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Human cadaver brain infusion model for neurosurgical training
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Surgical Neurology 72 (2009) 700 – 702 www.surgicalneurology-online.com
Technique
Human cadaver brain infusion model for neurosurgical training☆ Jon Olabe, MD a,⁎, Javier Olabe, MD, PhD a , Vidal Sancho, MD b a
Department of Neurosurgery Hospital Universitario Son Dureta, 07014, Andrea Doria, Palma de Mallorca, Spain b Institute of forensic anatomy, Cami CA L'ardiaca S/N, 07010, Palma de Mallorca, Spain Received 4 February 2009; accepted 25 February 2009
Abstract
Background: Microneurosurgical technique and anatomical knowledge require extensive laboratory training before mastering these skills. There are diverse training models based on synthetic materials, anesthetized animals, cadaver animals, or human cadaver. Human cadaver models are especially beneficial because they are the closest to live surgery with the greatest disadvantage of lacking hemodynamic factors. We developed the “brain infusion model” to provide a simple but realistic training method minimizing animal use or needs for special facilities. Methods: Four human cadaveric brains donated for educational purposes were explanted at autopsy. Carotids and vertebral arteries were cannulated with plastic tubes and fixed with suture. Water was flushed through the tubings until the whole arterial vasculature was observed as clean. The cannulated specimens were fixed with formaldehyde. Tap water infusion at a flow rate of 10 L/h was infused through the arterial tubings controlled with a drip regulator filling the arterial tree and leaking into the interstitial and cisternal space. Results: Multiple microneurosurgical procedures were performed by 4 trainees. Cisternal and vascular dissection was executed in a very realistic fashion. Bypass anastomosis was created as well as aneurysm simulation with venous pouches. Vessel and aneurysm clipping and rupture situations were emulated and solution techniques were trained. Conclusion: Standard microsurgical laboratories regularly have scarce opportunities for working with decapitated human cadaver heads but could have human brains readily available. The human brain infusion model presents a realistic microneurosurgical training method. It is inexpensive and easy to set up. Such simplicity provides the adequate environment for developing microsurgical techniques. © 2009 Elsevier Inc. All rights reserved.
Keywords:
Aneurysm; Bypass; Cadaver; Cerebrovascular; Infusion model; Neurosurgery; Surgical training
1. Background Refining microsurgical dexterity requires delicate intensive laboratory training. There are diverse training models
Abbreviations: MCA, Middle cerebral artery; ACA, Anterior cerebral artery. ☆ We have no conflict of interest in connection with the article, and neither the submitted material nor any similar paper has been or will be submitted to or published in any other printed or digital publication. All authors have participated in the design and execution, and they have all approved the final version of the manuscript. ⁎ Corresponding author. Tel.: +34 630587273. E-mail address: [email protected] (J. Olabe). 0090-3019/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2009.02.028
[1-3,6-17,19]; however, human cadaver models are anatomically the most realistic with a main disadvantage of lack of hemodynamic factors. The first human cadaveric circulation model was described by Garret [4] followed by Aboud et al [1] creating the dynamic pulsating cerebral model. The authors developed a simpler alternative. 2. Methods Four cadaveric brains donated for educational purposes were explanted at autopsy. Both carotids and vertebral arteries were cannulated with plastic tubings of and fixed with suture followed by abundant flushing with tap water
J. Olabe et al. / Surgical Neurology 72 (2009) 700–702
701
After the fixation period, each cerebrum was washed with tap water and positioned in a 4-L plastic container. Tap water infusion was initiated controlled by the serum flow regulator with a maximum flow rate of 10 L/h (Fig. 1). Pulsatility could be generated mechanically if required by adjusting the serum regulator.
3. Results
Fig. 1. Four-vessel brain cannulation with infusion drip regulation system and connection piece.
until the whole arterial vasculature was observed as clean and bloodless. The cannulated specimens were then fixed with 10% concentrated formaldehyde for 2 months.
