Donoho Daniel A, Pangal Dhiraj J, Kugener Guillaume, Rutkowski Martin, Micko Alexander, Shahrestani Shane, Brunswick Andrew, Minneti Michael, Wrobel Bozena B, Zada Gabriel
Departments of1Neurosurgery and.
2Department of Neurosurgery, Medical University Vienna, Austria; and.
J Neurosurg. 2021 Mar 19;135(5):1347-1355. doi: 10.3171/2020.9.JNS202672. Print 2021 Nov 1.
Internal carotid artery injury (ICAI) is a rare, life-threatening complication of endoscopic endonasal approaches that will be encountered by most skull base neurosurgeons and otolaryngologists. Rates of surgical proficiency for managing ICAI are not known, and the role of simulation to improve performance has not been studied on a nationwide scale.
Attending and resident neurosurgery and otorhinolaryngology surgeons (n = 177) were recruited from multicenter regional and national training courses to assess training outcomes and validity at scale of a prospective educational intervention to improve surgeon technical skills using a previously validated, perfused human cadaveric simulator. Participants attempted an initial trial (T1) of simulated ICAI control using their preferred technique. An educational intervention including personalized instruction was performed. Participants attempted a second trial (T2). Task success (dichotomous), time to hemostasis (TTH), estimated blood loss (EBL), and surgeon heart rate were measured.
Participant rating scales confirmed that the simulation retained face and construct validity across eight instructional settings. Trial success (ICAI control) improved from 56% in T1 to 90% in T2 (p < 0.0001). EBL and TTH decreased by 37% and 38%, respectively (p < 0.0001). Postintervention resident surgeon performance (TTH, EBL, and success rate) was superior to preintervention attending surgeon performance. The most improved quartile of participants achieved 62% improvement in TTH and 73% improvement in EBL, with trial success improvement from 25.6% in T1 to 100% in T2 (p < 0.0001). Baseline surgeon confidence was uncorrelated with T1 success, while posttraining confidence correlated with T2 success. Tachycardia was measured in 57% of surgeon participants, but was attenuated during T2, consistent with development of resiliency.
Prior to training, many attending and most resident surgeons could not manage the rare, life-threatening intraoperative complication of ICAI. A simulated educational intervention significantly improved surgeon performance and remained valid when deployed at scale. Simulation also promoted the development of favorable cognitive skills (accurate perception of skill and resiliency). Rare, life-threatening intraoperative complications may be optimal targets for educational interventions using surgical simulation.
颈内动脉损伤（ICAI）是鼻内镜鼻内入路手术中一种罕见但危及生命的并发症，大多数颅底神经外科医生和耳鼻喉科医生都会遇到。目前尚不清楚处理ICAI的手术熟练率，且尚未在全国范围内研究模拟训练对提高手术操作水平的作用。
从多中心区域和全国性培训课程中招募神经外科和耳鼻咽喉科的主治医生及住院医生（n = 177），通过使用先前验证过的灌注人体尸体模拟器，对一项旨在提高外科医生技术技能的前瞻性教育干预措施进行大规模培训效果和有效性评估。参与者先用其首选技术尝试模拟ICAI控制的初次试验（T1）。进行包括个性化指导的教育干预。参与者再尝试第二次试验（T2）。测量任务成功率（二分法）、止血时间（TTH）、估计失血量（EBL）和外科医生心率。
参与者评分量表证实，该模拟在八种教学环境中均保持了表面效度和结构效度。试验成功率（ICAI控制）从T1时的56%提高到T2时的90%（p < 0.0001）。EBL和TTH分别下降了37%和38%（p < 0.0001）。干预后住院医生的手术表现（TTH、EBL和成功率）优于干预前主治医生的表现。进步最大的四分位参与者的TTH提高了62%，EBL提高了73%，试验成功率从T1时的25.6%提高到T2时的100%（p < 0.0001）。基线时外科医生的信心与T1成功率无关，而训练后的信心与T2成功率相关。57%的外科医生参与者出现心动过速，但在T2期间有所减轻，这与恢复能力的发展一致。
在培训前，许多主治医生和大多数住院医生都无法处理ICAI这种罕见且危及生命的术中并发症。模拟教育干预显著提高了外科医生的手术表现，并且在大规模应用时仍然有效。模拟训练还促进了良好认知技能（对技能的准确感知和恢复能力）的发展。罕见且危及生命的术中并发症可能是使用手术模拟进行教育干预的最佳目标。
