Simulating the IMA Recipient Site for DIEP Flap Surgery: A New Model for Dynamic Microsurgery Simulation with Real-Time Respiration and a Pilot Study

Abstract

Background Breast reconstruction (BR) using autologous free flaps has been shown to have numerous psychosocial and quality-of-life benefits. Unfortunately, the microsurgical learning curve is quite steep due to some unique operative challenges. Currently, there is no realistic simulation model that captures real-life respiratory excursion and the depth of internal mammary vessels within the compact recipient site. The purpose of this study was to delineate intraoperative measurements of depth and motion, describe the resulting simulation model, and conduct a pilot study evaluating the simulator as an educational resource. Methods This is a single-center, ethics-approved study. For the intraoperative measurements, all consecutive patients undergoing free flap BR using internal mammary vessels as recipients were recruited. Patient and intraoperative factors as well as intraoperative measurements were recorded. A dynamic model was developed based on intraoperative parameters. For the pilot study, plastic and reconstructive surgery trainees were recruited to complete a hand-sewn internal mammary artery (IMA) anastomosis using the new simulator and completed objective questionnaires pre- and postsimulation. Subjective feedback was recorded and themes determined. Results Fifteen operative sites were analyzed. Flap pocket was found to be between 4 and 5 cm in depth with vertical excursion of 3.7 ± 1.0mm and a respiratory rate of 9 to 14 breaths/minute. Previous radiation, rib space, body mass index (BMI), blood pressure, heart rate, tidal volume, and respiratory rate showed no correlation to vessel depth/excursion. Laterality, rib space, BMI, radiation, vitals, and tidal volume had no correlation with vessel movement. Twenty-two trainees were included in the pilot. An increase in confidence and mixed results for anxiety was reported. Conclusion This study reports a novel microsurgical simulation model that provides a realistic deep inferior epigastric perforator free flap BR IMA anastomosis experience. It replicates movement of vessels in situ with real-time respiratory excursion and similar physical structures of the internal mammary system. This model shows promising results for increased use in microsurgical education.

Innovative Clinical Scenario Simulator for Step-by-Step Microsurgical Training

“…In our simulator, the inner baffling rods imitate deep and narrow diastema such as the oral cavity, intercostal space, and intracranial space, which trains novices to handle microsurgical instruments dexterously and rotate their wrists flexibly. Based on our clinical experience and literature report, 16 we set the training height of the inner baffling rods to be 5 cm, which is deep enough to cover most cavities in microsurgery. A study reported by Chauhan et al also noticed the importance of practicing vessel anastomosis in a deep cavity; however, the study only used single constrained factor and synthetic vessel material.…”

“…However, since the model was modified from a Medical SimMan, the cost was really high. 17 Furthermore, in our device, the combination of these artificial obstacles enhances the degree of training difficulty while replicating authentic microsurgical scenarios as accurately as possible. This article is protected by copyright.…”

“…Based on our clinical experience and literature report 17 , we set the training height of the inner baffling rods to be 5 cm, which is deep This article is protected by copyright. All rights reserved.…”

Blue-Blood Pig Thorax Model Increases Residents' Confidence in Internal Mammary Dissection

“…Ziolkowski et al recently published a pilot study of a novel, fully synthetic, DIEP flap IMA anastomosis surgical simulator. 25 This model focused on providing authentic simulation of chest excursion that occurs during natural breathing of a patient while completing the surgical anastomosis of this procedure. The authors demonstrated residents had an increase in confidence performing anastomoses after practice on the simulator, highlighting the importance of surgical simulation in the acquisition of the specific skills of insetting a DIEP flap and improving confidence prior to the operating theater.…”