RU2717071C1 - Simulator for mastering manual skills when forming surgical knots - Google Patents

Abstract

FIELD: medicine; training.

SUBSTANCE: invention refers to medical training devices for mastering practical skills in surgery. Simulator to develop manual skills when forming surgical knots includes a common platform with fixed on it working blocks for performing surgical knots. Number of working units is equal to twelve by number of most frequently used surgical knots. First – the third are made of a rubber tube stretched between three metal hooks and forming an isosceles triangle. Fourth to eighth are made of plastic pipes and fixed on common platform by means of plastic plugs of appropriate diameter. Two holes are formed at the height from the pipe bottom, through which a rubber tube is fixed and tensioned on the front side of the plastic tube. Seventh to eighth blocks are made of plastic pipes and provided with additional holes for ease of visual assessment of quality of application and extraction of used ligature. Eighth block is equipped with a rubber tube, one end of which is fixed on the pipe, and the other one freely hanging inside its lumen. Ninth and twelfth blocks are made in the form of metal hooks, at that, the ninth unit over the hook contains a rubber tube. Tenth and the eleventh blocks are made from a polyurethane tube fixed between the clamps and a dissected longitudinal incision directed upwards, on the opposite edges along the incision marks are marked in the form of a circle.

EFFECT: technical result consists in providing mastering of manual skills when forming most frequently used surgical knots.

1 cl, 10 dwg

Description

The invention relates to educational simulation devices, simulators of practical skills used in the educational process in higher medical institutions, at different stages of training students, and young specialists with the aim of demonstrating and learning the technique of knitting surgical knots or improving the skill level of manual skills.

The well-known surgical simulator Dock 2.0 * for general surgery for students and young specialists, on which it is possible to work out knotting and suturing, is a manufacturer of the Center for Innovative Methods of Medical Education LLC. This simulator is used to prepare and demonstrate practical skills in surgical surgery, as well as improving surgical techniques at home. Allows you to master and bring to the required level manual skill. Options: anti-slip platform, a set of elements for fixing, a block for fixing working platforms, including a simulator for working out nodes under tension, a simulator for working out nodes at a depth, a basic thread tension control simulator, an advanced thread tension control simulator, an intradermal (cosmetic ) seam. Skills practiced: the formation of surgical nodes when suturing superficial wounds and wounds at a depth, the development of the pulling force of the thread during the formation of the node, the development of the force to reduce the edges when suturing the wound, the formation of surgical nodal and continuous sutures, the formation of intradermal (cosmetic) suture, removal of skin nodal and continuous sutures, removal of the intradermal (cosmetic) suture. Operating rules for the Dock 2.0 * simulator: created for the development and development of the basic skills of the surgeon, as well as improving the surgical technique at home, placing it on a flat surface in a room with good lighting; Do not attempt to repair or modify the product yourself; do not try to change the design of the simulator yourself or use parts not purchased from an official manufacturer (www.wetlab.spb.ru / Surgical simulators for medical students from the WETLAB-WETLAB center).

The disadvantages of this simulator are: anti-slip platform is not stable in one place when performing thread tension in the process of practicing skills because of its size; the set of fixation elements and the fixation block of the working platforms consist of adhesive materials, which, when changing simulators for various purposes, which are included in the set and regular operation (less than a month) become unusable, and their replacement and the acquisition of a new set of fixation elements entails an increase training costs. The simulator for working off nodes at a depth is equipped with stationary conditions that do not allow varying the complexity and variability of clinical situations. The metal hook inside the tank is tightly fixed to the panel, without an element of imitation of turgor anatomical structure, which greatly complicates the formation of clinical skills in the formation of surgical nodes in the depth of the wound, working out the degree of tension of the thread during the formation of the node. The base tension tension control simulators and the advanced string tension control simulators are located on different blocks, which requires regular changes on the platform, as this is one of the initial levels of mastering surgical skills. Along with the foregoing, it should be noted the need to regularly rearrange the work units on an anti-slip platform, taking into account the skills being worked out. This contributes to additional cushioning and wear of the locking elements. In the simulator for working out the intradermal (cosmetic) suture, expensive material imitating the skin and fixing elements must also be replaced, which leads to a costlier learning process. In other words, regular use of the Dock 2.0 * simulator for educational purposes in an educational institution is not cost-effective, and the use of parts purchased from an unofficial manufacturer may be accompanied by damage to the device and the inability to fully use it. We should talk about limiting the use of this model.

The technical result of the proposed simulator is a technically simple, easy-to-use simulator that provides reliability and interchangeability of work units, equipped with a large set of work units, with the aim of varying the complexity of clinical situations and developing basic surgical skills, taking into account the elasticity of anatomical structures.

