Novel minimally invasive transoral surgery bleeding model implemented in a nationwide otolaryngology emergencies bootcamp


Post-operative hemorrhage is the most concerning complication after minimally invasive transoral surgery, as can result in airway compromise. Simulation-based medical education provides trainees with structured learning in an intensive and immersive environment allowing deliberate practice of skills and behaviors in the management of real-life situations. We implemented a novel post-oropharyngeal surgery bleeding model in a nationwide otolaryngology emergencies bootcamp, to teach and evaluate technical and non-technical skills required to competently manage this clinical scenario. 28 Otolaryngology residents from 11 programs in Canada participated in the annual Otolaryngology Emergencies Bootcamp of Western University in London, Ontario. After teaching technical aspects of emergency surgical airways in models, the course culminated with a complex scenario of a post-minimally invasive transoral surgery bleeding model using a fresh cadaver. The Non-Technical Skills for Surgeons (NOTSS) rating scale was applied to video analysis and a scenario-specific Medical Expert Checklist was implemented. The model design in a cadaveric torso is described for use in a simulation of a high-volume oropharyngeal bleed after a minimally invasive approach. Participants agreed that the model evoked an elevated degree of realism and conveyed the emotion of a life-threatening event. NOTSS analysis identified a marginal score in the domains of decision-making and communication and teamwork. Critical action checklist analysis highlighted the early mobilization of available resources and time to decision for surgical airway. We present the first report of a post-minimally invasive transoral surgery bleeding model. It was successful in recreating with high fidelity such a high-stake event and to teach technical and non-technical skills.

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  1. 1.

    Chen MM, Roman SA, Kraus DH, Sosa JA, Judson BL (2014) Transoral robotic surgery: a population-level analysis. Otolaryngol Head Neck Surg 150(6):968–975.

    Article  PubMed  Google Scholar 

  2. 2.

    Lörincz BB, Möckelmann N, Busch C-J, Knecht R (2015) Functional outcomes, feasibility, and safety of resection of transoral robotic surgery: single-institution series of 35 consecutive cases of transoral robotic surgery for oropharyngeal squamous cell carcinoma. Head Neck 37(11):1618–1624.

    Article  PubMed  Google Scholar 

  3. 3.

    Lörincz BB, Jowett N, Knecht R (2016) Decision management in transoral robotic surgery: Indications, individual patient selection, and role in the multidisciplinary treatment for head and neck cancer from a European perspective. Head Neck 38(Suppl 1):E2190–E2196.

    Article  PubMed  Google Scholar 

  4. 4.

    Gleysteen J, Troob S, Light T et al (2017) The impact of prophylactic external carotid artery ligation on postoperative bleeding after transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma. Oral Oncol 70:1–6.

    Article  PubMed  Google Scholar 

  5. 5.

    Mandal R, Duvvuri U, Ferris RL, Kaffenberger TM, Choby GW, Kim S (2016) Analysis of post-transoral robotic-assisted surgery hemorrhage: frequency, outcomes, and prevention. Head Neck 38(Suppl 1):E776–E782.

    Article  PubMed  Google Scholar 

  6. 6.

    Yeh DH, Fung K, Malekzadeh S (2017) Boot camps: preparing for residency. Otolaryngol Clin N Am 50(5):1003–1013.

    Article  Google Scholar 

  7. 7.

    Wu KY, Kim S, Fung K, Roth K (2018) Assessing nontechnical skills in otolaryngology emergencies through simulation-based training. Laryngoscope.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Yule S, Paterson-Brown S (2012) Surgeons’ non-technical skills. Surg Clin N Am 92(1):37–50.

    Article  PubMed  Google Scholar 

  9. 9.

    Chaturvedi AK, Anderson WF, Lortet-Tieulent J et al (2013) Worldwide trends in incidence rates for oral cavity and oropharyngeal cancers. J Clin Oncol 31(36):4550–4559.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Panwar A, Batra R, Lydiatt WM, Ganti AK (2014) Human papilloma virus positive oropharyngeal squamous cell carcinoma: a growing epidemic. Cancer Treat Rev 40(2):215–219.

    Article  PubMed  Google Scholar 

  11. 11.

    de Almeida JR, Byrd JK, Wu R et al (2014) A systematic review of transoral robotic surgery and radiotherapy for early oropharynx cancer: a systematic review. Laryngoscope 124(9):2096–2102.

    Article  PubMed  Google Scholar 

  12. 12.

    Nichols AC, Yoo J, Hammond JA et al. (2013) Early-stage squamous cell carcinoma of the oropharynx: Radiotherapy vs. Trans-oral robotic surgery (ORATOR)—study protocol for a randomized phase II trial. 13(1):133.

  13. 13.

    Bhatti NI (2017) Assessment of surgical skills and competency. Otolaryngol Clin N Am 50(5):959–965.

    Article  Google Scholar 

  14. 14.

    Musbahi O, Aydin A, Al Omran Y, Skilbeck CJ, Ahmed K. Current status of simulation in otolaryngology: a systematic review. J Surg Educ 74(2):203–215.

    Article  Google Scholar 

  15. 15.

    Ponton-Carss A, Kortbeek JB, Ma IWY (2016) Assessment of technical and nontechnical skills in surgical residents. Am J Surg 212(5):1011–1019.

    Article  PubMed  Google Scholar 

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This is a self-funded study.

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AS: data collection, analysis and manuscript preparation. DEE, IB, UD, SDM, AN, JY, KF, KR: manuscript preparation. All authors read and approved the final manuscript.

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Correspondence to Kathryn Roth.

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Authors AS, DE, IB, UD, SDM, AN, JY, KF, and KR declare they have no conflicts of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Sahovaler, A., Eibling, D.E., Bruni, I. et al. Novel minimally invasive transoral surgery bleeding model implemented in a nationwide otolaryngology emergencies bootcamp. J Robotic Surg 13, 773–778 (2019).

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  • TORS
  • TLM
  • Post-operative bleeding
  • Training
  • Bootcamp