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Microsurgery simulation training system and set up: An essential system to complement every training programme
Accepted Manuscript Microsurgery Simulation Training System and Set up- An Essential System to Complement Every Training Programme Dhalia Masud, FRCS plast, Nadine Haram, MRCS, Margarita Moustaki, MBBS, Whitney Chow, MRCS, Samer Saour, FRCS Plast, Pari Naz Mohanna, FRCS plast PII:
S1748-6815(17)30141-9
DOI:
10.1016/j.bjps.2017.03.009
Reference:
PRAS 5278
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 22 December 2016 Revised Date:
26 February 2017
Accepted Date: 7 March 2017
Please cite this article as: Masud D, Haram N, Moustaki M, Chow W, Saour S, Mohanna PN, Microsurgery Simulation Training System and Set up- An Essential System to Complement Every Training Programme, British Journal of Plastic Surgery (2017), doi: 10.1016/j.bjps.2017.03.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Microsurgery Simulation Training System and Set up- An Essential System to Complement Every Training Programme
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Dhalia Masud FRCS plast Microsurgery Institute 4 (MI4) Guys & St Thomas’ Hospital London SE1 7EH
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Nadine Haram MRCS Royal Free Hospital London, England
Whitney Chow MRCS Guys and St Thomas’ Hospital London, England
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Margarita Moustaki MBBS Guys and St Thomas’ Hospital London, England
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Samer Saour FRCS Plast St Andrews Plastic and Burns Centre Broomfield Hospital Chelmsford, England
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Pari Naz Mohanna FRCS plast Guys and St Thomas’ Hospital London, England
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CORRESPONDING AUTHOR Dhalia Masud FRCS plast [email protected] Microsurgery Institute 4 (MI4) Guys & St Thomas’ Hospital London UK Presentation •
Microsurgery training programme. D Masud, N Haram, P Mohanna Abstract presentation ACRM (Advances and Controversies in Reconstructive Microsurgery) 2016
•
A laboratory based microsurgical training programme to aid acquisition of Microsurgical Skills and help surgeons to objectify trainees level of proficiency SARS Meeting 2014, January (Abstract presentation) 1
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Abstract Introduction Microsurgical techniques are essential in Plastic Surgery but with changes in training, acquiring these skills can be difficult. To address this, we have
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designed a standardised laboratory-based microsurgical training programme which allows trainees to develop their dexterity, visuospatial ability, operative flow and judgement as separate components. Method Thirty trainees completed an initial
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microsurgical anastomosis on a chicken femoral artery assessed using the Structured Assessment of Microsurgical Skills (SAMS) method. The study group (n=18) then
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completed a three-month training programme whilst the control group (n=19) did not. A final anastomosis was completed by all trainees (n=30). Results The study group had a significant improvement in microsurgical technique assessed using the SAMS score when comparing initial and final scores (24 mean SAMS initial verses 49 mean
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SAMS final) p<0.05 Wilcoxan Rank test. The control group had a significantly lower rate of improvement (23 mean SAMS initial verse 25 mean SAMS final). There was still a significant difference between the final SAMS score of the study group
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compared to senior surgeons (49 mean study final SAMS verses 58 mean senior
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SAMS) Conclusion This validated programme is a safe, cost-effective and flexible method of allowing trainees to develop microsurgical skills in a non-pressured environment. In addition the objectified skills allow trainers to assess the trainees’ level of proficiency before operating on patients.
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ACCEPTED MANUSCRIPT Introduction
Microsurgical techniques are essential to reconstructive surgery. Research shows that flap failure can be associated with operator related technical errors (1), therefore comprehensive microsurgical training is essential. Constant scrutiny over theatre
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efficiency and productivity, stringent monitoring of surgical outcomes as well as restrictions on doctors working hours can result in training not fulfilling the trainees expectations or needs (2-4). Precisely for these reasons, it is important to ensure that
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trainee surgeons are proficient and efficient before operating on patients in theatre.
Simulation training has been a well recognised aid in developing surgical skills in a risk free environment (5-7) as well as eliminating the steep learning curve, novices
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often face (8,9). It is also recognised that skills acquired in this setting can be transferred to the operating theatre, thereby enhancing patient safety (8,9). Current microsurgical training programs are usually intensive training courses lasting a few days. (6,10-13). Basic microsurgical skill techniques have been described by Robert Acland (14) which has been the basis of many intensive training courses, however, if
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these skills are not regularly practiced there is decay of the acquired skills making mass learning on short courses, less effective than distributed learning on longer courses (,15,16).
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To address these needs we designed a microsurgical training programme that was incorporated into the trainees’ weekly timetable, allowing simulation training to occur
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in parallel with clinical training.
Materials and methods
Development of the training programme
A systematic literature review of the current methods available for microsurgical training was performed. Various simulation models for the human vessels have been devised including silicone tubes, rat femoral vessels, umbilical cords etc (10-13,1720), however, we found these impractical and expensive. Our aim was to design a training programme that allowed novices to build up their basic microsurgical skills 3
ACCEPTED MANUSCRIPT on specifically designed tasks before they are faced with the complex task of vessel anastomosis.
When devising our programme we ensured that the following criteria were met: 1) Self-assessment - trainees need to be able to monitor their own progress and
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modify the programme according to their strengths and weaknesses 2) Flexible training - the training programme had to revolve around the work patterns of both the trainees and trainers
3) Senior supervision - seniors had to be available to facilitate the training and to
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objectively assess trainees
4) Easily accessible and available - the equipment eg the microscopes,
trainees needs
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instruments and training models needed to be accessible 24/7 to suit the
5) Cost effective - as this was to be a continued training programme it was essential that the consumables were sourced such that they were cost effective and easy to order
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Using these criteria, we created a programme, which allows a graded acquisition of microsurgical skills from basic to more advance. As currently core trainees are spending four months in a plastic surgery rotation the programme was designed to run over a three-month period. The basic elements of microsurgery (Table 1) were
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judgment.
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identified as; needle dexterity, economy of movement, operative techniques and
These techniques were introduced sequentially, ensuring that trainees were not overwhelmed with the acquisition of the various components and were proficient in a specific skill before moving on.
Moreover, validated low fidelity models were
designed for the attainment of each of these skills (Table 2). The programme was reviewed by consultant microsurgeons to confirm comprehension and relevance.
Microsurgical Programme
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ACCEPTED MANUSCRIPT All trainees attended an initial didactic teaching session given by a senior microsurgeon explaining the techniques, as described by Acland, (14) required for proficient microsurgery and taught how to use the microscope.