The infusion system model causes vascular filling and gradual interstitial space leakage, which maintains the specimen effectively moist, softening the fixed tissue and increasing its compliance facilitating its manipulation. The cisterns and subarachnoid space are also washed by this clear liquid making cisternal dissection live like. Venous anatomy is not infused, so it may be complex to identify and dissect. Multiple microneurosurgical procedures were performed in a very realistic fashion by 4 trainees with the help of Zeiss Opmi 1 microscope magnification including cisternal and vascular dissection [5,18] and standard microvascular anastomosis such as terminoterminal, lateroterminal, and laterolateral high- and low-flow bypasses. Aneurysms were created using explanted chicken wing venous pouch so clipping and rupture situations could be simulated (Fig. 2). 4. Conclusion Laboratory training with human specimens provides an adequate environment for gaining both technical and
Fig. 2. A: Left sylvian fissure dissection exposing MCA bifurcation and branches. B: Clipping of left MCA bifurcation simulated aneurysm. C: Laterolateral left MCA M3 anastomosis. D: High-flow venous bypass to left MCA bifurcation.
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J. Olabe et al. / Surgical Neurology 72 (2009) 700–702
anatomical expertise. Standard microsurgical laboratories regularly have scarce opportunities for working with decapitated human cadaver heads but could have human brains readily available. Dr Aboud's pulsatile human head model with vascular coloring is the most realistic training model described to date but requires obtaining the specimen and some infrastructure including the intra-aortic balloon pump (System 90; Datascope Corp, Fairfield, NJ). The authors' model is a simplified but useful and inexpensive alternative.
References [1] Aboud E, Al-Mefty O, Yasargil MG. New laboratory model for neurosurgical training that simulates live surgery. J Neurosurg 2002; 97:1367-72. [2] Ayoudi S, Ward P, Naik S, Sankaran M. The use of placenta in a microvascular exercise. Neurosurgery 1992;30:252-4. [3] Galeano M, Zarabini AG. The usefulness of a fresh chicken leg as an experimental model during the intermediate stages of microsurgical training. Ann Plast Surg 2001;47:96-7. [4] Garret A. human cadaveric circulation model. J Vasc Surg 2001;33: 1128-30. [5] Gibo H, et al. Microsurgical anatomy of the middle cerebral artery. J Neurosurg 1981;54:151-69. [6] Govila A. A simple model on which to practice microsurgical techniques: a fresh chicken. Br J Plast Surg 1981;34:386-9. [7] Hino A. Training in microvascular surgery using a chicken wing artery. Neurosurgery 2003;52(6):1497-8.
[8] Krishnan KG, Dramm P, Schackert G. Simple and viable in vitro perfusion model for training microvascular anastomoses. Microsurgery 2004;24(4):335-8. [9] Kwon SS, Jeong JH, Chang H, Minn KW. Training of microanastomosis with chicken wing brachial artery. J Korean Soc Plast Reconstr Surg 2007;34(2):274-7. [10] Lannon DA, Atkins JA, Butler PE. Non-vital, prosthetic and virtual reality models of microsurgical training. Microsurgery 2001;21(8): 389-93. [11] Miko I, Brath E, Furka I. Basic teaching in microsurgery. Microsurgery 2001;21(4):121-3. [12] Mustafa E, Konstantin V, Amin-Hanjani S. Microvascular anastomosis training model based on a turkey neck with perfused arteries. Oper Neurosurg Suppl 2008;62(5). [13] Lausada NR, Escudero E, Lamonega R, Dreizzen E, Raimondi JC. Use of cryopreserved rat arteries for microsurgical training. Microsurgery 2005;25(6):500-1. [14] Remie R. The PVC-Rat and other alternatives in microsurgical training. Lab Anim 2001;30(9):48-52. [15] Senior MA, Southern SJ, Majumder S. Microvascular simulator- a device for microanastomosis training. Ann R Coll Surg Engl 2001;83 (5):358-60. [16] Hicdonmez T, Hamamcioglu M, Tiryaki M, et al. Microneurosurgical training model in fresh cadaveric cow brain: a laboratory study simulating the approach to the circle of Willis. Surg Neurol 2006;66:100-4. [17] Weber D, Moser N, Rosselin R. A synthetic model for microsurgical training: a surgical contribution to reduce the number of animal experiments. Eur J Pediatr Surg 1997;7:204-6. [18] Yasargil M. Microsurgical anatomy of the basal cisterns and vessels. New York: Thieme Medical Publishers; 1984. [19] Yen D, Arroyo R, Berezniak R, Partington M. New model for microsurgical training and skills maintenance. Microsurgery 1995;16: 760-2.
Surgical Neurology 72 (2009) 700 – 702 www.surgicalneurology-online.com
Technique
Human cadaver brain infusion model for neurosurgical training☆ Jon Olabe, MD a,⁎, Javier Olabe, MD, PhD a , Vidal Sancho, MD b a
Department of Neurosurgery Hospital Universitario Son Dureta, 07014, Andrea Doria, Palma de Mallorca, Spain b Institute of forensic anatomy, Cami CA L'ardiaca S/N, 07010, Palma de Mallorca, Spain Received 4 February 2009; accepted 25 February 2009
Abstract
Background: Microneurosurgical technique and anatomical knowledge require extensive laboratory training before mastering these skills. There are diverse training models based on synthetic materials, anesthetized animals, cadaver animals, or human cadaver. Human cadaver models are especially beneficial because they are the closest to live surgery with the greatest disadvantage of lacking hemodynamic factors. We developed the “brain infusion model” to provide a simple but realistic training method minimizing animal use or needs for special facilities. Methods: Four human cadaveric brains donated for educational purposes were explanted at autopsy. Carotids and vertebral arteries were cannulated with plastic tubes and fixed with suture. Water was flushed through the tubings until the whole arterial vasculature was observed as clean. The cannulated specimens were fixed with formaldehyde. Tap water infusion at a flow rate of 10 L/h was infused through the arterial tubings controlled with a drip regulator filling the arterial tree and leaking into the interstitial and cisternal space. Results: Multiple microneurosurgical procedures were performed by 4 trainees. Cisternal and vascular dissection was executed in a very realistic fashion. Bypass anastomosis was created as well as aneurysm simulation with venous pouches. Vessel and aneurysm clipping and rupture situations were emulated and solution techniques were trained. Conclusion: Standard microsurgical laboratories regularly have scarce opportunities for working with decapitated human cadaver heads but could have human brains readily available. The human brain infusion model presents a realistic microneurosurgical training method. It is inexpensive and easy to set up. Such simplicity provides the adequate environment for developing microsurgical techniques. © 2009 Elsevier Inc. All rights reserved.
Keywords:
Aneurysm; Bypass; Cadaver; Cerebrovascular; Infusion model; Neurosurgery; Surgical training
1. Background Refining microsurgical dexterity requires delicate intensive laboratory training. There are diverse training models
Abbreviations: MCA, Middle cerebral artery; ACA, Anterior cerebral artery. ☆ We have no conflict of interest in connection with the article, and neither the submitted material nor any similar paper has been or will be submitted to or published in any other printed or digital publication. All authors have participated in the design and execution, and they have all approved the final version of the manuscript. ⁎ Corresponding author. Tel.: +34 630587273. E-mail address: [email protected] (J. Olabe). 0090-3019/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2009.02.028
[1-3,6-17,19]; however, human cadaver models are anatomically the most realistic with a main disadvantage of lack of hemodynamic factors. The first human cadaveric circulation model was described by Garret [4] followed by Aboud et al [1] creating the dynamic pulsating cerebral model. The authors developed a simpler alternative. 2. Methods Four cadaveric brains donated for educational purposes were explanted at autopsy. Both carotids and vertebral arteries were cannulated with plastic tubings of and fixed with suture followed by abundant flushing with tap water
J. Olabe et al. / Surgical Neurology 72 (2009) 700–702
701
After the fixation period, each cerebrum was washed with tap water and positioned in a 4-L plastic container. Tap water infusion was initiated controlled by the serum flow regulator with a maximum flow rate of 10 L/h (Fig. 1). Pulsatility could be generated mechanically if required by adjusting the serum regulator.
3. Results
Fig. 1. Four-vessel brain cannulation with infusion drip regulation system and connection piece.
until the whole arterial vasculature was observed as clean and bloodless. The cannulated specimens were then fixed with 10% concentrated formaldehyde for 2 months.
