背景:胎儿镜脊柱裂修复(fSB修复)越来越多地被实践,但是有限的技能获取对广泛采用构成了障碍。广泛的培训相关的模型,包括前和体内模型可能会有所帮助。为了解决这个问题,一种负担得起的综合训练模式,现实和允许的技能分析将是有用的。
目的:创建一个高保真模型,用于使用合成材料训练胎儿镜脊柱裂修复的基本神经外科步骤。此外,我们的目标是获得一个廉价且易于复制的模型。
方法:我们开发了一个三层硅基模型,类似于典型的脊髓膜膨出病变的解剖层。它允许用液体填充囊肿并在修复后进行水密性测试。一个柔顺的硅球模仿子宫腔,并固定在坚固的3D打印底座上。带有病变(单次使用)的胎儿背部放置在子宫球内,它是可重复使用和可修复的,以允许多次练习端口插入和固定。插管插入后,子宫被吹气,和临床胎儿镜检查,可以使用机器人或原型仪器。在开放修复的手术步骤之后,三名熟练的内窥镜外科医生分别进行了六次模拟的胎儿镜修复。主要结果是手术成功,基于水密性的修理,手术时间<180分钟,客观结构技术技能评估(OSATS)评分≥18/25。使用能力计算总和(C-CUSUM)分析手术成功的复合二元结果来测量技能保留。次要结果是模型的成本和制造时间。
结果:我们制作了一个具有解剖细节的模拟脊柱裂修复神经外科步骤的模型,端口插入,释放和下降,破坏皮肤和肌肉层,和内窥镜缝合。该模型是用可重复使用的3D打印模具制成的,材料容易接近。一次性启动成本为211欧元,每个一次性使用模拟MMC病变的材料成本为9.5€,工作时间为50分钟。两名熟练的内窥镜外科医生进行了六次模拟三端口胎儿镜修复,而三分之一的人使用了达芬奇手术机器人。从第一次到最后一次试验,手术时间减少了30%以上。每个外科医生的六个实验未显示出明显的OSATS评分改善。C-CUSUM分析证实了每位外科医生的能力。
结论:这种高保真低成本脊柱裂模型可以模拟解剖和闭合脊髓膜膨出病变。
Fetoscopic spina bifida repair is increasingly being practiced, but limited skill acquisition poses a barrier to widespread adoption. Extensive training in relevant models, including both ex vivo and in vivo models may help. To address this, a synthetic training model that is affordable, realistic, and that allows skill analysis would be useful.
This study aimed to create a high-fidelity model for training in the essential neurosurgical steps of fetoscopic spina bifida repair using synthetic materials. In addition, we aimed to obtain a cheap and easily reproducible model.
We developed a 3-layered, silicon-based model that resemble the anatomic layers of a typical myelomeningocele lesion. It allows for filling of the cyst with fluid and conducting a water tightness test after repair. A compliant silicon ball mimics the uterine cavity and is fixed to a solid 3-dimensional printed base. The fetal back with the lesion (single-use) is placed inside the uterine ball, which is reusable and repairable to allow for practicing port insertion and fixation multiple times. Following cannula insertion, the uterus is insufflated and a clinical fetoscopic or robotic or prototype instruments can be used. Three skilled endoscopic surgeons each did 6 simulated fetoscopic repairs using the surgical steps of an open repair. The primary outcome was surgical success, which was determined by water tightness of the repair, operation time <180 minutes and an Objective Structured Assessment of Technical Skills score of ≥18 of 25. Skill retention was measured using a competence cumulative sum analysis of a composite binary outcome of surgical success. Secondary outcomes were cost and fabrication time of the model.
We made a model that can be used to simulate the neurosurgical steps of spina bifida repair, including anatomic details, port insertion, placode release and descent, undermining of skin and muscular layer, and endoscopic suturing. The model was made using reusable 3-dimensional printed molds and easily accessible materials. The 1-time startup cost was €211, and each single-use, simulated myelomeningocele lesion cost €9.5 in materials and 50 minutes of working time. Two skilled endoscopic surgeons performed 6 simulated, 3-port fetoscopic repairs, whereas a third used a Da Vinci surgical robot. Operation times decreased by more than 30% from the first to the last trial. Six experiments per surgeon did not show an obvious Objective Structured Assessment of Technical Skills score improvement. Competence cumulative sum analysis confirmed competency for each surgeon.
This high-fidelity, low-cost spina bifida model allows simulated dissection and closure of a myelomeningocele lesion. VIDEO ABSTRACT.