The senior residents (PGY 4–6) were more comfortable performing the operation independently the on their own [4 (0.8)]. As one would expect, the confidence to perform the operation independently increases with each PGY year. The small sample size limits the ability to calculate a meaningful P value and, therefore, the calculation was not done. The senior residents both participated and observed more than 15 DIEP flaps.
When reviewing the posttest, the residents felt the exercise increased their proficiency in the DIEP flap [4 (0.4)], the exercise was clear [4 (0.4)], easy to understand the format [4 (0.7)], did not require and excessive amount of time [2 [0.4)], and overall should be included in the curriculum of the PGY 1 and 2 resident training. The junior-level residents felt the exercise increased their anatomic knowledge of the abdominal wall [4 (0.8)], perforators [4 (0.8)], and intercostal vessels [4 (0.5)]. Both the junior- and senior-level residents felt the model exercise improved their proficiency of the operative steps [4 (0.5) and 4 (0.8), respectively].
Performing a successful surgical operation contains many steps that need to be executed in the appropriate sequence. Teaching this skill to residents is not without challenges in the current educational environment. Issues with patient safety and the need for greater supervision to ensure patient safety does not allow for residents to practice on patients. Faculty are ultimately responsible for ensuring the patients achieve satisfactory outcomes, and at the same time teach surgical skills to trainees. In that regard, the use of surgical simulators has become an attractive method of training the next generation of surgeons.
The ideal surgical simulator needs to be cost effective, replicate the surgical environment to make it as realistic as possible, and be readily accessible to faculty and trainees. Current models used in other specialties fall short of this idea. Many programs use cadaver dissection laboratories, but human cadavers are expensive, require appropriate facilities, and are in limited supplies. In perforator dissections, cadaver tissue is not similar to tissue encountered in live environment. Thus, it fails to reinforce the concepts and techniques in perforator dissections.
Computer simulators can demonstrate graphical representations of operations, but do not allow the trainee to physically interact with the model as is so important when it comes to surgical procedures. Plastic or rubber prefabricated models of anatomic body parts are theoretically possible to create, but are costly to manufacture for a focused specialty. Despite the limitation of surgical simulation, the literature supports the concept that surgical models accelerate technical skills, translate from the laboratory or model environment to the clinical environment, and help to establish technically competent residents.15,17–20
Given the positive impact on training, the Accreditation Council for Governing Medical Education and several subspecialties (General Surgery, Urology, and Obstetrics and Gynecology) have adopted procedural exercises into their residency curriculum. In fact, studies have been performed recommending that residency programs restructure their education to include procedure trainers.21 Unfortunately, to date, there does not exist standardized procedural trainers across the Plastic Surgery Residency programs in the country.
A major drawback to some of the current models is the lack of fidelity in recreating the actual surgical environment and condition. Furthermore, these models may be cost-prohibitive for many institutions. Despite their inherent limitations, the usefulness of these models in other specialties has clearly been demonstrated.15,17–20 We feel that there is a need in Plastic Surgery residency to have standardized procedural trainers that are cost effective and educational.
Indeed, in our preliminary study, we found that residents universally perceived a need for procedural trainers, especially in perforator flap dissections. Furthermore, we created 5 complete models for $30.00. This simple and cost-effective exercise was felt to be clear and helpful to the residents.
The exercise increased the junior residents’ level of anatomic proficiency as a whole. More importantly, it helped to increase their understanding of the intercostal vascular anatomy. This is especially important when determining the source of blood supply to lateral perforators and the remaining blood supply to caudal ends of the remaining rectus abdominus. In addition, this exercise increased the junior- and senior-level residents’ proficiency of understanding the operative steps in the DIEP flap and perforator dissection. As stated previously, there have been a number of studies that have shown that training modules allow the residents to increase their fine motor skills; however, unlike our training model, these models are complex and costly.15,17–19,21,22
Overall, the cost-effective DIEP training module was well received by the residents. They found the exercise easy to follow, clear to understand, and helpful. Not surprisingly, the model had a greater impact on the junior residents (PGY 1–3); where it increased the resident’s understanding of the anatomy of the abdominal wall, the vascular pedicle, specific perforator, and the intercostal vessels. In addition, both the junior and senior residents increased their proficiency in understanding and outlining the operative steps of the DIEP flap. As a whole, the residents felt this would be useful and should be included in the PGY 1–2 educational curriculum.
Our training module does have some limitations. The current prototype could be more realistic in design. This is a major area where we could improve the training. In the models current state, we believe this is a great adjunct when used with cadaver dissections. The cadaver allows for the realistic anatomical approach and the model allows reinforcement of the techniques required in perforator dissection in vivo.
In summary, this was a pilot study to help elucidate if (1) there was a need in plastic surgery residency for procedural trainers/models and (2) to determine if an economical model could be developed that would positively impact the resident’s understanding of perforator operations and techniques. We believe, as seen by our resident’s surveys and when examining the literature, there is a need for procedural training models and simulation exercises to teach and improve understanding of specific operations and techniques. We have created an economical model that is easy to use, clear to follow, and impacts the level of proficiency of the residents regardless of PGY level. Finally, after using the training module, the residents feel this exercise should be included in their PGY 1 and 2 curriculums to help explain the operation and the techniques required in the perforator flap harvest.
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microsurgery education; surgical education; medical education; perforator flap dissection; surgical techniques; DIEP flap; breast reconstruction; abdominal free flap
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