High fidelity simulation of the endoscopic transsphenoidal approach: Validation of the UpSurgeOn TNS Box

Abstract

ObjectiveEndoscopic endonasal transsphenoidal surgery is an established technique for the resection of sellar and suprasellar lesions. The approach is technically challenging and has a steep learning curve. Simulation is a growing training tool, allowing the acquisition of technical skills pre-clinically and potentially resulting in a shorter clinical learning curve. We sought validation of the UpSurgeOn Transsphenoidal (TNS) Box for the endoscopic endonasal transsphenoidal approach to the pituitary fossa.MethodsNovice, intermediate and expert neurosurgeons were recruited from multiple centres. Participants were asked to perform a sphenoidotomy using the TNS model. Face and content validity were evaluated using a post-task questionnaire. Construct validity was assessed through post-hoc blinded scoring of operative videos using a Modified Objective Structured Assessment of Technical Skills (mOSAT) and a Task-Specific Technical Skill scoring system.ResultsFifteen participants were recruited of which n = 10 (66.6%) were novices and n = 5 (33.3%) were intermediate and expert neurosurgeons. Three intermediate and experts (60%) agreed that the model was realistic. All intermediate and experts (n = 5) strongly agreed or agreed that the TNS model was useful for teaching the endonasal transsphenoidal approach to the pituitary fossa. The consensus-derived mOSAT score was 16/30 (IQR 14–16.75) for novices and 29/30 (IQR 27–29) for intermediate and experts (p < 0.001, Mann–Whitney U). The median Task-Specific Technical Skill score was 10/20 (IQR 8.25–13) for novices and 18/20 (IQR 17.75–19) for intermediate and experts (p < 0.001, Mann-Whitney U). Interrater reliability was 0.949 (CI 0.983–0.853) for OSATS and 0.945 (CI 0.981–0.842) for Task-Specific Technical Skills. Suggested improvements for the model included the addition of neuro-vascular anatomy and arachnoid mater to simulate bleeding vessels and CSF leak, respectively, as well as improvement in materials to reproduce the consistency closer to that of human tissue and bone.ConclusionThe TNS Box simulation model has demonstrated face, content, and construct validity as a simulator for the endoscopic endonasal transsphenoidal approach. With the steep learning curve associated with endoscopic approaches, this simulation model has the potential as a valuable training tool in neurosurgery with further improvements including advancing simulation materials, dynamic models (e.g., with blood flow) and synergy with complementary technologies (e.g., artificial intelligence and augmented reality).

A Handheld Robot for Endoscopic Endonasal Skull Base Surgery: Updated Preclinical Validation Study (IDEAL Stage 0)

“…A randomised cross-over study was conducted using a validated phantom model for the eTSA (UpSurgeOn Transsphenoidal (TNS) Box). 8 The TNS Box was prepared by creating a surgical corridor such that the tumour was accessible. Participants were tasked with performing a tumour resection after a short standardised introduction to the robot and standard instrument.…”

Training in Endoscopic Endonasal Neurosurgical Procedures: A Systematic Review of Available Models

“…Fourteen studies of simulation with synthetic models were identified. 11,15,[27][28][29][30][31][32][33][34][35][36][37][38] 2. 11,15 In Maza et al, both neurosurgery and otolaryngology residents and attendings were included and the pre/post-TTH were 105 and 40 sec while the pre/post-EBL were 690 and 272 mL.…”

“…the face and content validity of synthetic models in acquisition of anatomical knowledge and surgical expertise in EEN. 27,[29][30][31]35,36 Oyama et al described one of the most complete synthetic simulation models, in which the anterior, middle, and posterior fossa could be accessed through both sagittal and coronal plane approaches. 31 [29][30][31][32]35,36,38 whereas Wen et al…”

“…Fourteen studies of simulation with synthetic models were identified. 11,15,[27][28][29][30][31][32][33][34][35][36][37][38] 27,[29][30][31]35,36 Oyama et al described one of the most complete synthetic simulation models, in which the anterior, middle, and posterior fossa could be accessed through both sagittal and coronal plane approaches. 31 [29][30][31][32]35,36,38 whereas Wen et al enhanced the training of sellar tumor resection by curetting the inner content of an egg.…”

“…11,15,[27][28][29][30][31][32][33][34][35][36][37][38] 27,[29][30][31]35,36 Oyama et al described one of the most complete synthetic simulation models, in which the anterior, middle, and posterior fossa could be accessed through both sagittal and coronal plane approaches. 31 [29][30][31][32]35,36,38 whereas Wen et al enhanced the training of sellar tumor resection by curetting the inner content of an egg. 28 In addition, Shah et al aimed to produce a model that assisted in identifying patient-specific sphenoid sinus landmarks and tested the participant's acquired knowledge in the operating room.…”