James Tomlinson

Cadaveric Spinal Surgery Simulation: A Comparison of Cadaver Types.

Study Design Single-blinded study. Objective To assess the suitability of three types of cadaver for simulating pedicle screw insertion and establish if there is an ideal. Methods Three types of cadaver—Thiel-embalmed, Crosado-embalmed, and formaldehyde-embalmed—were draped and the spines exposed. Experienced surgeons were asked to place pedicle screws in each cadaver and give written questionnaire feedback using a modified Likert scale. Soft tissue and bony properties were assessed, along with the role of simulation in spinal surgery training. Results The Thiel cadaver rated highest for soft tissue feel and appearance with a median score of 6 for both (range 2 to 7). The Crosado cadaver rated highest for bony feel, with a median score of 6 (range 2 to 7). The formaldehyde cadaver rated lowest for all categories with median scores of 2, 2.5, and 3.5, respectively. All surgeons felt pedicle screw insertion should be learned in a simulated setting using human cadavers. Conclusion Thiel and Crosado cadavers both offered lifelike simulation of pedicle screw insertion, with each having advantages depending on whether the focus is on soft tissue approach or technical aspects of bony screw insertion. Both cadaver types offer the advantage of long life span, unlike fresh frozen tissue, which means cadavers can be used multiple times, thus reducing the costs.

A Multispecialty Evaluation of Thiel Cadavers for Surgical Training

BackgroundChanges in UK legislation allow for surgical procedures to be performed on cadavers. The aim of this study was to assess Thiel cadavers as high-fidelity simulators and to examine their suitability for surgical training.MethodsSurgeons from various specialties were invited to attend a 1xa0day dissection workshop using Thiel cadavers. The surgeons completed a baseline questionnaire on cadaveric simulation. At the end of the workshop, they completed a similar questionnaire based on their experience with Thiel cadavers. Comparing the answers in the pre- and post-workshop questionnaires assessed whether using Thiel cadavers had changed the surgeons’ opinions of cadaveric simulation.ResultsAccording to the 27 participants, simulation is important for surgical training and a full-procedure model is beneficial for all levels of training. Currently, there is dissatisfaction with existing models and a need for high-fidelity alternatives. After the workshop, surgeons concluded that Thiel cadavers are suitable for surgical simulation (pxa0=xa00.015). Thiel were found to be realistic (pxa0<xa00.001) to have reduced odour (pxa0=xa00.002) and be more cost-effective (pxa0=xa00.003). Ethical constraints were considered to be small.ConclusionThiel cadavers are suitable for training in most surgical specialties.

Perceptions About the Present and Future of Surgical Simulation: A National Study of Mixed Qualitative and Quantitative Methodology.

OBJECTIVESnAssess expert opinion on the current and future role of simulation in surgical education.nnnDESIGNnExpert opinion was sought through an externally validated questionnaire that was disseminated electronically.nnnPARTICIPANTSnHeads of Schools of Surgery (HoS) (and deputies) and Training Program Directors (TPD) (and deputies).nnnRESULTSnSimulation was considered a good training tool (HoS: 15/15, TPD: 21/21). The concept that simulation is useful mostly to novices and for basic skills acquisition was rejected (HoS: 15/15, TPDs: 21/21; HoS: 13/15, TPDs: 18/21). Further, simulation is considered suitable for teaching nontechnical skills (HoS: 13/15, TPDs: 20/21) and re-enacting stressful situations (HoS: 14/15, TPDs: 15/21). Most respondents also felt that education centers should be formally accredited (HoS: 12/15, TPDs: 16/21) and that consultant mentors should be appointed by every trust (HoS: 12/15, TPDs: 19/21). In contrast, there were mixed views on its use for trainee assessment (HoS: 6/15, TPDs: 14/21) and whether it should be compulsory (HoS: 8/15, TPDs: 11/21).nnnCONCLUSIONnThe use of simulation for the acquirement of both technical and nontechnical skills is strongly supported while views on other applications (e.g., assessment) are conflicting. Further, the need for center accreditation and supervised, consultant-led teaching is highlighted.

Does monitor position influence visual-motor performance during minimally invasive surgery?

Background: In minimally invasive surgery (MIS), the natural relationship between hand and eye is disrupted, i.e. surgeons typically control tools inserted through the patient’s abdomen while viewing the workspace on a remote monitor, which can be located in a variety of positions. This separates the location of visual feedback from the area in which a motor action is executed. Previous studies suggest that the visual display should be placed directly ahead of the surgeon (i.e. to preserve visual-motor mapping). However, the extent of the impact of this rotation on surgical performance is unknown. Methods: Eighteen participants completed an aiming task on a tablet PC within a surgical box trainer using a laparoscopic tool in a controlled simulated environment. Visual feedback was presented on a remote monitor located at 0°, ±45° and ±90°, with order randomised using the Latin Square method. Results: Movements were significantly slower when the monitor was 90° relative to midline, but spatial accuracy was unaffected by monitor position. Interestingly, the effect of reduced speed in the 90° condition was transient, decreasing over time, suggesting rapid adaptation to the rotation. Conclusions: We conclude that the angle of the visual display in the context of MIS may require a surgeon to adapt to a changed mapping between visual inputs and motor outputs. While this adaptation occurs relatively quickly, it may interfere with skilled actions (e.g. intracorporeal suturing) in complex surgical procedures.

