
==== Front
Heliyon
Heliyon
Heliyon
2405-8440
Elsevier

S2405-8440(24)12720-X
10.1016/j.heliyon.2024.e36689
e36689
Research Article
A novel 3D-printed educational model for the training of laparoscopic bile duct Exploration:a pilot study for beginning trainees
Yang Zhenyu a1
Tong Yao b1
Duan Dongfeng a1
Xin Wei a
Li Haoran a
Yi Jiangpu c
He Xianli wanghe@fmmu.edu.cn
a⁎
Bao Guoqiang guoqiang@fmmu.edu.cn
a⁎⁎
a Department of General Surgery, The Second Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China
b Department of Anesthesia and Surgery, The Second Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi, China
c 3D Printing Research Center of Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, China
⁎ Corresponding author. Department of General Surgery, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, China. wanghe@fmmu.edu.cn
⁎⁎ Corresponding author. Department of General Surgery, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, China. guoqiang@fmmu.edu.cn
1 These authors contributed equally to this work.

23 8 2024
15 9 2024
23 8 2024
10 17 e3668921 6 2023
29 7 2024
20 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background

Laparoscopic common bile duct exploration (LCBDE) is a minimally invasive procedure for the removal of bile duct stones that is often performed by experienced hepatobiliary surgeons; beginners do not easily master this approach.

Aim

To investigate the effectiveness and practicality of a three-dimensional printed (3DP) anatomical model based on radiographic images in the training of LCBDE techniques and formulate standardized educational workflows.

Methods

Colored LCBDE training models were produced using 3DP technology. Twenty standardized training trainees were randomly divided into two groups: a 3DP model training group and a traditional laparoscopic simulation training group. Both groups received the same number of teaching hours. After a 4-weeks training course, the trainees’ subjective and objective progress in basic knowledge and manipulations were evaluated and compared.

Results

Compared with traditional laparoscopic simulation, 3DP model simulation training is of great significance in improving trainers' understanding of surgical procedures and cooperation during the operation. Trainees with 3DP models training demonstrated a significant improvement in their understanding of the key points of surgery (χ2 = 6.139, p = 0.013) and skills scores, especially in core procedural steps operation. More importantly, the trainees showed higher levels of satisfaction and self-confidence while assisting in the surgery.

Conclusion

With the development of 3DP models, improvements in the learning effect for theoretical understanding and practical skills were significant. The present study is the initial educational experience with 3DP models to facilitate the operational capabilities of the trainees for LCBDE.

Highlights

• A colored 3DP anatomical model is created to train beginners in LCBDE.

• 3DP model training significantly enhances trainers' comprehension of surgical.

• Trainees using the 3DP model showed notable improvement in base knowledge and skills.

• A standardized workflow was created to improve LCBDE techniques using 3DP models.

Keywords

3D printing
Medical education
Laparoscopic bile duct exploration
Traditional laparoscopic simulation
==== Body
pmc1 Introduction

Laparoscopic common bile duct exploration (LCBDE) is widely used to treat choledocholithiasis [1]. It is surgically challenging owing to the complex anatomic architecture of the porta hepatis [2], making it difficult for junior surgeons, especially Chinese standardized residency training trainees, to operate on and master [3]. Meanwhile, for units and medical staff who perform LCBDE technology, efficient education and training are of great significance to swiftly master the technology and improve the success rate of the surgery.

In recent years, three-dimensional printing (3DP) techniques have been used to replicate complex anatomic structures based on stereoscopic visualization and individualized views, which is helpful for trainees to learn and understand anatomical structures as well as to design and simulate surgical procedures [4,5]. Meanwhile, because examinations or operations on real patients may not be readily available, 3DP technology has been widely used in modern medicine, especially in many postgraduate training programs and surgical education [6]. 3D reconstructions have previously been applied in hepatobiliary surgery with favorable results, including improved spatial recognition of biliary branches and increased accuracy of aspects of guided surgery [7,8].

The use of physical models constructed to simulate the LCBDE procedure are reported in the literature [9]; however, experience in the application of 3DP models in the simulation of the real and standard operation processes of LCBDE for the education of junior residents is scarce. The effects of learning biliary tract anatomy and LCBDE training were not the same between theoretical learning and practical operations in vitro. 3DP biliary tract models provide numerous practical opportunities for beginners and interns. Herein, we designed a novel 3DP biliary tract model based on the simulated LCBDE operation and assessed its educational value in Chinese standardized residency training and assessment.

