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Microsurgical Technical Training: Differences Between China and the United States
Microsurgery: Global Perspectives
I have been fortunate to work in two different countries in treating hand-related trauma and disorders, in which microvascular anastomosis is sometimes necessary. Though surgeons in both China and United States are considered to have advanced microsurgical techniques—and might themselves assume their practices are quite similar—in fact, I have noticed differences in their training, judgment, and practice in these two quite dissimilar cultures.
TRAINING Training in microvascular anastomosis is commonly included at the very beginning of the training of hand surgeons, mostly during orthopedic surgery residency in China, because orthopedic surgeons commonly perform soft tissue reconstructions and any on-call resident is likely to need to connect vessels during his or her third or fourth year of residency. Rat tails are usually used for practice, because the vessels are long and can be repaired at each segment under an operating microscope. Clinically digital replantation is usually performed by rather young surgeons, from fourth-year residents to junior attendings. However, there is no requirement that an attending be present for replantation; if the attending surgeon considers a senior resident sufficiently proficient, the attending may not scrub. If trauma is extensive or more than one digit are severed, replantation is usually performed by a team of two or three attending surgeons with assistants. Replantation is also done very frequently in non–teaching hospitals: one attending surgeon usually works with two assistants (hand or non–hand surgeons). Thus, training of microsurgical anastomosis is routine during very early hand surgery training. Consequently, one may also find some young surgeons who are very proficient at vascular anastomosis, yet still just beginning to learn classic hand surgery. In the United States, orthopedic or plastic surgery residents are often more exposed to classical hand surgery, but practice and training in microvascular anastomosis are usually
Clin Plastic Surg 44 (2017) xvii–xviii http://dx.doi.org/10.1016/j.cps.2017.01.002 0094-1298/17/Ó 2017 Published by Elsevier Inc.
delayed compared with those in the Chinese system; such training is also less mandatory in the United States than it is in China. When I compare residents at year four or five, I feel that those in the United States have much greater knowledge of disease classification and the mechanics of deformities in the hand, but some have had few opportunities to use microscopes and are virtually unable to dissect under a microscope. In contrast, after 4 or 5 years, it is common for a Chinese surgeon in a hand surgery center to perform a skillful replantation and to be very comfortable with microscopic dissection. These differences reflect variations in the requirements set by the department or training program in either country. Proficiency of microsurgical skills at expert levels likely is very similar in the two countries and in top microsurgical institutes training of residents and fellows under master surgeons likely is equally excellent in either country, but trainings in microsurgical skills differ greatly in general in the two countries. I believe that both countries would benefit from being aware of these differences in emphasis. In observing a young surgeon who skillfully performs a free flap transfer or a complex multiple digital replantation in China, one should not assume he or she is equally skillful in tendon transfer or secondary reconstruction of an extensor tendon defect. When a senior resident or junior hand surgeon in the United States impresses you with a wonderful presentation and systematic explanation of a topic of classic hand surgery, you should not assume he or she would impress you similarly with dissection under a microscope. Training background and culture are different; young residents and surgeons are more outspoken in the United States, while asian culture dictates residents and young surgeons speak less and be more silent in clinical or training settings. Some skilled surgeons in China often refrain from extensive speaking. Such cultural influences are seen not only in China but also in Japan and Korea. Understanding the differences enhances communication and exchanges across continents.
plasticsurgery.theclinics.com
Editorial M i c ro s u r g i c a l Tec h n i c a l Tr a i n i n g : D i ffe re n c e s B e t w e e n C h i n a a n d th e United States
xviii
Editorial CLINICAL JUDGMENT Young surgeons in the United States often rely heavily on Doppler signal to assess vascular perfusion, while Chinese young surgeons are much less reliant on this technology. If distal tissue perfusion is good, there is no need to use Doppler, but if distal perfusion is poor (judged by capillary refill and tissue color), the vascular supply is certainly insufficient. Doppler is only useful in judging where the blood flow stops in relatively large vessels, but terminal branches do not create blood flow to make the Doppler work reliably. Chinese microsurgeons consider it a waste of time to try to detect blood flow signal at fingertip, where the capillary flow in the pulp and nailbed is so easily assessable. I see some surgeons in the United States become suspicious about the patency of blood flow in the hand, if they do not detect a signal, though the fingertips are well perfused. Many Chinese microsurgeons consider the American colleagues (especially young colleagues) too reliant on “machines” to test, neglecting more plain clinical signs to make judgments. Judgments regarding tissue color also sometimes differ between the two countries. A certain degree of venous congestion is common in the 2 or 3 days after surgery. The color of the replanted part is not always normal within a few days after surgery; such suboptimal color could make less experienced surgeons worry, which is unnecessary.
