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Journal of Pediatric Endoscopic Surgery

, Volume 1, Issue 3, pp 99–105 | Cite as

The avian model: a novel and cost-effective animal tissue model for training in neonatal laparoscopic surgery

  • Peter ZimmermannEmail author
  • Ashley Xavérine Wiseman
  • Oliver Sanchez
  • Amulya K. Saxena
  • Enrico Brönnimann
Original Research
  • 147 Downloads

Abstract

Purpose

To design and validate a new and cost-effective animal tissue model for training neonatal minimal access surgery (MAS) skills.

Methods

A prospective observational study was performed during two Minimally Access Surgery Skill Labs in June 2018 and April 2019. Selected laparoscopic exercises were performed on fresh chicken cadavers using 3 mm MAS instruments (adhesiolysis, cholecystectomy and intestinal anastomosis). Data for validation were collected with a 5-point Likert scale questionnaire based on the Michigan Standard Simulation Experience Scale (MiSSES) and analysis was performed.

Results

Twenty-seven course participants were recruited (18 females: 9 males). Eighteen delegates (67%) had experience < 50 MAS cases, 6 delegates (22%) 50–100 cases and 3 delegates (11%) > 100 cases. The mean perceived degree of realism was 3.85 ± 0.99, and for abdominal cavity 4.00 ± 1.25, port placement 3.52 ± 1.40, pneumoperitoneum creation 3.59 ± 1.39, camera manipulation 4.07 ± 1.09, instrument manipulation 4.44 ± 1.13, tissue dissection 4.11 ± 0.99 and intracorporal suturing and knot tying 4.22 ± 1.37. The perceived degree of improvement of understanding MAS basics was 4.65 ± 0.55, knowledge 4.15 ± 1.11, confidence and ability 4.15 ± 1.11. The overall satisfaction with the avian model was 4.64 ± 0.56.

Conclusion

The novel avian tissue model for neonatal MAS training could be validated with success. Validation assessment demonstrates that this model is very realistic and effective, making it possible to gain laparoscopic skills especially with intracorporeal suturing and knot tying in a small space. The avian model is a proven and cost-efficient simulator for neonatal MAS training and expands the spectrum of already established simulation models for pediatric surgeons.

Keywords

Pediatric minimal access surgery Neonatal laparoscopic surgery Animal tissue model Simulation-based skills training Michigan Standard Simulation Experience Scale (MiSSES) 

Introduction

The role of minimal access surgery (MAS) techniques in pediatric surgery has increased owing to the benefits of better cosmesis, less trauma, less pain and better postoperative musculoskeletal function, in particular after thoracic procedures [1]. However, MAS requires specialized skills and presents technical challenges for the surgeon like reduced tactile feedback, two-dimensional vision, the “fulcrum effect”, and achievement of good eye–hand and hand–hand coordination. The reduction of working hours for residents, the increasing complexity of laparoscopic or thoracoscopic procedures and an emphasis on operating room efficiency have significantly reduced surgical training time and mentorship [2, 3]. Due to these circumstances, simulation-based training has been added to the trainees’ curriculum to prepare them better for the operating room [3]. Basic technical MAS skills are best achieved by training on inanimate models such as box or pelvic trainers, whereas for the acquisition of advanced MAS skills, mainly animal models like the rabbit and pig are more applicable [4]. However, the necessary infrastructure and the personnel resources usually lead to higher costs and course fees. Since the setup for live anesthetized animal models is quite elaborate, animal tissue models represent a good alternative simulation modality with high fidelity [5]. Learning objectives of a pediatric MAS training are the correct insertion of ports, optimal handling of 3 mm instruments in a small space, suturing, knot tying, tissue dissection, use of electrocautery and performing of different defined surgical exercises like cholecystectomy or intestinal anastomosis. Considering these learning objectives, the avian model represents an efficient and cost-effective new model for neonatal MAS training.

Materials and methods

Study design

A prospective observational study was done during two Pediatric Minimally Invasive Surgery Courses at the simulation lab of the Swiss Foundation for Innovation and Training in Surgery (SFITS) in Geneva, Switzerland in June 2018 and April 2019 to validate the avian model for practicing neonatal laparoscopic surgery skills. Recruitment of the course delegates to the study was on a voluntary basis without any financial or other conflicts of interest. Based on the participants self-reported laparoscopic experience levels, three groups were defined. Group I: trainees who had experience of performing < 50 MAS procedures, Group II: trainees who had experience of performing 50–100 MAS procedures, Group III: surgeons who had completed > 100 MAS procedures.

