The Blue-Blood Porcine Chest Wall: A Novel Microsurgery Training Simulator for Internal Mammary Vessel Dissection and Anastomosis
Background Preparation of the internal mammary artery (IMA) is a critical step in autologous breast reconstruction. Intraoperatively, there is limited opportunity for residents to practice this skill. Porcine models provide highly realistic simulation for vascular surgery; however, use of live laboratory pigs is expensive, inconvenient, and offers limited opportunity for repetitive training. We aimed to develop an inexpensive and effective training model for IMA preparation. This article describes creation of a novel microsurgical model using cadaveric chest walls of Wisconsin Miniature Swine embedded in a modified mannequin thorax and augmented with a blue-blood perfusion system.
Methods Anatomic comparison: five porcine chest walls were dissected, and various anatomic measurements were made for anatomic comparison to existing human data in the literature. Model assembly: the chest wall is prepared by cannulating the proximal and distal ends of the internal mammary vessels with angiocatheters, which are then connected to the blue-blood perfusion system. The model is assembled in four layers including: (1) a mannequin thorax with a window removed to expose the first to fourth intercostal spaces, bilaterally, (2) a layer of foam simulating fat, (3) the perfused pig chest wall, and (4) a second mannequin shell placed posteriorly for support.
Results The porcine chest walls are similar to humans with regards to vessel size and location. This model can be assembled quickly, with a one-time approximate cost of $55.00, and allows for six training sessions per specimen. The model allows residents to practice the key steps of IMA preparation including dissection, elevation of perichondria, and vascular anastomosis while working at a depth that closely simulates the human thorax. Continuous blue-blood perfusion provides immediate feedback on anastomosis quality.
Conclusion Overall, this novel model can provide inexpensive and realistic simulation of internal mammary vessel preparation and anastomosis.
* These authors contributed equally to this work.
Received: 07 May 2020
Accepted: 15 August 2020
21 September 2020 (online)
© 2020. Thieme. All rights reserved.
Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.
- 1 American Society of Plastic Surgeons. 2018 Plastic surgery statistics report. . Available at: https://www.plasticsurgery.org/documents/News/Statistics/2018/reconstructive-procedure-trends-2018.pdf (PMID: . Accessed February 29, 2020)
- 2 Ilonzo N, Tsang A, Tsantes S, Estabrook A, Thu Ma AM. Breast reconstruction after mastectomy: a ten-year analysis of trends and immediate postoperative outcomes. Breast 2017; 32: 7-12
- 3 Moran SL, Nava G, Behnam AB, Serletti JM. An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients. Plast Reconstr Surg 2003; 111 (06) 1876-1882
- 4 Serletti JM, Moran SL. Microvascular reconstruction of the breast. Semin Surg Oncol 2000; 19 (03) 264-271
- 5 Patel AJ, Malata CM. Intercostal drain insertion for pneumothorax following free flap breast reconstruction--a near miss!. J Plast Reconstr Aesthet Surg 2010; 63 (11) 1929-1931
- 6 Shulzhenko NO, Zeng W, Albano NJ. et al. Multispecialty microsurgical course utilizing the blue-blood chicken thigh model significantly improves resident comfort, confidence, and attitudes in multiple domains. J Reconstr Microsurg 2020; 36 (02) 142-150
- 7 Zeng W, Shulzhenko NO, Feldman CC, Dingle AM, Poore SO. “Blue-blood”- infused chicken thigh training model for microsurgery and supermicrosurgery. Plast Reconstr Surg Glob Open 2018; 6 (04) e1695
- 8 Cook JA, Tholpady SS, Momeni A, Chu MW. Predictors of internal mammary vessel diameter: a computed tomographic angiography-assisted anatomic analysis. J Plast Reconstr Aesthet Surg 2016; 69 (10) 1340-1348
- 9 Lee CD, Butterworth J, Stephens RE, Wright B, Surek C. Location of the internal mammary vessels for microvascular autologous breast reconstruction: the “1-2-3 rule”. Plast Reconstr Surg 2018; 142 (01) 28-36
- 10 Evgeniou E, Walker H, Gujral S. The role of simulation in microsurgical education. J Surg Educ 2018; 75 (01) 171-181
- 11 Sullivan BJ, Maliha S, Henderson PW. Microsurgery fellows impression of clinical and educational offerings during fellowship year. J Reconstr Microsurg 2020; 36 (03) 191-196
- 12 Costa AL, Cucinotta F, Fazio A. et al. Anterolateral thigh flap in a chicken model: a novel perforator training model. J Reconstr Microsurg 2019; 35 (07) 485-488
- 13 Renner S, Blutke A, Clauss S. et al. Porcine models for studying complications and organ crosstalk in diabetes mellitus. Cell Tissue Res 2020; 380 (02) 341-378
- 14 Briceno N, Annamalai SK, Reyelt L. et al. Left ventricular unloading increases the coronary collateral flow index before reperfusion and reduces infarct size in a swine model of acute myocardial infarction. J Am Heart Assoc 2019; 8 (22) e013586
- 15 Aigner B, Renner S, Kessler B. et al. Transgenic pigs as models for translational biomedical research. J Mol Med (Berl) 2010; 88 (07) 653-664
- 16 Lunney JK. Advances in swine biomedical model genomics. Int J Biol Sci 2007; 3 (03) 179-184
- 17 Judge EP, Hughes JM, Egan JJ, Maguire M, Molloy EL, O'Dea S. Anatomy and bronchoscopy of the porcine lung. A model for translational respiratory medicine. Am J Respir Cell Mol Biol 2014; 51 (03) 334-343
- 18 Curzer HJ, Perry G, Wallace MC, Perry D. The three Rs of animal research: what they mean for the institutional animal care and use committee and why. Sci Eng Ethics 2016; 22 (02) 549-565
- 19 Bartline PB, O'Shea J, McGreevy JM, Mueller MT. A novel perfused porcine simulator for teaching aortic anastomosis increases resident interest in vascular surgery. J Vasc Surg 2017; 66 (02) 642-648.e4
- 20 Peri L, Vilaseca A, Serapiao R. et al. Development of a pig model for laparoscopic kidney transplant. Exp Clin Transplant 2016; 14 (01) 22-26
- 21 Demertzis SD, Laschke MW, Siclari FPA, Menger MD. Non-robotic thoracoscopic internal mammary artery preparation in the pig. A training model. Interact Cardiovasc Thorac Surg 2008; 7 (04) 556-559
- 22 Banda CH, Mitsui K, Ishiura R, Danno K, Narushima M. A supermicrosurgery pig foot training model for practice of lymphaticovenular anastomosis. Microsurgery 2020; 40 (01) 91-92
- 23 Parrett BM, Caterson SA, Tobias AM, Lee BT. The rib-sparing technique for internal mammary vessel exposure in microsurgical breast reconstruction. Ann Plast Surg 2008; 60 (03) 241-243
- 24 Wilson S, Weichman K, Broer PN. et al. To resect or not to resect: the effects of rib-sparing harvest of the internal mammary vessels in microsurgical breast reconstruction. J Reconstr Microsurg 2016; 32 (02) 94-100