The traditional teaching method that is based on the Halsteadian principle, see one, do one, teach one, is less acceptable in today's medical practice. According to a developing body of literature on adult learning, consistent gradual performance improvement is contingent upon the following principles. First, participants should be instructed to improve some aspect of performance for a well-defined task. Second, they should receive detailed and immediate feedback on their performance. Finally, they must have ample opportunity to improve their performance via deliberate repetitive practice. Simulation-based learning utilizes all three principles of adult learning. The objective of this video is to discuss the importance of simulation-based training in surgical education, to illustrate the design of a simulation trainer for ureter ureterostomy and ureteroneocystostomy, to demonstrate open and robotic approaches using the simulator for these procedures. Simulation allows for training in a low-stress, risk-free environment and offers the surgeon an opportunity to develop competence and confidence prior or as a supplement to practicing the skills in the operating room. This method is particularly useful for gaining practice in a setting of low surgical volume. Multiple studies in recent literature have highlighted the importance of outside OR training, demonstrating that competency in simulation translates well to life performance. For example, laparoscopic skills acquired in an FLS trainer were demonstrated to be predictive of performance in live cholecystectomy. Likewise, virtual reality training in laparoscopic salpingectomy correlated with improvement of operative skills during the actual procedure. Seventy-five percent of injuries to the bladder and ureters take place during GYN procedures. Ureteral injuries are rare, occurring at the rate of 1 in 1,000 of pelvic surgeries. Thus, GYN trainees have few opportunities to learn the skills needed to manage these injuries. On average, a urology resident graduates with 10 to 15 ureteral reimplantation procedures. In fact, in the ABOG guidelines for the Fellowship in Female Pelvic Medicine and Reconstructive Surgery, the following requirements are listed. Specifically, a Fellow in this specialty must be able to repair and or resect an injured portion of the genitourinary system. We designed the simulation model as a supplement to the training of GYN and urology trainees. It can be used to practice key skills required for the ureter ureterostomy as well as ureteroneostostomy. The simulator is suited for an open procedure as well as for robotically-assisted surgery. The components can easily be replicated in the FLS box trainer. The simulator construction is affordable and easily reproducible. It includes a storage container, size 15 by 11 inches and 3 inches deep, twine, alligator clips, a large bag clip, and Velcro adhesive tape. The material used to simulate the bladder and the ureter is manufactured by Lifelike Bio-Tissue Company. The material is hydrogel, which is non-toxic, durable, affordable, and easily stored. It closely resembles tissue properties of the bladder and ureter. The design caliber and thickness can be specified and custom-made. Ureteroneostostomy begins with mobilization of the ureter, followed by the transection at the appropriate level, as distal as possible, to remove the damaged area. The distal ureter is then spatulated. A full-thickness cystotomy is then made at the level that allows a tension-free reanastomosis. As illustrated here, the double J stent can be inserted after the first anchoring stitch has been placed. In this demonstration, a cystotomy and spatulation of the ureter has been performed prior to the start of the procedure. A 6-French double J stent has also been placed between the ureter and the bladder. The reimplantation begins with placement of an anchoring suture that passes through the full thickness of the bladder and ureter. This anchoring suture is then used to perform a reanastomosis between the ureter and the bladder in a circumferential fashion. An absorbable fine suture should be used for the reanastomosis. We recommend a dyed suture to aid with visualization against the white model. In contrast to the tissue handling in the simulation model, the surgeon must grasp periureteral tissue when manipulating the ureter to avoid undue damage. It is important to note that this reimplantation can be performed using a variety of suturing techniques. A single running suture can be used to complete the reanastomosis. Alternatively, two running sutures can be used to complete 180 degrees of the reanastomosis. Finally, reimplantation can be done with a series of interrupted sutures. We will now demonstrate how the simulation model can be used for an open ureter ureterostomy. This procedure is most frequently utilized when repairing ureteral damage above the pelvic rib. Occasionally, it can be used for the injury below the pelvic brim as long as a tension-free reanastomosis can be achieved. Several different suturing techniques can be used in this procedure. As we demonstrated in the robotic ureteroneus ostostomy, a single running stitch can be used. The reimplantation can also be achieved with a series of interrupted stitches. Here we demonstrate a technique that involves using two sutures to complete the reanastomosis. Two halves of the defect are closed in the clockwise and counterclockwise direction, and the two ends are tied together. Our model focuses on optimizing the suturing techniques of the ureteral reanastomosis and reimplantation. However, as any simulation model, it is not a substitute for real-life learning, as it does not simulate some of the difficult aspects of these procedures. Ureterolysis and identification of the damaged portion of the ureter is perhaps the most challenging aspect of ureteral repair. When tension-free anastomosis is not feasible with simple reimplantation, the surgeon must be able to mobilize the bladder with a psoas hitch or perform a bowari flap. Our model does not allow the surgeon to practice the surgical technique necessary for these procedures. Despite these limitations, this model is easy to implement, it is affordable, it provides a training platform where a novice surgeon can obtain basic skills and an experienced surgeon can refine the surgical technique before performing a live surgery. Finally, it can be used as a standardized assessment tool for surgical skills. www.ottobock.com

simulation-based training

surgical education

ureterostomy

ureteroneocystostomy

simulation trainer