An Inexpensive, Reproducible Tissue Simulator for Teaching Thoracoscopic Lobectomy

doi:10.1016/j.athoracsur.2009.07.067

The Annals of Thoracic Surgery

Volume 89, Issue 2, February 2010, Pages 594-597

Presented at the Twenty-Second Annual Meeting of the General Thoracic Surgery Club, St. Petersburg, FL, March 12, 2009.

https://doi.org/10.1016/j.athoracsur.2009.07.067 Get rights and content

Purpose

Simulation is rapidly becoming an integral part of surgical education at all levels including the education of practicing surgeons in new techniques such as thoracoscopic lobectomy. Current thoracoscopic lobectomy simulator models have significant limitations including expense and requirement for specialized facilities. This study describes a novel low-cost, easily reproducible, bench top simulator.

Description

Tissue blocks consisting of a porcine heart and bilateral lungs with intact pericardium were secured from a commercially available source. The pulmonary artery and veins were statically distended with ketchup to more realistically mimic the technique of dissection and allow for simultaneous identification of technical errors.

Evaluation

This simulator has been used at seven different industry and society sponsored thoracoscopic lobectomy training programs by more than 100 participants. Qualitative data on the performance of the model was collected from faculty and course participants.

Conclusions

A low-cost porcine heart-lung block statically perfused with ketchup provides an inexpensive, easily reproducible model for teaching thoracoscopic lobectomy, which reasonably and accurately simulates a clinical experience.

Section snippets

Technology

In a recent review of The Society of Thoracic Surgeons' database, only 28% of anatomic lung resections were performed thoracoscopically [5]. Given that The Society of Thoracic Surgeons' database is weighted toward academic centers, this may even be an overestimate of the true prevalence of thoracoscopic lobectomy. Although the majority of graduates of thoracic surgery residency programs in the current era have been exposed to thoracoscopic lobectomy, it is possible that fewer finish their

Model Preparation

Commercially available porcine heart-lung tissue blocks were procured from Animal Technologies Inc (Tyler, TX). These blocks include the heart with intact pericardium, both lungs, and the esophagus (Fig 1). The mediastinal structures are preserved to create a realistic feel of operating on an intact hilum and mediastinum. Several groups have attempted to use this type of tissue block with a continuous flow pump system; however, liquids with low enough viscosity to flow easily through a

Clinical Experience

The porcine tissue block model has been used for the practical laboratory of seven thoracoscopic lobectomy training programs at six different sites aimed at practicing surgeons learning thoracoscopic lobectomy. A total of more than 100 participants and 17 faculty members have worked with this simulator and provided qualitative feedback. Tissue preparation was performed by either a member of the course faculty or in some cases by personnel from the course sponsor. Preparation time varied from 2

Comment

Surgical simulation training is growing in importance at the medical student, resident, and postgraduate levels, and development of improved simulators is an important initiative of the American Board of Thoracic Surgery and thoracic surgical societies. One goal of this project was to make simulation less expensive and more accessible in settings outside of major university centers. The cost of cadavers averages between $2,500 and $5,000 per specimen. Live porcine models have a similar cost

Disclosures and Freedom of Investigation

Research supported by a research grant from Covidien funding tissue purchase and stapling supplies and the National Institutes of Health training grant (grant no. NIHT35 HL07479) funding a medical student researcher (FL). The authors had full control of the development of this technology, analysis of its use, and production of the written report.

References (5)

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R.J. McKenna et al.
Video assisted thoracic surgery lobectomy: experience with 1100 cases
Ann Thorac Surg
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There are more references available in the full text version of this article.