The essence of the invention of the simulator for the development of manual skills in the formation of surgical nodes is blocks for performing the most commonly used 12 surgical nodes, each of which models a particular surgical situation, and a single platform for all these blocks is simple and convenient to use, ensuring reliability and interchangeability of working parts.

In FIG. 1 shows the general scheme of the simulator for the development of manual skills in the formation of surgical nodes. The simulator, which consists of a platform made of laminated chipboard, is rectangular in size 800 * 400 * 20 mm, on which 12 fixed objects are placed. Objects No. 1-3 are made of a rubber tube with an outer diameter of 5 mm, with a wall thickness of 2 mm, an inner diameter of 3 mm, a hardness of 45 Shore A (Fig. 2). Objects No. 1, No. 2, No. 3 are located along a rubber tube fixed between three metal hooks. Metal hooks are fixed on the platform so that the elastic stretched between them is 4 cm away from the platform and forms an isosceles triangle with a side length of 50 cm and a base of 15 cm. On long sections of the tube at a distance of 11 cm from the “top” of the triangle and 10 cm each marks from a friend are 2 cm long. Thus, the distance between marks at object No. 1 is 4.5 cm, at object No. 2 - 7.5 cm, at object No. 3 - 8.5 cm. At objects No. 1 - No. 3 simulate a comparison of the edges of the aponeurosis when suturing the laparotomy wound after common paws arotomy.

Objects No. 4-10 are made of plumbing plastic sewer pipes with a diameter of 110 mm, 75 mm, 50 mm, respectively (Fig. 3-4), 130 mm long (for objects No. 4-6) and 200 mm (for objects No. 7-8 ), which is fixed on the platform with a plumbing plastic sewer plug of the corresponding diameter and a rubber tube with an outer diameter of 5 mm, with a wall thickness of 2 mm, an internal diameter of 3 mm, a hardness of 45 Shore A, 180 mm long. At a height of 6 cm from the bottom of the pipe, 2 holes with a diameter of 6 mm are formed, through which a rubber tube is held, fixed in tension from the front of the plastic pipe using a bag clip. At facilities No. 4, 5, 6, 7, it is proposed to compare the edges of the stretched elastic bands by applying a knot in difficult conditions. At object No. 4, the ligation of the zonal branches of the splenic artery is modeled during splenectomy in the depth of the laparotomy wound by mid-median access. At object No. 5, a comparison of the legs of the diaphragm in the depth of the laparotomy wound with surgery for a hernia of the esophageal opening of the diaphragm is simulated. At object No. 6, the ligature of the upper thyroid artery is simulated during thyroidectomy or the comparison of the edges of the peritoneum in a mini-laparotomy wound during appendectomy.

Objects No. 7-8 are made of a pipe with a diameter of 50 mm, a height of 200 mm, with an additional hole for the convenience of visual assessment of the quality of the overlay node, as well as for the convenience of extracting the used ligature (Fig. 5-6). At the object No. 7 model the ligation of the cystic duct with cholecystectomy from mini-laparotomy access using an annular retractor with a set of fixed articulated retractors.

Object No. 8 has only one fixation point of the rubber tube at a height of 50 mm from the bottom of the pipe, the opposite end hangs freely inside the lumen of the plastic pipe (Fig. 7). At the facility No. 8, the ligation of the cystic artery is simulated during cholecystectomy from mini-laparotomic access using an annular retractor with a set of fixed articulated retractors.

Objects No. 9 and 12 are made of a metal hook 5 cm high, with a bend diameter of 3 cm fixed on the platform. At object No. 9, a rubber tube with an outer diameter of 5 mm, with a wall thickness of 2 mm, an inner diameter of 3 mm, and a hardness of 45 Shore A along its entire length is fixed over a metal hook (Fig. 8). At facility No. 9, suture material savings are modeled when creating an inter-intestinal anastomosis. At the facility No. 12, the pressure of the base of the appendicular process is simulated when performing laparoscopic appendectomy.

Objects No. 10, No. 11 are made of a foam tube used in construction for the insulation of a polypropylene pipe. The outer diameter of the foam tube is 8 cm, the inner diameter is 6 cm, 12 cm long (Fig. 9). Objects No. 10-11 are located along the foam-tube tube fixed between the clamps for the packages. The bag clips are fixed to the platform. The tube is dissected by a longitudinal section, which is directed upward. On opposite edges along the section at a distance of 5 cm from each other and 1.5 cm from the edge of the section, marks are made in the form of a circle with a diameter of 1 cm, respectively, to objects No. 10 and No. 11. At sites No. 10 and No. 11, the application of skin sutures to the laparotomy wound after a median laparotomy is simulated.

On the simulator, the trainee is offered to form the 12 most commonly used surgical units, each of which models a particular surgical situation. On the platform, 12 of the proposed objects are numbered, tasks are located as their level of complexity increases.