The structure of the three-month microsurgical programme involved an initial
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assessment to ascertain the trainees’ baseline level of microsurgical skills and a final assessment to evaluate the level of improvement. This involved anastomosis of a chicken femoral artery, which was filmed and evaluated. The anastomoses were recorded using a hand held camera on a flexible tripod (Figure 1). This provided an
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excellent view for visualising the vessels for training and assessment (Figure 2). Only the task area and the surgeons’ hands were video recorded, to ensure anonymity. These recordings were then scored by two independent assessors using the SAMS
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(Structured Assessment of Microsurgery Skills) scoring system (21). Each trainee was scored out of 60 on technique and the overall performance score out of 5, 1 being bad and 5 being excellent. Assessing whether the suture has caught the back wall is not part of the error list described by Chan et al (21), but this was added for the
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purpose of this study.
Following the initial assessment trainees commenced the programme. When they reached the target scores for each task they progressed to the next task.
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STEP 1. Needle Dexterity
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The first stage concentrates on steadiness and instrument handling, ensuring trainees are able to hold and manoeuvre the needle correctly. •
Round the clock task (Table 2a)
This is a recognised validated task, which can also be used as a warm up exercise (17,21). Sewing needles are arranged vertically in a clock face configuration by standing them in a piece of foam. Trainees were asked to pass an 8-0 needle though the eyes of the sewing needles. They needed to complete the task in 45 seconds before they were allowed to progress.
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ACCEPTED MANUSCRIPT •
In out up down (Table 2b)
This model was created by sandwiching a piece of Mepitel™ between two cardboard frames with standardised windows, which was then bent at an angle of 70 degrees. The trainees were asked to weave an 8-0 suture in and out of the Mepitel™ holes,
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going up one limb then down the other forehand and then repeating the exercise backhand. Trainees needed to complete the task in 2 minutes 40 seconds before they
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were allowed to progress.
STEP 2 Economy of movement
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Microsurgery involves operating in a narrow field. Our observations showed that novices had a tendency to hold their hands far apart leading to poor economy of movement, frequent inaccuracies and suture wastage. •
All tied up (Table 2c)
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This model educated the trainees to work in a narrow field by immobilising their little fingers in rubber bands fixed to a cardboard tray. With their hands in this position they were asked to tie instrument knots with an 8-0 nylon suture around hooks which had been fixed to the tray. Time to complete the knots and the quality of the knots
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were assessed. If a knot was deemed too loose and could easily be removed or fell off the hook then a score of 0 was given. If the knot sat securely after a tug with forceps a
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score of 1 was given. •
Suturing at angles task (Table 2d)
This model was created by sandwiching a piece of rubber glove in a cardboard frame with a standardised window measuring 10cm x 10cm. Four 1cm incisions were made at various angles. The trainees were asked to close the incisions with interrupted 8-0 nylon sutures placed, fronthand, backhand, vertically, horizontally and at angles. The time taken to complete the task and the quality of the knots were assessed. Trainees needed to complete the task in 7 minutes and 30 seconds with all of the knots being scored as 1 before they were allowed to progress.
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ACCEPTED MANUSCRIPT STEP 3 Operative flow
During microsurgery adequate vessel preparation and delicate tissue handling is
•
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crucial. This step in the programme combines the skills gained in step 1 and 2.
Stars the limit (Table 2e)
This model simulates fine tissue dissection. A standardised star is drawn onto the skin of a grape using a stencil. The trainees were asked to dissect the star shaped skin off
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the flesh of the grape. The task is scored according to the number of edges incised within the black lines, the number of perforations in the skin and the number of limbs of the star dissected with no grape flesh attached. Each star has 10 edges and 5 limbs.
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The trainee scores 1 point for every incision made within each marked edge with no deviation outside the mark, therefore scoring 10 when perfectly incised. The trainees also scored 1 point for every limb that is cleanly dissected using micro scissors with no grape flesh attached, therefore a further 5 scores when the star is cleanly dissected, giving a maximum score of 15. If a trainee inadvertently made a perforation 1 score
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was deducted for every perforation. Trainees must complete the task in 2 minutes and 25 seconds and achieve a score of 15 before progressing.
These tasks, were validated in terms of face, construct, content and criterion (22) by
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two senior Consultant Microsurgeons. Table 3 shows the target scores of each model before the trainees can progress to the next task. These were the mean times and
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scores of 13 senior microsurgeons after they had plateaued by repeating the tasks.
After developing the required competencies, trainees progressed to anastomosing the chicken femoral artery.
STEP 4 Operative judgment
Trainees observed the preparation of the chicken femoral artery by the trainer. Approximately 4-5 cm of vessel was prepared (Figure 1), before the artery was divided and stabilised in double clamps. The anastomosis was carried out using 8-0 7
ACCEPTED MANUSCRIPT nylon interrupted sutures. As trainees became more competent they progressed to an end to side anastomosis and then anastomosed vessels with a size discrepancy. During the first anastomosis a trainer was present, however as trainees became more confident they were able to self direct their training.
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Patency of the anastomosis was assessed using blackberry juice, as the colour contrast enhances the visibility of a leak. The juice was drawn up in a 5ml syringe and injected via a 25-gauge needle proximal to the anastomosis in between the clamps. The clamps may be placed further apart for easier access. The anastomosis was then cut
Methodology of study
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longitudinally to assess the quality of suture placement.
This was a prospective randomised control study. 42 trainees took part in the programme (5 medical students, 35 Senior House Officer level and 2 Junior House
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Officer level). All had either minimum or no microsurgical experience. All trainees attended the lecture and completed an initial femoral artery anastomosis, which was SAMS scored.
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Trainees where randomised to the training (n=18) or non-training (control) arm (n=19) of the study. The control group did not enter the training programme but
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continued with normal clinical duties. Those in the training arm entered the threemonth structured training programme.
For steps 3 and 4 trainees purchased their own chicken thighs at an approximate cost of £1.50 for three. We recommended trainees to practice for a minimum of 1-hour a week and take breaks after each hour of training. The laboratory with four microscopes was available 24 hours a day, 7 days a week. All control and study group trainees then completed a final chicken femoral artery anastomosis, which was filmed and scored.
Statistical analysis was carried out using SPSS software version 22.0. 8
ACCEPTED MANUSCRIPT Results
42 candidates were recruited at the start of the study, 5 dropped out due to poor attendance. Of the 37 remaining candidates, the average age was 28 years (range 23-
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39). There were 22 females and 15 males. There was no significant difference in either age or sex ratio between the study and the control groups.
There was no significant difference between the initial SAMS and initial overall
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performance scores between the study and control groups p>0.05 TTest (mean initial study group SAMS score was 24 (range 21-27) verses control group SAMS score 23
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(range 21-27)).