Design, preparation and use of the avian model

Fresh plucked chicken cadavers were positioned supine on a dissection table of a fully equipped laparoscopic working platform with two flat screen monitors, a carbon dioxide (CO2) insufflator, a set of 3 mm standard MAS instruments, 3 mm monopolar hook cautery and 5 mm 30° angled scope (Fig. 1). A 5 mm port was introduced into the peritoneal cavity through the ventral wall of the cloaca (Fig. 2). A 5 mm 30° scope was introduced to confirm intraperitoneal access and a pneumoperitoneum with a pressure of 6 mm Hg was established. Two additional 3 mm ports were placed in the right and left lower abdomen under direct vision. To prevent port dislodgement, they were wrapped with a rubber band obtained from a part of a glove and sutured to the abdominal wall (Fig. 2). Standard 3 mm MAS instruments (dissector, scissors, needle holder) and monopolar hook cautery were used, and different defined surgical exercises were performed (adhesiolysis, cholecystectomy, intestinal resection, intestinal anastomosis) (Figs. 3, 4, 5). Before each task, a video explaining the surgical exercise step-by-step with live commentary by one of the instructors was presented. There were two participants and one instructor per working platform and each trainee got his own avian model to fulfill the different exercises and switched between the roles of the surgeon and the assistant after a task was completed.
Fig. 1

Trainees performing MAS exercises on the avian model

Fig. 2

Camera port (#) placement through the ventral wall of the cloaca into the peritoneal cavity. Ports wrapped with a rubber and sutured to the abdominal wall to prevent dislodgement

Fig. 3

Adhesiolysis with monopolar hook cautery

Fig. 4

Cholecystectomy exercise with intracorporeal knot tying for ligation of the cystic duct

Fig. 5

Intracorporeal suturing. Side-to-side intestinal anastomosis with interrupted sutures (# —enterotomies; +—back wall of the anastomosis)

Data collection, face and content validity, and statistical analysis

Data were collected using a Likert scale (1 = strongly disagree/bad; 2 = somewhat disagree/somewhat bad; 3 = neutral/neutral; 4 = somewhat agree/somewhat good; 5 = strongly agree/good) on a structured standardized questionnaire based on the Michigan Standard Simulation Experience Scale (MiSSES) [6]. The questionnaire was anonymous and the participation non-mandatory. Criteria for validity were defined based on the commonly used definition and recommendation for validity testing for laparoscopic models and simulators (face validity: the degree of realism of the model in relation to the real anatomy and setup; content validity: the appropriateness of the model as an effective modality). Statistical analysis was performed using RStudio 1.2.1335 (RStudio Inc., 250 Northern Ave, Boston, MA 02210) and data were processed by one-way ANOVA (analysis of variance) with post hoc Tukey HSD (honestly significant difference) test.

Results

Demographics of participants

A total of 27 course participants were recruited. Eighteen of the course delegates were female and nine were male. The mean age was 33 years (33; 12 ± 6.31, range 25–50 years). The self-reported laparoscopic experience defined by the number of previous MAS procedures was between 0 and 200 (mean 42.68 ± 53.60; median 20; range 0–200). Eighteen participants had experience of performing < 50 MAS procedures (Group I: mean number of previous laparoscopic surgeries 10.44 ± 11.24; median 6.5; range 0–35), six had performed 50–100 MAS procedures (Group II: mean number of previous laparoscopic surgeries 66.67 ± 17.95; median 60; range 50–100), and three had performed > 100 MAS procedures (Group III: mean number of previous laparoscopic surgeries 166.67 ± 23.57; median 150; range 150–200). There were significant differences in the mean number of previously performed MAS procedures between Group I and II and also between I and III; but not between Group II and III (Group I vs. Group II: P =0.05; Group I vs. Group III: P <0.001; Group II vs. Group III: P = 0.07 (NS); between all groups: P < .001) (Table 1).
Table 1

