key: cord-0986964-cvyih3y4
authors: Gallardo, Federico Carlos; Clara, Martin; Aylen Andrea, Targa Garcia; Luis, Bustamante Jorge; Nuñez, Maximiliano; Enrique, Feldman Santiago
title: Home programme for acquisition and maintenance of Microsurgical Skills during the Covid-19 Outbreak
date: 2020-07-23
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.07.114
sha: a36232966f540c32d71327e046f58e8f8ab95ceb
doc_id: 986964
cord_uid: cvyih3y4

Abstract Background During the current global crisis unleashed by SARS-COV-2 outbreak, the surgical departments have considerably reduced the amount of elective surgeries. This leads to a less amount of time in surgical room to develop and improve the surgical skills of the residents. In this study we developed a training program to obtain and maintain microsurgical skills at home, using a smartphone camera and low cost materials, affordable for everyone. Methods Using as a magnification device, a smartphone camera, six participants performed five exercises (colouring grids, grouping colors, unraveling of a gauze, knots with suture threads, Hanoi tower), both with the dominant and the non-dominant hand, during 4 weeks. We compared the performance at the beginning and at the end of the training process. Each participant filled out an anonymous survey. Results When we compared the performance at the beginning and at the end of the training process we have found significant improvements (P = 0.05) with the dominant as well as the non-dominant hand in all the exercises. All the participants were satisfied or very satisfied with the definition of the objectives of the training process, material availability, the exercises performed, the choice of the time to train and general satisfaction with the training program. Conclusion We developed a microsurgical skills training program to be performed at home, which can be easily reproduced. It allowed residents to improve the manual coordination skills, was regarded as a feasible adjunt for ongoing training for surgical residents.

All this, inevitably leads us to lessening time within the operating room to develop and 45 improve surgical skills for residents 2, 7, 25 . In order to avoid leisure time or inactivity for 46 residents during the virus outbreak, they have chosen the use of virtual conferences and 47 presentations with videoconference technology to keep on the academic 48 training 13, 16, 29, 34, 37, 41 . 49

Nevertheless, one question arises at this point; Is it possible to adapt the training program in 50 surgical specialties where hands-on skills are required? Taking into consideration that it is 51 not possible to know the exact impact the isolation and distancing social period may have 52 in the surgical practice in general, and residents under training in particular, we need to 53 adapt a training program to the current situation. 54

One of the necessary elements in the microsurgical training is the surgical microscope. 55

However, diverse and alternative means of magnification sources have been proposed in 56 order to take training out of hospital area. One of them, as an element within everyone`s 57 reach, is the smartphone 22,26 . 58

We introduce a model of training for acquiring and keeping microsurgical skills at home, 59 based on the use of simulators which have previously been described, using the smartphone 60 camera and affordable and low-cost materials. 61

During the period from March 16 th to April 16 th 2020, 6 participants of the program for 63 neurosurgical residents of the Department of Neurological Surgery of Hospital "El Cruce", 64

Buenos Aires, Argentina (Table 1) have performed a training skills program at home.

Each participant used the back camera of their smartphone as a magnification device, 66

Redmi Note 8 (Xiaomi, Rainbow City, BJS), Iphone 7 and Iphone XR (Apple, Cupertino, 67 CA), with a minimum resolution of 12 megapixels, and amplification of 5X, which is 68 compatible with the 25X objective of a surgical microscope. We used a modified shoe box 69 as a support (Figure 1 ). This modified shoe box served not only as a support but also it 70 allowed the use of various instruments passed from the sides through it (Figure 2 ). 71

Each participant had been given a set of instruments necessary to perform this program at 72 home. Each set included microsurgical forceps (x2), scissors, surgical gauze (x5) and 73 adhesive tape. 74

Before the beginning of the program each participant had the chance to watch an 75 explanatory video of each exercise to perform. 76

Exercises 77

Aim: To exercise the fine movements to improve microsurgical precision. 79 Materials: One microfiber 0.5 mm grain and a strip of electrocardiogram (ECG) paper (5x5 80 cm) or any paper measured in millimeters. 81 A 5x5cm ECG paper was used for this exercise. The largest amount of 2x2mm microgrids 82 were meticulously colored in 30 seconds. Two consecutive microgrids couldn't be colored, 83 a free one had to be left amongst the colored ones ( Figure 2 Also, to encourage the motor development of the non-dominant hand. 100 Materials: One surgical gauze, two straight and curve forceps Dumont type number 3, 5 or 101 7, one small scissors or scalpel blade number 11, an adhesive tape and a dark-colored 102 sewing thread 100/2 thickness. 103

The surgical gauze was placed as described in the previous exercise. A 4cm sewing thread 104 piece was placed beneath two parallel threads of the gauze. Then, a knot was performed 105 with the sewing thread, putting together the two threads of the gauze. The exercise was 106 repeated 5 times with each hand (Figure 4 ).