Study group results Table 4. Figures 3,4
In the Study group, the mean initial SAMS score was 24 (range 21-27). This increased to a mean final SAMS score of 49 (range 40 – 55) which was significant at p<0.05 with a paired Wilcoxon rank. There was also a significant improvement in the
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overall performance score (mean initial score 2 (range 1-3) to mean final score 3 (range 3-5)) p<0.05 with a paired Wilcoxon rank (Figures 3 and 4). Therefore all trainees in the study group showed a significant improvement.
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Control group results Table 4. Figures 3,4 The control group showed a smaller increase in their SAMS score when comparing
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their initial and final mean SAMS scores (mean initial SAMS of 23 (range 21-28) to mean final SAMS of 25 (range 22-36)) but this was also significant at p<0.05 with a paired Wilcoxon rank. Six trainees in the control group showed no improvement whilst the remaining improved and no trainees deteriorated. There was however no significant difference between the initial and final overall performance scores (mean initial overall score 2 (range 1-3) to mean final overall score 2 (range 2-3)) p>0.05 TTEST.
Study verses Control group results Table 4. Figures 3-5
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ACCEPTED MANUSCRIPT Although both the study and control groups showed an improvement in their SAMS scores, the study group had a significantly greater improvement with a mean increase of 25 (range 13-30) vs the control group’s mean increase of 1 (range 0-8) p<0.001 TTEST (Figure 5). The Study group also had a significantly higher final mean SAMS score of 49 (range 40 - 55) compared to the control group’s final SAMS score of 25
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(range 22-36) p<0.001 TTEST.
In addition there was a statistically significant difference in the final mean overall performance score between the two groups; study group mean 4 (range 3-5) verses the
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control mean 3 (range 2-3) p<0.05 TTEST (figure 4).
Despite the increase in their SAMS score the study group still scored significantly
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lower than the Consultant Microsurgeons both in their SAMS (mean 59) and overall performance scores (mean 5), p<0.05 TTEST (Figure 3 and 4).
DISCUSSION
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The current climate for surgical training has demanded a change in the way surgical skills are acquired. With increasing pressures on hospital efficiency as well as increasing complexity in the treatment options provided, there is a greater need to ensure that trainee surgeons are proficient before operating on patients in theatre. In
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addition, with improved safety measures in the industrial setting (23) leading to fewer hand trauma and replantation cases, trainee exposure to microsurgery is more limited.
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Simulation training is a recognized aid to surgical skills acquisition. A recent systematic review showed that skills acquired from simulated training on low fidelity models led to acquisition of transferable skills and improved technical performance (5-8)
Many models have been described as an aid to microsurgery training, ranging from low fidelity to high fidelity models. (9-14,18-20, 29-35). The latter can be expensive and current evidence shows that low fidelity models are as effective as high fidelity ones (5). Evidence has also shown that distributed learning is far more effective than short bursts of intensive training , allowing self directed microsurgical skill acquisition with prolonged skill retention (16,36,). 10
ACCEPTED MANUSCRIPT We aimed to address these challenges whilst imposing minimal burden to the hosting training unit. The distributed nature of the programme allows simulation training to occur in parallel with clinical training, thereby giving the trainers and trainees an opportunity to identify areas for skill development. The goal directed nature of the tasks allows trainees to monitor their own progression as well as allowing
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comparisons with peers. The tasks can also be used as quick warm up exercises prior to the start of a microsurgical case.
The programme was tested with junior plastic surgical trainees. There was a clear
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improvement in skill acquisition in the study group with a statistically significant increase in their average SAMS score. In addition, the study group’s final SAMS
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score was significantly greater than that of the control group. These results therefore highlight the significant benefit of simulation training in parallel to clinical training. Furthermore the results show that with regular practice, the programme can potentially allow trainees to reach seniority in skill acquisition earlier than those not using the programme.
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Despite the significant improvement in scores, the study group’s score was still lower than consultants, emphasizing a need for continuous and further training. The programme is cost effective as most of the models are re-usable and the
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equipment needed to build them is readily available (card, sewing needle, mepitel™ dressing, sponge) requiring minimal set-up or preparation. The most expensive component is the tabletop microscopes however, these are a one-off purchase and
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subsequently more cost effective microscopes were sourced providing suitable quality for the programme (Table 5). The instruments were designed to be disposable but were reused during the programme (Table 6). The success of our programme is dependent on a proactive department making available, time, space, microsurgical expertise and resources for trainees, as well as trainees making time and taking advantage of the available resources. Specific to our programme was the ability to self-assess and monitor progress objectively. Senior microsurgeons provided training at relevant points in the programme but not constantly, thereby allowing trainees independance. 11
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The accessibility to the microscopes by local trainees was a crucial factor in the success of the programme. The laboratory is located within the department allowing constant access. Many trainees made impromptu training sessions during occasional
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quiet periods as well as in the evenings and weekends.
The obvious disadvantage of the programme is that the laboratory is an ex-vivo
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setting. In addition, although trainees may become proficient in the technical aspects of microsurgery, there are elements of microsurgical decision-making that cannot be replicated in the laboratory. Therefore the programme is designed to work in
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conjunction with clinical practice and to optimise the skills learnt in the operating theatre. Further studies are being undertaken to assess the decay in skills acquired after completion of the three-month programme.
Feedback from Consultants and a departmental review of the programme demonstrated a recognized improvement in the trainee’s microsurgical skills in the
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operating theatre. This recognition has led to the programme being incorporated into the weekly timetable of the trainees. As a result of these findings, the programme has been adopted in multiple units throughout the United Kingdom with plans to allow national peer comparison and assessment. Therefore trainees will be able to maintain
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and further develop their skills as they rotate through various units.
In the current NHS, acquisition and practice of microsurgical skills should not be solely dependant on the time spent in the operating theatre. Our microsurgical training programme allows trainees to self-direct development of their microsurgical skills, in a controlled stress free environment, ensuring that they are ready and confident to perform these continually progressive procedures.
Conflict of interest: none Funding: none
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ACCEPTED MANUSCRIPT REFERENCES 1. Khouri RK Avoiding free flap failure. Clin Plast Surg. 1992 Oct;19(4):773-81 2. Skipworth RJ, Terrace JD, Fulton LA, et al. Basic surgical training in the era of the European Working Time Directive: what are the problems and solutions? Scott Med J 2008;53:18–21.
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3. Lowry J, Cripps J. Results of the online EWTD trainee survey. Br R Coll Surg Engl 2005;87:86–7.