Skills practiced: the formation of surgical nodes when suturing superficial wounds, deep wounds, wounds in cramped conditions, that is, in physiological wells, including applying a ligature with short ends of the threads, using hemostatic clamps to save suture material, working out the thread tension force when the formation of the node, the development of the degree of force to reduce the edges when suturing the wound, the skill of controlling the application and fixation of the node in the desired place, that is, on one side of the wound surface, the formation x nodal and continuous sutures, the formation of an intradermal (cosmetic) suture, removal of skin nodal and continuous sutures, the removal of an intradermal (cosmetic) suture.

60 мм в диаметре, хирургический пинцет (200 мм).When performing tasks, the use of surgical instruments is recommended. A set of tools for completing tasks at sites No. 7-8: a dissector (200 mm), two hemostatic clamps (200 mm) for ligature under imaginary structures, a Vinogradov fork (knotter) for fixing the assembly at the bottom of the well. A set of tools for completing tasks at facility No. 9: two hemostatic clamps (200 mm). A set of tools for completing tasks at sites No. 10-11: needle holder (200 mm), traumatic cutting surgical needle

60 mm in diameter, surgical tweezers (200 mm).

In FIG. 10 presents a set of tools for completing tasks on the simulator.

On each of the objects it is necessary to impose a ligature and qualitatively fix the node in compliance with the standards and requirements for the surgical node. The difficulty of its formation and fixation lies in the development of the skill not to dissolve the first superimposed half-loop during the formation of the second half-loop, which allows you to reliably fix and compare adjacent tissues and anatomical structures.

When completing tasks at objects No. 1-12, they pay attention to the correct technique of knot formation, to the same length of the ends of the threads after the end of the knot formation (a difference in the length of the threads up to 3 cm is allowed), to the alternation of the “right” and “left” nodes in the formation process , the absence of diastasis between the comparable edges of the rubber tubes, the sufficient fixation of the last half-loop, for the duration of all 12 tasks.

An example of performing tasks at objects No. 1-3.

Suturing of a superficially located anatomical structure. The learner forms nodes along the rubber tube within the marked boundaries, in order to compare the edges of the rubber tube. From node No. 1 to node No. 3, the degree of tension increases, since the distance from the edges being compared also increases.

An example of performing tasks at objects No. 4-7.

Ligation of the anatomical structure in the physiological well. The trainee fixes the ligature at the ends of the branches of the hemostatic clamp for the convenience of feeding it into an imaginary physiological well. Fixing the dissector in his hand, starts it under the rubber tubes and opens the branches. At the same time, with the other hand, he lowers the hemostatic clamp in the well, feeding the ligature into the open branches of the dissector and fixes it. Then it opens the branches of the hemostatic clamp, releasing the ligature, and removes it from the well. Then it forms the first half-loop outside the cavity of the well and, using the Vinogradov fork, lowers it to the bottom of the well, comparing the edges of the rubber tubes. Holding both ends of the ligature in tension, it forms a second half-loop, changing the direction of the node, and immerses it on the first half-loop with a Vinogradov fork, thereby fixing the node. Changing the direction of the knot, forms the third half-loop, tightening the knot using the Vinogradov fork.

An example of the task at the facility number 8.

Ligation of the anatomical structure in the physiological well. Before the ligature is immersed in the well, the student fixes the end of the rubber tube inside the well with the jaws of the dissector. Further, it fixes the ligature at the ends of the branches of the hemostatic clamp for the convenience of feeding it into an imaginary physiological well. Then he lowers the hemostatic clamp with the ligature into the well with one hand and holds it under the branches of the dissector, so that the ligature tightly wraps around the rubber tube. It extracts a hemostatic clamp from the well, after which it opens the branches, freeing the end of the ligature. Further, from the two ends of the ligature outside the cavity of the well, it forms the first half-loop and with the help of a fork Vinogradova lowers it to the bottom of the well. Holding both ends of the ligature in tension, it opens the dissector jaws, removes it from the physiological well, and then forms a second half-loop, changing the direction of the node, and immerses it on the first half-loop, thereby fixing the node. Changing the direction of the node, forms a third half-loop.

An example of the task at the facility number 9.

Formation of a knot on a ligature 10 cm long using two hemostatic clamps. The trainee fixes the ends of the ligature between the ends of the branches of two hemostatic clamps. When forming a node, it intercepts the end of the ligature with a hemostatic clamp.

An example of performing tasks at facilities No. 10-11.

Suturing of a superficially located anatomical structure. The student charges the ligature into the needle fixed in the needle holder and flashes the foam tube using surgical tweezers. Performing a prick and puncture of a needle in the center of a round mark, brings the edges of the foam tube closer together. Forms a knot on the side that is closer to the learner, without going beyond the boundaries of the mark on the object No. 10. At the object No. 11 forms a node on the opposite side to the learner, without going beyond the boundaries of the applied mark.

