Medical course data
Page data
Type Medical course
Keywords pediatric surgery, surgical training, neonatal colostomy, anorectal malformation, gentle tissue handling skills, frugal innovation
SDGs Sustainable Development Goals SDG03 Good health and well-being
Published by Medical Makers
Published 2021
License CC BY-SA 4.0

This training module allows medical officers (non-specialist physicians) and general surgeons to become confident and competent in the gentle handling of delicate infant tissues as part of neonatal colostomy procedures performed in low to middle income countries (LMICs).

Syllabus[edit | edit source]

  • Overview
  • Simulator Set-Up
  • Relevant Anatomy
  • Patient Selection
  • Pre-Operative Management
  • Procedure Steps
  • Psychomotor Skills Training
  • Post-Operative Care
  • Self-Assessment Framework
  • Innovation and Scaling Adoption

Overview[edit | edit source]

Global Impact[edit | edit source]

According to the World Health Organization, nearly 2 billion children and adolescents worldwide lack access to surgical care.[1] Children account for over 40% of the population in sub Saharan Africa and 25-30% of the population in most LMICs. Performing surgery in this age group requires incredibly careful, gentle, and delicate handling of tissues to avoid complications and mortality. Handling neonatal tissue requires such psychomotor skills more than anywhere else and creating a safe colostomy for anorectal malformations - the leading congenital cause of intestinal obstruction in children in Africa[2] - is the most typical example where such skills are required.

In most of sub Saharan Africa and LMICs, there are very few paediatric surgeons and most neonates and children have no access to specialized care.[3] The World Health Organization recommended provider to patient ratio is 1 pediatric surgeon per 100,000 population below 18 years of age.[needs ref] In Nigeria, there is 1 pediatric surgeon per 760,000 population under 15 years of age [https://data.worldbank.org/indicator/SP.POP.0014.TO.ZS?locations=NG, 43% population under 14]. In 2021, there were an estimated 122 pediatric surgeons, and 58 pediatric surgery fellows (trainees) in only 43 tertiary hospitals across Nigeria.

This means that surgery on children in most of these settings are performed by non-specialist physicians and general surgeons who have little or no training in the surgical care of children. Training these categories of staff in careful, gentle and delicate tissue handling would make it possible for them to perform emergency and essential surgical procedures in children in a safe manner, thereby, avoiding and minimizing complications and mortality.

Frugal Simulators for Psychomotor Skills Training[edit | edit source]

How the identified psychomotor skill(s) will be acquired by the user of your prototype surgical training module. Please address both why you chose the particular technology(ies) and how you addressed the shortcoming of that type of simulation in teaching the performance of a physical skill. Please also address how the user's learnings will directly translate into clinical performance of that skill.

The specific psychomotor skills that this module teaches are:

  • Gentle and delicate tissue handling
  • Control of bleeding
  • Avoiding crushing tissue
  • Avoiding tight sutures
  • Avoiding undue tension and pull

This module uses low-tech simulators made from inexpensive materials that are readily available within the intended place of use.

Low-cost simulators are often improvised out of locally available materials in LMICs but these simulators lack objective data to validate that the user's learnings will directly translate into the safe, clinical performance of that psychomotor skill. We are addressing these shortcomings of our two inexpensive, low-tech simulators in teaching the performance of gentle tissue handling skills by validating that the compression forces exerted by learners who successfully complete the training tasks on our low-cost simulators are not statistically different from the force values exerted by paediatric surgeons operating on live animal models that are representative of human newborns.

The module provides a previously used wet cigarette model to teach tender tissue handling skills to the learner through avoiding undue tension and compression and the creation of sutures that are too tight. The wet cigarette model costs 20¢ USD and simulates the fragile, delicate tissues of a neonate. Although the wet cigarette suturing activity simulates a bowel anastomosis, the gentle tissue handling skills are the same for performing an enterocutaneous anastomosis in a newborn. The user's learnings from this wet cigarette suturing activity will directly translate into the clinical performance of the enterocutaneous anastomosis for a colostomy in a newborn.

