•Wet labs are a useful, cost-effective and safe tool in teaching of Cardiothoracic Surgery residents.•In a third world country where advance real life simulators are not available.•It improves resident\u27s tissue handling and surgical skills.•Allows faculty members to give continuous feedback to their residents

Asif, Narmeen

Fatimi, Saulat

Inam, Hina

Sohail, Abdul Ahad

English

eCommons@AKU

eCommons@AKU Section of Cardiothoracic Surgery Department of Surgery 7-16-2020 Wet labs: A useful tool in training surgical residents in a third world country Hina Inam Aga Khan University, hina.inam@aku.edu Narmeen Asif Aga Khan University, narmeen.asif@aku.edu Abdul Ahad Sohail Aga Khan University, abdul.ahad@aku.edu Saulat Fatimi Aga Khan University, saulat.fatimi@aku.edu Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_cardiothoracic  Part of the Cardiology Commons, Cardiovascular Diseases Commons, and the Surgery Commons Recommended Citation Inam, H., Asif, N., Sohail, A. A., Fatimi, S. (2020). Wet labs: A useful tool in training surgical residents in a third world country. Annals of Medicine and Surgery, 57, 137-139. Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_cardiothoracic/172 Contents lists available at ScienceDirectAnnals of Medicine and Surgeryjournal homepage: www.elsevier.com/locate/amsuShort CommunicationWet labs: A useful tool in training surgical residents in a third world countryHina Inama, Narmeen Asifb, Abdul Ahad Sohailb,∗, Saulat Hasnain Fatimiaa Department of Cardio-thoracic Surgery, Aga Khan University Hospital, PakistanbAga Khan University Hospital, Pakistan1. IntroductionWATCH ONE, DO ONE, TEACH ONE is a known dictum reflectingthe old tradition of surgical training, where residents and trainees wereexpected to not only perform but also teach a surgical procedure afterseeing it once [1]. However this may not be applicable in cardiac sur-gery. Cardiac surgery being time sensitive, having no margin of error,presence of extremely sick patients and performance of complicatedand technical procedures including microsurgical techniques and macroprocedures makes this impossible.However a paradigm shift has been seen in the surgical training ofresidents and trainee.William Halsted was a pioneer of surgical training and spearheadedthe first ever residency program in John Hopkins USA, in 1890. At thattime surgical training was composed of long hours of observing andretracting in the operation theatre. However just operating theater maynot be an ideal location for early training of surgical residents due togrowing ethical concerns, time constraints in the operating theater,changes in resident work hours, requiring more structured training,physician burnout and learning curve associated risks [2–4].Many studies report effective learning when trainees are involvedactively in the process. This can include making notes, diagrams, beingasked questions and being involved in the procedure being performed.However one retains only 5% of what has been taught via lectures [5].As per studies modern day advancements like wet lab, dry lab and si-mulators show enhanced performance and better results [6]. Extensivework had been done upon this in the field of Ophthalmology whichrequires precision and excellent hand eye coordination for its micro-surgical techniques with Alwadani et al. describing goat's eye as anideal tissue for ophthalmological wet labs and hence describing wetlabs an effective method to empower trainee surgeons to safely performcomplex procedure with lower complication rates and decreasing theirlearning curve [7,8].Wet labs using animal organs offer essential training and practiceoutside the operating theater. It is an important way to assess residentson the basis of their anatomy, concepts, instrument and tissue handlingand skills. Wet lab may come across as an ethical concern as far as usinglive animals are concerned, however it is something greatly valued bymedical students and residents [9]. The anatomical variations in animalorgans help nurture critical thinking and helps recall in a risk-free en-vironment. The wet lab provides a different preview for each partici-pant; students get the chance to learn basic surgical skills and techni-ques, whereas the trainees and the consultants can perform surgicalprocedures like coronary anastomosis, segmental resection of lunglobes etc. Bovine and swine tissues are the most common animal organsthat are taken for this teaching. Some countries make use of sheep anddogs as teaching organs for wet lab purposes.Simulation and animal laboratory experience have been used