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Current Status of Simulation in Thoracic Surgical Training
2023, Annals of Thoracic Surgery
Simulation is playing an increasingly important role in surgical training but is not yet a mandatory part of most surgical curricula. A simulator must undergo rigorous validation to verify it as a reliable tool. The aim of this study was to review the literature to identify simulators that are currently available to augment thoracic surgical training and to analyze any evidence supporting or validating them.
A literature search of the MEDLINE (1946 to November 2022) and Embase (1947 to November 2022) databases was performed to identify simulators for basic skills and procedures in thoracic surgery. A selection of keywords were used to perform the literature search. After identification of appropriate articles, data were extracted and analyzed.
Thirty-three simulators were found in 31 articles. Simulators for basic skills (n = 13) and thoracic lobectomy (n = 13) were most commonly described, followed by miscellaneous (n = 7). Most models were of a hybrid modality (n = 18). Evidence of validity was established in 48.5% (n = 16) of simulators. In total, 15.2% (n = 5) of simulators had 3 or more elements of validity demonstrated, and only 3.0% (n = 1) accomplished full validation.
Numerous simulators of varying modality and fidelity exist for a variety of thoracic surgical skills and procedures, although validation evidence is frequently inadequate. Simulation models may be able to provide training in basic surgical and procedural skills; however, further assessment of validity needs to be undertaken before consideration of their integration into training programs.
Crisis of confidence in cardiothoracic trainees: National trends in the use of minimally invasive esophagectomy
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Citation Excerpt :
McKenna and colleagues suggest a minimum of 50 cases to address the learning curve—a requirement that may be challenging to achieve in some training programs.8 The development of simulation and assessment tools may allow trainees to develop manual and cognitive skills without dependence on clinical volume.9,10 These efforts appear to be paying off; a recent study by Boffa and colleagues11 reported that 86% of surveyed graduates who entered a dedicated thoracic practice considered themselves proficient in VATS lobectomy.11
Commentary: Can a tool assess whether young thoracic surgeons are competent to perform video-assisted thoracoscopic lobectomy?
2019, Journal of Thoracic and Cardiovascular Surgery
Development of an In Situ Thoracic Surgery Crisis Simulation Focused on Nontechnical Skill Training
2018, Annals of Thoracic Surgery
Our vision was to develop an inexpensive training simulation in a functional operating room (in situ) that included surgical trainees and nursing and anesthesia staff to focus on effective interprofessional communication and teamwork skills.
The simulation scenario revolved around an airway obstruction by residual tumor after pneumonectomy. This model included our thoracic operating room with patient status displayed by an open access vital sign simulator and a reversibly modified Laerdal airway mannequin (Shavanger, Norway). The simulation scenario was run seven times. Simulations were video recorded and scored with the use of Non-Technical Skills for Surgeons (NOTSS) and TeamSTEPPS2. Latent safety threats (LSTs) and feedback were obtained during the debriefing after the simulation. Feedback was captured with the Method Material Member Overall (MMMO) questionnaire.
Several LSTs were identified, which included missing and redundant equipment and knowledge gaps in participants’ roles. Consultant surgeons received a higher overall score than thoracic surgery fellows on both NOTSS (3.8 versus 3.3) and TeamSTEPPS2 (4.1 versus 3.2) evaluations, suggesting that the scenario effectively differentiated learners from experts with regards to nontechnical skills. The MMMO overall simulation experience score was 4.7 of 5, confirming a high-fidelity model and useful experiential learning model. At the Canadian Thoracic Bootcamp, the MMMO overall experience score was 4.8 of 5, further supporting this simulation as a robust model.
An inexpensive in situ intraoperative crisis simulation model for thoracic surgical emergencies was created, implemented, and demonstrated to be effective as a proof of concept at identifying latent threats to patient safety and differentiating the nontechnical skills of trainees and consultant surgeons.
Measuring Error Identification and Recovery Skills in Surgical Residents
2017, Annals of Thoracic Surgery
Citation Excerpt :
The simulator consists of a previously described porcine heart lung block (Animal Technologies Inc, Tyler, Texas) with the pulmonary artery and veins distended with a blood-substitute fluid. Using this platform, an entire left upper lobectomy can be simulated and generally requires between 20 and 60 minutes to perform [6]. To allow multiple iterations with different errors in a reasonable time frame, the task chosen for this study is limited to the first major step only.
Although error identification and recovery skills are essential for the safe practice of surgery, they have not traditionally been taught or evaluated in residency training. This study validates a method for assessing error identification and recovery skills in surgical residents using a thoracoscopic lobectomy simulator.
We developed a 5-station, simulator-based examination containing the most commonly encountered cognitive and technical errors occurring during division of the superior pulmonary vein for left upper lobectomy. Successful completion of each station requires identification and correction of these errors. Examinations were video recorded and scored in a blinded fashion using an examination-specific rating instrument evaluating task performance as well as error identification and recovery skills. Evidence of validity was collected in the categories of content, response process, internal structure, and relationship to other variables.
Fifteen general surgical residents (9 interns and 6 third-year residents) completed the examination. Interrater reliability was high, with an intraclass correlation coefficient of 0.78 between 4 trained raters. Station scores ranged from 64% to 84% correct. All stations adequately discriminated between high- and low-performing residents, with discrimination ranging from 0.35 to 0.65. The overall examination score was significantly higher for intermediate residents than for interns (mean, 74 versus 64 of 90 possible; p = 0.03).
The described simulator-based examination with embedded errors and its accompanying assessment tool can be used to measure error identification and recovery skills in surgical residents. This examination provides a valid method for comparing teaching strategies designed to improve error recognition and recovery to enhance patient safety.
Implementing a VATS Lobectomy Program in Spain. The Wet Lab, a Necessary Tool
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^Disclaimer: The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.

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