The module provides a training activity using simulated vessels and bowel tissue made of sodium alginate to teach the user to apply gentle compression forces uniformly with forceps and to avoid crushing neonatal tissue during electrocautery coagulation. These simulators will be calibrated to provide targeted feedback to the user for a specific maximum compression force the user should not exceed when coagulating a vessel. The user's learnings from this simulation will directly translate into the clinical performance of securing hemostasis and gentle tissue handling skills for a colostomy in a newborn.

Simulator Set-Up[edit | edit source]

Our simulators can be built from materials that are readily available within the intended place of use or can be locally purchased. No tools, specialized equipment, or technical expertise are required.

Materials and Equipment[edit | edit source]

Materials That Are Readily Available Within the Intended Place of Use

  • Distilled water
  • 2 Beakers (minimum measurement volume of 100 mL)
  • Weigh scale
  • 2 Measuring cups
  • Mixing sticks
  • 1 mL fine gauge syringe
  • Smooth forceps
  • Shallow container (like a Petri dish)
  • Tap water
  • Smooth and Adson's toothed forceps
  • 2 Senn retractors
  • Cup
  • Standard needle driver
  • 4-0 or 5-0 Vicryl or PDS sutures
  • Mayo scissors
  • Digital camera or cellphone

Materials That Can Be Locally Purchased

  • Calcium chloride
  • Sodium alginate
  • Red food dye coloring
  • Purple food dye coloring
  • 2 cigarettes

How to Build the Simulator[edit | edit source]

Hemostasis Simulator[edit | edit source]

Materials[edit | edit source]
  • Distilled water
  • 2 Beakers (minimum measurement volume of 100 mL)
  • Calcium chloride
  • Sodium alginate
  • Weigh scale
  • 2 Measuring cups
  • Mixing sticks
  • Red food dye coloring
  • Purple food dye coloring
  • 1 mL fine gauge syringe
  • Smooth forceps
  • Shallow container (like a Petri dish)
  • Tap water
  • A digital camera (or cellphone) for taking digital images for remote evaluation and feedback by an expert (if required)
Assembly Steps[edit | edit source]
  1. Add 5 grams of calcium chloride to 100 mL of distilled or deionized water and stir well to make a 5% calcium chloride solution
  2. Add 2 grams of sodium alginate to 100 mL of distilled or deionized water and stir well to make a 2% sodium alginate solution
  3. Add a few drops of red food dye coloring to the 2% sodium alginate solution and mix well
  4. Draw up the colored 2% sodium alginate solution into a 1 mL fine gauge syringe
  5. Place the syringe into the 5% calcium chloride solution and allow a continuous stream of colored 2% sodium alginate to flow out of the syringe while moving the syringe to create small (< 1 mm), simulated arteries
  6. Remove simulated vessels and drain from the 5% calcium chloride solution
  7. Place simulated vessels in a shallow container (like a Petri dish) containing tap water
  8. Repeat Steps 1-7 with purple food dye coloring to make simulated veins
  9. Use smooth forceps to practice gentle hemostasis of simulated vessels*

*Once we have used the force-sensing forceps to collect force profiles on pediatric surgeons, we will titrate the ingredients so the simulated vessels will break when the learner exceeds a maximum compression force value.

Enterocutaneous Anastomosis Simulator[edit | edit source]

Materials[edit | edit source]
  • 2 Senn retractors
  • 2 cigarettes
  • 1 cup of clean water in a reusable cup
  • Standard needle driver
  • 4-0 or 5-0 Vicryl or PDS sutures
  • Adson's Forceps
  • Mayo scissors
  • A digital camera (or cellphone) for taking digital images for remote evaluation and feedback by an expert (if required)
Assembly Steps[edit | edit source]
  1. Use two Senn retractors to hold down two cigarettes whose ends have been dipped in water, which the learner then attempts to suture together.

