Role of Simulated Training for Carotid Endarterectomy: A Systematic Review.

Online October 21, 2022 doi: 10.3400/avd.ra.22-00021 Ann Vasc Dis Vol. 15, No. 4; 2022; pp 253–259 Review Article Role of Simulated Training for Carotid Endarterectomy: A Systematic Review Nadeem A. Siddiqui, MBBS, FCPS, FACS, MSc, Ammar Pirzada, MBBS, FCPS, Shoaib Badini, MBBS, FCPS, and Fareed A. Shaikh, MBBS, MRCSEd, FCPS-GS, FCPS-Vascular Surgery Vascular surgery trainees often do not get to perform carotid endarterectomy (CEA) directly on the patients as it requires meticulous surgical technique and has a high risk of procedure-related complications. Hence, the role of simulation in training future vascular surgeons becomes essential. This review aims to assess the types and utility of simulators available for CEA. In this systematic review, all the studies performed on CEA simulation were included. The purpose of this review was to assess different types of simulators and their usefulness for CEA. We identified 122 articles, of which 10 were eligible for review. A variety of simulators, ranging from animal models, virtual reality simulators and commercially designed models with high fidelity options were used. Technical competence was the major domain assessed in the majority of the studies (n=8), whereas four studies evaluated anatomical and procedural knowledge. Blinding was done in five studies for assessment purposes. The majority of studies (n=9) found the simulation to be an effective tool for achieving technical competence. This review shows the potential usefulness of simulation in acquiring technical skills and procedural acumen for CEA. The available literature is unfortunately too diverse to have a common recommendation. Section of Vascular Surgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan Received: January 31, 2022; Accepted: August 22, 2022 Corresponding author: Fareed A. Shaikh, MBBS, MRCSEd, FCPS-GS, FCPS-Vascular Surgery. Cardiothoracic and Vascular offices, Link Building, Section of Vascular Surgery, Department of Surgery, Aga Khan University Hospital, 74800, Stadium road, Karachi, Pakistan Tel: +92-3218110155; +92-21-34864708, Fax: +92-21-34934294 E-mail: ©2022 The Editorial Committee of Annals of Vascular Diseases. This article is distributed under the terms of the Creative Commons Attribution License, which permits use, distribution, and reproduction in any medium, provided the credit of the original work, a link to the license, and indication of any change are properly given, and the original work is not used for commercial purposes. Remixed or transformed contributions must be distributed under the same license as the original. Annals of Vascular Diseases Vol. 15, No. 4 (2022) Keywords: simulated training, surgical education, surgical training, carotid artery surgery, carotid endarterectomy Introduction Traditionally, surgical trainees have been trained on patients in the operating room, which has led to concerns like patient safety and overall cost due to increased length of procedure.1,2) Vascular surgery patients are generally more complex than other surgical specialties due to the nature of the disease.3) This poses a significant challenge to learn specialised skills without compromising the outcomes. In addition, work hour restrictions,4) reduced duration of residency,5) medicolegal complaints6) and an increasing acceptance of endovascular-first approach7) have greatly affected surgical trainings in general and open procedural skills in particular. Media reports like ʻBad surgeons cannot be detected,ʼ8) reduced exposure to hands-on surgery and the subsequent lack of confidence in graduating trainees to perform independent procedures were some of the reasons behind using simulations for surgical trainings. Simulation can be simply defined as a method, which is deployed to produce an experience without going through the real event.9) It allows for the safe practice of certain techniques and is becoming increasingly important in the shift towards improved education of trainees in surgery.10) A recent systematic review by Lawaetz et al.6) reported the benefit of simulated training in open vascular surgery; however, it included all open vascular procedures, whereas we aim to focus on Carotid Endarterectomy (CEA). CEA is the standard open procedure aimed to prevent imminent stroke in selected patients.11,12) In addition, guidelines for performing this complex procedure recommend that a vascular surgeon with high procedure volumes13) and perioperative stroke risk less than the natural course of carotid artery disease is eligible.14) This benchmark puts enormous pressure not only upon the novice surgical trainee but also on the supervising consultant, ultimately resulting in the consultant performing the main 253 Siddiqui NA, et al. steps of every procedure. Various simulation models, both bench top and bovine, have been described for the training of CEA with varying results.3,5,15–21) Given the limited opportunity for trainees to perform CEA and the delicate nature of the procedure, we decided to conduct this systematic review to look at the different models available and assess their benefits. The main objective of this systematic review was to identify different types of simulators used for the training of CEA and to assess the usefulness of all such simulators considered for simulated training on CEA. Methods This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.22) A systematic search for relevant studies was carried out, using search engines like Google Scholar, PubMed, Cochrane database, Medline and Scopus. Studies including observational to interventional trials, which reported the use of simulation in CEA were included. Exclusion criteria included simulationbased studies done solely on the vascular anastomosis, those involving animal research, in languages other than English and unpublished studies. Most of the innovations and advancements in the field of simulation in vascular surgery have been reported in the last two decades; hence, articles published after January 2000 were included, and the last date of the literature search was 31 August 2021. Search Strategy To identify relevant studies, the search strategy was based on concepts of population, intervention and outcome. Population was identified as trainees of vascular surgery programmes. The search terms used to look for population were ʻvascular surgery traineesʼ OR ʻfellows of vascular surgeryʼ OR ʻresidents of vascular surgeryʼ OR ʻvascular physiciansʼ OR ʻvascular surgeonsʼ AND ʻcarotid endarterectomyʼ OR ʻopen surgery for carotid artery stenosisʼ OR ʻcarotid artery surgery.ʼ Intervention of interest was simulation models used for CEA. For that, we used ʻsimulation modelsʼ OR ʻsimulation toolsʼ OR ʻsimulation trainingʼ OR ʻsimulation in vascular surgeryʼ as search terms. Outcome was the effectiveness of different types of simulators used for CEA. For such outcome, (...truncated)