An example of the task at the facility number 12.

The learner forms the Raeder knot. This loop should be of sufficient diameter for convenient anatomical structure through it, and should also shift in one direction - towards the narrowing (crushing) of the loop.

This simulator was tested in the academic year 2018-2019 at the Department of Operative Surgery and Topographic Anatomy of the Federal State Budget Educational Establishment of Higher Education, State Medical University of the Ministry of Health of the Russian Federation, Smolensk. The study was performed in two groups. In the first group of 15 people are 4-year students who are studying under the program "General Medicine", who do not have the skills to form nodes. In the second group of 15 people are residents of the surgical profile of the first year of training, who practice in general surgical hospitals. The residents initially had a low level of knot formation (the knot was not fixed enough, after the knot was formed, different lengths of the ligature ends were noted, there was diastasis between the structures being compared, tasks were completed rather slowly, about 20 minutes).

15 lessons of 1.5 academic hours on a given topic in each group were held. Each student spent at least 7 academic hours working out these skills. After the lessons in the first group, everyone mastered the basic skills of the formation of the node. In the final lesson, each of the students was able to form all 12 nodes and make the minimum number of errors. After the classes in the second group, a significant increase in the level of skill was noted, all 12 tasks were performed with minor errors. By the end of classes, the average time for completing assignments was 4 minutes.

Using the proposed simulator for the development of manual skills in the formation of surgical nodes provides the following advantages:

- on one panel, an imitation of a complex of 12 nodes, most often used when performing surgical interventions;

- the tasks are selected and located on the tablet panel as the execution conditions become more complicated, which allows you to build a skill and master the technique of knitting surgical nodes;

- allows you to master the technique of node formation when suturing laparotomic and thoracic wounds, ligation of blood vessels, ligation of structures in deep wounds (more than 15 cm), the technique of formation of endoscopic nodes;

- allows in the shortest possible time to master the basic skills of the formation of surgical nodes and improve them working individually and in a team when assisting;

- the simulator is highly mobile, the total weight of the product is 3500 g, does not require special conditions for use, can be placed in the classroom on the student desk, allows you to practice on it in any convenient place;

- the simulator is economical (can be assembled from materials that are in every hardware store), easy to manufacture;

- the cost of the component parts of the simulator makes it economically viable for educational institutions and for personal use.

The proposed simulator is universal and easy to use. It can be widely used in surgery, in particular, used in the educational process at different stages of training of students and young specialists. Perhaps its use in individual and collective work in the departments of advanced training, in simulation centers.

Claims (1)

A simulator for the development of manual skills in the formation of surgical nodes, including a common platform with fixed working blocks for performing surgical nodes, characterized in that the platform has dimensions 800 × 400 × 20 mm, the number of working blocks is twelve, the first and third are designed to simulate a comparison of the edges of the aponeurosis when suturing the laparotomy wound after general laparotomy, made of a rubber tube with an outer diameter of 5 mm, an inner diameter of 3 mm and a hardness of 45 Shore A, stretched I’m waiting with three metal hooks, while the tube is separated from the platform and forms an isosceles triangle, the fourth and eighth blocks are made of plastic pipes with a diameter of 110 mm, 75 mm or 50 mm and are fixed on a common platform with plastic plugs of the corresponding diameter, while at a height of 6 cm from the bottom of the pipes, 2 holes are formed through which a rubber tube is held, fixed with tension on the front side of the plastic pipe, while the fourth and sixth blocks are designed to simulate the bandaging zone branches of the splenic artery during splenectomy in the depth of the laparotomy wound by mid-median access, comparison of the legs of the diaphragm in the depth of the laparotomy wound with surgery for a hiatus hernia and ligation of the upper thyroid artery with thyroidectomy, or comparison of the margin of the carotid artery in the wound the eighth blocks are made of plastic pipes with a diameter of 50 mm and a height of 200 mm and are equipped with additional holes for the convenience of visual assessment of quality applying and extracting the used ligature, while the seventh block is used to simulate the ligation of the cystic duct in case of cholecystectomy, and the eighth block is equipped with a rubber tube, one end of which is fixed to the tube and the other hangs freely inside its lumen, to simulate the ligation of the cystic artery, the ninth and the twelfth blocks are made in the form of metal hooks, while the ninth block on top of the hook contains a rubber tube and is used to work out the method of saving suture material when creating of intestinal anastomosis, the twelfth block is used to simulate the performance of laparoscopic appendectomy, and the tenth and eleventh blocks are made of a foam tube with an external diameter of 8 cm 12 cm long, fixed between the clamps and dissected by a longitudinal section, which is directed upward, at opposite edges along the section at a distance 5 cm from each other and 1.5 cm from the edge of the incision marked in the form of a circle with a diameter of 1 cm to simulate the application of skin sutures on the laparotomy wound after midline laparotomy.

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