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5. Grober ED, Hamstra SJ, Wanzel KR, Reznick RK, Matsumoto ED, Sidhu RS, Jarvi KA. The educational impact of bench model fidelity on the acquisition of
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7. Atkins JL, Kalu PU, Lannon DA, Green CJ, Butler PETraining in microsurgical skills: Does course-based learning deliver? Microsurgery. 2005;25(6):481-5 Most improved some deteriorated 8. [Sturm LP, Windsor JA, Cosman PH, et al. A systematic review of skills
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11. Yen DM, Arroyo R, Berezniak R, Partington MTNew model for microsurgical training and skills maintenance. Microsurgery. 1995;16(11):760-2. 12. Ilie VG, Ilie VI, Dobreanu C, Ghetu N, Luchian S, Pieptu D. Training of microsurgical skills on nonliving models. Microsurgery. 2008;28(7):571-7. 13
ACCEPTED MANUSCRIPT doi: 10.1002/micr.20541. also programme 13. Penn protocol Creating, developing and mastering a superior microsurgical technique. By Ronald Berezniak, Ph.D., 126 pages, Sharpoint Inc., 1991 (page 163) Kenneth E. Korber Article first published online: 19 OCT 2005 | DOI: 10.1002/micr.1920130313
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14. Acland R, Microsurgery Practice Manual, Published by C V Mosby, 1980 15. Price J, Naik V, Boodhwani M, et al. A randomized evaluation of simulation training on performance of vascular anastomosis on a high-fidelity in vivo model: the role of deliberate practice. J Thorac Cardiovasc Surg
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20. Evidence-Based Microsurgical Skills Acquisition Series Part 2: Validated Assessment Instruments—A Systematic ReviewDanielle Dumestre, MD, Justin K. Yeung, MD, Claire Temple-Oberle, MD Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Calgary, Alberta, Canada 21. Chan WY, Niranjan N, Ramakrishnan V Structured assessment of microsurgery skills in the clinical setting J Plast Reconstr Aesthet Surg. 2010 Aug;63(8):1329-34. doi: 10.1016/j.bjps.2009.06.024. Epub 2009 Jul 22.
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ACCEPTED MANUSCRIPT 22. Carmines, E.G. and Zeller, R.A. Reliability and validity assessment. in: M.S. Lewis-Beck (Ed.) Quantitative Applications in the Social Sciences. Sage Publications, Thousand Oaks, California; 1979 validity 23. Health and safety executive UK http://www.hse.gov.uk/guidance/industries.htm
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24. Buckley G, Revalidation is the answer BMJ. 1999 Oct 30;319(7218):1145-6. 25. https://www.iscp.ac.uk/
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simulated laparoscopic skills Curr Surg. 2001 Mar;58(2):230-235 28. Barnes RW, Surgical handicraft: teaching and learning surgical skills Am J Surg. 1987 May;153(5):422-7value of bench models
29. Brosious JP, Tsuda ST, Menezes JM, Baynosa RC, Stephenson LL, Mohsin AG, Wang WZ, Zamboni WAObjective evaluation of skill acquisition in
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novice microsurgeons. J Reconstr Microsurg. 2012 Oct;28(8):539-42. doi: 10.1055/s-0032-1315774. Epub 2012 Jun 28. Drill 30. Marre D, Hontanilla B Intraluminal latex tubing for microsurgical training.J Reconstr Microsurg. 2011 Sep;27(7):449-50. doi: 10.1055/s-0031-1281525.
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32. Takeuchi M, Hayashi N, Hamada H, Matsumura N, Nishijo H, Endo S.A new training method to improve deep microsurgical skills using a mannequin head.Microsurgery. 2008;28(3):168-70. doi: 10.1002/micr.20473.PMID: 18286651 [PubMed - indexed for MEDLINE] drill 33. Dustagheer S, Brown AP Synthetic latex conduits as an aid for microsurgical training. Plast Reconstr Surg. 2008 Jul;122(1):321. doi: 10.1097/PRS.0b013e31817743fd. No abstract available.PMID: 18594437 [PubMed - indexed for MEDLINE] 34. Klein I, Steger U, Timmermann W, Thiede A, Gassel HJ. Microsurgical 15
ACCEPTED MANUSCRIPT training course for clinicians and scientists at a German University hospital: a 10-year experience Microsurgery. 2003;23(5):461-5 35. Lossing AG, Hatswell EM, Gilas T, Reznick RK, Smith LC. A technical-skills course for 1st-year residents in general surgery: a descriptive study Can J Surg. 1992 Oct;35(5):536-40. Also value of bench model and technical skills
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36. Barbe, Walter Burke; Milone, Michael N. (February 1981). "What we know about modality strengths" (PDF). Educational Leadership (Association for
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ACCEPTED MANUSCRIPT Figures and tables Table 1
NEEDLE DEXTERITY
Repeat 'round the clock'
Step 2 ECONOMY OF MOVEMENT
Week 2 1 x Round the clock Repeat 'up down in out'
Week 4
Week 5 1 x 'stars the limit' repeat 'suturing at angles'
Repeat 'Stars the limit' also any weak tasks from STAGE 1
Week 7
OPERATIVE FLOW
Femoral artery anastomosis
concept of Acland test
Week 11
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OPERATIVE JUDGMENT
Week 10 vessel discrepancy (vein to artery/ profunda to femoral artery)
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Step 4
Week 8 Dissection of femoral artery Femoral artery anastomosis if competant
1 x 'Round the clock' to start 1 x 'up down in out' Repeat 'all tied up' Week 6
1 x 'stars the limit'
1 x 'suturing at angles' repeat 'end is near' Week 9
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Step 3
Week 3
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Week 1
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Step 1
arteriotomy end to side anastomosis '
Dissection of femoral artery
Femoral vein anastomisis also femoral vein week 12
freestyle'
FINAL SAMS ASSESSMENT
ACCEPTED MANUSCRIPT Table 2 Image
Description Pass an 8-0 needle through the eyes of a need sewing needle placed in a clockwork circle
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Model Name (a) Round the Clock (x)
Pass an 8-0 needle the perforations of a Mepitel ™ dressing moving horizontally. Yellow- forehand Green- backhand
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(b) In out Up down
Tie a knot around the hooks with the little digit immobilized by rubber bands attached to a board.
