title: Validation of an inanimate low cost model for training minimal invasive surgery (MIS) of esophageal atresia with tracheoesophageal fistula (AE/TEF) repair.
abstract: We present the results of the validation of an inanimate model created for training thoracoscopic treatment of esophageal atresia with lower tracheoesophageal fistula (EA/TEF).
  
  
  METHODS
  We used different domestic materials such as a piece of wood (support), corrugated plastic tubes (PVC) of different sizes to simulate ribs, intercostal spaces, trachea and spine and tubular latex balloons to simulate the esophagus and lungs to make the basic model. This device was inserted into the thoracic cavity of a rubber dummy simulating a 3kg newborn with a work area volume of 50ml. The model was designed taking into account the experience of doing this procedure in neonates. The cost of the materials used was 50 US$. Regular video endoscopic equipment and 3mm instruments were used. Thirty-nine international faculty or pediatric surgeons attending hands on courses with different levels of training in minimal invasive surgery (MIS) repair of EA/TEF performed the procedure in the model. We compared the performance of the practitioners with their experience in thoracoscopic repair of EA. A Likert-type scale was used to evaluate results. Previous experience in MIS, anatomical appearance of the model, surgical anatomy compared to a real patient, and utility as a training method were analyzed. We also used a checklist to assess performance. We evaluated: number of errors and types of injuries, quality of the anastomosis, and duration of procedure. To analyze the results we used a T-test, chi-square test and Excel® database to match up some results.
  
  
  RESULTS
  Thirty-nine questionnaires were completed. Seven surgeons were experts (≥30 TEF/EA repairs as surgeon), 10 had intermediate level of experience (5 to 29 repairs as surgeon) and 22 were beginners (less than 5 repairs). To simplify the analysis we divided the respondents into low experience LE (<5 real procedures-beginners; n=22) and high experience HE (intermediate, 10; and experts, 7; n=17). In relation to the anatomical characteristics of the model, 94.48% (n=37) respondents considered that the model has a high degree of similarity or good similarity; in relation to surgical anatomy 88.2% (n=34) respondents considered that the model has a high degree of similarity or good similarity; 87.17% (n=34) respondents considered that the model can generate a good amount of skills and/or can generate great majority of skills to EA/TEF repair; and 12.82% (n=5) respondents consider that it can generate some skills or a few skills, only in relation to trocar placement, one of the surveyed items. The number of errors was 29±7 SD (20 to 51) for the low experience group (LE) and 9±6 SD (1 to 20) for the high experience group (HE) (P value<0.0001). Time in minutes was significantly lower in the HE group (40±9 SD; 26 to 58min), in relation with LE (81±19 SD; 49 to 118min) (P<0.0001, T-test). Deficient or incomplete anastomosis also showed differences: 7 (32%) in the LE group and 1 (6%) in the HE group (P = 0.04, chi-square test). We saw a correlation between the previous experience of the surgeon and their performance in the model considering operating time, quality of anastomosis and peripheral tissue damage. According to the suggestions registered in the questionnaires, we have now improved the model. We have also started using it in a scenario to simulate the whole neonatal MIS operative room setting and team work.
authors.affiliation: Pediatric Surgery Department, D.A.D.I-Surgical Simulation Center CeSim, "Prof. Dr. Juan P. Garrahan" Children's Hospital-S.A.M.I.C., Combate de los Pozos No. 1881 (C1245AAM), Cuidad Autónoma de Buenos Aires, República Argentina. Electronic address: maximaricic@yahoo.com.
authors.forename: Maximiliano Alejo
authors.initials: MA
authors.lastname: Maricic
authors.affiliation: Pediatric Surgery Department, D.A.D.I-Surgical Simulation Center CeSim, "Prof. Dr. Juan P. Garrahan" Children's Hospital-S.A.M.I.C., Combate de los Pozos No. 1881 (C1245AAM), Cuidad Autónoma de Buenos Aires, República Argentina.
authors.forename: María Marcela
authors.initials: MM
authors.lastname: Bailez
authors.affiliation: Teaching and Research Department, D.A.D.I-Surgical Simulation Center CeSim, "Prof. Dr. Juan P. Garrahan" Children's Hospital-S.A.M.I.C., Combate de los Pozos No. 1881 (C1245AAM), Cuidad Autónoma de Buenos Aires, República Argentina.
authors.forename: Susana P
authors.initials: SP
authors.lastname: Rodriguez
mesh_terms: D001118:Argentina; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D004933:Esophageal Atresia / Q000601:surgery*; D006801:Humans; D007231:Infant, Newborn; D008953:Models, Anatomic; D010372:Pediatrics / Q000193:education*; D013043:Specialties, Surgical / Q000193:education*; D066231:Surgeons / Q000193:education; D013906:Thoracoscopy / Q000193:education* / Q000379:methods; D014138:Tracheoesophageal Fistula / Q000601:surgery*
keywords: Esophageal atresia repair; Neonatal minimal invasive surgery; Surgical simulation; Thoracoscopy; Training model