J Reconstr Microsurg 2017; 33(06): 381-388
DOI: 10.1055/s-0037-1601423
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA

Surgeon-Reported Needs for Improved Training in Identifying and Managing Free Flap Compromise

Catherine McMillan
1   Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
,
Veerle D'Hondt
1   Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
2   Department of Surgery, University of Toronto, Toronto, Ontario, Canada
,
Alexandra H. Marshall
3   Marshall Medical Communications, Toronto, Ontario, Canada
,
Paul Binhammer
1   Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
2   Department of Surgery, University of Toronto, Toronto, Ontario, Canada
,
Joan Lipa
1   Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
2   Department of Surgery, University of Toronto, Toronto, Ontario, Canada
,
Laura Snell
1   Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
2   Department of Surgery, University of Toronto, Toronto, Ontario, Canada
› Author Affiliations
Further Information

Publication History

20 October 2016

23 February 2017

Publication Date:
11 April 2017 (online)

Abstract

Background This study examined the need for improved training in the identification and management of free flap (FF) compromise and assessed a potential role for simulated scenario training.

Methods Online needs assessment surveys were completed by plastic surgeons and a subsample with expertise in microsurgery education participated in focus groups. Data were analyzed using descriptive statistics and mixed qualitative methods.

Results In this study, 77 surgeons completed surveys and 11 experts participated in one of two focus groups. Forty-nine (64%) participants were educators, 65 and 45% of which reported having an insufficient volume of FF cases to adequately teach the management and identification of compromise, respectively. Forty-three percent of educators felt that graduating residents are not adequately prepared to manage FF compromise independently. Exposure to normal and abnormal FF cases was felt to be critical for effective training by focus group participants. Experts identified low failure rates, communication issues, and challenging teaching conditions as current barriers to training. Most educators (74%) felt that simulated scenario training would be “very useful” or “extremely useful” to current residents. Focus groups highlighted the need for a widely accepted algorithm for re-exploration and salvage on which to base the development of a training adjunct consisting of simulated scenarios.

Conclusion Trainee exposure to FF compromise is inadequate in existing plastic surgery programs. Early exposure, high case volume, and a standardized algorithmic approach to management with a focus on decision making may improve training. Simulated scenario training may be valuable in addressing current barriers.

