Giselle Coelho

Quality assessment of a new surgical simulator for neuroendoscopic training

OBJECT Ideal surgical training models should be entirely reliable, atoxic, easy to handle, and, if possible, low cost. All available models have their advantages and disadvantages. The choice of one or another will depend on the type of surgery to be performed. The authors created an anatomical model called the S.I.M.O.N.T. (Sinus Model Oto-Rhino Neuro Trainer) Neurosurgical Endotrainer, which can provide reliable neuroendoscopic training. The aim in the present study was to assess both the quality of the model and the development of surgical skills by trainees. METHODS The S.I.M.O.N.T. is built of a synthetic thermoretractable, thermosensible rubber called Neoderma, which, combined with different polymers, produces more than 30 different formulas. Quality assessment of the model was based on qualitative and quantitative data obtained from training sessions with 9 experienced and 13 inexperienced neurosurgeons. The techniques used for evaluation were face validation, retest and interrater reliability, and construct validation. RESULTS The experts considered the S.I.M.O.N.T. capable of reproducing surgical situations as if they were real and presenting great similarity with the human brain. Surgical results of serial training showed that the model could be considered precise. Finally, development and improvement in surgical skills by the trainees were observed and considered relevant to further training. It was also observed that the probability of any single error was dramatically decreased after each training session, with a mean reduction of 41.65% (range 38.7%-45.6%). CONCLUSIONS Neuroendoscopic training has some specific requirements. A unique set of instruments is required, as is a model that can resemble real-life situations. The S.I.M.O.N.T. is a new alternative model specially designed for this purpose. Validation techniques followed by precision assessments attested to the models feasibility.

Frameless Image-Guided Neuroendoscopy Training in Real Simulators

BACKGROUND Over the last decade, neuroendoscopy has re-emerged as an interesting option in the management of intraventricular lesions in both children and adults. Nonetheless, as it has become more difficult to use cadaveric specimens in training, the development of alternative methods was vital. The aim of this study was to analyze the performance of a real simulator, in association with image-guided navigation, as a teaching tool for the training of intraventricular endoscopic procedures. METHODS 3 real simulators were built using a special type of resin. 1 was designed to represent the abnormally enlarged ventricles, making it possible for a third ventriculostomy to be performed. The remaining 2 were designed to simulate a persons skull and brain bearing intraventricular lesions, which were placed as follows: in the foramen of Monro region, in the frontal and occipital horns of the lateral ventricles and within the third ventricle. In all models, MRI images were obtained for navigation guidance. Within the ventricles, the relevant anatomic structures and the lesions were identified through the endoscope and compared with the position given by the navigation device. The next step consisted of manipulating the lesions, using standard endoscopic techniques. RESULTS We observed that the models were MRI compatible, easy and safe to handle. They nicely reproduced the intraventricular anatomy and brain consistence, as well as simulated intraventricular lesions. The image-based navigation was efficient in guiding the surgeon through the endoscopic procedure, allowing the selection of the best approach as well as defining the relevant surgical landmarks for each ventricular compartment. Nonetheless, as expected, navigation inaccuracies occurred. After the training sessions the surgeons felt they had gained valued experience by dealing with intraventricular lesions employing endoscopic techniques. CONCLUSION The use of real simulators in association with image-guided navigation proved to be an effective tool in training for neuroendoscopy.

Anatomical pediatric model for craniosynostosis surgical training

IntroductionSeveral surgical training simulators have been created to improve the learning curve of residents in neurosurgery and plastic surgery. Laboratory training is fundamental for acquiring familiarity with the techniques of surgery and the skill in handling instruments. The aim of this study is to present a novel simulator for training in the technique of craniosynostectomy, specifically for the scaphocephaly type.Description of the simulatorThis realistic simulator was built with a synthetic thermo-retractile and thermo-sensible rubber which, when combined with different polymers, produces more than 30 different formulas. These formulas present textures, consistencies, and mechanical resistance similar to many human tissues. Fiberglass molds in the shape of the skull constitute the basic structure of the craniosynostectomy training module. It has been possible to perform computerized tomography images due to the radiopacity of this simulator and to compare the pre- and postoperative images.ResultsThe authors present a training model to practice the biparietal remodeling used in scaphocephaly correction. All aspects of the procedure are simulated: the skin incision, the subcutaneous and subperiosteal dissection, the osteotomies, and finally, the skull remodeling with absorbable microplates. The presence of superior sagittal sinus can simulate emergency situations with bleeding.ConclusionThe authors conclude that this training model can represent a fairly useful method to accustom trainees to the required surgical techniques and simulates well the steps of standard surgery for scaphocephaly. This training provides an alternative to the use of human cadavers and animal models. Furthermore, it can represent the anatomical alteration precisely as well as intraoperative emergency situations.

