The microsurgical training programme in Gothenburg, Sweden: early experiences.
Mihai Oltean, Paolo Sassu, Mats Hellström, Peter Axelsson, Lars Ewaldsson,
Anders G. Nilsson & Michael Axelsson. Journal of Plastic Surgery and Hand Surgery, 21016, DOI: 10.1080/2000656X.2016.1213735
Link to this article
Defining Standards in Experimental Microsurgical Training: Recommendations of the European Society for Surgical Research (ESSR) and the International Society for
Experimental Microsurgery (ISEM)
René H. Tolba, Zoltan Czigény, Suzanne Osorio Lujan, Mihai Oltean, Michael Axelsson, Yelena Akelina, Antonio Di Cataldo, Iren Miko, Istvan Furka, Uta Dahmen, Eiji Kobayashi, Mihai Ionac, Norbert Nemeth.
European Surgical Research, 2017, DOI: 10.1159/000479005
Link to this article
microTRACK – hand and finger motion recording system
A system for recording hand and finger movements and synchronous video during microsurgery for evaluation of skill development.
The system use three sensors per hand, back of hand, forefinger and thumb, they are atached using surgical tape or sticky gelpads. The sensors used are Bosch BNO055, that contain a triaxial 16bit gyroscope, a triaxial 14bit accelerometer and a geomagnetic sensor (https://www.bosch-sensortec.com/bst/products/all_products/bno055). A prototype of the system is show in the picture below.
The movements are recorded at 50-100 Hz together with video 30 fps (USB camera) and stored in a raw data analyses. The program also sumarize the data a smaller file that can be used for fast analyses.
Read more about the system microTRACK short manual
microVIEW – a viewing plattform for workstations
An affordable and powerful microscope camera system
At the Scandinavian Microsurgery Academy in Gothenburg we train both pre-clinical personal and clinically active surgeons in microsurgery (for more information see http://microsurgery.se ). We constantly try to improve the training curriculum within a limited budget. One important part of the training is to give the participants continuous feedback and instructions while they work under the microscope. In order to do so the instructors need to see what the participants are doing. Traditionally this was done using a side-tube or an extra set of oculars . Both side-tubes and extra set of oculars are expensive and you can only see the work by one student at the time. Another option is to use a camera mounted in a phototube showing the work field on a screen. This allows you to follow several students at the same time. If the system have some means to output the feed you can also use the system as an instruction microscope for the entire group. Buying commercially available video systems is expensive and the microscopes also need to have a phototube.
We have tested a cheaper system based on a modified Logitech c920 camera (mounted in a new house with a c-mount, http://lukse.lt/uzrasai/2013-07-modifying-logitech-c920-to-for-cs-lenses/) in combination with Samsung 10″ tablet and the CameraFi app, this combination cost around 600 EUR which is low compared to side-tubes and commercially available camera system.
With this system it is possible to view live full screen video, save images or video and cast (via Chrome cast) the live feed to the teaching screen in the front of the room. The downside is that in order to run the camera for a full day the tablet needs to be connected to the power adapter since the camera drains the battery. The solution is to use a Simulcharge OTG-adapter that allow you to charge the tablet at the same time as some other peripheral is connected but there are compatibility problems and it does not work without problems.
On the wih list
- A system that is more stable and do not have the problem with charging through the same input as the camera
- A more powerful system with more functions
- A system with an even lower price tag
Hardware Raspberry pi
We investigated the possibility to use a Raspberry pi computer and Camera V2 to meet the criteria above.
The Raspberry pi Camera V2 needs an adapter in order for it to be used. As part of this project three adapters were developed (for c-mount, ocular and side-tube) in two different versions, one for use with the standard flat cable (https://www.adafruit.com/product/1731) and one for HDMI cable in combination with the Pi Camera HDMI Cable Extension (https://www.tindie.com/products/freto/pi-camera-hdmi-cable-extension/).
Link to Sketchfab were the adapters can be viewed and downloaded, microVIEW adapters
If you plan to use the c-mount adapter on a phot tube you need to remove the lens from the Rspberri pi camera, there is a lens tool at Adafruit but you can also you a pair of fine forceps, to unscrew the lens. In some cases it is included when you buy the camera. Save the lens so that you can reamount it if you need the camera for the ocular or sidetube adapters.
The Raspberry pi need an external screen and can be connected to either a HDMI or VGA compatible screen. In order to be able to avoid using a keyboard and mouse we used a Sundfounder 10 screen (https://www.sunfounder.com/10-1-touch-screen.html, and in order to be able to mount the screen on a stand at the workstations a case for the screen was designed, this can also be downloaded in STL format
A cheaper solution is to use an old computer screen, it does not have to have a HDMI port, VGA or DVI works fine. If the screen only have an VGA input an HDMI to VGA adapter will be needed but if the screen also have a DVI input use an HDMI to DVI cable which is cheaper. You will need a mouse and a wireless mouse from Adafruit works just fine.
Software – microVIEW program
The video feed from the camera can be activated using a simple command line command but it does not give you any control of the camera settings or option for saving still images or video.