 
  • References

  • 1 Offodile II AC, Aherrera A, Wenger J, Rajab T, Guo L. Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? A risk factor analysis of 2,008 patients from the ACS-NSQIP database. Microsurgery 2017; 37 (01) 12-20
  • 2 Jones NF, Jarrahy R, Song JI, Kaufman MR, Markowitz B. Postoperative medical complications--not microsurgical complications--negatively influence the morbidity, mortality, and true costs after microsurgical reconstruction for head and neck cancer. Plast Reconstr Surg 2007; 119 (07) 2053-2060
  • 3 Salama AR, McClure SA, Ord RA, Pazoki AE. Free-flap failures and complications in an American oral and maxillofacial surgery unit. Int J Oral Maxillofac Surg 2009; 38 (10) 1048-1051
  • 4 Culliford IV AT, Spector J, Blank A, Karp NS, Kasabian A, Levine JP. The fate of lower extremities with failed free flaps: a single institution's experience over 25 years. Ann Plast Surg 2007; 59 (01) 18-21 , discussion 21–22
  • 5 Ligh CA, Nelson JA, Wink JD. , et al. An analysis of early oncologic head and neck free flap reoperations from the 2005-2012 ACS-NSQIP dataset. J Plast Surg Hand Surg 2016; 50 (02) 85-92
  • 6 Yang Q, Ren ZH, Chickooree D. , et al. The effect of early detection of anterolateral thigh free flap crisis on the salvage success rate, based on 10 years of experience and 1072 flaps. Int J Oral Maxillofac Surg 2014; 43 (09) 1059-1063
  • 7 Mirzabeigi MN, Wang T, Kovach SJ, Taylor JA, Serletti JM, Wu LC. Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure. Plast Reconstr Surg 2012; 130 (03) 579-589
  • 8 Khansa I, Momoh AO, Patel PP, Nguyen JT, Miller MJ, Lee BT. Fat necrosis in autologous abdomen-based breast reconstruction: a systematic review. Plast Reconstr Surg 2013; 131 (03) 443-452
  • 9 Smit JM, Acosta R, Zeebregts CJ, Liss AG, Anniko M, Hartman EH. Early reintervention of compromised free flaps improves success rate. Microsurgery 2007; 27 (07) 612-616
  • 10 Chen K-T, Mardini S, Chuang DC-C. , et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120 (01) 187-195
  • 11 Kroll SS, Schusterman MA, Reece GP. , et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98 (07) 1230-1233
  • 12 Chaput B, Vergez S, Somda S. , et al. Comparison of single and double venous anastomosis in head and neck oncologic reconstruction using free flaps: a meta-analysis. Plast Reconstr Surg 2016; 137 (05) 1583-1594
  • 13 Perez-Smith D, Wagels M, Theile DR. Jejunal free flap reconstruction of the pharyngolaryngectomy defect: 368 consecutive cases. J Plast Reconstr Aesthet Surg 2013; 66 (01) 9-15
  • 14 Yim JH, Yun J, Lee TJ, Kim EK, Cho J, Eom JS. Outcomes of take-back operations in breast reconstruction with free lower abdominal flaps. Arch Plast Surg 2015; 42 (06) 741-745
  • 15 Lee M, Chin RY, Eslick GD, Sritharan N, Paramaesvaran S. Outcomes of microvascular free flap reconstruction for mandibular osteoradionecrosis: a systematic review. J Craniomaxillofac Surg 2015; 43 (10) 2026-2033
  • 16 Fischer JP, Wink JD, Nelson JA. , et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013; 29 (06) 407-416
  • 17 Quillin III RC, Cortez AR, Pritts TA, Hanseman DJ, Edwards MJ, Davis BR. Operative variability among residents has increased since implementation of the 80-hour workweek. J Am Coll Surg 2016; 222 (06) 1201-1210
  • 18 Bell Jr RH, Biester TW, Tabuenca A. , et al. Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg 2009; 249 (05) 719-724
  • 19 Sachdeva AK, Flynn TC, Brigham TP. , et al; American College of Surgeons (ACS) Division of Education; Accreditation Council for Graduate Medical Education (ACGME). Interventions to address challenges associated with the transition from residency training to independent surgical practice. Surgery 2014; 155 (05) 867-882
  • 20 Zhong T, Fernandes KA, Saskin R. , et al. Barriers to immediate breast reconstruction in the Canadian universal health care system. J Clin Oncol 2014; 32 (20) 2133-2141
  • 21 Zhong T, Spithoff K, Kellett S. , et al. Breast cancer reconstruction surgery (immediate and delayed) across Ontario: patient indications and appropriate surgical options. Toronto (ON): Cancer Care Ontario; . Program in Evidence-Based Care Series No.: 17–10
  • 22 Canadian Medical Association. Canadian Medical Association Master File: Plastic Surgery Profile. 2015 Available at: https://www.cma.ca/Assets/assets-library/document/en/advocacy/Plastic-Surgery-e.pdf . Accessed August 21, 2016
  • 23 Doherty C, Nakoneshny SC, Harrop AR. , et al. A standardized operative team for major head and neck cancer ablation and reconstruction. Plast Reconstr Surg 2012; 130 (01) 82-88
  • 24 Khariwala SS, Alexander S, Yueh B. Creation and validation of a structured training program to train ICU nurses in free flap monitoring. J Reconstr Microsurg Open 2016; 1: 8-11
  • 25 Cervenka B, Bewley AF. Free flap monitoring: a review of the recent literature. Curr Opin Otolaryngol Head Neck Surg 2015; 23 (05) 393-398
  • 26 Kakarala K, Emerick KS, Lin DT, Rocco JW, Deschler DG. Free flap reconstruction in 1999 and 2009: changing case characteristics and outcomes. Laryngoscope 2012; 122 (10) 2160-2163
  • 27 Roehl KR, Mahabir RC. A practical guide to free tissue transfer. Plast Reconstr Surg 2013; 132 (01) 147e-158e
  • 28 Ericsson KA. Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Acad Med 2015; 90 (11) 1471-1486
  • 29 Wayne DB, Butter J, Siddall VJ. , et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med 2006; 21 (03) 251-256
  • 30 McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Medical education featuring mastery learning with deliberate practice can lead to better health for individuals and populations. Acad Med 2011; 86 (11) e8-e9
  • 31 McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med 2011; 86 (06) 706-711
