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Diagram of the bowel anastomosis model demonstrating the two segments of sheep intestine. The proposed placement of the 5/0 absorbable sutures to represent a mesenteric (superior) and antimesenteric (inferior) border is shown
Source publication
Background
Surgical simulation is an important aspect of competency-based training. Recent trends in paediatric surgical simulations have migrated towards high-fidelity simulation with advanced technology resulting in models which are expensive and largely inaccessible in low- and middle-income countries.
Methods
This article describes four wet si...
Context in source publication
Context 1
... model uses a bisected segment of sheep intestine. The two bowel segments are aligned facing each other, and corner stitches are placed using 5/0 absorbable suture. These represent the mesenteric and anti-mesenteric borders. The stitch is placed from outside-into inside-out so the knot is on the outside (Fig. 1). The anterior wall is then closed with a 5/0 absorbable suture using an interrupted seromuscular stitching technique. The corner stitches should now be reversed by passing the mesenteric stitch through the defect in the mesentery and flipping the antimesenteric stitch in the other direction (Fig. 2). The anastomosis is completed by ...
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Background:
Simulation is integral to the development and maintenance of micro- surgical skills. Several simulation models have been described ranging from bench- top to live animal models. High fidelity models are often burdened by cost and ethical issues limiting widespread implementation. This study aims to determine the feasibility of a micros...
Citations
... They have not only sponsored surgeries but have also been instrumental in training local surgeons and providing necessary equipment. Training has also been facilitated by the development of low cost simulation models that can be created using readily available resources [40], which has enabled more healthcare professionals to perform laparoscopic surgery [41] and neonatal surgery. ...
This review explores the significant advancements in paediatric surgery in Africa during the twenty-first century, with a particular focus on capacity-building, education, infrastructural development, and research. Historically, paediatric surgery has been an overlooked sector, especially in low-and-middle-income countries in Africa. However, recent years have seen considerable progress. Collaborative efforts such as the Global Initiative for Children’s Surgery, and the formation of the Pan African Paediatric Surgery Association, the College of Surgeons of East, Central and Southern Africa and the West African College of Surgeons have facilitated knowledge sharing, collaboration, and advocacy for enhancing surgical standards. Local training programmes, including Master of Medicine programmes and fellowships, have been instrumental in building a skilled workforce. These initiatives have been complemented by infrastructural developments through non-governmental organisations like Kids Operating Room, which have expanded access to paediatric surgical care. Technological advancements, particularly in telemedicine, have further enhanced accessibility. Task-sharing strategies, where non-specialist physicians are trained in paediatric surgical skills, have also been utilised to address the shortage of specialised surgeons. Research in paediatric surgery has experienced an upswing, with local health professionals taking the lead. Research has been crucial for understanding the epidemiology of paediatric surgical conditions, and developing prevention strategies, and is increasingly leading to the inclusion of paediatric surgery in national health plans. Despite the progress, challenges remain, including the need for sustainable funding, continued investment in infrastructure, and training and retention of healthcare professionals. The review emphasises the importance of ongoing efforts in community engagement, innovative technologies, and health systems strengthening for the sustainable development of paediatric surgical services in Africa.
... A seromuscular stitching approach with a running 4-0 monofilament thread was used to complete an end-to-end anastomosis aligning bisected segments. This model has previously been reported as a suitable bowel anastomosis surgical simulation model [13]. ...
... We compared the study subjects trained in laparoscopy with the study subjects trained in open surgery regarding In the study's training phase, we used fresh tissue models to mimic a clinical environment. We modified a simulation model previously used as a training tool for laparoscopic [16,17], robotic [16], and open surgical [13,18] simulations. The simulated robotic surgical tasks in the final test were performed as a higher fidelity simulation with a live pig model, incorporating components like tissue manipulation, dissection, and anatomical understanding. ...
Background
Within the last decades, robotic surgery has gained popularity. Most robotic surgeons have changed their main surgical activity from open or laparoscopic without prior formal robotic training. With the current practice, it is of great interest to know whether there is a transfer of surgical skills. In visualization, motion scaling, and freedom of motion, robotic surgery resembles open surgery far more than laparoscopic surgery. Therefore, our hypothesis is that open-trained surgeons have more transfer of surgical skills to robotic surgery, compared to surgeons trained in laparoscopy.
Methods
Thirty-six surgically inexperienced medical students were randomized into three groups for intensive simulation training in an assigned modality: open surgery, laparoscopy, or robot-assisted laparoscopy. The training period was, for all study subjects, followed by performing a robot-assisted bowel anastomosis in a pig model. As surrogate markers of surgical quality, the anastomoses were tested for resistance to pressure, and video recordings of the procedure were evaluated by two blinded expert robotic surgeons, using a global rating scale of robotic operative performance (Global Evaluative Assessment of Robotic Skills (GEARS)).
Results
The mean leak pressure of bowel anastomosis was 36.25 (7.62–64.89) mmHg in the laparoscopic training group and 69.01 (28.02–109.99) mmHg in the open surgery group, and the mean leak pressure for the robotic training group was 108.45 (74.96–141.94) mmHg. The same pattern was found with GEARS as surrogate markers of surgical quality. GEARS score was 15.71 (12.37–19.04) in the laparoscopic training group, 18.14 (14.70–21.58) in the open surgery group, and 22.04 (19.29–24.79) in the robotic training group. In comparison with the laparoscopic training group, the robotic training group had a statistically higher leak pressure ( p = 0.0015) and GEARS score ( p = 0.0023). No significant difference, for neither leak pressure nor GEARS, between the open and the robotic training group.
Conclusion
In our study, training in open surgery was superior to training in laparoscopy when transitioning to robotic surgery in a simulation setting performed by surgically naive study subjects.
... In the case of suture breakage, the study subject was provided with an additional suture. This model had previously been described as a useful surgical simulation model for bowel anastomosis [5]. ...
... In this study, we investigated if simulation training improved the surgical skills in three different surgical modalities using fresh tissue models to mimic the clinical setting. We modified a [5,6], robotic [7] and laparoscopic simulation [7,8]. Previous studies have demonstrated the efficacy of simulation-based training in improving trainees' basic skills [9][10][11][12][13]. ...
Background:
Robot-assisted laparoscopic surgery has gained popularity, which has contributed to a decrease in the number of open procedures. Hence a growing concern regarding the ability of laparoscopically trained surgeons to perform open surgery (e.g. due to bleeding complications) has been raised. The aim of the study was to investigate the ability of conversion to open surgery following exclusively robotic or laparoscopic training.
Methods:
Thirty-six medical students were randomized into three groups: Open surgery, laparoscopy, and robot-assisted laparoscopy. All underwent intensive simulation training in the allocated surgical modality. Subsequently, all study subjects performed an open bowel anastomosis in a pig model where anastomoses were tested for resistance to pressure and leak as a surrogate marker of surgical quality.
Results:
The primary endpoint was the surgical quality of an open surgery model assessed as, leak pressure, which was 80.01 ± 36.16 mmHg in the laparoscopic training group, 106.57 ± 23.03 mmHg in the robotic training group, and 133.65 ± 18.32 mmHg in the open surgery training group (mean, SD). We found that there were no significant differences between the open surgery training group and the robotic training group whereas a significant difference was found when comparing laparoscopic and open surgery training groups in favor of open procedure training (p < 0.001).
Conclusion:
In a surrogate open surgery model based on bowel anastomosis, we found that skills acquired through practice on robotic simulation platforms were not significantly worse when compared to skills acquired through training in open surgery, whereas skills acquired from laparoscopic training were significantly poorer when compared to open surgery practice.
... Low-cost "homemade" simulators are inexpensive and easily reproducible [9]. The 2030 Lancet Commission on Global Surgery meeting also suggested the use of locally available and affordable models for training in low-and middle-income countries (LMICs) [13]. These cost-effective models have proven efficacious for simulation-based training in achieving expertise in many clinical tasks [11] including Point of care ultrasound (POCUS) [14]. ...
Background
Simulators are an extensively utilized teaching tool in clinical settings. Simulation enables learners to practice and improve their skills in a safe and controlled environment before using these skills on patients. We evaluated the effect of a training session utilizing a novel intubation ultrasound simulator on the accuracy of provider detection of tracheal versus esophageal neonatal endotracheal tube (ETT) placement using point-of-care ultrasound (POCUS). We also investigated whether the time to POCUS image interpretation decreased with repeated simulator attempts.
Methods
Sixty neonatal health care providers participated in a three-hour simulator-based training session in the neonatal intensive care unit (NICU) of Aga Khan University Hospital (AKUH), Karachi, Pakistan. Participants included neonatologists, neonatal fellows, pediatric residents and senior nursing staff. The training utilized a novel low-cost simulator made with gelatin, water and psyllium fiber. Training consisted of a didactic session, practice with the simulator, and practice with intubated NICU patients. At the end of training, participants underwent an objective structured assessment of technical skills (OSATS) and ten rounds of simulator-based testing of their ability to use POCUS to differentiate between simulated tracheal and esophageal intubations.
