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Plast Reconstr Surg Glob Open
Plast Reconstr Surg Glob Open
GOX
Plastic and Reconstructive Surgery Global Open
2169-7574
Lippincott Williams & Wilkins Hagerstown, MD

GOX-D-24-00494
00010
10.1097/GOX.0000000000006135
3
Education
Ideas and Innovations
Teaching Atraumatic Soft Tissue Handling in the Simulation Laboratory: Development of a Novel Training System
Andersen Emily S. MD *
Newsom Megan R. MD *
Jamal Tameem MD †
Mountziaris Paschalia MD, PhD *
Rhodes Jennifer L. MD *
Wayne Jennifer PhD ‡
From the * Division of Plastic and Reconstructive Surgery, Virginia Commonwealth University, Richmond, Va.
† Department of General Surgery, Grand Strand Medical Center, Myrtle Beach, S.C.
‡ Department of Biological Systems Engineering, College of Engineering, Virginia Tech, Blacksburg, Va.
Megan R. Newsom, MD, Division of Plastic and Reconstructive Surgery, Virginia Commonwealth University, 1250 E Marshall Street, Richmond, VA, E-mail: megan.newsom@vcuhealth.org
9 2024
04 9 2024
12 9 e61356 5 2024
17 7 2024
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Summary:

Atraumatic soft issue handling is essential for optimal wound healing. Simulation is a safe and effective way to improve surgical skills outside the operating room. Our primary aim was the development of a pressure-sensing forceps that measures the force applied to a given tissue and provides real-time biofeedback. Seventy-eight students and trainees performed four trials of a continuous subcuticular closure using our Tissue Handling Trainer System device on a silicone skin model. We recorded the occurrence of above-threshold pressure and duration of time over the threshold. A one-way analysis of variance with Tukey post hoc test was used to analyze duration above-threshold pressure. There were statistically significant differences in the duration above threshold from trials 1 to 3 (P < 0.001). A 36% reduction occurred between trials 1 and 2 after participants learned of the study purpose, but a 70% reduction between trials 2 and 3 with audible feedback. There was no statistically significant difference between trials 3 and 4 (P = 0.807). The Tissue Handling Trainer System may be an effective technique for improving tissue handling skills in the surgical simulation laboratory.

OPEN-ACCESSTRUE
COUNTRYUNITED STATES
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pmcTakeaways

Question: Can a biofeedback training device and a skin simulation model successfully improve medical student and resident tissue handling?

Findings: Seventy-eight students and trainees performed continuous trials of a continuous subcuticular closure using our Tissue Handling Trainer System device on a silicone skin model. During each trial, the amount of force used to handle the skin was measured. There was a significant decrease in the force used to handle the skin in both the resident and medical student groups.

Meaning: Our tissue handling training system was able to improve medical student and resident tissue handling.

INTRODUCTION

Scar formation is influenced by three independent factors: patient history, the nature of the wound, and technical factors. Thoughtful handling of the skin during incision closure is essential for optimal wound healing.1 Rough handling of tissue, especially using instruments that crush the skin, causes local tissue injury and ischemia. The result is local inflammation and increased deposition of extracellular collagen potentiating hyperplastic scar formation.2–4

Simulation training promotes medical student education, but the role of clinical simulation for surgical techniques remains unclear.5 There is no standardized method to train students on proper tissue handling with forceps.6

There is a need for more standardized and effective suturing training methods. Accordingly, we have developed a device to help develop proper techniques when using forceps in a simulation laboratory setting. Our device is a pressure-sensing forceps that measures the force applied to a given tissue and provides real-time biofeedback. We hypothesized that our Tissue Handling Trainer System (THTS) would be able to train users to apply less pressure when manipulating skin with forceps. [See Video (online), which displays the device being used.]

Video 1 which displays the device being used.

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METHODS

Thirty-seven surgery residents and 41 medical students (n = 78) participated in this study. Each participant performed a continuous subcuticular closure on a silicone skin model using the forceps over four trials in a single sitting. Each participant was also given a pair of forceps with an embedded pressure transducer to be held under the participant’s thumb to record the pressure applied to the tissue with the forceps while suturing.

There were four different closure trials: (1) no knowledge of the goal of the study to reduce pressure applied during suturing and no audible feedback from the pressure-sensing device, (2) knowledge of the study and no audible feedback from the pressure-sensing device, (3) audible feedback from the pressure-sensing device, and (4) no audible feedback.