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(c )All tied up
(e) Suturing at angles
(f) Stars the limit
Four 1 cm incisions are made in a sheet of latex glove placed in a cardboard frame. Tie interrupted knots along the incision horizontally, vertically and at angles Incise within the black line of a standard drawn star on a grape. Use dissecting scissors to peal the star of
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TIME 45 second 4 minutes 40 seconds 25 seconds
Stars the Limit
2 minutes 25 seconds
Suturing at Angles End Loop Stitch
7 minutes 30 seconds 45 seconds
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Table 4 Mean Scores of each group. Control Group
23 (21-27) 25 (21-27)
Study Group 24 (21-27) 49 (40 - 55)
2 (1-3)
2 (1-3)
2(2-3)
4 (3-5)
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Initial SAMS Score Final SAMS score Initial Overall Score Final Overall Score
Table 4 Training models were reusable. Equipment
Cost
Microscope Carl Zeiss, Other
£10,000
microscopes eg leica (£8000), Brunel (£1600 ),
QUALITY
All knots satisfactory suture Line Accuracy =10/10, Fully dissected limb 5/5, number of perforations perforations All knots satisfactory All knots satisfactory
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TASK Round the Clock In out up down All Tied Up
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Table 3
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the flesh of the grape
Consultant Group 59 (55-59)
5 (4-5)
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Fridge
£150
Equipment Shelves
£50
Desks and Chairs
Provided without charge
Room
Provided without charge
Instruction posters
£100
All training models
£40
Total
£10,540
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Cost per candidate
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Sutures
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Table 5
Equipment
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Camera and and hard drive x 1
Cost £4 per suture – 20 sutures per candidate £40 per set
Cleaning Wipes
Need to find cost
Chicken thighs
£1.50 for 3 approx
Total
£120 + chicken thigh cost
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Micro instruments
Figure 1 Chicken vessels prepared with trainee completing an anastomosis
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Figure 2 Camera recording set up on tripod
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Figure 3 SAMS Rating Scale 59
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60 49
40 30
24
Study Group
25
23
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SAMS rating scale
50
Control Group
20
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10 0 Initial SAMS
Final SAMS
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Figure 4
Mean Senior Score
Overall performance score
4 3
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5
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Overall Perfomance Score
6
2
5
3.
2.
Study Group
2
Control Group
1 0
Overall score initial
Overall score final
Mean senior score
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Figure 5 Increase in SAMS score between study and control
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30
20
Study Group
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15
Control Group
10 5 0
Control Group
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Study Group
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Mean increase in SAMS
25
S1748-6815(17)30141-9
DOI:
10.1016/j.bjps.2017.03.009
Reference:
PRAS 5278
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 22 December 2016 Revised Date:
26 February 2017
Accepted Date: 7 March 2017
Please cite this article as: Masud D, Haram N, Moustaki M, Chow W, Saour S, Mohanna PN, Microsurgery Simulation Training System and Set up- An Essential System to Complement Every Training Programme, British Journal of Plastic Surgery (2017), doi: 10.1016/j.bjps.2017.03.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Microsurgery Simulation Training System and Set up- An Essential System to Complement Every Training Programme
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Dhalia Masud FRCS plast Microsurgery Institute 4 (MI4) Guys & St Thomas’ Hospital London SE1 7EH
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Nadine Haram MRCS Royal Free Hospital London, England
Whitney Chow MRCS Guys and St Thomas’ Hospital London, England
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Margarita Moustaki MBBS Guys and St Thomas’ Hospital London, England
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Samer Saour FRCS Plast St Andrews Plastic and Burns Centre Broomfield Hospital Chelmsford, England
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Pari Naz Mohanna FRCS plast Guys and St Thomas’ Hospital London, England
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CORRESPONDING AUTHOR Dhalia Masud FRCS plast [email protected] Microsurgery Institute 4 (MI4) Guys & St Thomas’ Hospital London UK Presentation •
Microsurgery training programme. D Masud, N Haram, P Mohanna Abstract presentation ACRM (Advances and Controversies in Reconstructive Microsurgery) 2016
•
A laboratory based microsurgical training programme to aid acquisition of Microsurgical Skills and help surgeons to objectify trainees level of proficiency SARS Meeting 2014, January (Abstract presentation) 1
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Abstract Introduction Microsurgical techniques are essential in Plastic Surgery but with changes in training, acquiring these skills can be difficult. To address this, we have
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designed a standardised laboratory-based microsurgical training programme which allows trainees to develop their dexterity, visuospatial ability, operative flow and judgement as separate components. Method Thirty trainees completed an initial
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microsurgical anastomosis on a chicken femoral artery assessed using the Structured Assessment of Microsurgical Skills (SAMS) method. The study group (n=18) then
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completed a three-month training programme whilst the control group (n=19) did not. A final anastomosis was completed by all trainees (n=30). Results The study group had a significant improvement in microsurgical technique assessed using the SAMS score when comparing initial and final scores (24 mean SAMS initial verses 49 mean
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SAMS final) p<0.05 Wilcoxan Rank test. The control group had a significantly lower rate of improvement (23 mean SAMS initial verse 25 mean SAMS final). There was still a significant difference between the final SAMS score of the study group
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compared to senior surgeons (49 mean study final SAMS verses 58 mean senior
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SAMS) Conclusion This validated programme is a safe, cost-effective and flexible method of allowing trainees to develop microsurgical skills in a non-pressured environment. In addition the objectified skills allow trainers to assess the trainees’ level of proficiency before operating on patients.
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ACCEPTED MANUSCRIPT Introduction
Microsurgical techniques are essential to reconstructive surgery. Research shows that flap failure can be associated with operator related technical errors (1), therefore comprehensive microsurgical training is essential. Constant scrutiny over theatre
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efficiency and productivity, stringent monitoring of surgical outcomes as well as restrictions on doctors working hours can result in training not fulfilling the trainees expectations or needs (2-4). Precisely for these reasons, it is important to ensure that
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trainee surgeons are proficient and efficient before operating on patients in theatre.
Simulation training has been a well recognised aid in developing surgical skills in a risk free environment (5-7) as well as eliminating the steep learning curve, novices
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often face (8,9). It is also recognised that skills acquired in this setting can be transferred to the operating theatre, thereby enhancing patient safety (8,9). Current microsurgical training programs are usually intensive training courses lasting a few days. (6,10-13). Basic microsurgical skill techniques have been described by Robert Acland (14) which has been the basis of many intensive training courses, however, if
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these skills are not regularly practiced there is decay of the acquired skills making mass learning on short courses, less effective than distributed learning on longer courses (,15,16).
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To address these needs we designed a microsurgical training programme that was incorporated into the trainees’ weekly timetable, allowing simulation training to occur
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in parallel with clinical training.
Materials and methods
Development of the training programme
A systematic literature review of the current methods available for microsurgical training was performed. Various simulation models for the human vessels have been devised including silicone tubes, rat femoral vessels, umbilical cords etc (10-13,1720), however, we found these impractical and expensive. Our aim was to design a training programme that allowed novices to build up their basic microsurgical skills 3
ACCEPTED MANUSCRIPT on specifically designed tasks before they are faced with the complex task of vessel anastomosis.