New anatomical simulator for pediatric neuroendoscopic practice

IntroductionThe practice of neuroendoscopic procedures requires many years of training to obtain the adequate skills to perform these operations safely. In this study, we present a new pediatric neuroendoscopic simulator that facilitates training.Description of the simulatorThis realistic simulator was built with a synthetic thermo-retractile and thermo-sensible rubber called Neoderma® which, when combined with different polymers, produces more than 30 different formulae, which present textures, consistencies, and mechanical resistances similar to many human tissues. Silicon and fiberglass molds, in the shape of the cerebral ventricles, constitute the basic structure of the neuroendoscopic training module. The module offers the possibility for practicing many basic neuroendoscopic techniques such as: navigating the ventricular system to visualize important anatomic landmarks (e.g., septal and thalamostriate veins, foramen of Monro, temporal horns, aqueduct, and fourth ventricle), performing third ventriculostomy and choroid plexus cauterization, and resecting intraventricular “tumors” that bleed.ConclusionIt is important to emphasize that it is possible to perform with this simulator not only the rigid but also the flexible endoscopy, with good correspondence to reality and no risks. Notable future perspectives can be considered regarding this new pediatric simulator, for example, to improve the learning curve for nonexperienced neurosurgeons and to spread the flexible endoscopy technique.

The role of simulation in neurosurgery

It is increasingly apparent that the standards for surgical training are shifting from time-based to criterion-based parameters that emphasize obtaining and maintaining competencies [24]. The formation of a surgeon demands significant dedication and effort, in addition to time [54]. Current, wellestablished methods of surgical training are being challenged as the environment becomes increasingly competitive and litigious with greater scrutiny of patient outcomes [14, 17, 40, 44, 50]. In order to increase patient safety and improve treatment outcomes, several strategies such as problem-based learning and objective structured clinical examinations have promoted the development of new curricula in surgical education [13, 15, 35, 51, 52]. Some of these changes have been driven by events in the 1980s and 1990s such as medical misconduct and overworked, unsupervised resident staff that contributed to patient morbidity and mortality. This also coincided with a growing medical malpractice crisis. As a result, regulatory bodies began to initiate new standards of work hour restrictions and supervision for residents in training. The New York Health Code of 1989 compiled regulations restricting resident work hours (80 h per week) and one day free a week and placed limits on the number of calls [24, 32]. Concerns arose about the long-established methods of training surgical residents, and solutions were sought to reduce preventable errors and perioperative complications [24, 9]. The airline industry, with the development of flight simulators and pilot coaching methods, proved to be an excellent precedent for innovation in surgical education. Many surgical educators believe such methods are keys to accelerating the acquisition of fundamental skills and the rate of performance improvement among surgical residents. A Yale University study demonstrated that criterion-based simulator training decreased operating time by 30 % and operative errors by 85 % [47, 48]. Neurosurgical trainees in particular face great challenges in learning to plan and perform increasingly complex procedures in which there is little room for error [10]. The educator’s task becomes ever more daunting as the number and complexity of neurosurgical procedures continue to increase in parallel with technological developments such as minimally invasive spine surgery and instrumentation, interventional neuroangiography, image-guided navigation, and endoscopic surgery. The necessity of innovative surgical curriculum development that incorporates safe learning environments and objective skill assessments is thus obvious and needs to be led by trained surgical educators [5]. Adjuvant, non-clinical, surgical training can be grouped into four broad categories:

Ventricular and skull base neuroendoscopy simulation in residency training: feasibility, cost, and resident feedback

