>surgical marking pen</td>
			<td>Aspen Surgical</td>
			<td></td>
			<td>Regular #2750</td>
		</tr>
		<tr>
			<td>allis</td>
			<td>V.Mueller</td>
			<td></td>
			<td>SU4055</td>
		</tr>
		<tr>
			<td>tie suture</td>
			<td>Covidein</td>
			<td></td>
			<td>non-needle</td>
		</tr>
		<tr>
			<td>3.5&#215; surgical loupe</td>
			<td>zeiss</td>
			<td></td>
			<td>eyemag smart</td>
		</tr>
		<tr>
			<td>double clamp without frame</td>
			<td>V.Mueller</td>
			<td></td>
			<td>CH7155</td>
		</tr>
		<tr>
			<td>microscissors</td>
			<td>AESCULAP</td>
			<td></td>
			<td>FD038R</td>
		</tr>
		<tr>
			<td>Ringer&#39;s lactate</td>
			<td>Daehan</td>
			<td></td>
			<td>500ml/1bag</td>
		</tr>
		<tr>
			<td>amoxicillin&#8211;clavulanate</td>
			<td>Ilsung</td>
			<td></td>
			<td>0.6g/V</td>
		</tr>
		<tr>
			<td>Meloxicam</td>
			<td>Samil</td>
			<td></td>
			<td>7.5mg</td>
		</tr>
		<tr>
			<td>propofol</td>
			<td>Dong Kook</td>
			<td></td>
			<td>120mg/V</td>
		</tr>
		<tr>
			<td>intravenous KCl solution</td>
			<td>Daehan</td>
			<td></td>
			<td>20ml/50P</td>
		</tr>
		<tr>
			<td>mosquito curved</td>
			<td>SOLCO</td>
			<td></td>
			<td>013-0111</td>
		</tr>
		<tr>
			<td>mosquito straight</td>
			<td>SOLCO</td>
			<td></td>
			<td>05-1050</td>
		</tr>
		<tr>
			<td>ethilone 10-0 suture</td>
			<td>ethicone</td>
			<td></td>
			<td>10/0W1756</td>
		</tr>
		<tr>
			<td>Vicryl 3-0.</td>
			<td>ethicone</td>
			<td></td>
			<td>3/0W9890</td>
		</tr>
		<tr>
			<td>buprenorphine</td>
			<td>Hanlim</td>
			<td></td>
			<td>0.3mg</td>
		</tr>
	</tbody>
</table>

porcine as a training 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&#215; 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.

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 ...

Watch this Scientific Journal Video about Porcine As a Training Module for Head and Neck Microvascular Reconstruction at JoVE.com

Porcine As a Training Module for Head and Neck Microvascular Reconstruction

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 ...

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