The Flower Petal Training System in Microsurgery

Abstract

Introduction: Despite hundreds of training models for microsurgery being available in the literature, very few of them are scientifically validated. We chose to validate our low-fidelity training model on flower petals by comparing it headto-head with a moderate fidelity training model, the anastomosis on chicken leg femoral artery. Materials and methods: A total of 16 participants of different levels of expertise were randomized into 2 groups, 1 training on flower petals and 1 on chicken leg femoral arteries. The groups were evaluated on performing a rat femoral artery anastomosis using the validated Stanford Microsurgical Assessment (SMaRT) Scale. The Mann-Whitney U test was used to check for statistically significant differences between the groups. The flower petal sutures were also evaluated and Pearson correlation was used to check for associations between better petal anastomosis scores and better final SMaRT results. Results: After 6 weeks of flower petal training, microsurgical trainees had significantly better overall SMaRT scores than trainees using chicken leg training, better fine tissue feeling, and better scores in knot tying. The anastomosis times for the rat femoral arteries did not differ between the 2 groups. Good scores for flower petals strongly correlated with a better SMaRT score for the anastomosis. The number of rats used in training reduced after the implementation of this model in continuous training. Conclusions: The flower petal technique, despite being a low-fidelity model, shows superiority in developing fine tissue feeling and improved knot tying in microsurgery beginners and intermediate level practitioners adding this training model to their program. Further research needs to establish if the improvements also apply to already seasoned microsurgeons and whether the petal score has predictive value for future clinical application.

Reduction of the Number of Live Animals Used for Microsurgical Skill Acquisition: An Experimental Randomized Noninferiority Trial

“…Although there are several publications that support low-fidelity models for training 1 15 17 18 and the importance of a learning curve when performing microvascular anastomosis, 13 19 a specific training program which may be followed by a novice in microsurgery has not yet been described. The aim of the present study was to compare the efficiency of groups working on additional laboratory rats, not to explore the differences between working on a murine or an alternative model.…”

“…Each anastomosis and each flower petal suturing were assessed by blinded outcome assessors, all expert microsurgeons (> 10 years of experience in microsurgery and in evaluating microsurgical results). The flower petals were evaluated according to the validated model published in Volovici et al, 15 (see Appendix A ) the procedures on laboratory rats were evaluated using the Stanford Microsurgery and Resident Training (SMaRT) scale, 16 (see Appendix B ) and the procedures on chicken legs were evaluated according to the validated scale used in our laboratory for evaluation of end-to-end anastomoses, as shown in Table 2 .…”

“…The time required to perform these procedures was evaluated, alongside the end result, according to the scales developed internally and published. 15 Thirteen students were evaluated, of which four students were excluded due to a significantly higher microsurgical skill level. The nine remaining students were subsequently randomized using a computer program into three arms, based on the number of live rats they would train on: group A (training on a live rat every 4 weeks), group B (training on a live rat every 6 weeks), and group C (training on a live rat every 8 weeks).…”

“…Previous studies have attempted to compare low- and moderate-fidelity models to the live rat model, but no research endeavor so far has focused on systematically addressing the minimal number of live rats necessary for durable skill acquisition. 1 2 3 4 5 6 9 10 11 12 13 14 15…”

Studies of Microsurgical Skill—The Key Lies in the Design

“…We are firm believers that tremor, while inevitable, can be trained using a dedicated microsurgical program supervised by experienced microsurgical teachers . This holds true even for anastomoses of vessels smaller than 0.5 mm or toe-to-thumb transfer in rats.…”