2 Materials and methods

2.1 Study methodology

From January 2022 to December 2022, 20 trainees (15 men and 5 women) underwent standardized residency training at our department. All participants successfully completed a five-year undergraduate primary medical education program. Furthermore, they shared the same age and had similar medical backgrounds. All participants were considered novices in the field and lacked any prior experience in laparoscopic surgery training. They were randomly divided into two groups, the 3D-printed model training group (3DPMT group) and the traditional laparoscopic simulation training group (TLCST group), which were used to strengthen the skills of bilateral coordination, precise gripping, switching, knotting, and suturing during laparoscopic surgery. There were eight men and two women in the 3DMPT group and seven men and three women in the TLCST group. All training sessions were conducted using the laparoscopic modular simulation trainers (Johnson & Johnson, USA).

Based on the syllabus, especially for the courses, the basics of vascular and biliary structures as well as the standardized surgical procedure of LCBDE were reviewed together by watching operation videos before continuing hands-on training. Before the training project started, all trainees received similar disease information, imaging scans, planned surgery, and related risks of complications, as well as basic laparoscopic operation skills. This information was delivered during face-to-face consultations using computed tomography (CT) images and operational videos.

2.2 Design

The LCBDE surgical training model was designed based on two real patients with biliary tract dilatation and bile duct stones. The imaging data were obtained using a helical Philips iCT256 scanner (Philips Electronics Co., Netherlands). The scanning parameters were as follows: layer thickness, 0.6 mm; layer spacing, 0.6 mm; tube voltage, 120 kV; effective mAs, 280; field of view, 220 mm. The contrast agent used was iohexol injection 350 (Shanghai GE Pharmaceutical Co., Ltd.) at a flow rate of 4.0 mL/s. The original image data were coded in the standard Digital Imaging and Communications in Medicine (DICOM) format.

DICOM data were analyzed using Mimics Innovation Suite software (version 22.0; Materialize, Leuven, Belgium) to check whether the scanning range was within the anatomical site required by clinical practice. The image files of the liver parenchyma, gallbladder, duodenum, hepatic artery, portal vein, and bile duct were calculated and exported as STL files using Mimics for printing. Next, the image files were processed using Magics software (version 25.0) for 3D reconstruction and modifications including model smoothing, deletion, clipping, and other commands. 3DP was then performed using a 3D printer (Stratasys J850, USA), and hollow-centered bile duct reconstruction models were produced on a 1:1 scale (Fig. 1).Fig. 1 The digital modeling and flexible 3D-printing model of stimulated LCBDE operation. The parenchyma was cast using photosensitive polymer materials in layers with ease of visualization: The venous structure (Blue), The artery tree (Pink), gallbladder (Green), portal vein (Violet). A: Digital modeling view. B: Digital modeling of Hollow-centered bile duct. C: The rigid 3D printing model with replaced hollow-centered bile duct. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 1

The digital model was printed using Stratasys J850 3D printer with Agilus30\Vero Vivid\Vero Ultra as model material. Based on these requirements, the printing hardness was adjusted between 50 and 60, and different colors were selected for printing according to the anatomical structures of the gallbladder (green), portal vein (violet), and hepatic artery (red), as shown in Fig. 1. The production of a 3D printed training model required an estimated duration of 15 h, which was achieved through the application of various photosensitive resin materials in distinct hues onto a single plane. Additionally, the expenditure on printing materials amounted to approximately $320 USD, with the potential for further reduction as the quantity of prints increased. To reduce the cost of the model, the hollow-centered bile duct was designed to be replaced and printed separately using a soft support material.

2.3 Evaluation of the 3D-printed surgical training model

Eleven experienced surgeons were asked to complete a short Questionnaire #1 regarding their impressions of the 3D-printed surgical training model (Appendix 1). Satisfaction was graded on a 10-point Likert scale [10] (1 = very unrealistic, 10 = very realistic) and evaluated using the following criteria: (1) overall impression, (2) color and luster, (3) tissue pliability, and (4) texture material. To assess the utility of the model, a similar scale was used to identify basic LCBDE techniques for teaching (1 = not useful at all, 10 = very useful).