Aim: To train speed in fine movements and associative capacity. 110

Materials: Three bottle lids, fifteen sweet candies (such as "tic tac") of three different 111 colors (5 of each color) and one dissection forceps. 112

The bottle lids, which were used as the sweet candies containers, were placed in the center 113 of the training field. Afterwards, the candies were randomly spread around the containers. decreased manner (no bigger disc can be placed over a smaller one).

We selected five metallic washers (or discs) in a growing size available at local market, 129 which were colored for a pleasant visual feedback ( Figure 6 ). 130

The exercises are performed once a day, three times a week during an initial period of four 132 weeks. It has been suggested that the training should be performed as the first activity of 133 the day. 134

The participant must take his or her time with a chronometer and film his practice for a 135 subsequent control with a designated tutor. 136

Participants were given auto examination papers to record the time and the achievements 137 Considering that during this current situation the residents will spend an uncertain amount 178 of time out of the operating room, is that home-training is required. There are existing 179 training models, such as the one published by Belykh 5 , but using a portable microscope. In 180 our case, not all the residents could afford a microscope, therefore it was necessary to look 181 for alternative sources of magnification that allow us to compensate the lack of microscope 182 during training process. 183

The top-notch smartphones with high resolution cameras may be used as such alternatives. 184

In 2014, Kim 26 described the first training with these alternative methods of magnification. 185

In his work the participants performed vascular anastomosis in synthetic 2 mm vessels 186 using 8-0 sutures and a smartphone as a source of magnification. Hourtarinen 22 also uses 187 smartphones to train in fields with greater magnification, but unlike Kim, who use a 188 support arm to keep the smartphone stable, Hourtarinen attached it to a coffee cup.

With the objective of using the smartphone screen to perform the exercises, and to avoid 190 the use of direct vision, we decided to adapt a shoe box as a support for the smartphone 191 while performing exercises within it. 192

The main limitation of the smartphone as a source of magnification is the lack of 193 stereoscopic vision that the surgical microscope provides. 194

However the lack of stereopsis has been compensated by the proprioception. The outcome, in our experience, shows a significant improvement with both 211 hands in the manual skills performance, after training process; that is to say, all the participants improved, regardless of the previous level of skills they had. 213

The record of activities in the sheet provided, allowed the participant not only to be self 214 examined, but also to be objectively assessed by a "blind" tutor. The tutor has been asked 215 not only to evaluate the rate of improvement in the participants skills but also to give a 216 positive feedback regarding the skills to maintain and the ones to improve with further 217 training. 218

Each participant filled out an anonymous survey when they finished the training program. 219

All the participants referred to be satisfied with the program and with the possibility to 220 perform microsurgical training at home with affordable materials. One of the items that 221 caused greater satisfaction was the chance to choose the time of the day to perform the 222 training program. Regarding the affordable and easily found materials used, all the 223 participants agreed that the program allowed them to continue to improve their skills and 224 the hand-eye coordination when the surgical activity is severely limited. Moreover, many 225 participants mentioned that using materials similar to the ones used in regular surgical 226 practice, could provide a larger benefit; however, the cost increase would negatively affect 227 accessibility of such training. The exercises using surgical gauze were considered the most 228 similar to the normal surgical practice. 229 A special attention should be given on the exercise named Hanoi Tower, which allowed the 230 participants to improve their performance not only with both hands, but also improve on 231 planning the next movement to achieve the goal of the exercise with the least amount of 232 movements and time possible. Consequently, it is not only an exercise that stimulates 233 manual performance, but also the cognitive activity. It is important to mention that this 234 exercise was the only one that showed a better performance with the non-dominant hand, comparing with the dominant one. We believe that this result may be due to the fact that 236 the movement of the forceps, in this exercise was widely developed by the surgeons non-237 dominant hand. 238

All the participants believe the training program has a positive impact on their professional 239 practice, because it allowed them to get skills, improve the coordination and make delicate 240 movements with a better precision in a controlled environment. 241 242

We introduced a microsurgical practice program to be held at home which makes it easily 244 reproducible. It also allowed participants to improve the manual coordination skills, making 245 it a feasible adjunt for the ongoing training for surgical residents. 

Impact of the COVID-19 pandemic on urology residency training in Italy

Academic Neurosurgery Department Response to COVID-19 Pandemic: The 298 University of Miami/Jackson Memorial Hospital Model

Deliberate practice and the acquisition and maintenance of expert 301 performance in medicine and related domains

The role of deliberate practice in the 303 acquisition of expert performance

COVID-19 Disruption 305 in Cardiothoracic Surgical Training: An Opportunity to Enhance Education 306

The Effects of COVID-19 on Academic Activities and 310

Surgical Education in Italy

Microgrids: A 313 Model for Basic Microsurgery Skills Training

COVID-19 and its impact on 336 neurosurgery: our early experience in Singapore

Cardiothoracic 339 Education in the Time of COVID-19: How I Teach It

Simulation in neurosurgery: possibilities and 343 practicalities: foreword

Development of a laparoscopic training 345 model using a smartphone

Teaching in the time of COVID-19

Construction and 350 validation of a low-cost surgical trainer based on iPhone technology for training 351 laparoscopic skills

Abbreviations SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2

CRediT author statementAll authors contributed equally.

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: