RU2768594C1 - Set of simulators for training in extracorporeal and intracorporeal suture technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to teaching aids in medicine. Set of simulators comprises seven simulators, each representing a transparent rectangular platform of polymethylmethacrylate with size of 16*16 cm and thickness of 0.5 cm. First simulator for practicing skills for making sutures contains in the centre of platform 5.5 cm from the front and back edges and 4 cm from side faces of content tape with size of 8*5 cm with plastic hooks for fixation of foam material. Second simulator for forming surgical assemblies comprises two solid plates fixed on two opposite faces of the platform, the plates are bent at angle of 90° to form an upper face and posts and have dimensions of 3*3.5 cm, in the upper face of the plate there are slots with depth of 7 mm and width of 3 mm for fixation between opposite posts of a rubber with diameter of 4 mm, which is used for development of formation of single and double loops for subsequent making of the assembly. Third simulator for positioning a surgical needle in space includes a plate of transparent polymethyl methacrylate 6 cm high, 16 cm wide and 0.4 cm thick, located at 11 cm from the front face of the horizontally located platform and fixed at angle of 90 degrees relative to the platform, on the plate there is a black geometric figure in the form of a continuous non-intersecting line, on which sixteen screw rings are fixed perpendicular to the line for passing an atraumatic needle with a thread, ten of which are on a horizontal platform, and six are on the plate. Fourth simulator for suturing tissues at an angle comprises two panels measuring 16*16 cm, 0.4 cm thick with a cutout in the centre of platform measuring 13*13 cm, which are superimposed on the platform and form 1.5 cm wide edging along the perimeter, and a white elastic synthetic fabric with a graphic pattern applied on it in form of 8 beams 5 cm long, extending from the centre of the platform, along each beam, at 0.12 cm from the centre of the platform, there are four paired marks in the form of points located from the beam line by 0.4 cm on each side. Fifth training simulator for working with clamps includes 15 cm long and 7.5 cm wide plate of transparent solid polymethyl methacrylate located at 7.5 cm from the front face of the platform, bent at angle of 115 degrees, on the plate, at 2.5 cm from the side faces and in the centre from the upper and lower faces of the platform, 2 through holes with diameter of 2 cm are formed, a satin ribbon with width of 2 cm and length of 170 cm is passed through the holes, in order to bring the satin ribbon from one hole to the front part of the platform by alternately grasping the ribbon from the right clamp into the left clamp and inserting it into the other hole. Sixth simulator for the formation of longitudinal and transverse sutures includes three lines of a sealant located on the platform and consisting of two polyurethane rollers 10 mm wide and 6 mm high for performing an intracorporeal continuous or interrupted suture, as well as extracorporeal interrupted suture in transverse or longitudinal direction. Seventh hollow organ closure trainer comprises two metal clamps located at angle of 45° on the farthest from the trainee side of the platform with size of 8 cm and turned to the centre of the platform, which are intended for fixation of the cadaver material or the hollow organ simulator in the form of a rubberized textile glove put on an air-inflated rubber medical glove.

EFFECT: providing skills of forming extracorporeal and intracorporeal sutures in laparoscopic surgery.

1 cl, 7 dwg

Description

The invention relates to simulation medical simulators and makes it possible to teach the technique and work out the technique of extracorporeal and intracorporeal suture in laparoscopic surgery.

The purpose of this invention is to create a simple and cost-effective set of simulation simulators for step-by-step training in the technique of forming a laparoscopic suture.

The essence of the invention is a set of simulation simulators for teaching the technique of extracorporeal and intracorporeal suture in laparoscopic surgery are 7 simulators, each of which simulates the stage of formation of a laparoscopic suture or the method of applying it, as well as auxiliary techniques when performing laparoscopic operations.