Results
The majority of the participants in the training had an average of 7.0 years (SD 4.9) of clinical experience. After controlling for gender, profession, years of practice and POCUS knowledge, linear mixed model and mixed effects logistic regression demonstrated marginal improvement in POCUS interpretation over repeated simulator testing. The mean time-to-interpretation decreased from 24.7 (SD 20.3) seconds for test 1 to 10.1 (SD 4.5) seconds for Test 10, p < 0.001. There was an average reduction of 1.3 s (β = − 1.3; 95% CI: − 1.66 to − 1.0) in time-to-interpretation with repeated simulator testing after adjusting for the covariates listed above.
Conclusion
We found a three-hour simulator-based training session had a significant impact on technical skills and performance of neonatal health care providers in identification of ETT position using POCUS. Further research is needed to examine whether these skills are transferable to intubated newborns in various health settings.
Trial registration
ClinicalTrials.gov Identifier: NCT03533218. Registered May 2018.
... This group has previously published a paper on four wet model simulations for neonatal surgical procedures, namely bowel anastomosis, open Stamm gastrostomy, duodenoduodenostomy and oesophageal atresia and tracheoesophageal fistula repair [5]. In this paper, we describe a technical innovation whereby we have constructed a model for stoma formation. ...
Stoma formation is a common paediatric surgical procedure and yet, there is no low-cost stoma model for technical skills training. We describe a low-cost low-fidelity simulator for stoma formation made from simple easily available materials using porcine bowel and skin. The model was introduced at a regional training day for paediatric surgical registrars. All the trainees rated it as excellent and life-like. We describe an inexpensive stoma model for simulation-based training in technical skills especially in low–middle-income countries (LMICs) due to the cost benefit.
... All anastomoses were performed by two experienced general surgeons with more than 5 years of experience. Handsewn sutured anastomosis were performed in single layered 10,12 with an interrupted prolene 5-0 suture. To objectively measure the amount of stenosis and leakage, we used a system that allowed water to flow through the anastomosis 13 (Fig. 2). ...
... The use of simulators facilitates the development of initial surgical skills that will be transposed into clinical practice, reducing surgical time, number of complications, length of stay and morbidity and mortality [6][7][8][9] . In recent years, there has been a shift towards high-fidelity simulation involving advanced technology such as virtual reality and 3-D printed models 10 . Nevertheless, the high cost limits the access to high-income tertiary centers 6,7,10,11 . ...
... In recent years, there has been a shift towards high-fidelity simulation involving advanced technology such as virtual reality and 3-D printed models 10 . Nevertheless, the high cost limits the access to high-income tertiary centers 6,7,10,11 . ...
Purpose:
To develop a new low-cost, easy-to-make and available training model using chickens' intestine for infant intestinal anastomosis.
Methods:
Segments of chicken intestine were used to create an intestinal anastomosis simulator. We tried to perform an end-to-end, end-to-side and side-to-side anastomosis. Handsewn sutured anastomosis were performed in single layered with interrupted prolene 5-0 suture. The parameters analyzed were cost, intestine's diameter and length, anastomosis patency and flow-through and leakage amount.
Results:
In all cases it was possible to make the anastomosis in double layered without difficulties, different from the usual ones. There was a positive patency at all anastomoses after the end of the procedure, with no need for reinterventions.
Conclusion:
The new training model using chickens' intestine for infant intestinal anastomosis is low-cost, easy-to-make and easy available.
... Uygulamalı eğitimde kalitenin arttırılması için cerrahi eğitim simülatörlerinin kullanımı önem kazanmakta ve gittikçe yaygınlaşmaktadır (2)(3)(4) . Sanal gerçeklik (VR), kadavra, hayvan, cerrahi eldiven hatta çocuk balonu kullanılarak hazırlanan ya da dışardan temin edilen çeşitli simülasyon modelleri olmakla birlikte uygulamada etik kurul izni, enfeksiyon riski, özelleşmiş laboratuvar ve malzeme gerekliliği, teknoloji alt yapısı eksikliği, istenilen kazanımları sağlamada yetersiz kalma, yüksek maliyet gibi kısıtlamalarla karşılaşılmaktadır (5)(6)(7)(8)(9)(10)(11) . Çocuk cerrahisinin ve çocuk ürolojisinin geniş spektrumlu hasta profili dikkate alındığında tek bir anatomik görüntüye, yaş grubuna ya da senaryoya bağlı modeller yeterli olmamakta hastaya özel senaryoya özel başka bir deyişle kişiselleştirilmiş simülasyon modellerine ihtiyaç duyulmaktadır. ...