0181 COMPARISON OF CADAVER TYPES FOR SPINAL SURGERY TRAINING

Background Spine pedicle screw insertion is technically demanding, with potentially serious risks if screws are misplaced, and an established learning curve of approximately 70 screws placed before there is a significant reduction in screw misplacement. Despite this most units continue to teach screw insertion for the first time in live surgery, both in the UK and worldwide. This study was a single blinded comparison of cadaver types to simulate screw insertion. Methodology Three cadaver types – Thiel, Crosado and Formaldehyde were positioned prone and a posterior approach to the spine performed. The spines were all exposed by a single surgeon. Experienced spinal surgeons placed screws in each cadaver type sequentially and gave feedback on the tissue quality and feel using a modified Likert scale. Results Thiel cadavers rated most highly for soft tissue feel and appearance with a median score of 6. Crosado cadavers rated most highly for bony properties, with a median score of 6. Formaldehyde cadavers rated poorly for soft tissue feel, appearance and bony qualities with median scores of 2, 2.5 and 3.5 respectively. Conclusions There is a strong argument that pedicle screw insertion should be taught away from the operating theatre but this will have significant cost implications. Cadaveric screw simulation offers the most realistic simulation, with Thiel and Crosado cadavers both rating highly for their properties. Further work is now needed on a larger scale to further explore this valuable resource in surgical training. References Bergeson RK, Schwend RM, DeLucia T, Silva SR, Smith JE, Avilucea FR. How accurately do novice surgeons place thoracic pedicle screws with the free hand technique? Spine 2008;33(15):E501–7 Gonzalvo A, Fitt G, Liew S, et al. The learning curve of pedicle screw placement: how many screws are enough? Spine 2009;34(21):E761–5 Gautschi OP, Schatlo B, Schaller K, Tessitore E. Clinically relevant complications related to pedicle screw placement in thoracolumbar surgery and their management: a literature review of 35,630 pedicle screws. Neurosurg Focus 2011;31(4):E8

0061 Should Simulation Training Be Compulsory For Trainees In All Surgical Specialties

Background Simulation is a useful adjunct to surgical training and there is a plethora of evidence demonstrating its value.1,2 In our region there are seven state of the art simulation centres hosting both low and high fidelity simulators. Use of these facilities requires commitment by both trainees and trainers. Thus, we have compared the uptake of simulation in ophthalmology where the programme is compulsory to both general surgery and gynaecology that run optional programmes. Methods One of the skills centres, hosts virtual reality simulators for ophthalmology (EyeSim/SimSci, US), general surgery (LapMentor, Simbionix/Israel) and obstetrics and gynaecology (LapMentor, Simbionix/Israel). Access to them has been booked online since August 2013. Data from the booking system was retrieved (Aug ’13-May ’14) to determine the use. Results EyeSim (SimSci, US) was used 163 times whilst the LapMentor (Simbionix/Israel) was used on 34 occasions (26/34 for research purposes rather than training) and 43 times by general surgery and gynaecology trainees respectively. Bookings for the EyeSim (SimSci, US) were made by 28 individuals, whilst only 7 general surgery trainees (including 2 research fellows conducting a trial) booked time on the LapMentor (Simbionix/Israel). By comparison 17 gynaecology trainees used the simulator. Within our region there are twice as many trainees in general surgery and gynaecology compared to ophthalmology. Discussion A significantly larger proportion of ophthalmology trainees have trained on simulators compared to both surgery and gynaecology with surgical trainees making least use of the facility. Furthermore, the frequency of usage by trainees was greater for ophthalmology trainees. This suggests that simulation training should become compulsory for trainees and that confirmation of appropriate learning should be demonstrated prior to operating on patients. References Kurashima Y, Feldman LS, Kaneva PA, Fried GM, Bergman S, Demyttenaere SV, Li C, Vassiliou MC. Simulation-based training improves the operative performance of totally extraperitoneal (TEP) laparoscopic inguinal hernia repair: a prospective randomized controlled trial. Surg Endosc. 2014 Mar;28(3):783–8 Nagendran M, Gurusamy KS, Aggarwal R, Loizidou M, Davidson BR. Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database Syst Rev. 2013;27:8