Cadaveric dissection is still considered the gold standard for non-clinical surgical training, but it does not accurately replicate fine operative manipulations and it does not provide operating during specific pathologies. Moreover, it can have ethical implications in some countries and restrictions in its use for obtaining CT and scan. Cadaver acquisition and maintenance are also expensive and available only at major centers.27
Cadaveric brains have small ventricles, being difficult to cannulate and rendering ventriculostomy extremely difficult and not representative of the actual circumstances of the procedure. Some advance has been accomplished in an adult cadaver with induced ventricular dilatation.28 The same cadaveric anatomical restrictions can be cited for spine and craniosynostosis training. Animal models are also limited because of the ethical issues, problems with anesthesia, lack of reproducibility, and formidable cost.
Moreover, these physical simulators present other advantages that need to be highlighted: (1) the material maintenance is convenient and there is no need for any kind of special preparation. It is easier to maintain when compared with animal models and does not require anesthesia; (2) the model expresses the appropriate spine size and the dimensions observed in real patients. Thereby, the identification of anatomical landmarks and, more importantly, the depth perception are feasible; (3) these virtual and physical simulators include all the necessary planning steps of the surgery, from positioning to skin closure. The user is also allowed the normal degree of freedom for the surgical instruments to accurately perform the complex approaches; (4) the presence of CSF circulation in the spine simulator permit the handling of emergency situations; (5) the ability to obtain realistic imaging studies provides knowledge of the pathological condition and its diagnosis, and allows pre- and postoperative comparison studies; (6) the reproducibility is important and possible for both virtual and realistic simulators. This parameter is important for both scientific studies and the learning of surgical skills. Lastly, there are no ethical restrictions to its use or the necessity of a specific place to work with these simulators.
On the other hand, it is important to emphasize some disadvantages of these simulators. Although the handmade and hand tuned process of developing such a simulator has the most preferable characteristics (to represent the tissue properties adequately and to express the anatomical structures with precise localization), it can be difficult and extremely time consuming to create.
The authors thank Marcos Lyra; Jair Lyra; Georgina Barretto, and Josemi Fabricio da Silva for their attendance and notable dedication in developing the physical simulators, and Gustavo Zagatto for the virtual simulators creation; Maíra Coelho R. Caselato and Valéria Aires Cruz for their assistance in preparing the pictures. Finally, the authors thank the simulation center SIEDI for the financial support.
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