Evaluation and implementation of a mannequin-based surgical simulator for margin-involving eyelid laceration repair – a pilot study

Zhao et al. BMC Medical Education (2021) 21:170 https://doi.org/10.1186/s12909-021-02600-3 RESEARCH ARTICLE Open Access Evaluation and implementation of a mannequin-based surgical simulator for margin-involving eyelid laceration repair – a pilot study Jiawei Zhao1, Meleha Ahmad1, Emily W. Gower2, Roxana Fu3, Fasika A. Woreta1 and Shannath L. Merbs4* Abstract Background: Repair of margin-involving eyelid lacerations is a challenge for beginning ophthalmology residents, yet no commercially-available simulation models exist for learning this skill. The objective of the study was to modify a mannequin-based surgical simulator originally developed for trachomatous trichiasis surgery training to teach margin-involving eyelid laceration repair and to evaluate its success within a residency wet-lab environment. Methods: We modified a previously developed mannequin-based training system for trachomatous trichiasis surgery into a simulator for margin-involving eyelid laceration repair. Six ophthalmology residents from a tertiary care academic institution performed at least one simulated margin-involving eyelid laceration repair using the surgical simulator between September 2019 and March 2020. Each session was video recorded. Two oculoplastic surgeons reviewed the videos in a blinded fashion to assess surgical proficiency using a standardized grading system. Participants were surveyed on their comfort level with eyelid laceration repair pre- and post-completion of simulation. They were also queried on their perceived usefulness of the surgical simulator compared to past methods and experiences. Results: Six residents completed 11 simulation surgeries. For three residents who completed more than one session, a slight increase in their skills assessment score and a decrease in operative time over two to three simulation sessions were found. Self-reported comfort level with margin-involving eyelid laceration repairs was significantly higher post-simulation compared to pre-simulation (p = 0.02). Residents ranked the usefulness of our surgical simulator higher than past methods such as fruit peels, surgical skill boards, gloves, and pig feet (p = 0.03) but lower than operating room experience (p = 0.02). Residents perceived the surgical simulator to be as useful as cadaver head and emergency department/consult experience. (Continued on next page) * Correspondence: 4 Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, 419 W. Redwood St., Suite 420, Baltimore, MD 21201, USA Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Zhao et al. BMC Medical Education (2021) 21:170 Page 2 of 8 (Continued from previous page) Conclusions: We developed a surgical simulator for teaching eyelid laceration repair and showed its utility in developing trainees’ surgical skills. Our surgical simulator was rated to be as useful as a cadaver head but is more readily available and cost effective. Keywords: Surgical simulator, Resident education, Surgical training, Eyelid laceration repair, Oculoplastic surgery, Ophthalmology Background Surgical training across multiple specialties, including ophthalmology, has traditionally been based on an apprenticeship model, resulting in significant variability in a trainee’s experience and exposure to different procedures. There has also been a decrease in resident autonomy as rules for ensuring patient safety have increased [1]. A growing number of simulation-based models have become available in ophthalmology allowing for the training and assessment of procedural skills without associated patient risk [2, 3]. Eyelid lacerations associated with ocular and periocular trauma often occur outside of regular clinic hours, when residents take primary call. Therefore, it is important for an ophthalmology resident to be proficient at eyelid laceration repairs early during their training. Eyelid laceration repair has been prioritized as one of the top 10 procedures that should be practiced in a simulation-based manner to achieve proficiency before working with actual patients [4]. Lacerations involving the eyelid margin are particularly challenging to repair, and they require a complex, layered closure with several different suture materials. Familiarity with the steps of the technique and an appreciation for the feel of the tissues involved can help the ophthalmology resident achieve a well-reconstructed eyelid that is both functional and aesthetic. Very few simulation models exist for teaching oculoplastics procedures. Cadaver-based models are advantageous because of their fidelity and realism, but they have limited applications due to low availability and high cost [5, 6]. A surgical skill board has been employed to teach simple wound closure in a 1-day surgical course run by Moorfields Eye Hospital [7]. Animal models, such as pig eyelid [8] and split pig-head models [9], have been used to teach eyelid laceration repair. However, there can be inconsistency in the quality of the animal tissue and important anatomic differences when compared to the human eyelid. The aim of this study was to develop and evaluate a cost-effective and reproducible surgical simulator to teach margin-involving eyelid laceration repair. In addition, we investigated the implementation of the simulator within a wet lab training environment. Methods All study procedures were approved by the Institutional Review Board of the Johns Hopkins University School of Medicine and adhered to the requirements of the Health Insurance Portability and Accountability Act. Mannequin-based simulator A mannequin-based training system called the Human Eyelid Analog Device for Surgical Training and skills Reinforcement in Trichiasis (HEAD START, Ho’s Art LLC, Yadkinville, NC) was previously developed for trachomatous trichiasis surgery training [10]. The mannequin head is made out of (...truncated)