ex-tensively in cardiothoracic surgery research and training. Fann andcoworkers [10] discussed about the use of porcine hearts in residenttraining. They also evaluated cardiothoracic surgery residents’ perfor-mance after one week of practice on task stations and beating heartsimulator showing about 20% decrease in time for residents to performanastomosis on task stations and 15% decrease in time on beating heartsimulators, hence proving that practice outside the operation theatre isessential, safe and effective way of improving surgical skills for cardi-othoracic surgery residents [10]. Divisi et al. describes the use of swinemodel in wet labs for VATS (Video Assisted Thoracoscopic Surgery)lobectomy and simulation based learning to decrease the residentslearning curve during their course of training [11].1.1. Purpose of this documentThis letter to editor details the technicalities of a wet lab, its ad-vantages. What it takes and how it is done. The technical proof ofconcept is the first phase in development of wet lab as an integral partin the curriculum of residents learning.1.2. Rationale behind the conceptTraining of residents in patients is time consuming and may beharmful for patients and therefore Wet labs can help train these re-sidents. They are able to develop skills which are helpful in operatingrooms.https://doi.org/10.1016/j.amsu.2020.07.014Received 9 June 2020; Received in revised form 27 June 2020; Accepted 3 July 2020∗ Corresponding author. Department of Cardiothoracic Surgery, 346, 347, Street number 19, B.M.C.H.S, Sharfabad, Karachi, Pakistan.E-mail addresses: hinam7066@gmail.com (H. Inam), narmeen_asif@hotmail.co.uk (N. Asif), abdulahad7@hotmail.com (A.A. Sohail),saulat.fatimi@aku.edu (S.H. Fatimi).Annals of Medicine and Surgery 57 (2020) 137–1392049-0801/ © 2020 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/BY/4.0/).T2. Material and methodsThe Department of Cardiothoracic Surgery at the Aga KhanUniversity Hospital initiated Wet labs in anatomy dissection halls andwas able to conduct these bimonthly workshops in valve repair, re-placements and coronary anastomoses.It is easy to establish. We get our Bovine Hearts from a butcher at aminimal cost of a few hundred Pakistani rupees. We have dissectingwax trays in our dissection hall. We use old sutures or sutures that havebeen opened in the operation theatre but not used. We use veins savedin formalin from our coronary artery bypasses. Every resident has theirown set of basic instruments (scissors, forceps, needle holder, hemo-stats) which they bring with them to each wet lab (Fig. 1).Each wet lab session had been facilitated by a faculty member (whomoderates the session and provides basic background knowledge on thetopic that had been chosen for that particular session), while all otherfaculty members and consultants teach and supervise the residents onone to one basis at each table. The number of residents attending thesesessions are all previously trained in general surgery and range fromyear 1 to year 4 cardiac surgery residents with approximately 5–7 re-sidents in each session depending on their availability. The residents areevaluated on the basis of their anatomical knowledge, tissue handlingand technical skills pre and post session.2.1. Performance assessmentThe residents are directly supervised by a faculty cardiac surgeonand chief resident during the entire session; continuous feedback isgiven to the resident regarding graft handling and orientation, instru-ment use and suture placement during the entire session. After com-pletion, the anastomoses/valves are inspected by the moderator andadditional feedback is given to the resident and the faculty membersupervising that particular resident.2.2. ObservationsThe residents were observed to become well versed and confidentwhen it came to tissue handling, anastomosis and anatomical re-lationships of the heart even when working in the operation theatre.2.3. StrengthsThis is a single center experience with wet lab used as an integratedtool for residents teaching. Such wet labs are carried out regularly inthe western countries and have shown remarkable results.We have been able to conduct three successful workshops here atAga Khan University Hospital on Valve Sparing Aortic root replace-ment, Segmental lobectomy of lung, mitral valve replacement, atrialand ventricular septal defect closures. All were attended by well re-nowned national and international cardiac surgeons. Also this is thefirst time such wet labs had been conducted in our institute and noother department in surgery had ever conducted it previously