Use of Bubble Wrap for Microsurgical Training

In this letter to the editor we describe the use of bubble wraps as a novel in vitro microsurgical training tool. Laboratory training is important for developing neurosurgical skills in microsurgery.[1] [2] [3] Several different in vitro and in vivo models have been described for this purpose. The usefulness of in vitro, nonanimal models in microsurgical training is well-established as a first step in training. These models include rubber practice pads, silicone tubes, latex gloves, suture practice cards, surgical gauzes, leafs, and vessels-models.[2] [4] [5] [6] They are cheap and an excellent way to establish the basic microsurgical techniques for which an in vivo model should not be sacrificed. The use of in vivo models should be retained for specialized training and can be easily replaced by in vitro models for basic training.

Bubble wrap is a cheap and easy to find training tool, with a thickness varying from 3/16 to 1-in. big bubbles ([Fig. 1]). For laboratory training the small size bubbles are preferred. The very thin upper layer of the plastic is very fragile and needs very careful handling during exercise. This compels the trainee to be very cautious. In neurosurgery, the bubble wrap resembles the same frailty of the arachnoid or very small intracranial vessels, such as the distal cortical vessels.

Fig. 1 (A) An overview of the small bubble wrap preferred for training. (B) Detail of the thin layer of a cut bubble wrap.

The trainee has to pay very good attention in needle placement and pulling the thread through the bubble, since pulling on the needle can cause rupture of the thin layer of the bubble.

First, the trainee starts with getting used to the microscope with simple exercises for instrument and “tissue” handling. During all stages of training, we recommend to use surgical gloves, simulating human surgical circumstances. Whenever the first step is under control, various exercises can be performed, such as interrupted sutures, running sutures, and anastomoses ([Fig. 2]). The difficulty can be increased steadily after the trainee has mastered these exercises, by for example suturing in depth, through narrow openings or even performing anastomoses under a layer of water.

Fig. 2 (A) Interrupted sutures. (B) Running sutures performed during training.

These advanced exercises simulate the complexity of intracranial circumstances.[3]

In contrast to a silicone tube, the bubble wrap is more frail and flexible, giving a realistic tissue handling on vessel manipulation. In our opinion this is the most important advantage compared with other in vitro training tools for microsurgery.

With the increasing use of robotics in different fields of surgery as well neurosurgery,[7] in our opinion the training with a delicate material such as bubble wrap can also be used to gain experience with robotic instrumentation.

An additional advantage of bubble wrap above all other microsurgical training tools is the option to obtain immediate stress relief during and after training, as popping bubbles has been described as a popular approach to stress relief.

In our experience bubble wrap is an excellent training tool, which can help to train microsurgical skills, since it resembles the very thin and fragile structures common to intracranial compartments. This new training tool can help in training for specific anastomoses in neurosurgery.

• References

• 1 Chan WY, Matteucci P, Southern SJ. Validation of microsurgical models in microsurgery training and competence: a review. Microsurgery 2007; 27 (5) 494-499
• 2 Usón J, Calles MC. Design of a new suture practice card for microsurgical training. Microsurgery 2002; 22 (8) 324-328
• 3 Menovsky T. A human skull cast model for training of intracranial microneurosurgical skills. Microsurgery 2000; 20 (7) 311-313
• 4 Balasundaram I, Aggarwal R, Darzi LA. Development of a training curriculum for microsurgery. Br J Oral Maxillofac Surg 2010; 48 (8) 598-606
• 5 Nam SM, Shin HS, Kim YB, Park ES, Choi CY. Microsurgical training with porcine thigh infusion model. J Reconstr Microsurg 2013; 29 (5) 303-306
• 6 Matsumura N, Horie Y, Shibata T, Kubo M, Hayashi N, Endo S. Basic training model for supermicrosurgery: a novel practice card model. J Reconstr Microsurg 2011; 27 (6) 377-382
• 7 Hong W-C, Tsai J-C, Chang SD, Sorger JM. Robotic skull base surgery via supraorbital keyhole approach: a cadaveric study. Neurosurgery 2013; 72 (Suppl. 01) 33-38