2.4 Training methods

The trainees in the 3DPMT group underwent standardized LCBDE workflow training with a supervised 3DP model (Fig. 2). Meanwhile, the TLCST group only received virtual 3D images of the same model on a computer and was trained with a traditional endoscopic simulator (Fig. 3), including the endoscopic bean clamping module (Fig. 3A), endoscopic nail transfer module (Fig. 3B), endoscopic fine shearing module (Fig. 3C), and endoscopic suture knotting module (Fig. 3D).Fig. 2 Standardized LCBDE procedures. A: Suture and retraction bile duct with absorbable surgical suture; B: The common bile duct (CBD) was cut open; C: Choledochoscope insertion and maneuvering; D: The stone were captured and extracted by rinsing, clamping, or using a choledochoscopic basket. E: The stone were removed using a choledochoscopic basket. F: T-tube insertion; G: The CBD incision was sutured in an interrupted pattern; H: Check the T-tube suture effect; I: T-tube exteriorization drainage and fixation.

Fig. 2

Fig. 3 The traditional laparoscopic simulation training. A: Laparoscopic bean clamping module; B: Laparoscopic nail transfer module; C: Laparoscopic fine shearing module; D: Laparoscopic suture knotting module.

Fig. 3

2.5 Evaluation of the effect of training

The training was fixed three times a week for 120 min each time. After 4 weeks of continuous training, the two groups were compared in terms of theoretical scores, surgical skill objectives, and training project satisfaction. First, to better evaluate the accuracy of the model, actual effect of training, and difficulty of the exercise, a post-training test was administered immediately after the procedural skills training intervention for all trainees. The trainees had to perform the tasks listed in Questionnaire #2 (Appendix 2).

Second, all trainees' skill performance was assessed using the 3DP model, and the application value as a teaching aid was evaluated based on the scoring of procedural operations. The final assessment consisted of several crucial steps of LCBDE (Questionnaire #3) [9]: choledochotomy, bile duct stone capture and extraction using a basket via choledochoscopy, T-tube drainage, and choledochotomy closure. The trainees were also assessed by recording the core procedural operation time and rating scales using the objective structured assessment of technical skills (OSATS) tool [11,12] (Appendix 3). Third, Questionnaire #4 investigated trainees' satisfaction using visual analogue scale (VAS) (Appendix 4). Simultaneously, a senior hepatobiliary surgeon in charge of teaching from the Tang-du Hospital served as a supervisor for both evaluating their master's level of basic knowledge and cooperation degree in real LCBDE operations by performing the tasks listed in Questionnaire #5, where the agreement to each statement was rated on a VAS (Appendix 5).

2.6 Statistics

In order to evaluate the training effect more intuitively, the selected number was used as the endpoint in Questionnaires #1, #3, #4, and #5. The number of correct responses to the questions in Questionnaire #2 was used as the endpoint. In addition, the measurement data are represented as mean ± standard deviation (x‾±Sd) and examined using t-test or Wilcoxon signed rank test. The evidence of construct validity was recorded using the median [range] scores of experienced experts. The enumeration data were examined by χ2 or Fisher's exact test when appropriate. Statistical significance was set at p < 0.05. Statistical analyses were performed using SPSS statistical software 26.0. (IBM Corporation, Armonk, NY, USA).

3 Results

3.1 3D-printed LCBDE surgical training model were better

Eleven experienced surgeons completed a comparison survey and scored the 3DP training model based on the real CT imaging data of the patient. In summary, the experts rated all the assessed dimensions higher. Furthermore, the majority of experts believed that the 3DP model would be useful as an educational tool for LCBDE training and would be superior to other available models. The evaluation of the 3DP model in terms of overall impression, color and luster, tissue pliability, and texture material is shown in Table 1.Table 1 Scores for model fidelity compared with a human LCBDE.

Table 1Items	Median [range] scorea:	
Overall impression	8 [[6], [7], [8], [9]]	
Color and luster	7 [6,7]	
Tissue pliability	6 [[4], [5], [6], [7], [8], [9]]	
Texture material	6 [[4], [5], [6], [7]]	
Usefulness in teaching ERCP	9 [[6], [7], [8], [9], [10]]	
a Median scores (25%–75 % interquartile range) are based on a 10-point Likert-scale (1, lowest; 10, highest rating) (Appendix 1, Questionnaire #1).

3.2 No improvement in trainees’ understanding based on the base knowledge

All trainees had taken relatively standardized clinical theory courses and were given a systematic basic knowledge review before training. All the trainees performed well in answering the physiological and anatomical knowledge about choledocholithiasis (χ2 = 1.222, p = 0.727). Although the 3DPMT group performed better in answering the base knowledge about planned surgical procedure of the LCBDE compared to the TLCST group, the difference was not significant (χ2 = 1.333, p = 0.248) (Table 2).Table 2 Trainees’ understanding assessment on the base knowledge and key surgical procedures between different training models.