I - simulator for acquiring manual skills in a laparoscopic surgeon (for practicing skills on a foam rubber sponge)

The base of the simulator consists of a transparent platform of polymethyl methacrylate measuring 16*16 cm and 0.5 cm thick, on which a content tape with small plastic hooks for fixing is placed in the center of the platform, 5.5 cm from the front and back faces and 4 cm from the side faces. material, tape size 8 * 5 cm (Fig. 1-1). The foam rubber sponge is a favorite material for surgeons around the world to practice general surgical and laparoscopic skills. As a rule, a foam rubber sponge is fixed to a universal base using needles from syringes, stationery pins, and paper clips. The presence of foreign objects that fix the foam sponge distract attention and interfere with the development of manual skills. The proposed simulator allows you to fix the foam sponge, used in domestic needs, to the content tape with the abrasive part down, which ensures its reliable fixation, without additional fixing elements (Fig. 1-2). The ability to fix the foam sponge without additional devices provides convenience when practicing laparoscopic skills.

When working on this simulator, depending on the exercise performed, a laparoscopic needle holder (Needle Holder V type), a laparoscopic clamp (Atrau Fenestrated), laparoscopic Metzenbaum scissors and a laparoscopic dissector (Traditional Maryland) are used.

While working on the simulator, trainees perform a number of tasks. For example, marginal continuous or nodal extracorporeal and intracorporeal sutures are performed, a pre-applied incision is sutured, the formed hole is sutured, the formation of a sliding knot and the positioning of the needle on the tissue are practiced.

II - a simulator for acquiring manual skills in laparoscopic surgery (for the formation of various types of knots)

The simulator consists of a transparent platform 16*16 cm in size made of polymethyl methacrylate 0.5 cm thick, on which 2 solid plates bent at an angle of 90°, 3 cm high and 3.5 cm base, made of transparent material, are fixed on two opposite sides - polymethyl methacrylate. In the upper face, slots with a depth of 7 mm and a width of 3 mm are formed, which makes it possible to fix elastic bands with a diameter of 4 mm between opposite posts. 4 slots are formed on each plate, on the vertical part of the plate - on the edge, the plane of which is parallel to the platform base. The first slot is made 4 cm from the side face, the second slot is made 4 cm from the other side face. The third and fourth slots are formed, stepping back from the second one by 1 cm in each direction. On the second plate, the first and second slots are formed, as well as on the first plate, at a distance of 4 cm from the side faces. However, the third and fourth slots are already positioned relative to the first at a distance of 1 cm (Fig. 2). Depending on the task being performed, various geometric shapes can be formed with the help of rubber bands (solid line, isosceles triangle, rectangle), and the degree of tension of the rubber bands can be adjusted. It is possible to use various rubber bands with sufficient elasticity and hardness, for example, stationery rubber bands.

When working on this simulator, trainees perform the techniques used in laparoscopic surgery. When performing exercises, a laparoscopic needle holder (Needle Holder V type), a laparoscopic clamp (Atrau Fenestrated) or a dissector (Traditional Maryland) is used.

On an elastic band fixed between the uprights in symmetrical slots, it is proposed to work out the formation of a single and double loop, which is necessary when practicing the skill of forming a half-loop to form a knot. First, it is necessary to fix the thread in the center of the gum, forming 2 knots, while one end of the thread should be 10 cm, and the other end can be 2-3 cm. around the fixed laparoscopic needle holder to the right, then to the left. As the skill grows, it is necessary to leave the laparoscopic dissector motionless and wind the thread by rotating the laparoscopic needle holder. And further, in the formation of the node, it is necessary to use a laparoscopic needle holder and a laparoscopic dissector. After practicing these movements, you can change the manipulators by taking the laparoscopic dissector in your dominant hand. Mastering this exercise is the key to the successful formation of the laparoscopic node.

On rubber bands fixed in the form of an isosceles triangle, it is proposed to practice the skill of forming a sliding laparoscopic knot or a laparoscopic surgical knot. To do this, without tightening, form the right and left half-loop and slide the knot onto the elastic using a tool or pulling on one of the threads. When forming a surgical knot, it is necessary to form a double half-loop, which is further fixed with a single half-loop. For this exercise, it is preferable to use a laparoscopic needle holder (Needle Holder V type) and clamp (Atrau Fenestrated) or dissector (Traditional Maryland).