The software that we use is written by Bill Williams
This program allow us to:
(not a complete list of functions):
- View life video in different resolution settings up to 30fps
- Adjust the camera settings
- Save still images (3280 x 2464 pixels)
- Save video (1080 p30)
- Create time laps video/photos
- Annotate the video/images with date and time information
- Stream the live feed over the internet
- Change the interface language
The finished setup
Below are pictures of the finished setups for all three adapters and the Sounfounder screen mounted in the 3D printed casing
A. Setup with the side tube adapter mounted on a Leica microscope side-tube (Series M400/500), B detailed view of the adapter
A. Setup with the c-mount adapter mounted on a photo tube, B detailed view of the adapter
A. Setup with the ocular adapter mounted in one of the ocular tube of the extra ocular set, B detailed view of the adapter
See also the pi-Top blog post about how to set up and use the microVIEW on a pi-Top and pi-ToCEED system
microRINGS – suturing rings
With inspiration from the original Sun Lee´s practice disc for microsurgery training for beginners (see Lee_et_al-1983-Microsurgery) and the Practi-rings (see Anastomosis device_MD) from Ren Remie Surgical Skill Center (https://www.rrssc.eu/) we designed a new version of this training tool.
The major difference is that the rubber membrane is fastened without creating any tension in the membrane and this allows complex patterns to be cut without distorsions
The microRING consists of two 3D-printe parts an O-ring and a thin stainless steel ring. The top and bottom parts are screwed together clamping the rubber membrane between the O-ring and the stainless stell ring.
The image above show a screen shot from Spaceclaim that was used for designing the suturing ring that was then 3D printed using a Formlab 2 printer. The green parts are the bottom and top 3D printed parts, the black ring is the O-ring and the blue ring is the thin stainless steel ring.
The image below shows the punch used to cut out various patterns in the rubber dam that is used.
You can download STL files for the 3D modeled parts
Ergonomic handles for Dumond foreceps
Even if the personal skills play the major role for the outcome of any surgical procedure the quality of the tools used also play a role. In surgical training programs it is important that the participants are trained using tools that are ergonomic and of good quality (Ref). Surgical, and especially microsurgical, tools are expensive and constitutes a high cost when setting up a microsurgical training facility. Due to the delicate nature of the microsurgical tools there is also a high risk of damage that can increase the running costs of the courses.
In a microsurgical tools set you need at least two straight micro-forecps and also one angled micro-forceps.
There are very good micro-forceps on the market, one example is the balanced S&T forceps but they come at a high price.
When we set up the training facility in Gothenburg we looked for alternatives and started to use Dumond 5 (standard and biology) forceps. They are around 1/10th of the price compared to the S&T and is relatively easy to refurbish in house when damaged. There are of cause large quality and ergonomic differences between the two types, one is the lenght (11 versus 15cm) and the other the flat sides of the Dumond forceps compared to the round handles of the S&T that make fine positioning of the tips easier. To compensate for this we designed an extension and two rounded part using a direct modelling software (Spaceclaim) and printed these on a 3D printer (Formlab 2) using a standard Fomlab Grey resin or the Ridgid resin
The extension is pressure fitted and can therefore easily be removed if somebody prefer a shorter forceps or transferred to a new forceps when the original is damaged beyond repair. The rounded parts for the handles are glues on and are not reused when the forceps is exchanged. The end of the extension is hollow and covered by a cap, if needed stainless steel pellets can be used to balance the weight of the forceps similar to the S&T forceps.
The pictures below shows the preassembled Dumond forceps with the 3D printed parts (A) and the assembled forceps.
The picture below shows the assembled Dumond forceps (A) and the balanced S&T forceps (B) when held
The 3D printed parts fits Dumond 5 standard and biology straight or 45 degree angled. During the courses we have a number of spare forceps to make sure that nobody have to work with a damaged forceps. After each course all the forceps are checked and refurbished if needed or if they are damaged beyond repair replaced. This have kept the initial and running cost down since the Dumond forceps are easy to refurbish and cheaper to replace.
microBACK – visibility background for anastomoses work
During anastomoses work it is good practice to use a background in order to create a cleaner working area with good contrast. Mercian Surgical Supply Co Ltd sells excellent Visibility Background Material, they are sterilized and ready to use in clinical work and therefore also expensive, at least for use in a microsurgical training situation.
During microsurgery training cut pieces of blue or green lab gloves are often used, this is suboptimal since the glove material is not flat, the texture is different and there is no grid.
In order to let the participants use backgrounds with similar function as the Mercian visibility backgrounds that they hopefully will be using in the clinic without the high cost for the training facility backgrounds were molded in silicon using a 3D printed mold.
There are four different molds generating four different thicknesses
The molds have a a 1×1 mm grid that
The steps for molding the backgrounds are outlined below.
The mold needs to be greased so that it will be possible to remove the silicone. Use Vaseline to grease the mold and a clean lint free compress or cloth to wipe of the Vaseline thoroughly
You need a cover glass further on in the process.
Mix the 2 component RTV silicone and pour it on the mold and spread it over the entire mold.
Use the cover glass to scrape of the excess silicone and then let the silicon set.
You can download the STL files