Relevant Anatomy[edit | edit source]

xxxx

Patient Selection[edit | edit source]

xxxx

Conditions for Emergency Transfer[edit | edit source]

Multiple congenital anomalies

[review textbook]

Safe Transfer of a Newborn[edit | edit source]

  1. Request Emergency Health Transport (e.g. Riders for Health)
  2. Place infant in a transport container, like a basket
  3. Position infant [supine?] to minimize the risk of vomiting and aspiration
  4. Keep the infant warm with blankets

Pre-Operative Management[edit | edit source]

xxx

Procedure Steps[edit | edit source]

Descending Colostomy with Separated Stomas[edit | edit source]

  1. Initiate general anaesthesia.
  2. Position patient in supine position.
  3. Clean and drape to expose only the lower abdomen below the umbilicus.
  4. Make skin incision in the oblique left lower quadrant.
  5. Deepen incision to expose muscle.
  6. Ensure hemostasis.
  7. Cut muscles and secure hemostasis.
  8. Open peritoneum between 2 hemostats.
  9. Identify sigmoid colon (taenia coli, no attached omentum) and trace proximally until the junction with descending colon is reached (fixed end).
  10. Withdraw a loop of the proximal sigmoid colon out of the abdomen.
  11. Create a window in the sigmoid colon mesentery, and divide the loop. Ensure hemostasis.
  12. Place the proximal limb in the upper lateral end of the wound and the distal limb in the lower medial end of the wound.
  13. Close the fascia between the 2 limbs using Vicryl 3-0 or PDS 3-0 suture. Ensure closure is not too tight around the 2 limbs.
  14. Close the skin between the 2 bowel limbs using Vicryl 4-0 or PDS 4-0 suture.
  15. Secure the proximal limb to the fascia using Vicryl or PDS 4-0 seromuscular stitches at the 4 quadrants. Then suture the full thickness of the bowel edge to the skin (leaving a 1-2 cm spout), circumferentially, 5 mm apart. Ensure these stitches are not too tight.
  16. Repeat the same technique with the distal limb. While doing this, place the stitches in such a way as to narrow the bowel opening to admit just the little finger. Suture flush to skin without creating spout.
  17. Wash out the lumen of the distal limb using warm normal saline instilled through an appropriate size Foley's catheter or similar soft tube.
  18. Inspect both stomas to ensure that they remain pink and viable.
  19. Clean wound and surrounding gently with appropriate antiseptic and dry with sterile gauze.
  20. Apply dressing to the skin bridge.
  21. Apply Vaseline gauze (lubricated gauze) over the stoma and place sterile gauze over it.

The two simulators will be integrated into the hemostasis and enterocutaneous anastomosis activities of the stoma creation procedure (see steps 6, 7, 11 and 15 above).

Psychomotor Skills Training[edit | edit source]

Learning Objectives[edit | edit source]

  • Gentle and delicate tissue handling
  • Control of bleeding
  • Avoiding crushing tissue
  • Avoiding tight sutures
  • Avoiding undue tension and pull

Hemostasis[edit | edit source]

xxx

Enterocutaneous Anastomosis[edit | edit source]

Basic Skills Training[edit | edit source]

  1. The filter end of two cigarettes are dipped in water to make them wet.
  2. The learner then attempts to suture the two wet ends together using 4-0 or 5-0 Vicryl or PDS sutures, taking care not to tear or squash the cigarettes.
  3. Multiple interrupted sutures at 0.5 cm apart are placed circumferentially.
  4. If unsuccessful, the procedure is repeated at the same session or at other convenient times until successful suturing is achieved (no tears on the cigarette wrap, ends not rumpled or squashed).
  5. The learner can self-assess by inspecting the cigarette and reviewing a checklist.

Advanced Skills Training[edit | edit source]

  1. Once successful with the filter ends of the cigarette, the learner moves to the next stage.
  2. In the second stage, the lighting ends of two cigarettes are briefly dipped in water to make them wet but not soggy.
  3. The same process as in Stage 1 is repeated until successful (no spilling of the contents of the cigarettes, no tears in the wrap, ends not rumpled or squashed).

Once a learner has mastered a task, they can start timed trials of a specific task. The goal is to improve their economy of movement and efficiency, and fluidity of instrument use while consistently handling tissue with the minimum amount of damage.

Both models after each stage are inspected by the learner, reviewed using a checklist and can be photographed and saved by the learner using a digital camera (or a cellphone camera) for remote evaluation and feedback by an expert (if required).

Post-Operative Care[edit | edit source]

xxxx

Self-Assessment Framework[edit | edit source]

[A description of the methods you used to create your module's self-assessment framework. Self- assessment of the quality of the skill acquisition must include some mechanism for the user to self-generate targeted feedback which enables the user to: ensure they are practicing the appropriate skills; modify their performance to improve competence; and determine when they have practiced to a sufficient level of mastery to perform the procedure in a patient.]

