Abstract
Varicose vein surgery has traditionally been an excellent training operation allowing the surgical trainee the opportunity to perfect operative skills; in particular dissection and exposure of a vessel, together with accurate knot-tying, learned through repetition of tying first and second-order tributaries. 1,2
Unfortunately for the junior surgical trainee (but probably of great benefit to the patient), open varicose vein surgery is becoming increasingly less commonplace, being replaced with more minimally invasive procedures. A recent survey of vascular trainees has highlighted their lack of exposure to open venous procedures. 3 This is an area where the use of training models may be of benefit. 4
As the majority of minimally invasive procedures are performed under local anaesthetic, training a novice can be fraught for not only the patient but also the trainee, and many trainers report poor attendance by trainees at their lists perhaps for this reason. We would argue that these operations offer new training opportunities for the 21st-century vascular surgeon. Endoluminal surgery requires an understanding of vascular ultrasound as well as a modicum of wire skill, the latter of which is invaluable for the vascular surgeon who will be practicing endovascular arterial surgery, whether this be lower limb arterial or aortic and carotid intervention. 5
Many of the skills described below can be taught more easily with the patient under
general anaesthesia but this negates some of the medical and cost-related benefits of
performing the procedure under local anaesthesia especially in those patients who are of
higher than average surgical risk.
6,7
This is again an area where training models may be of use and these could cover
the three main aspects of endoluminal venous surgery:
Cannulation: Numerous ‘phantoms’ exist for
learning cannulation skills and probably the most difficult concept to grasp is
the relationship between the two-dimensional image seen on the screen and the
three-dimensional procedure being performed. However, even a novice can be
trained to cannulate the phantoms available and it would not be difficult to
alter the complexity of the model by including a smaller vessel at greater
depth;
Tumescent local anaesthesia: This is probably the
most crucial part of the procedure to master when performing on an awake
patient. Accurate infiltration in the perivenous sheath can limit the amount of
skin punctures required to provide adequate tumescence. While there are some
models available, none simulate this satisfactorily;
Catheter tip positioning: Although models exist
to simulate this step of the operation, they do not take into account natural
human variation in anatomy and morphology of the patient.
The vascular surgical trainee is evolving, learning new skills. Venous
intervention provides a useful training opportunity and provides essential groundwork
needed for the vascular surgeons of the future. However, as well as the skills required
for superficial venous intervention techniques, the vascular surgeon (specialist) of
tomorrow needs to embrace the increasing knowledge base in phlebology to be able to
offer patients the optimal managements.