Surgical Art | Innovations

Digital Microsurgical Laboratory (DML)

Microsurgery has traditionally been taught using table mounted microscopes with teaching arms. Instruction is provided by a pre-recorded video presentation. Practice is supervised by instructors standing over trainees’ using the teaching arm. The aim was to improve this limiting teaching model by applying digital technologies to create a novel Digital Microsurgery Laboratory(DML).  Standard training stereo microscopes with extra trinocular simultaneous lenses are mounted with high resolution digital video cameras providing digital live feed for stills/video recordings. These are linked to laptop displays for every trainee microscope and to a projector for the trainer microscope. Instruction is provided by live demonstration of the operation, with concurrent discussion between trainers and trainees. All aspects of microsurgical practice are covered – set-up, basic/advanced surgical techniques and managing complications. Trainee displays are arranged in a design so that all displays can be viewed simultaneously by the trainer. Trainees practice under active supervision by the trainer who can use the training microscope/projector to demonstrate corrections and tips/tricks. Videos can be recorded as by trainee or trainer for assessment and audit.


Microsurgical Flow System

The Microsurgical Flow System was developed to enable the success of repairs in microsurgical training.  The repaired vessel is attached to the system, the valve is released and fluid is pushed through the vessel.  The system allows both end-to-end and end-to-side anastomoses to be tested.


Hand Fracture Model

The Hand Fracture Model is an avian based model, that uses humerus and femurs from chickens to mirror the bone structure of the hand, moving away from the more traditionally used saw bones. This model has been used in numerous training settings and is well received for its real bone feel, enabling a more realistic simulation of both fracture and repair.



Microsurgical Training - (Inside Out)

A critical part of microsurgery is ensuring a successful anastomosis of both the intravascular and extravascular elements of a vessel.  However traditionally in training both trainee and trainer only have an extravascular view.  Using an endoscope, and the digital training model (see other innovations), Surgical-Art has developed a model to allow the intravascular repair to be viewed.


The Surgical-Art Face

The cadaveric model remains the Holy Grail for Local Flap training. Overcoming this expensive and resource limiting model, whilst still providing the key elements of the face, was the aim of this project.  To develop this complex face model the authors studied movements of different facial sub-units that influence local flap design. A variety of different silicone grades and fabric with multiple properties were tested in an attempt to mirror the anisotropic qualities of the face. A number of prototypes were developed, each selectively simulating a component of the desired face. Following this the multiple components were then hybridised. The end product was a tri-laminar mask mounted on a base unit that can be used to design,elevate and suture local flaps for training.  This model was tested in both a training and OSCE setting with overwhelmingly successful feedback from trainees and trainers. The face provided a realistic and tactile experience that is required to gauge the unique movement of the different facial sub-units.  The Surgical-Art Face is a unique innovation that simulates facial contours, movement and material handling to provide a sophisticated and accessible training, assessment and research tool for facial reconstruction. It can also be used for patient education.


Performing for the FRCS

Enhancing verbal and non-verbal proficiency using a multi-disciplinary approach.

Presenting the examiners with the confidence of a day 1 Consultant is not easy, knowledge alone will not demonstrate experience and capability. Presentation and strategy is paramount. The aim of the programme was to assess and improve the candidates demeanour and delivery, critical to success. The authors partnered with communication experts to design a course that addresses the different verbal and non-verbal components of the examination. The parameters of this extensive field were distilled and a structured approach with the mnemonic ‘BLISS ‘ (Body Language, Listening, Introspection(Stress), Speech and Strategy) developed. The course was run as a series of ‘mock exam’ and ‘drama teaching exercises. The mock exams i.e. clinical (with simulated patients) and viva were run by Consultant Plastic Surgeons with communications input. The assessment and feedback in these stations was solely to address the components of BLISS and not clinical knowledge. The theatre training exercises were physical and vocal along with bespoke communications sessions on presentation and delivery. The course, run over 2 days a month apart, is designed to provide bespoke feedback and targeted exercises at multiple stages. Feedback from delegates and faculty was overwhelmingly positive. There was an overall improvement in one or more aspects on the BLISS score for every candidate. 7 out of 9 delegates from the pilot programme who took the FRCS(Plast) exam passed.  We believe that Performing for the FRCS, a previously unexplored programme, is crucial not only for the exam but in all clinical interactions.


Porcine Forequarter as a single training model

Porcine Forequarter as a single training model for neurovascular pedicle dissection and perforator based flap elevation.

For perforator flap training, the use of fresh soft pliable tissues as well as predictable vascular pedicles comparable to human vascular anatomy is mandatory. We evaluated the porcine forequarter as a single model to provide material for different perforator based fasciocutaneous flaps and brachial plexus dissection for trainees of all grades. Porcine forequarter was identified as a potential model based on historic studies by Taylor et al. as a training model for neurovascular dissection and fasciocutaneous flap elevation. The forequarter was obtained with the ribs already sectioned allowing access to the brachial plexus and major vessels. The first exercise was brachial plexus and vessel dissection. This taught tissue handling skills and pedicle dissection. The second exercise was designing and elevating fasciocutaneous flaps. After injection of dye into source vessels, intramuscular and septal perforating vessels could be used as the basis of multiple perforator flaps. Chimeric flaps were also raised where two tissue types were identified on a single branching pedicle. Once raised, the flaps could be detached and anastomosed to recipient vessels in a parallel microsurgical workshop. Feedback from both faculty and delegates indicates that the porcine model is sophisticated and covers the training requirements from basic to advanced levels very well. The location and quality of the perforators was fairly predictable but at times a free style approach had to be adopted as in real clinical scenarios.  This novel use of the porcine forequarter provides varied models for nerve and vessel dissection and raising a number of perforator based flaps in a training environment.


The Surgical-Art Z-Plasty Model

The Z-Plasty is often a difficult concept for the trainee to design and execute. Simulating a scar that needs either re-orientation or lengthening has not been previously explored. Our aim was to create an effective model that incorporates the key elements of Z-Plasty training and assessment. The authors researched a variety of fabrics with different properties (strength, elasticity and anisotropy) along with mechanisms to simulate tension in a scar. A number of fabric prototypes were evaluated and one with high elasticity and anisotropy was identified. Multi-lamina models were then produced using carefully selected adhesives and silicones to provide a realistic simulation that allowed design and suture placement. This composite structure was then mounted on a tensioning device. This allowed for the creation of a tactile scar with a visual aid that is measurable, to calculate the distance between two points on the scar before and after “surgery”. Different types of scarring (thick/thin bands and high/low tension) and variations of Z-Plasty were trialled in a laboratory setting. This model has been evaluated and used successfully in Surgical-Art’s laboratory and training environment. The haptic and visual feedback from the model has been found to be an exceptional simulation of a scar for training. When released with a Z-Plasty the scar can be visually and objectively assessed, and has received excellent feedback.  The Surgical-Art Z-Plasty Model is an intuitive innovation to simulate a scar, advancing training and assessment for Z-Plasty and scar release. The model can also be used for patient education.