Table 2Items	Number of correct responsesa:	χ2	p	
3DPMT group	TLCST group	
Total	
 Basic anatomy and physiology	45	46	1.222	0.727	
 Planned surgical procedure	40	35	1.333	0.248	
 Key details of the surgical procedures	42	31	6.139	0.013	
Female	
 Basic anatomy and physiology	12	13	0.053	0.817	
 Planned surgical procedure	9	9	0.000	1.000	
 Key details of the surgical procedures	9	4	2.210	0.137	
Male	
 Basic anatomy and physiology	33	33	0.000	1.000	
 Planned surgical procedure	31	26	1.020	0.313	
 Key details of the surgical procedures	33	27	1.500	0.221	
a According to Appendix 2, each trainee answer 5 questions about each section knowledge, the total number of each section is 50.

3.3 Significant improvement in trainees’ understanding of the key points of surgery

The trainees were also asked to identify the site of bile duct incision and the key points of the LCBDE surgical procedure. The combination of 3DP model training and watching operation videos led to obvious improvements in all trainees (χ2 = 6.139, p = 0.013) (Table 2). Meanwhile, the responses of trainers of different genders in each group were compared separately. All the trainees showed good performance in answering the base knowledge. We found 3DPMT group performed better in understanding of the key points of surgery compared to the TLCST group, but this difference was not observed between different genders.

3.4 Skills scores improved after training in both groups

All trainees were asked to complete key surgical procedures in the traditional endoscopic suture knotting module and the 3DP model. During this test, the trainees’ single-skill scores were calculated by taking the average of two examinations in that specific session, which included simple interrupted sutures, suture and retraction of the bile duct, choledochoscopy stone extraction, and T-tube drainage. Compared to the TLCST group, the 3DPMT group required significantly less time for suture and retraction of the bile duct (2.5 ± 0.5 versus 3.0 ± 0.9 min; p = 0.025), choledochoscopy stone extraction (7.9 ± 1.1 versus 9.8 ± 1.3 min; p = 0.007), and T-tube drainage (7.7 ± 1.4 versus 10.1 ± 1.2 min; p = 0.006). However, there was no statistically significant difference in traditional endoscopic simple interrupted sutures test (2.7 ± 0.7 versus 2.9 ± 0.7 min; p = 0.531) (Table 3).Table 3 The operation time of each surgical procedures (minutes).

Table 3Items	3DPMT group	TLCST group	t	p	
Simple interrupted sutures	2.7 ± 0.7	2.9 ± 0.7	0.392	0.531	
Suture and retraction bile duct	2.5 ± 0.5	3.0 ± 0.9	5.000	0.025	
Choledochoscopy stone extraction	7.9 ± 1.1	9.8 ± 1.3	7.200	0.007	
T-tube drainage	7.7 ± 1.4	10.1 ± 1.2	7.500	0.006	

In addition, to further evaluate the trainees’ performance based on key surgical points of the LCBDE, three experienced surgeons scored using the OSATS tool according to a Likert-type scale (range, 0–4 points). The results suggested that the self-efficacy and skills scores of all participants were significantly positive after the two different training strategies, and the key operation skills performance of trainees in the 3DPMT group was significantly superior to those in the TLCST group (p = 0.015), especially in choledochoscope insertion and maneuvering, stone capture and extraction, T-tube insertion, and choledochotomy closure (Table 4).Table 4 Performance and technical realism of core procedural steps.

Table 4Items	3DPMT group	TLCST group	t	p	
Cumulative score (range, 0–40)a	28.8 ± 1.6	19.7 ± 4.6	5.926	0.015	
Choledochotomy	2.9 ± 0.7	2.7 ± 0.6	0.392	0.531	
Choledochoscope insertion and maneuvering	2.6 ± 0.8	1.3 ± 0.8	5.495	0.019	
Stone capture and extraction	2.9 ± 0.7	1.9 ± 0.7	5.501	0.025	
T-tube insertion	2.9 ± 0.5	1.6 ± 0.8	9.899	0.002	
Closure of common bile duct	2.9 ± 0.7	2.0 ± 0.6	5.051	0.025	
T-tube exteriorization	3.1 ± 0.6	2.6 ± 0.5	2.222	0.136	
a All items scored on a Likert type Scale (range 0–4 points), and cumulative score (sum of all items, with possible range of 0–40 points). Values represent mean ± standard deviation.