NUMBERS OF MICROSURGEONS AND VOLUME OF PRACTICE The annual meeting of the American Society for Reconstructive Microsurgery currently draws around 300 attendees; though this apparently is not the total number of microsurgeons in the United States, it may provide an estimate. There are a number of excellent training centers in the United States with high volumes of elective cases or emergency microsurgical cases. The analogous Chinese microsurgery society meeting is attended by 1500 to over 1800 surgeons currently. The population of China is more than four times that of the United States. The volume of trauma-related microsurgical procedures is dramatically larger in China due to the size of the population and the resultant larger number of traumatic injuries to factory workers or farmers and traffic accidents. These differences render much greater chances for training of microsurgical skills in China. In a very recent endeavor to pursue further microsurgical skills, Dr Reena Bhatt from Brown University spent a 6-week academic sabbatical at Shandong Provincial Hospital in Jinan, China in
September and October 2016; she participated in replanting multiple digits and extremities at this single microsurgical center in 6 weeks. During these 6 weeks, this center replanted 96 digits with 1 failure. This implies that this center performs 16 digital replants in a week, or the number of such cases at her home institution over 6 to 8 years. Dr Bhatt noted that the Chinese team use brachial blocks with sedation as their preferred anesthesia in replantation. Their approach is with teams of surgeons to reduce fatigue. She recognized the immense dexterity and focus on efficient and sharp debridement with irrigation. Replantation of multilevel amputations is routine when feasible. Often free tissue transfers, including small perforator based glabrous flaps, are used immediately for soft tissue coverage as indicated. Intravenous infusion of Dextran is in routine use after replantation. The Shandong team is experienced enough to reliably predict survival of replanted digits; 95 out of 96 replanted digits survived, with the one failure predicted but attempted in a child with four finger multilevel trauma. Difficult replantation becomes a predictable surgery with their experience. This microsurgical center is now open to overseas microsurgeons for fellowship training and shortterm visits for concentrated experience and training. Trainees can participate in any replantation cases on call, and multiple flap surgeries are also performed in the emergency setting. It appears that actual working experience is the best indicator of the state of microsurgery, and certainly institutes within each country will differ. It is clear that more profound understanding will come from actual on-site visits and spending days or weeks observing surgeries (participating in surgery and performing vascular anastomoses as a visiting surgeon is permitted in China). This featured essay is aimed to encourage microsurgeons across the Pacific Ocean—presumably in the two countries with the largest number of practicing microsurgeons—to understand each other better through initiating another level of communication and opening a new avenue of cooperative training for future generations of microsurgeons. Jin Bo Tang, MD Department of Hand Surgery Affiliated Hospital of Nantong University The Hand Surgery Research Center Nantong University 20 West Temple Road Nantong 226001, Jiangsu, China E-mail address: [email protected]
I have been fortunate to work in two different countries in treating hand-related trauma and disorders, in which microvascular anastomosis is sometimes necessary. Though surgeons in both China and United States are considered to have advanced microsurgical techniques—and might themselves assume their practices are quite similar—in fact, I have noticed differences in their training, judgment, and practice in these two quite dissimilar cultures.
TRAINING Training in microvascular anastomosis is commonly included at the very beginning of the training of hand surgeons, mostly during orthopedic surgery residency in China, because orthopedic surgeons commonly perform soft tissue reconstructions and any on-call resident is likely to need to connect vessels during his or her third or fourth year of residency. Rat tails are usually used for practice, because the vessels are long and can be repaired at each segment under an operating microscope. Clinically digital replantation is usually performed by rather young surgeons, from fourth-year residents to junior attendings. However, there is no requirement that an attending be present for replantation; if the attending surgeon considers a senior resident sufficiently proficient, the attending may not scrub. If trauma is extensive or more than one digit are severed, replantation is usually performed by a team of two or three attending surgeons with assistants. Replantation is also done very frequently in non–teaching hospitals: one attending surgeon usually works with two assistants (hand or non–hand surgeons). Thus, training of microsurgical anastomosis is routine during very early hand surgery training. Consequently, one may also find some young surgeons who are very proficient at vascular anastomosis, yet still just beginning to learn classic hand surgery. In the United States, orthopedic or plastic surgery residents are often more exposed to classical hand surgery, but practice and training in microvascular anastomosis are usually
Clin Plastic Surg 44 (2017) xvii–xviii http://dx.doi.org/10.1016/j.cps.2017.01.002 0094-1298/17/Ó 2017 Published by Elsevier Inc.