This module enables learners to self-assess their own knowledge and skills through targeted feedback and by completing digital quizzes, checklists, surveys, timed trials, and objective structured assessment of technical skills (OSATS) forms based on a review of the literature. All these self-assessment tools [were] reviewed and validated by [up to] 16 paediatric surgeon members of the Global Institute for Children's Surgery.

Hemostasis Simulator[edit | edit source]

The learner uses standard forceps to simulate electrocautery coagulation. If excessive force is applied, then the simulated vessel will break, giving feedback to the learner to reduce the compression forces of the forceps to achieve coagulation. Once the learner has adjusted the forceps compression, they will repeat this task to achieve the desired outcome a specified number of times.

Enterocutaneous Anastomosis Simulator[edit | edit source]

The learner compares their models with detailed images to determine if they have practiced to a sufficient level of mastery.

Basic Skills Training Checklist[edit | edit source]

  • Two cigarettes with wet filter ends are successfully sutured
  • No spilling of the contents of the cigarettes
  • No tears on the cigarette wrap
  • Ends not rumpled or squashed

Advanced Skills Training Checklist[edit | edit source]

  • Two cigarettes with wet lighting ends are successfully sutured
  • No spilling of the contents of the cigarettes
  • No tears on the cigarette wrap
  • Ends not rumpled or squashed

Ideal Features of a Neonatal Stoma[edit | edit source]

  • Proper siting on the abdomen
  • No stenosis
  • Adequate peristomal skin protection
  • No prolapse
  • Good spout for functional stoma
  • Pink colour
  • Everted, protuberant stoma to allow better application of bag and less spillage
  • Easy to apply bag or collect stool

Innovation and Scaling Adoption[edit | edit source]

Innovation[edit | edit source]

How your module(s) is innovative i.e. better than or more effective than traditional approaches available in that [target environment] to your [target practitioner(s)?

Surgical simulation training is primarily focused on adult patients and not customized to neonatal patients with congenital anomalies.[4] This module is designed to reach and support as many medical officers and general surgeons in LMICs as possible and enable paediatric surgical skills acquisition and self-assessment outside of training centers. This frugal, replicable, and self-assessed simulation-based training module does not require access to teachers, cadavers, animal models or expensive mannequins, and uses locally available and low-cost materials for psychomotor skills training. When possible, the equipment is reusable to minimize the use of consumables and maximize its lifespan in the place of use.

This module offers significant value for money in comparison to existing approaches for pediatric surgical simulation training. The most commonly used surgical simulation training models for newborns are live, anesthetized animals, such as very small rabbits, piglets, or baby goats. We calculated the total anesthesia, staffing, and consumable material costs (excluding sutures) per live animal model in Nigeria is $368.81 USD. The total known material costs of our simulators in Nigeria is $2.40 USD. Thus, this module saves $366.41 USD and is 154 times cheaper compared to training on a live animal model. The learner also saves on the costs of course fees, travel, lodging, and missing work.

Evaluation[edit | edit source]

A description of how you iterated on your original prototype design following user testing throughout the development of your prototype.

Design for Extreme Accessibility in Low Resource Settings[edit | edit source]

  1. Who are your intended users and how have you tailored the design of your surgical training module prototype to ensure their needs are met?
  2. How have you considered adoption in low resource settings in the design of your surgical training module?
  3. How have you ensured reproducibility of your module in it's intended place of use? Highlight design choices for your module undertaken to ensure replicability.
  4. How have you ensured that surgical practitioners from anywhere in the world will be able to engage with the content without barriers or gate keeping?

This module applies user-centered, data-driven, and reproducible design choices to maximize access in resource-constrained settings.

Medical officers are fully trained physicians who have not undergone any additional formal surgical training. Nevertheless, they are required to perform (or are performing) surgical procedures in children in LMICs due to severe shortages of paediatric surgeons. General surgeons have undergone formal advanced training in the surgical care of adults but have not been trained to perform surgery on children. They are currently involved in providing surgical care for children in LMICs due to severe shortages of paediatric surgeons.