  • 32 Kempton SJ, Bentz ML. Making master surgeons out of trainees: part I. Teaching surgical judgment. Plast Reconstr Surg 2016; 137 (05) 1646-1653
  • 33 Sadideen H, Hamaoui K, Saadeddin M, Kneebone R. Simulators and the simulation environment: getting the balance right in simulation-based surgical education. Int J Surg 2012; 10 (09) 458-462
  • 34 Evgeniou E, Tsironi M, Riley D. Improving fellowship training in microsurgery: a threshold concepts perspective on the curricula of fellowship programs. J Reconstr Microsurg 2015; 31 (08) 579-589
  • 35 Dedy NJ, Bonrath EM, Ahmed N, Grantcharov TP. Structured training to improve nontechnical performance of junior surgical residents in the operating room: a randomized controlled trial. Ann Surg 2016; 263 (01) 43-49
  • 36 Dedy NJ, Fecso AB, Szasz P, Bonrath EM, Grantcharov TP. Implementation of an effective strategy for teaching nontechnical skills in the operating room: a single-blinded nonrandomized trial. Ann Surg 2016; 263 (05) 937-941
  • 37 Nguyen N, Watson WD, Dominguez E. An event-based approach to design a teamwork training scenario and assessment tool in surgery. J Surg Educ 2016; 73 (02) 197-207
  • 38 Henderson PW, Landford W, Gardenier J, Otterburn DM, Rohde CH, Spector JA. A simple, visually oriented communication system to improve postoperative care following microvascular free tissue transfer: development, results, and implications. J Reconstr Microsurg 2016; 32 (06) 464-469
  • 39 Sullivan ME, Yates KA, Inaba K, Lam L, Clark RE. The use of cognitive task analysis to reveal the instructional limitations of experts in the teaching of procedural skills. Acad Med 2014; 89 (05) 811-816
  • 40 Clark RE, Pugh CM, Yates KA, Inaba K, Green DJ, Sullivan ME. The use of cognitive task analysis to improve instructional descriptions of procedures. J Surg Res 2012; 173 (01) e37-e42
  • 41 Bui DT, Cordeiro PG, Hu Q-Y, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007; 119 (07) 2092-2100
  • 42 Sezgin B, Ayhan S, Tuncer S, Sencan A, Aral M. Hypercoagulability in microvascular breast reconstruction: an algorithmic approach for an underestimated situation. J Reconstr Microsurg 2012; 28 (08) 515-520
  • 43 Motakef S, Mountziaris PM, Ismail IK, Agag RL, Patel A. Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines. Plast Reconstr Surg 2015; 135 (01) 290-299
  • 44 Hirche C, Kneser U, Xiong L. , et al. Microvascular free flaps are a safe and suitable training procedure during structured plastic surgery residency: a comparative cohort study with 391 patients. J Plast Reconstr Aesthet Surg 2016; 69 (05) 715-721
  • 45 Sodhi K, Singla MK, Shrivastava A. Institutional resuscitation protocols: do they affect cardiopulmonary resuscitation outcomes? A 6-year study in a single tertiary-care centre. J Anesth 2015; 29 (01) 87-95
  • 46 Ameh CA, van den Broek N. Making it happen: training health-care providers in emergency obstetric and newborn care. Best Pract Res Clin Obstet Gynaecol 2015; 29 (08) 1077-1091
  • 47 Chin CJ, Chin CA, Roth K, Rotenberg BW, Fung K. Simulation-based otolaryngology - head and neck surgery boot camp: ‘how I do it’. J Laryngol Otol 2016; 130 (03) 284-290
  • 48 Hanasono MM, Butler CE. Prevention and treatment of thrombosis in microvascular surgery. J Reconstr Microsurg 2008; 24 (05) 305-314
  • 49 Damen TH, Morritt AN, Zhong T, Ahmad J, Hofer SO. Improving outcomes in microsurgical breast reconstruction: lessons learnt from 406 consecutive DIEP/TRAM flaps performed by a single surgeon. J Plast Reconstr Aesthet Surg 2013; 66 (08) 1032-1038
  • 50 Chen WF, Kung YP, Kang YC, Eid A, Tsao CK. Protocolisation and ‘end’ point of free-flap salvage. J Plast Reconstr Aesthet Surg 2012; 65 (09) 1272-1275
  • 51 Janis JE, Vedder NB, Reid CM, Gosman A, Mann K. Validated assessment tools and maintenance of certification in plastic surgery: current status, challenges, and future possibilities. Plast Reconstr Surg 2016; 137 (04) 1327-1333
  • 52 Flurry M, Brooke S, Micholetti B. , et al. Nurse training with simulation: an innovative approach to teach complex microsurgery patient care. Ann Plast Surg 2012; 69 (04) 459-461
  • 53 Haddock NT, Gobble RM, Levine JP. More consistent postoperative care and monitoring can reduce costs following microvascular free flap reconstruction. J Reconstr Microsurg 2010; 26 (07) 435-439
  • 54 Penel N, Mallet Y, Roussel-Delvallez M, Lefebvre JL, Yazdanpanah Y. Factors determining length of the postoperative hospital stay after major head and neck cancer surgery. Oral Oncol 2008; 44 (06) 555-562
  • 55 Farwell DG, Reilly DF, Weymuller Jr EA, Greenberg DL, Staiger TO, Futran NA. Predictors of perioperative complications in head and neck patients. Arch Otolaryngol Head Neck Surg 2002; 128 (05) 505-511
  • 56 Chalian AA, Kagan SH, Goldberg AN. , et al. Design and impact of intraoperative pathways for head and neck resection and reconstruction. Arch Otolaryngol Head Neck Surg 2002; 128 (08) 892-896
  • 57 Husbands JM, Weber RS, Karpati RL. , et al. Clinical care pathways: decreasing resource utilization in head and neck surgical patients. Otolaryngol Head Neck Surg 1999; 121 (06) 755-759
  • 58 Knight LJ, Gabhart JM, Earnest KS, Leong KM, Anglemyer A, Franzon D. Improving code team performance and survival outcomes: implementation of pediatric resuscitation team training. Crit Care Med 2014; 42 (02) 243-251
  • 59 Hunt EA, Walker AR, Shaffner DH, Miller MR, Pronovost PJ. Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes. Pediatrics 2008; 121 (01) e34-e43
  • 60 Pannucci CJ, Wilkins EG. Identifying and avoiding bias in research. Plast Reconstr Surg 2010; 126 (02) 619-625
  • 61 Cohen L, Manion L, Morrison K. Research Methods in Education, 7th ed. New York: Routledge; 2011