III - simulator for acquiring manual skills in laparoscopic surgery (for positioning the surgical needle in space)

The simulator consists of a transparent platform 16*16 cm in size made of polymethyl methacrylate 0.5 cm thick, on which, 11 cm from the front face of the platform, there is a plate made of transparent polymethyl methacrylate 6 cm high, 16 cm wide and 0.4 cm thick, fixed at an angle of 90 degrees relative to a horizontal platform. On the front of the horizontal transparent platform and on 6 cm of a vertically located plate, a complex black geometric figure is applied in the form of a continuous non-intersecting line, which originates on the edge of the horizontal platform facing the student, on the same edge the line ends, while the figure passes on a vertical plate. 16 screw-rings are fixed on the line at various distances from each other perpendicular to the line, 10 rings are fixed on a horizontal platform, 6 rings on a vertically located plate, the rings are made of metal wire with a diameter of 1.5 mm. The inner diameter of the rings is 5 mm. The rings rise above the horizontal platform and the vertical plate by 4 mm.

When working on this simulator, trainees perform the techniques and skills that are used in laparoscopic surgery. For this task, it is suggested to use 1 laparoscopic dissector (Traditional Maryland) and 1 laparoscopic needle holder (Needle Holder V type).

The trainee is offered to pass an atraumatic needle with a thread, following a predetermined line, while it is necessary to ensure that the needle, passing through the holes of the rings, is as perpendicular as possible to the plane of the ring, and the point and the place of fixation of the thread are placed upwards, i.e. as if “smiling”, and the middle of the needle is downward relative to the plane of the surface on which the ring is located, regardless of whether it is a horizontal or vertical surface. A needle holder with a needle fixed in it, when passing through the hole, performs a rotational movement according to the diameter and radius of the bend of the needle, while simulating the injection of the needle into the tissue of the organ. To comply with these conditions, the trainee positions the needle in the needle holder. For this task, it is preferable to use an atraumatic suture material with a polyfilament thread. When practicing manual skills, the trainee acquires the ability to position the needle in the needle holder in different planes, at different angles on vertical and horizontal surfaces, which fully meets the requirements for performing intracorporeal and extracorporeal laparoscopic suture and is an integral part of this laborious process.

IV - a simulator for acquiring manual skills in laparoscopic surgery (for practicing the skill of stitching tissues at different angles)

The simulator consists of a transparent platform of polymethyl methacrylate 16*16 cm in size and 0.5 cm thick, on which there are two panels 16*16 cm in size, 0.4 cm thick with a cutout in the center of the platform 13*13 cm in size, which form a border around the perimeter with a width of 1.5 cm. One panel is fixedly fixed to the platform of the simulator, in it, at 4 corners, retreating 0.7 cm from each of the outer faces, holes with a diameter of 4 mm are formed and a thread for the fixing bolt is applied. In the second overlay panel in the projection of the holes of the first panel, through holes with a diameter of 4.2 mm are formed. On the first, fixed panel, a white elastic synthetic fabric with a graphic pattern printed on it is applied. The fabric is pressed with a second overlay panel with through holes and fixed at four corners with four metal bolts 0.8 cm long and 4 mm in diameter. The pattern on the fabric is made in the form of 8 beams 5 cm long, emerging from the center of the platform, along each beam, retreating from the center of the platform by 0.12 cm, four paired marks in the form of dots are applied, spaced from the line of the beam by 0.4 cm from each sides. The fabric has sufficient tension and elasticity, which is comparable to the turgor of tissues and structures of the human body.

It is preferable to use a laparoscopic needle holder (Needle Holder V type), a laparoscopic forceps (Atrau Fenestrated) or a dissector (Traditional Maryland) when using this simulator.

On this simulator, it is proposed to perform a laparoscopic purse-string suture, consisting of 8 single sutures along circles of various diameters. The trainee must flash 8 rays. In this case, it is necessary to ensure that the injection and puncture of the needle is carried out strictly according to the marked points. Trainees form the manual skill of needle positioning and the ability to stitch tissues and organs at different angles and at different distances from the center, which provides a different viewing angle and a different angle of injection with an atraumatic needle.

