Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators

Abstract

Fetoscopic laser coagulation of arterio-venous anastomoses (AVA) in a monochorionic placenta is the standard of care for twin-twin transfusion syndrome (TTTS), but is technically challenging and can lead to significant complications. Acquiring and maintaining the necessary surgical skills require consistent practice, a critical caseload, and time. Training on realistic surgical simulators can potentially shorten this steep learning curve and enables several proceduralists to acquire procedure-specific skills simultaneously. Here we describe realistic simulators designed to allow the user familiarity with the equipment and specific steps required in the surgical treatment of TTTS, including fetoscopic handling, approaches to anterior and posterior placenta, recognition of anastomoses, and efficient coagulation of vessels. We describe the skills that are especially important in conducting placental laser coagulation that the surgeon can practice on the model and apply in a clinical case. These models can be adapted easily depending on the availability of materials and require standard fetoscopy equipment. Such training systems are complementary to traditional surgical apprenticeships and can be useful aids for fetal medicine units that provide this clinical service.

Mentoring a surgical team towards procedural competence in the early learning curve for selective fetoscopic laser photocoagulation

“…(3) The multidisciplinary team consisted of fetal therapists, maternal-fetal medicine specialists, obstetric anaesthetists, nurse specialists and administrative support staff, who had prepared for this clinical service together with workflow drills and training on high-fidelity models. (7,19) Patients were informed upfront about the relative inexperience of the surgical team and the on-site or telepresence of the overseas-based surgeon-mentors for support and supervision. All patients provided written informed consent for the SFLP, video recording, photography and placental dye studies, and agreed to the mentoring arrangement.…”

“…Pre-procedural planning involved placental and vascular equator mapping to determine the point of fetoscope entry. (7,19) Surgery was scheduled as soon as the mentor could travel to our centre; when this was not possible, real-time telementoring was arranged via multiple-user internet teleconferencing applications Skype (Skype Technologies SARL, Palo Alto, CA, USA) and WhatsApp (WhatsApp Inc, Mountain View, CA, USA) over fourth-generation (4G) broadband cellular networks, as the operating room was not equipped for formal videoconferencing. Fetoscopic images were captured directly from the screen and transmitted to the mentor, who was able to follow the entire surgery and advise on the proceedings.…”

“…Patient position and choice of fetoscope (curved or straight; Karl Storz Endoskope Berlin GmbH, Berlin, Germany) were determined by placental location, and surgical team members performed specific roles, as previously described. (7,19) Selective ablation of all identified AVAs along the vascular equator was achieved using a 400-μm or 600-μm diode laser at 15-30 W (Medilas D Multibeam; Dornier MedTech Asia, Singapore), followed by ablation of residual superficial anastomoses across the vascular equator from one placental margin to the other (Solomon technique), if technically feasible, to minimise the risk of post-SFLP TAPS. (32) Bleeding from ablated AVAs was handled using coagulation of feeder vessels and by applying transabdominal pressure to achieve a tamponade effect.…”

“…(15)(16)(17)(18) Continued off-site mentoring after the initial training phase, combined with skills practice on high-fidelity models and competence-based assessments, can be an effective strategy to overcome the aforementioned situational limitations and ensure that procedural competence is maintained beyond the period of formal training. (19)(20)(21)(22) We have previously described our team-based approach to implementing SFLP, which relied on model practice and stepwise skills learning with an on-site ('hands-off') proctor for the first three cases performed at our institution. (7) We herein discuss a natural extension of this arrangement to include continued off-site mentoring for the second phase of cases, leading to independent surgery without a stand-by mentor, updating the 'see one, do one, teach one' approach.…”

A novel “video‐game” simulator for training fetoscopic laser coagulation of anastomoses in twin‐to‐twin transfusion syndrome

“…2 Surgical training with twin-twin simulators has been proposed in order to help centres meet these challenges. Recent publications have described TTTS simulators, both physical 3,4 and digital. [5][6][7] We present a report of trainee satisfaction comparing two customized TTTS simulators designed at our institution: an established high-fidelity silicone mannequin and a novel digital "video game" phantom.…”