When devising our programme we ensured that the following criteria were met: 1) Self-assessment - trainees need to be able to monitor their own progress and
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modify the programme according to their strengths and weaknesses 2) Flexible training - the training programme had to revolve around the work patterns of both the trainees and trainers
3) Senior supervision - seniors had to be available to facilitate the training and to
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objectively assess trainees
4) Easily accessible and available - the equipment eg the microscopes,
trainees needs
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instruments and training models needed to be accessible 24/7 to suit the
5) Cost effective - as this was to be a continued training programme it was essential that the consumables were sourced such that they were cost effective and easy to order
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Using these criteria, we created a programme, which allows a graded acquisition of microsurgical skills from basic to more advance. As currently core trainees are spending four months in a plastic surgery rotation the programme was designed to run over a three-month period. The basic elements of microsurgery (Table 1) were
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judgment.
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identified as; needle dexterity, economy of movement, operative techniques and
These techniques were introduced sequentially, ensuring that trainees were not overwhelmed with the acquisition of the various components and were proficient in a specific skill before moving on.
Moreover, validated low fidelity models were
designed for the attainment of each of these skills (Table 2). The programme was reviewed by consultant microsurgeons to confirm comprehension and relevance.
Microsurgical Programme
4
ACCEPTED MANUSCRIPT All trainees attended an initial didactic teaching session given by a senior microsurgeon explaining the techniques, as described by Acland, (14) required for proficient microsurgery and taught how to use the microscope.
The structure of the three-month microsurgical programme involved an initial
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assessment to ascertain the trainees’ baseline level of microsurgical skills and a final assessment to evaluate the level of improvement. This involved anastomosis of a chicken femoral artery, which was filmed and evaluated. The anastomoses were recorded using a hand held camera on a flexible tripod (Figure 1). This provided an
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excellent view for visualising the vessels for training and assessment (Figure 2). Only the task area and the surgeons’ hands were video recorded, to ensure anonymity. These recordings were then scored by two independent assessors using the SAMS
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(Structured Assessment of Microsurgery Skills) scoring system (21). Each trainee was scored out of 60 on technique and the overall performance score out of 5, 1 being bad and 5 being excellent. Assessing whether the suture has caught the back wall is not part of the error list described by Chan et al (21), but this was added for the
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purpose of this study.
Following the initial assessment trainees commenced the programme. When they reached the target scores for each task they progressed to the next task.
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STEP 1. Needle Dexterity
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The first stage concentrates on steadiness and instrument handling, ensuring trainees are able to hold and manoeuvre the needle correctly. •
Round the clock task (Table 2a)
This is a recognised validated task, which can also be used as a warm up exercise (17,21). Sewing needles are arranged vertically in a clock face configuration by standing them in a piece of foam. Trainees were asked to pass an 8-0 needle though the eyes of the sewing needles. They needed to complete the task in 45 seconds before they were allowed to progress.
5
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In out up down (Table 2b)
This model was created by sandwiching a piece of Mepitel™ between two cardboard frames with standardised windows, which was then bent at an angle of 70 degrees. The trainees were asked to weave an 8-0 suture in and out of the Mepitel™ holes,
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going up one limb then down the other forehand and then repeating the exercise backhand. Trainees needed to complete the task in 2 minutes 40 seconds before they
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were allowed to progress.
STEP 2 Economy of movement
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Microsurgery involves operating in a narrow field. Our observations showed that novices had a tendency to hold their hands far apart leading to poor economy of movement, frequent inaccuracies and suture wastage. •
All tied up (Table 2c)
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This model educated the trainees to work in a narrow field by immobilising their little fingers in rubber bands fixed to a cardboard tray. With their hands in this position they were asked to tie instrument knots with an 8-0 nylon suture around hooks which had been fixed to the tray. Time to complete the knots and the quality of the knots
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were assessed. If a knot was deemed too loose and could easily be removed or fell off the hook then a score of 0 was given. If the knot sat securely after a tug with forceps a
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score of 1 was given. •
Suturing at angles task (Table 2d)
This model was created by sandwiching a piece of rubber glove in a cardboard frame with a standardised window measuring 10cm x 10cm. Four 1cm incisions were made at various angles. The trainees were asked to close the incisions with interrupted 8-0 nylon sutures placed, fronthand, backhand, vertically, horizontally and at angles. The time taken to complete the task and the quality of the knots were assessed. Trainees needed to complete the task in 7 minutes and 30 seconds with all of the knots being scored as 1 before they were allowed to progress.
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ACCEPTED MANUSCRIPT STEP 3 Operative flow
During microsurgery adequate vessel preparation and delicate tissue handling is
•
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crucial. This step in the programme combines the skills gained in step 1 and 2.
Stars the limit (Table 2e)
This model simulates fine tissue dissection. A standardised star is drawn onto the skin of a grape using a stencil. The trainees were asked to dissect the star shaped skin off
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the flesh of the grape. The task is scored according to the number of edges incised within the black lines, the number of perforations in the skin and the number of limbs of the star dissected with no grape flesh attached. Each star has 10 edges and 5 limbs.
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The trainee scores 1 point for every incision made within each marked edge with no deviation outside the mark, therefore scoring 10 when perfectly incised. The trainees also scored 1 point for every limb that is cleanly dissected using micro scissors with no grape flesh attached, therefore a further 5 scores when the star is cleanly dissected, giving a maximum score of 15. If a trainee inadvertently made a perforation 1 score
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was deducted for every perforation. Trainees must complete the task in 2 minutes and 25 seconds and achieve a score of 15 before progressing.
These tasks, were validated in terms of face, construct, content and criterion (22) by
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two senior Consultant Microsurgeons. Table 3 shows the target scores of each model before the trainees can progress to the next task. These were the mean times and
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scores of 13 senior microsurgeons after they had plateaued by repeating the tasks.
After developing the required competencies, trainees progressed to anastomosing the chicken femoral artery.
STEP 4 Operative judgment
Trainees observed the preparation of the chicken femoral artery by the trainer. Approximately 4-5 cm of vessel was prepared (Figure 1), before the artery was divided and stabilised in double clamps. The anastomosis was carried out using 8-0 7
ACCEPTED MANUSCRIPT nylon interrupted sutures. As trainees became more competent they progressed to an end to side anastomosis and then anastomosed vessels with a size discrepancy. During the first anastomosis a trainer was present, however as trainees became more confident they were able to self direct their training.
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Patency of the anastomosis was assessed using blackberry juice, as the colour contrast enhances the visibility of a leak. The juice was drawn up in a 5ml syringe and injected via a 25-gauge needle proximal to the anastomosis in between the clamps. The clamps may be placed further apart for easier access. The anastomosis was then cut
Methodology of study
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longitudinally to assess the quality of suture placement.