We conducted a survey of paediatric surgeons around the world through the Global Initiative for Children's Surgery (GICS) to identify the key psychomotor skills required to safely perform colostomy in the newborn and the ideal features of a neonatal stoma. GICS has already engaged with these medical officers and general surgeons and created the Optimal Resources for Children's Surgery[5] which carefully lays out the skills required by these personnel to perform surgical procedures in children.[6] This module addresses their needs by teaching them preparation of a child for surgery, surgical decision-making in children, gentle tissue handling as well as postoperative care following surgery in children to ensure a safe outcome.

This module is available in the 6 official languages of the United Nations, and other languages in order to reach and support as many practitioners and trainees in LMICs as possible in resource-constrained settings. The frugal simulators are made from readily available and inexpensive materials and are designed to be fully reproducible in the intended place of use. No tools, specialized equipment, or technical expertise is required to construct these simulators.

Traditional self-directed training is often only available online or via mobile apps. But over 4 billion people do not have access to the Internet [8]. The penetration of high-speed Internet connectivity (broadband, 3G, or better mobile connections) is less than 30% in rural regions [9]. Over 236 million people require humanitarian assistance and millions of the most vulnerable people in conflict zones are unable to access essential surgical care [13]. Another drawback of online modules is that open-source, Web-based repositories are vulnerable to cyberattacks. These data breaches could result in counterfeit files and/or be used to target cyber or direct attacks on hospitals or people in conflict zones that access training modules through the Internet [12]. It is critical that this training module be available offline to remain isolated from any surveillance from an external Internet connection in order to prevent hackers from targeting healthcare workers and facilities in conflict zones.

Moreover, smartphones only make up 50% of total connections in sub Saharan Africa [10]. An estimated 770 million people worldwide lack access to electricity and 600 million of these individuals reside in sub Saharan Africa [11]. This training module can be made available on an ultraportable, offline, solar-powered, energy-efficient Raspberry Pi with touchscreen display to provide self-assessed surgical training in rural settings with limited or no access to the Internet, smartphones, and grid electricity. Paper-based versions of surgical training modules are inadequate because they cannot provide video and digital interactive content which is essential for surgical skills training and self-assessment frameworks.

The offline version of this training module can be delivered cross-country by motorcycles, typically within 1-2 days [ref. Seyi Omole, Director, Procurement & SCM, personal communication, Riders for Health, Nigeria, June 25, 2021] and delivered up to 80 km away on demand via fixed wing drones.[Zipline reference] The offline version this training module weighs less than 2 kg and is designed to fit in the cargo payload of the Zipline drone.

References[edit | edit source]

  1. Mullapudi B, Grabski D, Ameh EA, Ozgediz D, Thangarajah H, Kling K, Alkire B, Mearae JG, Bickler S. Estimates of number of children and adolescents without access to surgical care, Bull World Health Organ 2019;97:254–258. DOI: https://doi.org/10.2471/BLT.18.216028
  2. Lawal TA. Overview of Anorectal Malformations in Africa. Front. Surg. 2019 Mar;6:7. DOI: https://doi.org/10.3389/fsurg.2019.00007
  3. Sanjay Krishnaswami, Benedict C. Nwomeh, Emmanuel A. Ameh, The pediatric surgery workforce in low- and middle-income countries: problems and priorities, Seminars in Pediatric Surgery. Volume 25, Issue 1, 2016, Pages 32-42, ISSN 1055-8586, https://doi.org/10.1053/j.sempedsurg.2015.09.007.
  4. Dr. Shant Shekherdimian. Personal communication. MIT Solveathon - Eastern Europe +  Middle East & North Africa, September 19, 2020.
  5. Grabski, D., Ameh, E., Ozgediz, D. et al. Optimal Resources for Children's Surgical Care:  Executive Summary. World J Surg. 2019 Apr;43(4):978–980. DOI: https://doi.org/10.1007/s00268-018-04888-7.
  6. Goodman LF, St-Louis E, Yousef Y, Cheung M, Ure B, Ozgediz D, Ameh EA, Bickler S,  Poenaru D, Oldham K, Farmer D, Lakhoo K; GICS Collaborators. The Global Initiative for  Children's Surgery: Optimal Resources for Improving Care. Eur J Pediatr Surg. 2018  Feb;28(1):51-59. DOI: https://doi.org/10.1055/s-0037-1604399.