Teaching subfascial perforator veins surgery: survey on a 2-day hands-on course

The present paper describes a training method with objective evaluation to enhance video-assisted surgical skills in subfascial endoscopic perforator veins surgery (SEPS). Training was scheduled during a 2-day intensive course.

Hands-on exercises were performed (i) on a simulator to assess whether specific training exercises were helpful in attainment of skills; (ii) on a known animal model that uses the swine abdominal wall and which allows practice in endoscopic dissection and perforator veins (PV) using appropriate instrumentation in an environment that is a reasonable surrogate for the human calf; and (iii) assisting a senior surgeon performing SEPS. Thirty surgeons without experience in SEPS were trained to perform a sequence of standardized drills connected with the SEPS technique. The SEPS simulator consisted of an artificially constructed subfascial space of the leg in which false perforator veins had to be localized, and cut. The participants performed a sequence of drills three times in order to improve their dexterity. The same exercises were then performed on a swine model. The model consisted of the arteries and veins penetrating the rectus fascia and passing into the overlying cutaneous trunci muscle and hypodermis on either side of the midline between the arch of the ribs cranially and the umbilicus caudally. Trainees were required to achieve operative space in the animal subcutaneous fat, to reach and identify the "perforating" subcutaneous vessels, and to interrupt some of them with a 5-mm clamp coagulator ultrasonic scalpel. The time required to perform each dexterity drill was recorded in seconds. Finally, the day after, trainees were asked to drive the senior operator during clinical SEPS performed on eight patients, suggesting the following manoeuvres in order to: (i) enter the subfascial space of the leg; (ii) make operative space; (iii) identify the incompetent perforator vein(s); and (iv) coagulate and divide them with the ultrasonic scalpel. Each of these four steps scored 1 point.

All the trainees showed a steady improvement in skill acquisition on the SEPS simulator (P < 0.001), and on the animal model with the single-port technique (P < 0.001). These results reflect positively on the animal model using the dual-port technique, and on the scores achieved in the operating theatre during clinical SEPS.

The validity of the 2-day course was demonstrated by significant improvement in performance with increasing skill on the training models, and in clinical practice.