Face and content validity parameters measured during the study

Areas assessed

Group scoresa

P values**

Group scoresa overall

I (no of previous laparoscopic surgeries < 50) N = 18

II (no of previous laparoscopic surgeries 50–100) N = 6

III (no of previous laparoscopic surgeries > 100) N = 3

I + II + III

Demographics

Age

31.83 ± 6.10

32.60 ± 4.72

41.67 ± 3.40

< 0.001

33.12 ± 6.41

Gender

 F

12 (66%)

5 (83%)

12 (33%)

0.50

18 (66%)

 M

6 (33%)

1 (17%)

6 (66%)

 

9 (33%)

No previous laparoscopic surgery

10.44 ± 11.24

66.67 ± 17.95

166.67 ± 23.57

< 0.001

42.68 ± 53.60

Face validity

 Fidelity

  Realistic model

3.88 ± 1.13

3.82 ± 0.69

3.67 ± 0.47

0.94

3.85 ± 0.99

  Realistic environment

3.83 ± 1.50

4.50 ± 0.50

4.00 ± 0.00

0.72

4.00 ± 1.28

  Realistic abdominal wall

3.06 ± 1.39

4.33 ± 0.47

4.00 ± 0.00

0.72

3.44 ± 1.29

  Realistic abdominal cavity

3.89 ± 1.24

4.33 ± 0.47

4.00 ± 0.00

0.72

4.00 ± 1.05

  Realistic tissue

4.06 ± 1.16

3.83 ± 0.69

3.67 ± 0.47

0.75

3.96 ± 1.02

  Realistic gallbladder

3.78 ± 1.47

3.33 ± 1.60

3.67 ± 0.94

0.65

3.67 ± 1.47

  Realistic intestine

3.06 ± 1.72

4.17 ± 0.37

4.33 ± 0.47

0.24

3.44 ± 1.52

  Port placement

3.44 ± 1.54

3.67 ± 1.11

3.67 ± 0.94

0.68

3.52 ± 1.40

  Pneumoperitoneal creation

3.78 ± 1.31

3.17 ± 1.77

3.33 ± 0.47

0.57

3.59 ± 1.39

  Camera

4.17 ± 1.17

3.83 ± 0.90

4.00 ± 0.82

0.81

4.07 ± 1.09

  Tissue dissection

4.11 ± 1.10

4.00 ± 0.58

4.33 ± 0.94

0.94

4.11 ± 0.99

  Suture

3.94 ± 1.58

4.67 ± 0.47

5.00 ± 0.00

0.38

4.22 ± 1.37

  Instrument manipulation

4.28 ± 1.33

4.67 ± 0.47

5.00 ± 0.00

0.68

4.44 ± 1.13

Content validity

 Self-efficacy

  Knowledge

4.06 ± 1.31

4.33 ± 0.47

4.33 ± 0.47

0.68

4.15 ± 1.11

  Confidence

4.22 ± 0.85

4.67 ± 0.47

5.00 ± 0.00

0.13

4.41 ± 0.78

  Ability

4.50 ± 0.60

4.83 ± 0.37

4.33 ± 0.47

0.31

4.56 ± 0.57

  Independence

3.82 ± 1.20

4.67 ± 0.47

4.33 ± 0.47

0.91

4.08 ± 1.07

 Educational value

  Knowledge acquisition

4.50 ± 0.69

4.50 ± 0.50

4.67 ± 0.47

0.53

4.52 ± 0.63

  Skill acquisition

4.56 ± 0.76

4.83 ± 0.37

5.00 ± 0.00

0.47

4.67 ± 0.67

  Basics resources

4.71 ± 0.57

4.67 ± 0.47

4.33 ± 0.47

0.49

4.65 ± 0.55

  Laparoscopic cholecystectomy resources

3.65 ± 1.23

4.33 ± 0.75

4.00 ± 0.00

0.28

3.85 ± 1.10

  Laparoscopic intestinal anastomosis resources

3.13 ± 1.50

3.33 ± 1.60

4.00 ± 0.82

0.52

3.29 ± 1.49

 Overall

  Simulation global evaluation

4.56 ± 0.60

4.80 ± 0.40

5.00 ± 0.00

0.49

4.64 ± 0.56

  Model global evaluation

2.82 ± 0.92

3.00 ± 0.82

2.66 ± 0.47

0.91

2.85 ± 0.86

aAll scores presented as mean ± standard deviation.**P values given for ANOVA test. P < 0.05 was considered to be statistically significant. Data were collected using a Likert scale (1 = strongly disagree/bad; 2 = somewhat disagree/somewhat bad; 3 = neutral/neutral; 4 = somewhat agree/somewhat good; 5 = strongly agree/good) on a structured standardized questionnaire based on the Michigan Standard Simulation Experience Scale (MiSSES) [6]