3.5 Evaluation of the trainees’ satisfaction level for the training project

A 10.0-point Likert scale was used to evaluate the trainees' feedback on the different training models, such as interest in learning, harvesting, and enhanced ability. On the basis of the primary outcome, more complete helpfulness was seen in the 3DPMT group than in the TLCST group. Trainee satisfaction was assessed using questionnaires with Minnesota Satisfaction Scale. A higher teaching satisfaction rate was observed in the 3DPMT group than in the TLCST group, regardless of their understanding of the basic knowledge or the field associated with surgery and surgical details. Furthermore, 70 % (7/10) of the trainees considered that they technically benefitted from the project. Standardized LCBDE surgery simulation training can increase residents’ confidence and improve their performance (Table 5).Table 5 Median score of the trainees’ satisfaction level on the different training project.

Table 5Items	3DPMT group	TLCST group	t	p	
Like to use this simulation	8.5 [[7], [8], [9], [10]]	7 [[6], [7], [8]]	6.667	0.010	
Value of the simulator as a training and testing tool	9 [[8], [9], [10]]	7 [[6], [7], [8]]	10.769	0.001	
Benefit from this training project	9.5 [[8], [9], [10]]	8 [[6], [7], [8], [9]]	7.200	0.007	
Self-confidence for participating the operation assistance	7.5 [[6], [7], [8], [9]]	6 [[5], [6], [7]]	6.667	0.010	

3.6 Evaluation of the monitors' satisfaction level for trainees’ cooperation during the surgery

Finally, to further evaluate the usefulness of 3DP model as an educational tool for LCBDE training, the degree of control of basic knowledge and assistance level during real operations were assessed by a senior hepatobiliary surgeon in charge of teaching. Hands-on 3DP model-trained trainees cooperated better during the surgery, especially in the spatial positioning and operation prediction of laparoscopic surgery. In addition, the performance of the 3DPMT group in assisting surgery and their degree of mastery of basic knowledge were evaluated better by supervisors than those of the TLCST group (Table 6).Table 6 Median score of the monitors’ satisfaction level for the trainees.

Table 6Items	3DPMT group	TLCST group	ta	p	
Master level of basic knowledge	8 [[6], [7], [8], [9], [10]]	7 [[5], [6], [7], [8], [9]]	3.968	0.046	
Performance in assisted surgery	6 [[5], [6], [7]]	4 [[2], [3], [4], [5], [6], [7]]	5.000	0.025	
The score was given using a visual scale from 1 to 10 with 1 = “No satisfaction” and 10 = “Of a great satisfaction” (“Appendix 5”). For each evaluation item, the score among the group of trainees reflects the monitors' satisfaction level.

a Wilcoxon tests.

4 Discussion

With the development of minimally invasive technology, an increasing number of complex laparoscopic procedures are being performed, including liver, biliary, and pancreatic surgeries. LCBDE, a difficult procedure to master and with a significant learning curve, is the first-choice procedure of common bile duct stones [13], and trainees usually require longer training periods to become familiar with these techniques. Owing to the good knowledge of extrahepatic bile duct anatomy and precise technique with attention to detail, which is essential for LCBDE, excellent training simulators are crucial for improving the skills of inexperienced operators. The training effect and experience of laparoscopic surgeons on surgical skills are closely related to the incidence of complications in laparoscopic surgery [14]. Surgeons need extensive practical training to master surgical operation skills, and only by experiencing sufficient surgical cases can they ensure the completion of high-quality surgery [15].

Traditional laparoscopy simulators provide training of only few basic skills (such as grasps, cuts, positions, and sutures), and the operating environment lacks specific organs and tissues, which is quite different from the real operating environment. 3DP technology, a new scientific and technological achievement, has been widely used in medicine and plays an important role. Using 3DP technology, medical data can be displayed as solid structure. Over the past two decades, 3D reconstruction and 3DP technologies have been used in an increasing number of applications, including tumor diagnosis, personalized surgical planning, premedical education, and medical research [[16], [17], [18]]. In addition to facilitating knowledge acquisition in anatomy and surgical procedures, 3DP models can reveal the anatomical relationships between organs and their surrounding tissues [19]. The application of 3DP technology to develop surgical simulation models and training devices is a valuable resource for clinical trainees in surgical training exercises, contributing to their understanding of surgical procedures, improving surgical performance to improve training quality, and reducing learning curves [20,21].