V - simulator for acquiring manual skills in laparoscopic surgery (for practicing the "rope ladder" technique)

The simulator consists of a transparent platform of polymethyl methacrylate measuring 16 * 16 cm, 0.5 cm thick, on which, 7.5 cm from the front face of the platform, there is a plate 15 cm long and 7.5 cm wide, made of monolithic transparent polymethyl methacrylate, bent at an angle of 115 degrees, forming sides of 2.5 cm and 5 cm. The smaller side of the 2.5 cm plate is fixed to the platform, and the larger 5 cm side of the plate, with an inclination from the student, forms an angle with the platform of 65 degrees. In this plate, stepping back from the side faces by 2.5 cm and in the center from the upper and lower faces of the platform, 2 through holes with a diameter of 2 cm are formed. A satin ribbon 2 cm wide and 170 cm long is passed through the holes, which is fixed with a metal clamp behind an inclined plate located at a distance of 2 cm from the rear face and symmetrically from the side faces (Fig. 5).

It is preferable to use 2 laparoscopic forceps (Atrau Fenestrated) or 2 laparoscopic dissectors (Traditional Maryland) to operate this simulator.

When completing the task, it is proposed at the first stage to bring the satin ribbon out of one hole to the front of the platform by alternately intercepting the ribbon from the right clamp to the left clamp. Performing this stage, they imitate the pulling of the free end of the thread when performing an intracorporeal suture, pulling the turunda or tourniquet under the anatomical structures, or removing intestinal loops from the hernial sac, and work out the "rope ladder" technique. At the second stage of the task, it is proposed to invaginate the satin ribbon into the opposite hole, by alternately invaginating and intercepting the satin ribbon, which can imitate the passage of gauze turunda under the mobilized esophagus when performing operations on the abdominal part of the esophagus, or installing a tubular drainage in the gallbladder bed, or to the site surgical intervention. Work on this simulator allows you to master the technique of turning over the loops of the small intestine during diagnostic laparoscopy.

VI - Simulator for the acquisition of manual skills in laparoscopic surgery (for the formation of longitudinal and transverse sutures)

The simulator consists of a transparent platform of polymethyl methacrylate measuring 16 * 16 cm and 0.5 cm thick, on which there are 3 sealing lines, consisting of two polyurethane rollers 10 mm wide each and 6 mm high. Seals are located symmetrically, two are located 2 cm from the side face and 1 cm from the front and back faces. The middle seal is placed in the middle of the platform 3 cm from the side seals and 1 cm from the front and rear faces (Fig. 6). On this simulator, it is proposed to perform a laparoscopic continuous suture or an interrupted suture along the entire length of the seal. The quality of polyurethane imitates the physiological turgor of tissues and structures of the body, polyurethane has a moderate density and, with excessive pressure on it, the material is damaged, which helps the student to feel the degree of traumatization of body tissues during manipulations. The platform is fixed relative to the trainee both perpendicularly and horizontally, which allows you to work out the technique of forming longitudinal and transverse seams.

After the wear of the polyurethane seal, it is easily dismantled from the platform, a new section of the polyurethane seal is installed in this place along the guide line.

It is preferable to use a laparoscopic needle holder (Needle Holder V type), a laparoscopic forceps (Atrau Fenestrated) or a dissector (Traditional Maryland) during operation.

The trainee is offered to perform an intracorporeal continuous or interrupted suture, as well as an extracorporeal interrupted suture in the transverse or longitudinal direction, depending on the location of the platform.

VII - simulator for acquiring manual skills in laparoscopic surgery (when suturing a hollow organ)

The simulator consists of a transparent platform made of polymethyl methacrylate measuring 16*16 cm and 0.5 cm thick, on which 2 metal clamps are located on the far side of the trainee, at an angle of 45° 8 cm in size deployed to the center of the platform (Fig. 7-1). These clamps are intended for fixation of cadaveric material or an artificial simulator of a surgical situation.