This was a prospective randomised control study. 42 trainees took part in the programme (5 medical students, 35 Senior House Officer level and 2 Junior House
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Officer level). All had either minimum or no microsurgical experience. All trainees attended the lecture and completed an initial femoral artery anastomosis, which was SAMS scored.
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Trainees where randomised to the training (n=18) or non-training (control) arm (n=19) of the study. The control group did not enter the training programme but
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continued with normal clinical duties. Those in the training arm entered the threemonth structured training programme.
For steps 3 and 4 trainees purchased their own chicken thighs at an approximate cost of £1.50 for three. We recommended trainees to practice for a minimum of 1-hour a week and take breaks after each hour of training. The laboratory with four microscopes was available 24 hours a day, 7 days a week. All control and study group trainees then completed a final chicken femoral artery anastomosis, which was filmed and scored.
Statistical analysis was carried out using SPSS software version 22.0. 8
ACCEPTED MANUSCRIPT Results
42 candidates were recruited at the start of the study, 5 dropped out due to poor attendance. Of the 37 remaining candidates, the average age was 28 years (range 23-
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39). There were 22 females and 15 males. There was no significant difference in either age or sex ratio between the study and the control groups.
There was no significant difference between the initial SAMS and initial overall
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performance scores between the study and control groups p>0.05 TTest (mean initial study group SAMS score was 24 (range 21-27) verses control group SAMS score 23
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(range 21-27)).
Study group results Table 4. Figures 3,4
In the Study group, the mean initial SAMS score was 24 (range 21-27). This increased to a mean final SAMS score of 49 (range 40 – 55) which was significant at p<0.05 with a paired Wilcoxon rank. There was also a significant improvement in the
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overall performance score (mean initial score 2 (range 1-3) to mean final score 3 (range 3-5)) p<0.05 with a paired Wilcoxon rank (Figures 3 and 4). Therefore all trainees in the study group showed a significant improvement.
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Control group results Table 4. Figures 3,4 The control group showed a smaller increase in their SAMS score when comparing
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their initial and final mean SAMS scores (mean initial SAMS of 23 (range 21-28) to mean final SAMS of 25 (range 22-36)) but this was also significant at p<0.05 with a paired Wilcoxon rank. Six trainees in the control group showed no improvement whilst the remaining improved and no trainees deteriorated. There was however no significant difference between the initial and final overall performance scores (mean initial overall score 2 (range 1-3) to mean final overall score 2 (range 2-3)) p>0.05 TTEST.
Study verses Control group results Table 4. Figures 3-5
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ACCEPTED MANUSCRIPT Although both the study and control groups showed an improvement in their SAMS scores, the study group had a significantly greater improvement with a mean increase of 25 (range 13-30) vs the control group’s mean increase of 1 (range 0-8) p<0.001 TTEST (Figure 5). The Study group also had a significantly higher final mean SAMS score of 49 (range 40 - 55) compared to the control group’s final SAMS score of 25
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(range 22-36) p<0.001 TTEST.
In addition there was a statistically significant difference in the final mean overall performance score between the two groups; study group mean 4 (range 3-5) verses the
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control mean 3 (range 2-3) p<0.05 TTEST (figure 4).
Despite the increase in their SAMS score the study group still scored significantly
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lower than the Consultant Microsurgeons both in their SAMS (mean 59) and overall performance scores (mean 5), p<0.05 TTEST (Figure 3 and 4).
DISCUSSION
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The current climate for surgical training has demanded a change in the way surgical skills are acquired. With increasing pressures on hospital efficiency as well as increasing complexity in the treatment options provided, there is a greater need to ensure that trainee surgeons are proficient before operating on patients in theatre. In
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addition, with improved safety measures in the industrial setting (23) leading to fewer hand trauma and replantation cases, trainee exposure to microsurgery is more limited.
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Simulation training is a recognized aid to surgical skills acquisition. A recent systematic review showed that skills acquired from simulated training on low fidelity models led to acquisition of transferable skills and improved technical performance (5-8)
Many models have been described as an aid to microsurgery training, ranging from low fidelity to high fidelity models. (9-14,18-20, 29-35). The latter can be expensive and current evidence shows that low fidelity models are as effective as high fidelity ones (5). Evidence has also shown that distributed learning is far more effective than short bursts of intensive training , allowing self directed microsurgical skill acquisition with prolonged skill retention (16,36,). 10
ACCEPTED MANUSCRIPT We aimed to address these challenges whilst imposing minimal burden to the hosting training unit. The distributed nature of the programme allows simulation training to occur in parallel with clinical training, thereby giving the trainers and trainees an opportunity to identify areas for skill development. The goal directed nature of the tasks allows trainees to monitor their own progression as well as allowing
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comparisons with peers. The tasks can also be used as quick warm up exercises prior to the start of a microsurgical case.
The programme was tested with junior plastic surgical trainees. There was a clear
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improvement in skill acquisition in the study group with a statistically significant increase in their average SAMS score. In addition, the study group’s final SAMS
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score was significantly greater than that of the control group. These results therefore highlight the significant benefit of simulation training in parallel to clinical training. Furthermore the results show that with regular practice, the programme can potentially allow trainees to reach seniority in skill acquisition earlier than those not using the programme.
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Despite the significant improvement in scores, the study group’s score was still lower than consultants, emphasizing a need for continuous and further training. The programme is cost effective as most of the models are re-usable and the
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equipment needed to build them is readily available (card, sewing needle, mepitel™ dressing, sponge) requiring minimal set-up or preparation. The most expensive component is the tabletop microscopes however, these are a one-off purchase and
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subsequently more cost effective microscopes were sourced providing suitable quality for the programme (Table 5). The instruments were designed to be disposable but were reused during the programme (Table 6). The success of our programme is dependent on a proactive department making available, time, space, microsurgical expertise and resources for trainees, as well as trainees making time and taking advantage of the available resources. Specific to our programme was the ability to self-assess and monitor progress objectively. Senior microsurgeons provided training at relevant points in the programme but not constantly, thereby allowing trainees independance. 11
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The accessibility to the microscopes by local trainees was a crucial factor in the success of the programme. The laboratory is located within the department allowing constant access. Many trainees made impromptu training sessions during occasional
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quiet periods as well as in the evenings and weekends.
The obvious disadvantage of the programme is that the laboratory is an ex-vivo
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setting. In addition, although trainees may become proficient in the technical aspects of microsurgery, there are elements of microsurgical decision-making that cannot be replicated in the laboratory. Therefore the programme is designed to work in
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conjunction with clinical practice and to optimise the skills learnt in the operating theatre. Further studies are being undertaken to assess the decay in skills acquired after completion of the three-month programme.
Feedback from Consultants and a departmental review of the programme demonstrated a recognized improvement in the trainee’s microsurgical skills in the
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operating theatre. This recognition has led to the programme being incorporated into the weekly timetable of the trainees. As a result of these findings, the programme has been adopted in multiple units throughout the United Kingdom with plans to allow national peer comparison and assessment. Therefore trainees will be able to maintain
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and further develop their skills as they rotate through various units.
In the current NHS, acquisition and practice of microsurgical skills should not be solely dependant on the time spent in the operating theatre. Our microsurgical training programme allows trainees to self-direct development of their microsurgical skills, in a controlled stress free environment, ensuring that they are ready and confident to perform these continually progressive procedures.
Conflict of interest: none Funding: none
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ACCEPTED MANUSCRIPT doi: 10.1002/micr.20541. also programme 13. Penn protocol Creating, developing and mastering a superior microsurgical technique. By Ronald Berezniak, Ph.D., 126 pages, Sharpoint Inc., 1991 (page 163) Kenneth E. Korber Article first published online: 19 OCT 2005 | DOI: 10.1002/micr.1920130313
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microsurgical training: a new point of view.Microsurgery. 2010 Sep;30(6):505-6. doi: 10.1002/micr.20785 drill
32. Takeuchi M, Hayashi N, Hamada H, Matsumura N, Nishijo H, Endo S.A new training method to improve deep microsurgical skills using a mannequin head.Microsurgery. 2008;28(3):168-70. doi: 10.1002/micr.20473.PMID: 18286651 [PubMed - indexed for MEDLINE] drill 33. Dustagheer S, Brown AP Synthetic latex conduits as an aid for microsurgical training. Plast Reconstr Surg. 2008 Jul;122(1):321. doi: 10.1097/PRS.0b013e31817743fd. No abstract available.PMID: 18594437 [PubMed - indexed for MEDLINE] 34. Klein I, Steger U, Timmermann W, Thiede A, Gassel HJ. Microsurgical 15
ACCEPTED MANUSCRIPT training course for clinicians and scientists at a German University hospital: a 10-year experience Microsurgery. 2003;23(5):461-5 35. Lossing AG, Hatswell EM, Gilas T, Reznick RK, Smith LC. A technical-skills course for 1st-year residents in general surgery: a descriptive study Can J Surg. 1992 Oct;35(5):536-40. Also value of bench model and technical skills
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36. Barbe, Walter Burke; Milone, Michael N. (February 1981). "What we know about modality strengths" (PDF). Educational Leadership (Association for
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Supervision and Curriculum Development): 378–380.
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ACCEPTED MANUSCRIPT Figures and tables Table 1
NEEDLE DEXTERITY
Repeat 'round the clock'
Step 2 ECONOMY OF MOVEMENT
Week 2 1 x Round the clock Repeat 'up down in out'
Week 4
Week 5 1 x 'stars the limit' repeat 'suturing at angles'
Repeat 'Stars the limit' also any weak tasks from STAGE 1
Week 7
OPERATIVE FLOW
Femoral artery anastomosis
concept of Acland test
Week 11
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OPERATIVE JUDGMENT
Week 10 vessel discrepancy (vein to artery/ profunda to femoral artery)
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Step 4
Week 8 Dissection of femoral artery Femoral artery anastomosis if competant
1 x 'Round the clock' to start 1 x 'up down in out' Repeat 'all tied up' Week 6
1 x 'stars the limit'
1 x 'suturing at angles' repeat 'end is near' Week 9
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Step 3
Week 3
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Week 1
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Step 1
arteriotomy end to side anastomosis '
Dissection of femoral artery
Femoral vein anastomisis also femoral vein week 12
freestyle'
FINAL SAMS ASSESSMENT
ACCEPTED MANUSCRIPT Table 2 Image
Description Pass an 8-0 needle through the eyes of a need sewing needle placed in a clockwork circle
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Model Name (a) Round the Clock (x)
Pass an 8-0 needle the perforations of a Mepitel ™ dressing moving horizontally. Yellow- forehand Green- backhand
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(b) In out Up down
Tie a knot around the hooks with the little digit immobilized by rubber bands attached to a board.
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(c )All tied up
(e) Suturing at angles
(f) Stars the limit
Four 1 cm incisions are made in a sheet of latex glove placed in a cardboard frame. Tie interrupted knots along the incision horizontally, vertically and at angles Incise within the black line of a standard drawn star on a grape. Use dissecting scissors to peal the star of
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TIME 45 second 4 minutes 40 seconds 25 seconds
Stars the Limit
2 minutes 25 seconds
Suturing at Angles End Loop Stitch
7 minutes 30 seconds 45 seconds
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Table 4 Mean Scores of each group. Control Group
23 (21-27) 25 (21-27)
Study Group 24 (21-27) 49 (40 - 55)
2 (1-3)
2 (1-3)
2(2-3)
4 (3-5)
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Initial SAMS Score Final SAMS score Initial Overall Score Final Overall Score
Table 4 Training models were reusable. Equipment
Cost
Microscope Carl Zeiss, Other
£10,000
microscopes eg leica (£8000), Brunel (£1600 ),
QUALITY
All knots satisfactory suture Line Accuracy =10/10, Fully dissected limb 5/5, number of perforations perforations All knots satisfactory All knots satisfactory
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TASK Round the Clock In out up down All Tied Up
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Table 3
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the flesh of the grape
Consultant Group 59 (55-59)
5 (4-5)
ACCEPTED MANUSCRIPT £200
Fridge
£150
Equipment Shelves
£50
Desks and Chairs
Provided without charge
Room
Provided without charge
Instruction posters
£100
All training models
£40
Total
£10,540
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Cost per candidate
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Sutures
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Table 5
Equipment
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Camera and and hard drive x 1
Cost £4 per suture – 20 sutures per candidate £40 per set
Cleaning Wipes
Need to find cost
Chicken thighs
£1.50 for 3 approx
Total
£120 + chicken thigh cost
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Micro instruments
Figure 1 Chicken vessels prepared with trainee completing an anastomosis
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Figure 2 Camera recording set up on tripod
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Figure 3 SAMS Rating Scale 59
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60 49
40 30
24
Study Group
25
23
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SAMS rating scale
50
Control Group
20
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10 0 Initial SAMS
Final SAMS
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Figure 4
Mean Senior Score
Overall performance score
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Overall Perfomance Score
6
2
5
3.
2.
Study Group
2
Control Group
1 0
Overall score initial
Overall score final
Mean senior score
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Figure 5 Increase in SAMS score between study and control
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30
20
Study Group
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15
Control Group
10 5 0
Control Group
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Mean increase in SAMS
25