delayed compared with those in the Chinese system; such training is also less mandatory in the United States than it is in China. When I compare residents at year four or five, I feel that those in the United States have much greater knowledge of disease classification and the mechanics of deformities in the hand, but some have had few opportunities to use microscopes and are virtually unable to dissect under a microscope. In contrast, after 4 or 5 years, it is common for a Chinese surgeon in a hand surgery center to perform a skillful replantation and to be very comfortable with microscopic dissection. These differences reflect variations in the requirements set by the department or training program in either country. Proficiency of microsurgical skills at expert levels likely is very similar in the two countries and in top microsurgical institutes training of residents and fellows under master surgeons likely is equally excellent in either country, but trainings in microsurgical skills differ greatly in general in the two countries. I believe that both countries would benefit from being aware of these differences in emphasis. In observing a young surgeon who skillfully performs a free flap transfer or a complex multiple digital replantation in China, one should not assume he or she is equally skillful in tendon transfer or secondary reconstruction of an extensor tendon defect. When a senior resident or junior hand surgeon in the United States impresses you with a wonderful presentation and systematic explanation of a topic of classic hand surgery, you should not assume he or she would impress you similarly with dissection under a microscope. Training background and culture are different; young residents and surgeons are more outspoken in the United States, while asian culture dictates residents and young surgeons speak less and be more silent in clinical or training settings. Some skilled surgeons in China often refrain from extensive speaking. Such cultural influences are seen not only in China but also in Japan and Korea. Understanding the differences enhances communication and exchanges across continents.
plasticsurgery.theclinics.com
Editorial M i c ro s u r g i c a l Tec h n i c a l Tr a i n i n g : D i ffe re n c e s B e t w e e n C h i n a a n d th e United States
xviii
Editorial CLINICAL JUDGMENT Young surgeons in the United States often rely heavily on Doppler signal to assess vascular perfusion, while Chinese young surgeons are much less reliant on this technology. If distal tissue perfusion is good, there is no need to use Doppler, but if distal perfusion is poor (judged by capillary refill and tissue color), the vascular supply is certainly insufficient. Doppler is only useful in judging where the blood flow stops in relatively large vessels, but terminal branches do not create blood flow to make the Doppler work reliably. Chinese microsurgeons consider it a waste of time to try to detect blood flow signal at fingertip, where the capillary flow in the pulp and nailbed is so easily assessable. I see some surgeons in the United States become suspicious about the patency of blood flow in the hand, if they do not detect a signal, though the fingertips are well perfused. Many Chinese microsurgeons consider the American colleagues (especially young colleagues) too reliant on “machines” to test, neglecting more plain clinical signs to make judgments. Judgments regarding tissue color also sometimes differ between the two countries. A certain degree of venous congestion is common in the 2 or 3 days after surgery. The color of the replanted part is not always normal within a few days after surgery; such suboptimal color could make less experienced surgeons worry, which is unnecessary.
NUMBERS OF MICROSURGEONS AND VOLUME OF PRACTICE The annual meeting of the American Society for Reconstructive Microsurgery currently draws around 300 attendees; though this apparently is not the total number of microsurgeons in the United States, it may provide an estimate. There are a number of excellent training centers in the United States with high volumes of elective cases or emergency microsurgical cases. The analogous Chinese microsurgery society meeting is attended by 1500 to over 1800 surgeons currently. The population of China is more than four times that of the United States. The volume of trauma-related microsurgical procedures is dramatically larger in China due to the size of the population and the resultant larger number of traumatic injuries to factory workers or farmers and traffic accidents. These differences render much greater chances for training of microsurgical skills in China. In a very recent endeavor to pursue further microsurgical skills, Dr Reena Bhatt from Brown University spent a 6-week academic sabbatical at Shandong Provincial Hospital in Jinan, China in
September and October 2016; she participated in replanting multiple digits and extremities at this single microsurgical center in 6 weeks. During these 6 weeks, this center replanted 96 digits with 1 failure. This implies that this center performs 16 digital replants in a week, or the number of such cases at her home institution over 6 to 8 years. Dr Bhatt noted that the Chinese team use brachial blocks with sedation as their preferred anesthesia in replantation. Their approach is with teams of surgeons to reduce fatigue. She recognized the immense dexterity and focus on efficient and sharp debridement with irrigation. Replantation of multilevel amputations is routine when feasible. Often free tissue transfers, including small perforator based glabrous flaps, are used immediately for soft tissue coverage as indicated. Intravenous infusion of Dextran is in routine use after replantation. The Shandong team is experienced enough to reliably predict survival of replanted digits; 95 out of 96 replanted digits survived, with the one failure predicted but attempted in a child with four finger multilevel trauma. Difficult replantation becomes a predictable surgery with their experience. This microsurgical center is now open to overseas microsurgeons for fellowship training and shortterm visits for concentrated experience and training. Trainees can participate in any replantation cases on call, and multiple flap surgeries are also performed in the emergency setting. It appears that actual working experience is the best indicator of the state of microsurgery, and certainly institutes within each country will differ. It is clear that more profound understanding will come from actual on-site visits and spending days or weeks observing surgeries (participating in surgery and performing vascular anastomoses as a visiting surgeon is permitted in China). This featured essay is aimed to encourage microsurgeons across the Pacific Ocean—presumably in the two countries with the largest number of practicing microsurgeons—to understand each other better through initiating another level of communication and opening a new avenue of cooperative training for future generations of microsurgeons. Jin Bo Tang, MD Department of Hand Surgery Affiliated Hospital of Nantong University The Hand Surgery Research Center Nantong University 20 West Temple Road Nantong 226001, Jiangsu, China E-mail address: [email protected]