Fidelity and face validity of the model

The mean perceived degree of realism of the model in relation to the real anatomy and setup given by the participants was 3.85 ± 0.99, for the simulation environment 4.00 ± 1.28, for the perceived reality of the abdominal wall 3.44 ± 1.29, for abdominal cavity 4.00 ± 1.25, for sensation and texture of the tissue 3.96 ± 1.02, of the gallbladder and intestine 3.67 ± 1.47 and 3.44 ± 1.52, respectively. The perception of the avian model as critical in addressing port placement was rated with 3.52 ± 1.40, for pneumoperitoneum creation 3.59 ± 1.39, for camera manipulation and cavity inspection 4.07 ± 1.09, for instrument manipulation in a small cavity 4.44 ± 1.13, for tissue dissection 4.11 ± 0.99, and intracorporal suturing 4.22 ± 1.37. There were no significant differences in the rates of the aforementioned items between the three groups (Table 1).

Content validity of the model

All participants agreed that the avian model is a good training tool for knowledge and skill acquisition (4.52 ± 0.63; 4.67 ± 0.67) (Table 1). The perceived degree of improvement of understanding laparoscopic basics was 4.65 ± 0.55, for improvement in laparoscopic cholecystectomy and intestinal anastomosis 3.85 ± 1.10 and 3.29 ± 1.49, respectively. Regarding issues of self-efficacy, all delegates agreed that the avian model helped to improve their knowledge, confidence, ability, and independence to perform basic laparoscopic surgery techniques in a small cavity (4.15 ± 1.11; 4.41 ± 0.78; 4.56 ± 0.57; 4.08 ± 1.07). The overall satisfaction with the avian model was 4.64 ± 0.56. No significant differences in the rates of the aforementioned items between the three groups were found (Table 1). Sixteen participants (89%) would recommend the avian model for practicing pediatric MAS skills to a colleague with a similar experience level (no response from two participants; 11%). Twelve delegates (67%) would recommend this training model to a younger trainee, whereas three (16.5%) would not (no response from two participants).

Discussion

Reduced working hours of residents, rising operating room costs, a growing number of complex surgical techniques, limited exposure to advanced MAS procedures during their clinical training, and increased ethical concerns around skill acquisition on actual patients makes it difficult for pediatric surgery trainees to acquire the necessary MAS skills training [7, 8, 9, 10, 11]. To overcome these barriers, the concept of simulation-based training has been developed over the years [3]. Simulation-based training can augment the rate of technical skill acquisition [12]. Single parts of a procedure or the entire procedure can be trained in a deliberate and repetitive manner in a safe inexpensive learning environment and the level of complexity of the simulated surgical tasks can be refined to provide educational challenges according to their level of training [8, 10, 11]. Simulation-based training may facilitate skill acquisition by pediatric surgical trainees who are likely to have limited exposure to rare conditions [7, 8].

Various types of laparoscopic surgery simulators have been described [8, 13, 14]. There are inanimate models such as box trainers or pelvic trainers, virtual reality simulators, cadaveric models, animal tissue models, and animal models [3, 4, 15, 16, 17, 18, 19]. Basic technical MAS skills like dexterity, coordination, depth perception, cutting, and suturing are best achieved by training on inanimate models such as box or pelvic trainers. For the acquisition of advanced MAS skills, mainly animal models like the rabbit and pig model are used for training [4]. The most common modality of MAS training is the dry laboratory box endotrainer which is cheap, easily available, and cost-effective [14]. Cadaveric and animal tissue models represent high-fidelity models [5]. Human cadaveric models have the highest fidelity, but there is a limited availability of cadavers, and real operating room setup is required, which is costly. Additionally, there are ethical, legal, and infectious issues with the potential for cross-contamination of surgical instruments, which make human cadavers a less attractive option [3]. Living animal models for training in laparoscopic surgery have been described and the porcine model is the most widely used [4, 13]. In pediatric MAS training, the rabbit model seems to be the preferred model since it simulates the anatomical situation more realistic and it allows to perform more different procedures [4]. However, intravenous anesthesia and in case of thoracoscopic procedures endotracheal intubation are necessary. Additionally, animal rights must be observed, and the required infrastructure and human resources usually lead to higher costs and course fees. Since the setup for living animal models is quite elaborate, animal tissue models represent a good alternative simulation modality with high fidelity [5]. Animal tissue models have been shown to be superior and are the preferred method for surgical trainees to acquire technical skills in laparoscopic surgery when a suitable organ or tissue can be found in an animal [2, 20]. Only few laparoscopic training models have been described using chicken. Ramachandran et al. described a model for laparoscopic pyeloplasty using chicken crop, Laguna et al. have presented a chicken model for urethrovesical anastomosis and Singh et al. for laparoscopic ureteric reimplantation [21, 22, 23].