The infusion system model causes vascular filling and gradual interstitial space leakage, which maintains the specimen effectively moist, softening the fixed tissue and increasing its compliance facilitating its manipulation. The cisterns and subarachnoid space are also washed by this clear liquid making cisternal dissection live like. Venous anatomy is not infused, so it may be complex to identify and dissect. Multiple microneurosurgical procedures were performed in a very realistic fashion by 4 trainees with the help of Zeiss Opmi 1 microscope magnification including cisternal and vascular dissection [5,18] and standard microvascular anastomosis such as terminoterminal, lateroterminal, and laterolateral high- and low-flow bypasses. Aneurysms were created using explanted chicken wing venous pouch so clipping and rupture situations could be simulated (Fig. 2). 4. Conclusion Laboratory training with human specimens provides an adequate environment for gaining both technical and
Fig. 2. A: Left sylvian fissure dissection exposing MCA bifurcation and branches. B: Clipping of left MCA bifurcation simulated aneurysm. C: Laterolateral left MCA M3 anastomosis. D: High-flow venous bypass to left MCA bifurcation.
702
J. Olabe et al. / Surgical Neurology 72 (2009) 700–702
anatomical expertise. Standard microsurgical laboratories regularly have scarce opportunities for working with decapitated human cadaver heads but could have human brains readily available. Dr Aboud's pulsatile human head model with vascular coloring is the most realistic training model described to date but requires obtaining the specimen and some infrastructure including the intra-aortic balloon pump (System 90; Datascope Corp, Fairfield, NJ). The authors' model is a simplified but useful and inexpensive alternative.
References [1] Aboud E, Al-Mefty O, Yasargil MG. New laboratory model for neurosurgical training that simulates live surgery. J Neurosurg 2002; 97:1367-72. [2] Ayoudi S, Ward P, Naik S, Sankaran M. The use of placenta in a microvascular exercise. Neurosurgery 1992;30:252-4. [3] Galeano M, Zarabini AG. The usefulness of a fresh chicken leg as an experimental model during the intermediate stages of microsurgical training. Ann Plast Surg 2001;47:96-7. [4] Garret A. human cadaveric circulation model. J Vasc Surg 2001;33: 1128-30. [5] Gibo H, et al. Microsurgical anatomy of the middle cerebral artery. J Neurosurg 1981;54:151-69. [6] Govila A. A simple model on which to practice microsurgical techniques: a fresh chicken. Br J Plast Surg 1981;34:386-9. [7] Hino A. Training in microvascular surgery using a chicken wing artery. Neurosurgery 2003;52(6):1497-8.
[8] Krishnan KG, Dramm P, Schackert G. Simple and viable in vitro perfusion model for training microvascular anastomoses. Microsurgery 2004;24(4):335-8. [9] Kwon SS, Jeong JH, Chang H, Minn KW. Training of microanastomosis with chicken wing brachial artery. J Korean Soc Plast Reconstr Surg 2007;34(2):274-7. [10] Lannon DA, Atkins JA, Butler PE. Non-vital, prosthetic and virtual reality models of microsurgical training. Microsurgery 2001;21(8): 389-93. [11] Miko I, Brath E, Furka I. Basic teaching in microsurgery. Microsurgery 2001;21(4):121-3. [12] Mustafa E, Konstantin V, Amin-Hanjani S. Microvascular anastomosis training model based on a turkey neck with perfused arteries. Oper Neurosurg Suppl 2008;62(5). [13] Lausada NR, Escudero E, Lamonega R, Dreizzen E, Raimondi JC. Use of cryopreserved rat arteries for microsurgical training. Microsurgery 2005;25(6):500-1. [14] Remie R. The PVC-Rat and other alternatives in microsurgical training. Lab Anim 2001;30(9):48-52. [15] Senior MA, Southern SJ, Majumder S. Microvascular simulator- a device for microanastomosis training. Ann R Coll Surg Engl 2001;83 (5):358-60. [16] Hicdonmez T, Hamamcioglu M, Tiryaki M, et al. Microneurosurgical training model in fresh cadaveric cow brain: a laboratory study simulating the approach to the circle of Willis. Surg Neurol 2006;66:100-4. [17] Weber D, Moser N, Rosselin R. A synthetic model for microsurgical training: a surgical contribution to reduce the number of animal experiments. Eur J Pediatr Surg 1997;7:204-6. [18] Yasargil M. Microsurgical anatomy of the basal cisterns and vessels. New York: Thieme Medical Publishers; 1984. [19] Yen D, Arroyo R, Berezniak R, Partington M. New model for microsurgical training and skills maintenance. Microsurgery 1995;16: 760-2.