The current study presented an innovative medical immersion training with a combination of a traditional laparoscopy simulator and 3DP technologies in LCBDE training, which allows the trainee to gain direct feedback through understandable and manipulatable operational processes. Evaluation of the questionnaires showed that the participants were very satisfied with training on the 3DP models. Compared to traditional training tools, our participants have reported a good agreement in anatomy learning and skill acquisition, suggesting the potential benefits for trainees in clinical training education. In addition, 3DP models are highly suitable for training purposes in this field.

Experience regarding the use of a constructed physical model to simulate the LCBDE procedure has been reported [9]; however, none of the studies to date have reported the application of 3DP models to perform standardized medical education training for junior residents. LCBDE are more difficult to learn than open surgery because they require different psychomotor skills, thus requiring more authentic, scientific, and easy-to-operate models, as well as longer training times to achieve the necessary skills. Our study demonstrates that technical training based on 3DP models can not only significantly improve trainees’ understanding of the key points of surgery and skills scores but also increase the degree of satisfaction and favorable feedback from both trainees and hepatobiliary surgeons.

Consequently, based on our findings, this standardized LCBDE surgery simulation training significantly increased participants’ operative confidence and interest. The participants agreed that they would profit from such training opportunities and confirmed their acceptance of this type of training. We believe that this novel application will eventually be used as a powerful tool in the field of Chinese standardized residency training.

This study and 3DP training model used in this study has some limitations. First, this study exclusively recruited only twenty standardized residency training trainees. The use of a small and singular sample size may introduce bias, thereby necessitating a large-scale trial in the future. Additionally, the presence of solely a senior hepatobiliary surgeon as supervisor and the absence of blinding during assessment represent the most significant limitations of this study. Second, 3DP models cannot fully simulate the deformation, elasticity differences, and biomechanical characteristics of human tissues. Therefore, the loss of these characteristics may not entirely reflect the mechanical characteristics and surface smoothness of the normal bile ducts and may significantly affect the tactile perception and feedback of the trainee. Third, although these models replicate the procedure well, there are still many disease procedures for which models have not been created. Furthermore, as an emerging technology, 3DP has many barriers to widespread clinical adoption owing to its high cost [22,23]. Fortunately, in the present study, the hollow-centered bile duct was designed to be replaced and printed separately with a soft support material.

5 Conclusion

Medical 3DP model training has emerged as a teaching standard. We successfully created a novel 3DP training model of simulated LCBDE surgery, specifically for standardized residency training trainees and junior residents, to help improve standardized operative skills and decrease the slope of the learning curve. We expect some application value as a teaching aid in the practice and assessment of Chinese standardized residency training.

Funding

This study was funded by the Innovation Programs of the Second Affiliated Hospital of the Air Force Medical University (No. 2020XKPT010 and 2020XKPT013 ).

Data availability statement

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Ethical statement

The authors are accountable for all aspects of the work and ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All trainees received oral information and provided written informed consent regarding the objectives and methodology of the study. All CT images were anonymized before use in 3D modeling. This study was approved by the Ethics Committee of the Tangdu Hospital of Air Force Medical University (No. K202207-07) and was conducted in accordance with the standards of the Declaration of Helsinki.

Consent for publication

Not applicable.

CRediT authorship contribution statement

Zhenyu Yang: Writing – review & editing, Writing – original draft, Conceptualization. Yao Tong: Formal analysis, Data curation. Dongfeng Duan: Writing – original draft, Formal a. Wei Xin: Writing – review & editing, Formal analysis. Haoran Li: Validation, Resources, Methodolog. Jiangpu Yi: Visualization, Resources. Xianli He: Writing – review & editing, Project administration, Funding acquisition. Guoqiang Bao: Writing – review & editing, Supervision, Project administration, Funding acquisition.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data

The following are the Supplementary data to this article:Multimedia component 1

Multimedia component 1

Multimedia component 2

Multimedia component 2

Multimedia component 3

Multimedia component 3

Multimedia component 4

Multimedia component 4

Multimedia component 5

Multimedia component 5

Acknowledgments

The authors thank the students who participated in this study. The authors also thank Xi 'an Ma Ke Medical Technology Ltd. and Mr. Kejun Ma for their assistance in providing resources related to 3DP models.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2024.e36689.
==== Refs
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