As a cadaver material, a portion of the non-fixed small intestine is used to practice the technique of forming an interintestinal anastomosis, the dome of the caecum with the appendicular process to practice the stages of surgical intervention for the removal of the inflamed appendicular process, the uterus with appendages to practice gynecological operations.

As an artificial simulator, a rubberized textile glove is used, put on an air-inflated rubber medical glove (Fig. 7-2). At the same time, a cut of 2-3 cm in size is formed in the center of the textile glove. In this state, the glove is fixed to the platform using metal clips. When performing this exercise, it is suggested to suture a tissue defect on a rubberized textile glove, while not grabbing the fabric of a rubber glove into the seam, which will indicate that the posterior wall of the hollow organ is captured. This defect can be sutured with a single-row continuous or single interrupted suture, and the suture can also be double-row.

When performing this task, it is preferable to use a laparoscopic needle holder (Needle Holder V type), a laparoscopic clamp (Atrau Fenestrated) or a dissector (Traditional Maryland), laparoscopic Metzenbaum scissors.

On this simulator, when using cadaveric material, you can work out various stages of surgical interventions, and when using a construction made of rubber and textile gloves, you can work out the technique of suturing a hollow organ using an intracorporeal laparoscopic suture or applying an extracorporeal suture using a laparoscopic fork.

This set of simulation simulators for teaching the technique of extracorporeal and intracorporeal suture was tested in the 2019-2020 academic year at the Department of Operative Surgery and Topographic Anatomy of the Federal State Budgetary Educational Institution of Higher Education of the State Medical University of the Ministry of Health of the Russian Federation, Smolensk and from 2020 to 2021 on the basis of the Swiss University Clinic, which is a clinical base FGBOU DPO RMANPO Ministry of Health of the Russian Federation. The study was carried out in three groups. The first group consisted of 10 senior students enrolled in the program "Medicine", possessing the basic skills of laparoscopic surgery. In the second group, there are 10 surgical residents of the first year of study, who practice in general surgical hospitals. The third group consists of 10 surgeons (surgeons and gynecologists) who are proficient in open surgery techniques and basic skills in laparoscopic surgery. At the first trial session, all participants in the study showed a low level of loop formation, the duration of needle positioning, and the inability to suture in various planes. When working on simulators I-VII, each student was given a task on a specific simulator, the time to complete one task was more than 20 minutes in all three groups. At the same time, there was a violation of the technique of intracorporeal suture, inaccuracy of suturing, different distances between the ties, different levels of injection and puncture, difficulty in correct positioning of the needle.

10 lessons were held for 3 academic hours on a given topic in each group. Each trainee spent at least 27 academic hours practicing these skills. After the classes in the first group, everyone formed the skill of intracorporeal and extracorporeal suture. At the final lesson, each of the students was able to complete all tasks on tablets I-VII and make the minimum number of mistakes. After the trainings in the second group, there was a significant increase in the level of skill, all tasks were performed with minor errors. By the end of the classes, the average time to complete tasks in the first and second groups was 7 minutes. In the third group of trainees, mastering the basic techniques of laparoscopic surgery was faster than in the previous two groups; by the 6th lesson, the speed and accuracy of the task with minor errors were noted. The 10th control session showed in the group of doctors the minimum time to complete the task with maximum accuracy or minor blots.

The use of the proposed set of simulators for teaching the technique of extracorporeal and intracorporeal suture has the following advantages:

- allows you to master the whole range of techniques and actions necessary in laparoscopic surgical technique, such as the formation of various types of laparoscopic knots, the skill of applying a laparoscopic suture, the ability to position the needle in a laparoscopic needle holder, the ability to handle suture material in an enclosed space, the skill to work with laparoscopic scissors, the skill invagination and removal of turundas and turnstiles in anatomical structures in a closed space, coordination of movements, interaction of the right and left hands;

- the kit includes simulators that allow developing the skills of using laparoscopic instruments at a high level of skill;

- in the process of training on this set, the principle of gradual acquisition of basic manual skills from simple to complex is laid, simulators form the skill of applying a laparoscopic suture in stages, from the correct position of the instrument and needle injection to tightening the knot;