Background: Shifting paradigms in neurosurgical education are promoting the development of different simulators in order to promote faster and safer surgical training. Neuroendoscopy simulators have been created with the intention of decreasing the learning curve of resident training in neuroendoscopy techniques. The objective was to study the potential usefulness of organized implementation of neuroendoscopy simulators in resident training, with particular attention to resident feedback and cost. Methods: A total of 19 residents from two separate academic institutions performed 83 simulated endoscopic procedures. These were classified as ventricular (n = 49) and skull base (n = 34). In turn, each procedure was classified into one of three difficulty levels (easy, medium, and hard). Evaluations regarding self-perceived performance were completed after each exercise in accordance with a Physician Performance Diagnostic Inventory Scale based on the Likert format. Subject identification was blinded to junior or senior resident. Wilcoxon rank testing was used to compare the self-perceived performance improvement within and between both groups. Results: Perceived improvement was statistically significant for all the ventricular and skull base/pituitary simulation procedures listed (P5 0.001) based on the Wilcoxon sign rank test. These results were not particularly influenced by simulation exercise group (ventricular vs skull base, P = 0.48), institution (United States vs Brazil, P = 0.44), resident training level (junior vs senior, P = 0.48), or the level of difficulty of the simulation procedure (easy, medium, hard, P = 0.98). The average cost of the ventricular and skull base/pituitary simulation modules was US

History of surgical simulation and its application in Neurosurgery

6367.50 and US

Multimaterial 3D printing preoperative planning for frontoethmoidal meningoencephalocele surgery

7065.50, respectively, per program. Conclusion: The use of neuroendoscopic surgery simulators in neurosurgical training is regarded favorably by trainees and should be considered as an adjuvant in neurosurgical simulation training curricula.

Board 131 - Program Innovations Abstract The Combination of Virtual and Realistic Anatomical Models in Spine Surgical Training (Submission #1032)

OBJETIVOS: Neste artigo, os autores abordam a evolucao historica da simulacao cirurgica, tendo como foco a sua aplicacao em Neurocirurgia. METODOS: A revisao da literatura foi feita nas bases de dados PubMed/Medline e Scopus, utilizando os termos “ history AND simulation ”; e “ simulation AND neurosurgery ”. Nao houve limite de data de publicacao. RESULTADOS: Foram selecionados 30 artigos cujo conteudo inclui dados de interesse para o objetivo do estudo. A simulacao tem sido usada durante seculos de varias formas, incluindo dissecacao de cadaveres pelos primeiros medicos (como Galeno) e treinamento militar (como por exemplo nos jogos de guerra). Modelos anatomicos foram criados no seculo XVIII e seguiram se aperfeicoando nos seculos seguintes. Ja a simulacao por realidade virtual foi primeiramente utilizada em 1987, popularizando-se no inicio da decada de 1990. Posteriormente foram criados modelos anatomicos sinteticos que reproduzem cenarios cirurgicos proximos ao real, com grande aplicabilidade atualmente. CONCLUSOES: A revisao da literatura destacou aspectos evolutivos da simulacao e sua aplicacao atual em educacao medica. As inovacoes nesse campo foram muito apreciadas por membros da comunidade neurocirurgica, que reconheceram o vasto potencial da simulacao para revolucionar esta especialidade, onde erros intraoperatorios podem ter consequencias desastrosas. Esta revisao historica podera contribuir para melhor compreensao do relevante papel da simulacao e tambem para sua implementacao no curriculo medico, especialmente em especialidades de alta complexidade, como a Neurocirurgia.

Board 536 - Technology Innovations Abstract Anatomical Shoulder Simulator for Arthroscopy Training (Submission #831)

IntroductionSurgical correction of frontoethmoidal meningoencephalocele, although rare, is still challenging to neurosurgeons and plastic reconstructive surgeons. It is fundamental to establish reliable and safe surgical techniques. The twenty-first century has brought great advances in medical technology, and the 3D models can mimic the correct tridimensional anatomical relation of a tissue organ or body part. They allow both tactile and spatial understanding of the lesion and organ involved. The 3D printing technology allows the preparation for specific surgery ahead of time, planning the surgical approach and developing plans to deal with uncommon and high-risk intraoperative scenarios.Case presentationThe present report describes a case of frontoethmoidal encephalocele, (nasofrontal subtype) of a 19-month-old girl, whose surgical correction was planned using 3D printing modeling.ConclusionThe 3D model allowed a detailed discussion of the aspects of the surgical approach by having tissues of different consistencies and resistances, and also predicting with millimetric precision the bilateral orbitotomy measurements. Moreover, it was a fundamental and valuable factor in the multidisciplinary preoperative discussion. This approach allowed reducing the time of surgery, accurately planning the location of the osteotomies and precontouring the osteosynthesis material. 3D models can be very helpful tools in planning complex craniofacial operative procedures.