Robotically Assisted Microsurgery: Development of Basic Skills Course

Robotically assisted microsurgery or telemicrosurgery is a new technique using robotic telemanip­ulators. This allows for the addition of optical magnification (which defines conventional micro­surgery) to robotic instrument arms to allow the microsurgeon to perform complex microsurgical procedures. There are several possible applications for this platform in various microsurgical disciplines. Since 2009, basic skills training courses have been organized by the Robotic Assisted Microsurgical and Endoscopic Society. These basic courses are performed on training models in five levels of increasing complexity. This paper reviews the current state of the art in roboti­cally asisted microsurgical training

Robotically Assisted Microsurgery: Development of Basic Skills Course

Robotically assisted microsurgery or telemicrosurgery is a new technique using robotic telemanipulators. This allows for the addition of optical magnification (which defines conventional microsurgery) to robotic instrument arms to allow the microsurgeon to perform complex microsurgical procedures. There are several possible applications for this platform in various microsurgical disciplines. Since 2009, basic skills training courses have been organized by the Robotic Assisted Microsurgical and Endoscopic Society. These basic courses are performed on training models in five levels of increasing complexity. This paper reviews the current state of the art in robotically asisted microsurgical training

A prospective study of preoperative computed tomographic angiography for head and neck reconstruction with anterolateral thigh flaps

Background: During anterolateral thigh flap harvest, inadequate perforators may necessitate modification of the flap design, exploration of the contralateral thigh, or additional flap harvest. Computed tomographic angiography may facilitate perforator mapping and optimize flap design. The authors performed this pilot study to determine the predictive power of computed tomographic angiography in anterolateral thigh flap planning and execution. Methods: Sixteen consecutive computed tomographic angiography-mapped anterolateral thigh flaps for head and neck reconstruction were studied. Perforator location, origin, caliber, and course were compared between computed tomographic angiography and intraoperative findings. The relationship of patient characteristics, imaging studies, and intraoperative factors to flap design and surgical outcomes was analyzed. Results: Among the 16 anterolateral thigh flaps, 40 of 54 perforators identified intraoperatively were visible on computed tomographic angiography, resulting in 74 percent sensitivity. Intraoperative perforator location averaged 0.35 cm from the computed tomographic angiography-predicted location. The overall ability of computed tomographic angiography to predict perforator size was 67.5 percent. Its overall accuracy in predicting whether a perforator took a septocutaneous or intramuscular course before perforating the deep fascia was 77.5 percent. Preoperative angiography resulted in surgeons modifying the operative plan in 37 percent of cases and 57 percent of double-island flap cases. All flaps were elevated successfully and survived. Conclusions: Computed tomographic angiography identified larger perforators better than smaller ones and proximal perforators better than distal ones. It accurately predicted the location and origin of visible perforators and less accurately predicted the size and course of visible perforators. Most importantly, the information it provided influenced surgeons to modify their reconstructive strategy, resulting in a higher level of recipient-site specificity. Copyright © 2011 by the American Society of Plastic Surgeons

Bovine versus Porcine Acellular Dermal Matrix: A Comparison of Mechanical Properties

Background: Porcine and bovine acellular dermal matrices (PADM and BADM, respectively) are the most commonly used biologic meshes for ventral hernia repair. A previous study suggests a higher rate of intraoperative device failures using PADM than BADM. We hypothesize that this difference is, in part, related to intrinsic mechanical properties of the matrix substrate and source material. The following study directly compares these 2 matrices to identify any potential differences in mechanical properties that may relate to clinical outcomes. Methods: Sections of PADM (Strattice; Lifecell, Branchburg, N.J.) and BADM (SurgiMend; TEI Biosciences, Boston, Mass.) were subjected to a series of biomechanical tests, including suture retention, tear strength, and uniaxial tensile strength. Results were collected and compared statistically. Results: In all parameters, BADM exhibited a superior mechanical strength profile compared with PADM of similar thickness. Increased BADM thickness correlated with increased mechanical strength. In suture tear-through testing with steel wire, failure of the steel wire occurred in the 4-mm-thick BADM, whereas the matrix material failed in all other thicknesses of BADM and PADM. Conclusions: Before implantation, BADM is inherently stronger than PADM at equivalent thicknesses and considerably stronger at increased thicknesses. These results corroborate clinical data from a previous study in which PADM was associated with a higher intraoperative device failure rate. Although numerous properties of acellular dermal matrix contribute to clinical outcomes, surgeons should consider initial mechanical strength properties when choosing acellular dermal matrices for load-bearing applications such as hernia repair

TelemicrosurgeryRobot Assisted Microsurgery /

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Tracking the learning curve in microsurgical skill acquisition

Background: Despite advances in surgical training, microsurgery is still based on an apprenticeship model. To evaluate skill acquisition and apply targeted feedback to improve their training model, the authors applied the Structured Assessment of Microsurgery Skills to the training of microsurgical fellows. They hypothesized that subjects would demonstrate measurable improvement in performance throughout the study period and consistently across evaluators. Methods: Seven fellows were evaluated during 118 microsurgical cases by 16 evaluators over three 1-month evaluation periods in 1 year (2010 to 2011). Evaluators used the Structured Assessment of Microsurgery Skills questionnaire, which measures dexterity, visuospatial ability, operative flow, and judgment. To validate the data, microsurgical anastomoses in rodents performed by the fellows in a laboratory at the beginning and end of the study period were evaluated by five blinded plastic surgeons using the same questionnaire. Primary outcomes were change in scores between evaluation periods and interevaluator reliability. Results: Between the first two evaluation periods, all skill areas and overall performance improved significantly. Between the second two periods, most skill areas improved, but only a few improved significantly. Operative errors decreased significantly between the first and subsequent periods (81 versus 36; p < 0.05). In the laboratory study, all skills were significantly (p < 0.05) or marginally (0.05 < p < 0.10) improved between time points. The overall interevaluator reliability of the questionnaire was acceptable ([α] = 0.67). Conclusions: The Structured Assessment of Microsurgery Skills questionnaire is a valid instrument for assessing microsurgical skill, providing individualized feedback with acceptable interevaluator reliability. Use of the questionnaire is anticipated to enhance microsurgical training.8 page(s