Starting from Scratch: Experiences from Developing the First Vascular Anastomotic Training Program in North Macedonia Using the Porcine Thigh as a Simulation Model

Abstract Microsurgical reconstruction constitutes a fundamental part of plastic and reconstructive surgery. It demands high dexterity and intricate technical skills. Its steep learning curve benefits from thorough training throughout residency, where using realistic simulation models in the appropriate sequence of complexity progression is essential in ensuring patient safety prior to progressing to a clinical setting. Commencing training on microvascular-like small diameter vessels could prove unsuitable and ineffective for inexperienced surgeons, however, the larger diameter neurovascular structures in the porcine thigh can provide excellent anastomotic training without compromising the animal tissue training sought after by residents. We present the results from implementing the first vascular anastomotic course in our country, where reconstructive theory was combined with simulated anastomotic training on the porcine thigh. Junior plastic surgery residents described acquiring comprehensive knowledge of reconstructive techniques and could successfully complete anastomoses, despite none to minimal previous experience. Using the porcine thigh should be encouraged as a start-up vascular anastomotic training tool as it provides realistic conditions and tissue handling training, and could improve quality of further training on microvascular structures.

thighs were evaluated, and the latter was chosen due to its large vessel and nerve sizes (about 5 mm diameter), considered ideal for novices.The porcine thigh was dissected as described by Nam et al. 1 A linear incision was made on the fascia extending down to the pedicle.The femoral vessels were found between the vastus medialis muscle and the sartorius above the knee carefully dissecting the intermuscular septum between these muscles (►Fig.1).All porcine thighs were partially prepared for our residents and the course efficacy was evaluated via an 18-question Likert scale questionnaire (►Table 1).

Course Structure Theoretical Lectures
The course started with a 3-day lecture series aimed to take the residents through the microsurgical process of planning and execution.The initial day covered the foundations of reconstructive theory, flap classifications, terminology, and microvascular anatomy.Day 2 delved into operative planning of flap inset, pedicle position, and postop monitoring.On the third day, attendees were introduced to flap harvesting, aided by detailed surgical step-by-step videos and valuable surgical pointers.

Hands-on Training
On the fourth day, practical surgical training took the center stage.Residents, grouped in pairs, practiced vascular and nerve anastomosis on porcine thigh models, under the guidance of instructional videos.They were equipped with basic microsurgical instruments and had a 5-hour window to complete their tasks (►Fig.2).Real-time guidance was available through a looped video tutorial, and the session concluded with a patency check of the anastomoses.

Results
All participants successfully executed an average of three anastomoses each, which speaks volumes about the efficacy of the course and the chosen model.The postcourse feedback highlighted the structured approach of the course, with both lectures and practical elements as its strongest aspect (►Table 2).Despite varying levels of prior experience, the porcine model aided all in completing their tasks and all anastomoses were found patent.The feedback was overwhelmingly positive, with the majority affirming the course relevance, utility, and impact on their skills and future aspirations.Feedback further revealed that working collaboratively was beneficial.Most were satisfied with their  contributions, and while a significant number expressed a desire to attend an international course, the majority were content with the local setup.Participants largely agreed on the adequacy of time and instruments provided, with some recommendations for future courses, such as extended durations, increased practical training, and follow-up sessions.

Discussion
Training in reconstructive microsurgery is a challenging endeavor that requires an appropriate educational environment, tools, and sequence in complexity progression.Animal models arguably simulate human conditions the closest, and can thereof provide the optimal vascular simulation model.This study provides an insight into the feasibility of successful vascular anastomotic training in the porcine thigh by junior residents as a first step in the skills progression from large to small diameter vascular anastomotic training.An optimal starting point for novice trainees in their journey of reconstructive surgical practice is training on simple to complex models, 2 and a complete animal-based pathway has been shown to be preferred by residents. 3The porcine model is particularly advantageous for beginners, but has only been described in three papers thus far. 1,4,5Despite the large-diameter structures in the porcine thigh not providing a true microsurgical environment, adopting a correct suturing technique in initially larger structures could improve speed and efficacy in the later performance on true microsurgical anastomoses. 1 Encouraging novice residents to embrace  In conclusion, the meticulous introduction of novice residents into the world of microsurgery is imperative for fostering understanding of its interdisciplinary role, complexity, and precision in reconstructive surgery.The utilization of the porcine thigh model is optimal for providing realistic, hands-on experience to junior trainees and can serve as a suitable stepping stone in a fully animal-based large-to-small caliber vascular skills progression.It is this dedication to learning and mastery of skills, combined with a passion for innovation and a commitment to patient care, that will continue to drive the advancements in reconstructive microsurgery, pushing the boundaries of what is medically possible.Furthermore, active collaboration between plastic surgery units is vital for sharing knowledge and improving plastic surgery training, microsurgical practice and patient outcomes worldwide.

Fig. 1
Fig. 1 Exposure of the femoral artery (red arrow) and tibial nerve (yellow arrow) between the vastus medialis muscle and the sartorius above the knee, of the porcine thigh model.

Table 1
Eighteen-question 5-point Likert scale questionnaire 1.I will use the skills learned in the course in the future I would attend the next microsurgery course in our country 11.The course motivated me to continue my education in the field of microsurgery 12.I am satisfied with my contribution to the microsurgery course 13.I would rather attend a microsurgery course in our country than abroad 14.The duration of the course was enough to complete the given tasksEighteen-question 5-point Likert scale questionnaire for evaluation of satisfaction of the course (1 point, strongly disagree; 2 points, disagree; 3 points, neither; 4 points, agree; 5 points, strongly agree).

Table 2
The results from the 18-question 5-point Likert scale questionnaire Vascular Anastomotic Training Dimovska et al.the challenges posed by microsurgery is essential, and in this regard, the porcine thigh model serves not just as a stepping stone but as a catalyst; inspiring aspiring surgeons to delve in to the vast, challenging, and rewarding realm of microsurgery.Furthermore, plastic surgery residents should arguably seek to develop their training further by gaining a deeper understanding of reconstructive theory through lectures as well.
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