in ourinstitute. To the best of our knowledge, no other studies or literature isavailable from our region that describes the use of wet labs or simu-lation based teaching of cardiac surgery residents in third worldcountry.3. ConclusionConducting wet labs is a cost-effective strategic teaching tool forresidents which not only inculcates confidence in their surgical skillsbut also is helpful in teaching advanced skills at consultant's level andcan greatly enhance surgical residents training and skills especially inthird world countries where expensive simulators are not available intraining institutes for residents practice.Ethical approvalResearch studies involving patients require ethical approval. Pleasestate whether approval or exemption has been given, name the relevantethics committee and the state the reference number for their judge-ment. Please give a statement regarding ethnical approval that will beincluded in the publication of your article, if the study is exempt fromethnical approval in your institution please state this. I am submittingthis Letter to Editor which is exempted from ethical approval in AgaKhan University Hospital.Source of fundingNone.Fig. 1. A resident practicing valve replacement procedure on a bovine heart.H. Inam, et al. Annals of Medicine and Surgery 57 (2020) 137–139138DeclarationDeclaration: This manuscript has neither been presented nor pub-lished elsewhere before. However, the abstract has been publishedpreviously as part of conference abstract in CHEST regional congress(Athens 2019) by the same author under the title: ‘WET LAB AS A TOOLFOR TEACHING CARDIO THORACIC SURGERY RESIDENT: WHATWOULD HALSTED SAY? [12].CRediT authorship contribution statementHina Inam: Conceptualization, Writing - original draft, Writing -review & editing. Narmeen Asif: Conceptualization, Writing - originaldraft, Writing - review & editing. Abdul Ahad Sohail:Writing - originaldraft, Writing - review & editing. Saulat Hasnain Fatimi:Conceptualization, Writing - review & editing.Declaration of competing interestNone.References[1] J.L. Cameron, William stewart halsted. Our surgical heritage, Ann. Surg. 225 (5)(1997 May) 445.[2] R.K. Reznick, H. MacRae, Teaching surgical skills—changes in the wind, N. Engl. J.Med. 355 (25) (2006 Dec 21) 2664–2669.[3] R. Reznick, G. Regehr, H. MacRae, J. Martin, W. McCulloch, Testing technical skillvia an innovative “bench station” examination, Am. J. Surg. 173 (3) (1997 Mar 1)226–230.[4] J.D. Beard, B.C. Jolly, D.I. Newble, W.E. Thomas, J. Donnelly, L.J. Southgate,Assessing the technical skills of surgical trainees, Br. J. Surg.: IncorporatingEuropean Journal of Surgery and Swiss Surgery 92 (6) (2005 Jun) 778–782.[5] J.D. Beard, J. Robinson, J. Smout, Problem-based learning for surgical trainees,Ann. R. Coll. Surg. Engl. 84 (4) (2002 Jul) 227.[6] S. Barry Issenberg, W.C. Mcgaghie, E.R. Petrusa, D. Lee Gordon, R.J. Scalese,Features and uses of high-fidelity medical simulations that lead to effectivelearning: a BEME systematic review, Med. Teach. 27 (1) (2005 Jan 1) 10–28.[7] S. Alwadani, Cataract surgery training using surgical simulators and wet-labs:course description and literature review, Saudi journal of ophthalmology 32 (4)(2018 Oct 1) 324–329.[8] M. Acharya, J.H. Farooqui, A. Dave, Commentary: training in wet labs and onsurgical simulators: need of the hour, Indian J. Ophthalmol. 67 (4) (2019 Apr) 549.[9] B. Solomon, C. Bizekis, S.L. Dellis, J.S. Donington, A. Oliker, L.B. Balsam, M. Zervos,A.C. Galloway, H. Pass, E.A. Grossi, Simulating video-assisted thoracoscopic lo-bectomy: a virtual reality cognitive task simulation, J. Thorac. Cardiovasc. Surg.141 (1) (2011 Jan 1) 249–255.[10] J.I. Fann, A.D. Caffarelli, G. Georgette, S.K. Howard, D.M. Gaba, P. Youngblood,R.S. Mitchell, T.A. Burdon, Improvement in coronary anastomosis with cardiacsurgery simulation, J. Thorac. Cardiovasc. Surg. 136 (6) (2008 Dec 1) 1486–1491.[11] D. Divisi, M. Barone, G. Zaccagna, A. De Palma, F. Gabriele, R. Crisci, Video-assistedthoracoscopic surgery lobectomy learning curve: what program should be offered ina residency course? J. Vis. Surg. 3 (2017).[12] H. Inam, Wet lab as a tool for teaching CARDIO THORACIC surgery resident: whatWOULD HALSTED SAY? Chest 155 (6) (2019 Jun 1) A330.H. Inam, et al. Annals of Medicine and Surgery 57 (2020) 137–139139

Wet labs: A useful tool in training surgical residents in a third world country

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Wet labs: A useful tool in training surgical residents in a third world country

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