Background Simulation is increasingly being adopted by healthcare educators throughout the developed world as it offers a safe environment to practice skills. While there is literature on learning via simulation in healthcare in the developed world, more studies are required to investigate the factors influencing this approach in the developing world. Objective This scoping review highlights the key factors that act as deterrents as well as encouragement to the uptake of simulation as a teaching methodology in healthcare education in developing countries. Design The MEDLINE (via OVID, using keywords and MeSH in OVID), and PubMed (via NCBI using MeSH), and CINAHL databases were searched between January 2000 and January 2024 for research articles published in peer reviewed English language journals using a combination of keywords. Results A total of 48 articles were included in the final analysis. Challenges and opportunities were divided into professional, academic, and resource-based factors, and their individual sub-themes. The main challenges reported were the lack of a contextual curriculum, content heavy curricula, dearth of trained simulationists and cost of simulators. Performance anxiety was an important challenge reported by both trainers and trainees. Main opportunities were an interest in adopting simulation-based education from both trainers and trainees, and the opportunity to improve patient safety and quality of education. Other findings were that academic leadership and faculty show interest and urgency to adopt simulation in curricula and allocate funds for this. Facilitators need to be provided with protected time to become simulationists. Local manufacturers need to be sourced for simulators, and transfer of technology and expertise needs to be negotiated. Conclusion Simulation needs to be looked at from the lens of not only education, but more importantly of patient safety in developing countries to allow simulation-based education to be mainstreamed in health professions education in low- and middle-income contexts.
Objectives:
Identify barriers to surgical simulation in multiple countries across the income spectrum. Evaluate whether a novel, portable surgical simulator (GlobalSurgBox) would be valuable to surgical trainees and overcome these barriers.
Design:
Trainees from high-, middle-, and low-income countries were instructed on how to perform surgical skills using the GlobalSurgBox. Participants were sent an anonymized survey after 1 week to evaluate practicality and helpfulness of the trainer.
Setting:
Academic medical centers in 3 countries: USA, Kenya, and Rwanda.
Participants:
48 medical students, 48 surgery residents, 3 medical officers, and 3 cardiothoracic surgery fellows.
Results:
99.0% of respondents agreed surgical simulation was an important aspect of surgical education. Despite 60.8% having access to simulation resources, only 3 of 40 (7.5%) US trainees, 2 of 12 (16.7%) of Kenyan trainees, and 1 of 10 (10.0%) Rwandan trainees used these resources routinely. 38 (95.0%) US trainees, 9 (75.0%) Kenyan trainees, and 8 (80.0%) Rwandan trainees with access to simulation resources stated there were barriers to using them. The frequently cited barriers included lack of convenient access and lack of time. After using the GlobalSurgBox, 5 (7.8%) US participants, 0 (0%) Kenyan participants, and 5 (38.5%) Rwandan participants reported lack of convenient access as a continued barrier to simulation. 52 (81.3%) US trainees, 24 (96.0%) Kenyan trainees, and 12 (92.3%) Rwandan trainees stated the GlobalSurgBox was a good facsimile of the operating room. 59 (92.2%) US trainees, 24 (96.0%) Kenyan trainees, and 13 (100%) Rwandan trainees stated the GlobalSurgBox better prepared them for clinical settings.
Conclusions:
A majority of trainees across all 3 countries reported multiple barriers to simulation in their current surgical training. The GlobalSurgBox eliminates many of these barriers by providing a portable, affordable, and realistic way to practice skills needed in the operating room.
Background
: A shortage of specialist paediatric surgeons in Malaysia led to establishment of a national postgraduate training programme in 2004. We aimed to identify sociodemographic factors impacting training experience, and to define pressure points during training to inform targeted trainee support strategies.
Methods
: We conducted an anonymised online survey in June 2021 on all programme graduates. Participants were asked for sociodemographic data, both current and during training. Likert scale responses were required for questions regarding adequacy of support received for family, health and personal issues during training. A free text response question soliciting suggestions for programme improvement was included. Data are reported as median (range). Chi-square/Fisher's exact tests for categorical variables and Mann-Whitney U tests for continuous variables were used, with p<0.05 significance.
Results
: Of 53 eligible participants, 52 (98%) responded, 24 (46%) were female. Marital status was similar between genders at entry, but female trainees were more likely to be unmarried on exit (p=0.001), and less likely to have children while training (p=0.017). Of the 6 female and 18 male trainees who had children while training, women were more likely to take parental leave (p=0.01). The majority felt advice given regarding parental leave and managing training while having children were poor. In thematic analysis of free text answers, lack of hands-on experience was the most common concern.
Conclusion
: Factors related to marriage and parenthood significantly associate with gender amongst trainees in Malaysia despite both genders being well represented. Concerns regarding adequacy of hands-on training highlight the need for educational innovations such as simulation models.
Level of Study
: Level III