For each trial, we recorded the amount of time it took to complete 10 passes and the duration that the participant applied an above-threshold pressure. We calculated the relative amount of time over threshold with respect to the first trial. Statistical analysis was performed with either a one-way or two-way analysis of variance with Tukey post hoc test using R Studios Statistics software (R Studios, Boston, Mass.).

RESULTS

Disclosure of the study objective to the participants and the addition of an audible stimulus both produced decreases in the duration of time above threshold from trial 1 (T1; Figs. 1 and 2; Tables 1 and 2). There was a 36.6% reduction in mean duration above-threshold pressure from T1 to T2 after the participants were informed of the goal of the study, and a 48.1% reduction in mean duration above threshold from T2 to T3 with the introduction of the audible stimulus when the participants applied an above-threshold pressure with the forceps (P < 0.01). There was no difference in duration above the threshold pressure between T3 and T4 when the audible stimulus was removed, indicating maintenance in force applied when suturing.

Table 1. Relative Time over Threshold of Each Trial and Change in Time with Respect to Each Trial

	Relative Time Over Threshold	Change in Time Over Threshold from Trial 1	Change in Time Over Threshold from Trial 2	Change in Time Over Threshold from Trial 3	
	Trial 2	Trial 3	Trial 4	T1–T2	T1–T3	T1–T4	T2–T3	T2–T4	T3–T4	
Count	75	75	75							
Mean	63.4%	15.3%	20.9%	36.6%*	84.7%*	79.1%*	48.1%*	42.5%*	−5.6%	
SD	29.0%	14.5%	17.3%							
* P < 0.01.

Table 2. Relative Time over Threshold of Each Trial with Respect to Level of Training

	Trial 2
(Resident)	Trial 2
(Student)	Trial 3
(Resident)	Trial 3
(Student)	Trial 4
(Resident)	Trial 4
(Student)	
Count	38	37	38	37	38	37	
Mean	59.2%	67.8%	11.6%	19.1%	17.8%	24.1%	
SD	33.1%	23.8%	12.5%	15.5%	18.9%	15.2%	

Fig. 1. Time over threshold by trial.

Fig. 2. Normalized time over threshold per trial with respect to trial 1.

In the medical student group, there was a decrease in duration above threshold with the information about the study goal (32.2% reduction in mean, P < 0.01) and introduction of the audible stimulus (48.7% reduction in mean, P < 0.01), but no difference from the removal of the audible stimulus. The resident group alone had similar behavior with a reduction from T1 to T2 (40.8% reduction in mean relative time, P < 0.01) and T2 to T3 (47.6% reduction in mean relative time, P < 0.01), and no change from T3 to T4. There was no difference between the students and residents in each trial.

DISCUSSION

Our study demonstrates that the THTS is a novel training tool that provides feedback about the force generated by forceps when suturing. It also demonstrates a decrease in the use of excessive force through providing audible biofeedback. There was a decrease between groups 2 and 3 (48.1%), illustrating that the audible biofeedback assists subjects in using minimal force. The use of audible feedback likely conditions subjects to apply less force when handling skin, which allows for better tissue handling. This is supported by the lack of significant difference between groups 3 and 4 once the audible feedback is turned off. We demonstrate no difference in the results from medical student and resident participants, which shows that the THTS provides benefits to different levels of trainees.

This project has several limitations. Notably, our sample size is small because this was a proof-of-concept investigation. Future studies should expand to include a much larger population of learners. Another major limitation of our study is the use of a silicone suture model because the skills learned on this model are inconsistently translatable to a human setting. Future studies should use a more realistic animal model, such as a chicken thigh. Lastly, based on our study design, it is difficult to distinguish if practice itself or the device is improving tissue handling. This may be clarified by measuring the force applied by a participant after practicing suturing without the device compared with after practicing with the device. In the future, we would like to refine this concept and our device design. For example, if this force sensor was more sensitive, it could be used for microsurgery practice.

Several articles have addressed the importance of measuring force or pressure as a quantitative method for soft tissue handling.7–9 The THTS, and applications like it, could help train future surgeons.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENT

We acknowledge Dr. Patrick Jones for his help in the development of the THTS model.

Published online 4 September 2024.

Presented at the American Society of Plastic Surgeons 89th Meeting, May 2020, San Francisco, Calif.

Disclosure statements are at the end of this article, following the correspondence information.

Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
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