Effectiveness of Simulator Training Mimicking a Patient's Specific Situation for Neonatal Congenital Diaphragmatic Hernia
Effectiveness of Simulator Training Mimicking a Patient's Specific Situation for Neonatal Congenital Diaphragmatic Hernia
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模拟新生儿先天性膈疝患者具体情况的模拟器训练的有效性
DOI：
10.1089/vor.2018.0542
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发表时间：
2019
期刊：
影响因子：
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通讯作者：
Ieiri Satoshi
中科院分区：
文献类型：
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作者：
Nakame Kazuhiko;Onishi Shun;Yano Keisuke;Murakami Masakazu;Kawano Masato;Baba Tokuro;Harumatsu Toshio;Yamada Koji;Yamada Waka;Masuya Ryuta;Kawano Takafumi;Machigashira Seiro;Mukai Motoi;Kaji Tatsuru;Ieiri Satoshi
简介：先天性腹股沟疝（CDH）是一种严重程度不同的疾病，从产前发现的需要进行胎儿手术的严重病例到出生后发现的需要进行选择性治疗的轻度病例。关于膈肌的修复，通过开放和微创方法的胸部和腹部技术是可用的。在新生儿病例中，胸腔镜修复术是推荐的，因为将器官从胸腔转移到腹腔是容易和安全的。然而，内窥镜手术的适用情况是有限的，因为不同程度的严重性。因此，小儿外科医生没有机会进行许多情况下的胸腔镜修复CDH，这可能会降低他们的准备和熟悉的程序。我们开发了一个训练模拟器的新生儿CDH，可以重现患者的具体解剖条件。这样的模拟器训练新生儿先天性髋关节脱位被认为是有效的培训经验不足的儿科医生，如本video.Methods：一个零天大的女孩被转移到我们医院怀疑有先天性髋关节脱位。她是通过阴道分娩足月出生的，产前没有发现先天性髋关节肥大。她因出生后呼吸衰竭而出现紫绀。胸部X线显示肠疝进入胸腔。插管和通气后，我们计划进行选择性微创手术由一个没有经验的儿科医生的指导下，一个专家surgeon.Operative结果和程序：手术前，外科医生进行了模拟器培训。我们使用她的计算机断层扫描数据创建了一个覆盖有橡胶皮肤的患者胸腔的物理三维模型。超声波检查显示，疝出的器官只是肠，而不是肝脏或脾脏。然后，我们在模拟器模型中重现了这种情况。将模型置于右侧位，并插入三个套管针（5 mm，用于内窥镜的腋中第四肋间隙（ICS）; 5 mm，用于操作者右手的腋前第五ICS; 3 mm，用于操作者左手的腋后第五ICS）。 训练菜单包括肠的减少和横膈膜的修复。在轻微复位肠后，使用3-0 BB双缝线（Ethicon，辛辛那提，OH）和Roeder结技术闭合有缺陷的隔膜（3× 1 cm大小）。 在操作者掌握了足够的技能后，他进行了临床操作。患者体位和穿刺器放置与模拟器培训中相同。采用CO2充气法（5 mm Hg，1 L/min）建立人工气胸模型。 在使用5 mm 30°内窥镜检查时，证实疝出的器官是小肠和大肠，然后将其复位。膈肌缺损为3.5 × 1.5 cm，采用BB双极缝线闭合，方法与模拟训练相同。 术后2天拔管，无复发。术后过程顺利。模拟器培训描绘患者的具体解剖条件是有效的，即使是没有经验的外科医生，甚至在实际手术前不久进行。致谢：我们感谢Brian Quinn的评论和帮助文章。没有竞争的经济利益存在。视频长度：5分钟3秒
Introduction:Congenital diaphragmatic hernia (CDH) is a disease with varying degrees of severity, from severe cases found prenatally who need fetal surgery to mild cases found after birth who undergo elective treatment. Regarding the repair of the diaphragm, thoracic and abdominal techniques through both open and minimally invasive approaches are available. In neonate cases, thoracoscopic repair is recommended because of the ease and safety for moving the organs from the thoracic cavity to the abdominal cavity. However, applicable cases of endoscopic surgery is limited because of the varying degrees of severity. Pediatric surgeons, therefore, do not have the opportunity to perform many cases of thoracoscopic repair of CDH, which can reduce their readiness and familiarity with the procedure. We developed a training simulator of neonatal CDH that can reproduce patient-specific anatomical conditions. Such simulator training for neonatal CDH was found to be effective in training inexperienced pediatric surgeons,,as shown in this video.Methods:A zero-day-old girl was transferred to our hospital suspected of having CDH. She was born at full term through vaginal delivery and was not found to have CDH prenatally. She showed cyanosis because of respiratory failure after birth. Chest X-ray showed intestinal herniation into the thoracic cavity. After intubation and ventilation, we planned to perform elective minimally invasive surgery by an inexperienced pediatric surgeon under the instruction of an expert surgeon.Operative Findings and Procedure:Before the operation, the surgeon underwent simulator training. We created a physical three-dimensional model of the thoracic cavity of the patient covered with rubber skin using her computed tomography data. Ultrasonography showed that the herniated organs were only the intestine, not the liver or spleen. We then reproduced this situation in the simulator model. The model was placed in a right lateral position, and three trocars were inserted (5 mm, middle axillary fourth intercostal space (ICS) for the endoscope; 5 mm, anterior axillary fifth ICS for the operator's right hand; 3 mm, posterior axillary fifth ICS for the operator's left hand). The training menu comprised the reduction of the intestine and repair of the diaphragm. After gentle reduction of the intestine, the defective diaphragm (3 × 1 cm in size) was closed using 3-0 BB Ethibond sutures (Ethicon, Cincinnati, OH) with Roeder's knot technique. After the operator had acquired sufficient skills, he performed the clinical operation. The patient's position and trocar placement were the same as in the simulator training. Artificial pneumothorax by CO2inflation (5 mm Hg, 1 L/min) was established. Under inspection using a 5-mm 30° endoscope, the herniated organs were confirmed to be the small and large intestines that were then reducted. The defect of the diaphragm was 3.5 × 1.5 cm and was closed using BB Ethibond sutures in the same manner as in the simulator training.Conclusion:There were no intra- or postoperative complications. The patient was extubated 2 days after the operation, and no recurrence occurred. The postoperative course was uneventful. Simulator training depicting patient-specific anatomical conditions is effective, even for inexperienced surgeons and even when performed only shortly before the actual surgery.Acknowledgment:We thank Brian Quinn for his comments and help with the article.No competing financial interests exist.Runtime of video: 5 mins 3 secs