A MAS training model should be realistic, appropriate, and effective as a teaching and training tool. The learning objectives of a neonatal MAS simulation-based training are port insertion, handling of instruments in a small space, tissue dissection, as well as cutting and coagulation, suturing, knot tying, and in case of an animal tissue model the performance of different defined surgical exercises like adhesiolysis, resections, and intestinal anastomosis. With the avian model, these learning objectives can be reached. Advantages of the avian model are that the dimensions of the abdominal cavity are more challenging than a term neonate and it is possible to create a real pneumoperitoneum, which requires the correct insertion of the camera port and use of the insufflator. Additional ports are placed in a realistic way for further standard 3 mm instruments. The handling of the instruments in the small abdominal cavity can be trained as well as real tissue dissection, ligating and suturing. Also, real electrosurgery can be used. It is possible to perform adhesiolysis, cholecystectomy, intestinal resections and intestinal anastomosis. However, the limitations are that fewer surgical procedures can be performed when compared to the rabbit model and there is no simulation of bleeding. But compared to living animal models, the costs are lower. We believe that the presented avian model makes it possible to acquire a laparoscopic skills level which makes the training with living animal models like the rabbit more valuable and effective for the trainees since they are already pre-trained.

To examine the fidelity, authenticity, and efficiency of a new MAS model validation is necessary [24, 25, 26]. MAS models can be validated in a variety of ways. In this study, the data for validation were collected with an anonymous MiSSES questionnaire on participants’ experience with the avian model which represents a subjective method for face and content validation [6]. No significant differences regarding face validity and content validity have been seen between the three groups (Table 1). All participants agreed that the avian model is a good training tool for knowledge and skill acquisition. The overall satisfaction with the avian model was 4.64 ± 0.56 with the highest rating (5.00 ± 0) by Group III, but this difference was not statistically significant. In summary, there was a positive endorsement of the avian model.

However, a limitation of the study might be that the data for validation were only collected on participants’ experience and not on the experts’ (course instructors) experience, although experts had performed all the exercises successfully and understood the levels of technical difficulties before implementing the model in the course. Additional limitations might be a recall bias regarding the self-reported expertise as participants are likely to over- or underestimate their experience [11] and lack of validation techniques like expert scoring of video-recorded attempts or haptic measuring devices which are highlighted by some reports [27, 28].

However, a newly designed animal tissue model for neonatal MAS training is reported. Validation assessment demonstrates that the avian model is a very realistic and effective model making it possible for the trainee to gain laparoscopic skills. The avian model is a potent and cost-efficient simulator for neonatal MAS training and expands the spectrum of already established simulation models.

Notes

Compliance with ethical standards

Ethical approval

This article does not contain any studies with human participants or living animals performed by any of the authors.

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Copyright information

© Springer Nature Singapore Pte Ltd 2019

Authors and Affiliations

  1. 1.Department of Pediatric SurgeryUniversity of LeipzigLeipzigGermany
  2. 2.Department of Pediatric SurgeryUniversity of Geneva, Geneva University Hospitals (HUG)GenevaSwitzerland
  3. 3.Department of Pediatric SurgeryUniversity of Lausanne, University Hospital of Lausanne (CHUV), University Center of Pediatric Surgery of Western SwitzerlandLausanneSwitzerland
  4. 4.Department of Pediatric SurgeryChelsea Children’s Hospital, Chelsea and Westminster NHS Foundation Trust, Imperial College LondonLondonUK

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