- allows you to quickly master the technique of intracorporeal and extracorporeal suture;

- high versatility, as the kit is suitable when working on any simulation complex;

- the set has a high economic component;

- a set of simulation simulators is easy to manufacture;

The proposed kit can be widely used in teaching the technique of intracorporeal and extracorporeal suture in laparoscopic surgery, as it allows you to master the correct technique for the formation of a laparoscopic suture in a short period of time, has a high economic profitability and corresponds to the modern system of teaching students and young professionals. The provisions of the modern training system show that training at the early stages should be carried out using simulation models and simulators to acquire basic manual skills, then on biological tissues and laboratory animals to work out the technique and stages of surgical intervention. Multi-stage preparation is the main component in the provision of highly qualified care to the patient. This confirms the relevance and possibility of using the kit in individual and collective training at the departments of advanced training of surgical doctors and simulation centers.

Claims (8)

A set of simulation simulators for teaching the technique of extracorporeal and intracorporeal suture, containing seven simulators, each representing a transparent rectangular platform made of polymethyl methacrylate 16 * 16 cm in size and 0.5 cm thick, while the first simulator for practicing the skills of making seams contains in the center of the platform 5.5 cm from the front and back faces and 4 cm from the side faces an 8 * 5 cm content tape with plastic hooks for fixing the foam material, the second simulator for the formation of surgical knots contains two solid plates fixed on two opposite sides of the platform, the plates are bent at an angle of 90° with the formation of the upper side and racks and have dimensions of 3 * 3.5 cm, cuts 7 mm deep are formed in the upper side of the plate and 3 mm wide for fixing between opposite posts of an elastic band with a diameter of 4 mm, used to practice the formation of a single and double loop for the subsequent execution of the knot; the third simulator for positioning the surgical needle in space includes a transparent polymethyl methacrylate plate 6 cm high, 16 cm wide and 0.4 cm thick, located 11 cm from the front face of the horizontally located platform and fixed at an angle of 90 degrees relative to the platform, a black geometric figure is applied to the plate colors in the form of a continuous non-intersecting line, on which sixteen screw-rings are fixed perpendicular to the line for holding an atraumatic needle with a thread, ten of which are on a horizontal platform, and six are on a plate; the fourth simulator for sewing fabrics at an angle contains two panels 16*16 cm in size, 0.4 cm thick with a cutout in the center of the platform 13*13 cm in size, which are superimposed on the platform and form a 1.5 cm wide edging along the perimeter, and an elastic synthetic white fabric with a graphic pattern printed on it in the form of 8 beams 5 cm long, emerging from the center of the platform, along each beam, retreating from the center of the platform by 0.12 cm, four paired marks in the form of dots are applied, spaced from the line of the beam by 0 .4 cm on each side; the fifth simulator for working out the technique of working with clamps includes a plate 15 cm long and 7.5 cm wide, located 7.5 cm from the front face of the platform, made of monolithic transparent polymethyl methacrylate, bent at an angle of 115 degrees, on the plate, stepping back from the side faces by 2, 5 cm and in the center from the upper and lower faces of the platform, 2 through holes with a diameter of 2 cm are formed, a satin ribbon 2 cm wide and 170 cm long is passed through the holes in order to bring the satin ribbon out of one hole to the front of the platform by alternately intercepting tapes from the right clamp to the left clamp and insertion into another hole; the sixth simulator for the formation of longitudinal and transverse seams includes three sealing lines located on the platform and consisting of two polyurethane rollers 10 mm wide and 6 mm high for performing an intracorporeal continuous or nodal suture, as well as an extracorporeal nodal suture in the transverse or longitudinal direction; but the seventh simulator for suturing a hollow organ contains two metal clamps located at an angle of 45° on the farthest side of the platform 8 cm in size from the trainee and deployed to the center of the platform, which are designed to fix the cadaver material or a hollow organ simulator in the form of a rubberized textile glove worn on an inflated air rubber medical glove.

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