IntroductionEarly exposure to practical skills in surgical training is essential in order to master technically demanding procedures such as the design and execution of local skin flaps. Changes in working patterns, increasing subspecializations, centralization of surgical services, and the publication of surgeon-specific outcomes have all made hands-on-training in a clinical environment increasingly difficult to achieve for the junior surgeon. This has been further compounded by the COVID-19 pandemic. This necessitates alternative methods of surgical skills training. To date, there are no standardized or ideal simulation models for local skin flap teaching.AimThis systematic review aims to summarize and evaluate local skin flap simulation and teaching models published in the literature.Materials and MethodsA systematic review protocol was developed and undertaken in accordance with PRISMA guidelines. Key search terms encompassed both “local skin flaps” and “models” or “surgical simulation”. These were combined using Boolean logic and used to search Embase, Medline, and the Cochrane Library. Studies were collected and screened according to the inclusion criteria. The final included articles were graded for their level of evidence and recommendation based on a modified educational Oxford Center for evidence-based medicine classification system and assessed according to the CRe-DEPTH tool for articles describing training interventions in healthcare professionals.ResultsA total of 549 articles were identified, resulting in the inclusion of 16 full-text papers. Four articles used 3D simulators for local flap teaching and training, while two articles described computer simulation as an alternative method for local flap practicing. Four models were silicone based, while gelatin, Allevyn dressings, foam rubber, and ethylene-vinyl acetate-based local flap simulators were also described. Animal models such as pigs head, porcine skin, chicken leg, and rat, as well as a training model based on fresh human skin excised from body-contouring procedures, were described. Each simulation and teaching method was assessed by a group of candidates via a questionnaire or evaluation survey grading system. Most of the studies were graded as level of evidence 3 or 4.ConclusionMany methods of simulation for the design and execution of local skin flaps have been described. However, most of these have been assessed only in small cohort numbers, and, therefore, larger candidate sizes and a standardized method for assessment are required. Moreover, some proposed simulators, although promising, are in a very preliminary stage of development. Further development and evaluation of promising high-fidelity models is required in order to improve training in such a complex area of surgery.
Aim Determine junior doctors’ awareness of bullying and harassment policy and legal requirements of the health board. If lack of knowledge/training, provide required training in the form of staff teaching. Improve workplace culture and staff safety. Method All junior doctors (total of 10) in the plastic surgery department were asked to fill in questionnaire about their experience of bullying and harassment in the workplace. They were asked about their personal experience of bullying and harassment, awareness of the health boards duty, reporting culture and barriers to reporting. The change implemented was staff training and information on where to access health board policies and protocols. After training, a second questionnaire was filled in to see if there was better understanding of the health board policy and the necessary steps in the event of a bullying or harassment incident. Results The health boards policy was easy find on the health board intranet. In the initial questionnaire: 6 out of 10 junior doctors reported experiencing bullying or harassment in the NHS, all 10 reported not being able to define bullying and harassment; and a lack awareness of NHS Wales’ bullying and harassment policy. All 10 reported that they had not reported any bullying and harassment experienced. The junior doctors were asked about barriers to reporting, all 10 identified concerns about repercussions professionally as the main barrier. Conclusions Training on how to identify bullying and harassment, the pathways of escalation and a change in culture over professional repercussions are vital for surgical trainees going forward in the NHS.
Aim To date, there is no clear consensus regarding the best way to obliterate the pelvic dead space, as seen in patients treated for recurrent perineal herniation and entero-cutaneous fistuli following total pelvic exenteration (TPE) for locally advanced rectal cancer. We present a novel technique using saline-filled breast expander to fill the dead space and create an artificial pelvic floor using the implant capsule, thus preventing intestinal herniation and fistuli formation in the multi-operated and irradiated pelvis scenario. Method We present 2 patients who initially had TPE, IGAP flap perineal reconstruction and neoadjuvant chemoradiotherapy. Patient 1 had 2 laparotomies for persistent enteroperineal fistulae in the 2-year postoperative period. Patient 2 had persistent wound discharge 2 years post TPE and underwent an enterocutaneous fistula repair and wound debridement. Both cases were complicated by perineal herniation and re-presented with persistent fistulation. A Becker 25 breast expander was placed into the pelvis and inflated with 150 ml of saline, to help contain the small bowel in the abdomen and reduce the risk of perineal re-herniation and fistulae. Results The silicone device was removed at 7-12 months, preserving its capsule, by the time the wound had healed. The wounds remained healed at post-operative follow up without any further perineal wound complications, herniation or fistuli Conclusions Addressing the dead pelvic space by using a breast expander may treat this particular TPE complication. The capsule created following placement of breast implant, facilitates artificial pelvic floor.
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