An alternative ex-vivo live multivisceral training simulator Smagister for animal labs in Undergraduate Surgical Education: Balancing Technical Competence and Ethical Constraints

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However, current simulation modalities (e.g., virtual reality platforms) remain limited in their capacity to replicate the critical haptic feedback and tissue responsiveness characteristic of open surgical procedures. Methods A randomized crossover trial (n=20) was conducted to compare the teaching effects of the intervention group (Smagister ex vivo organ perfusion system) and the control group (live Beagle dogs) in an undergraduate surgical skills course. The primary endpoints were Basic Technical Skills (BTS) and Objective Structured Assessment of Technical Skills (OSATS) scores, while secondary endpoints included ethical distress and teaching experience. Results There was no significant difference in basic skills scores between the two groups (P>0.05). The intervention group had significantly higher OSATS scores in the first phase than the live group (23.1±4.5 vs. 19.5±2.5, P=0.05), and also had certain advantages in preparation time, surgical field, and biosafety. The control group had advantages in team collaboration (recognized by 12/20) and tissue viability assessment (16/20), but there was no difference in ethical distress levels between the two groups ( P=0.7). Conclusions The Smagister system achieves parity with live animal training in educational outcomes while offering superior cost, ethical, and safety profiles, making it an optimal choice for undergraduate surgical education. Trial registration The study was registered with Medical Research Ethics Committee of the Eighth Affiliated Hospital of Sun Yat-sen University (Protocol Number: Sun Yat-sen University Affiliated Eighth Hospital Research Ethics [Animal] 2025-014-01) Ex vivo training Surgical skills education Alternatives to animal use Medical ethics Simulation fidelity Undergraduate medical education Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction The traditional mode of using live animal experiments has long been employed in the teaching of surgical operations. However, the issues such as animal ethical controversies, high costs associated with animal breeding, anesthesia, and operating room construction, as well as biosafety risks, are becoming increasingly disturbing. There is a growing need for alternative approaches [ 1 , 4 ] . For example, in the case of using dogs for teaching purposes, a single session can cost approximately $ 500 (including anesthesia, feeding, and postoperative care), and the ethical approval process for animal experiments can take as long as 3–6 months in some of the Chinese institutes, which severely limiting the efficiency of teaching [ 1 ] . In some countries, the use of live animals for surgical education is even prohibited. To reduce the use of live animals, alternative solutions such as virtual reality (VR) and synthetic models have been widely explored [ 7 ] . However, VR technology fails to replicate key physiological feedbacks in open surgery, such as tissue elasticity and dynamic bleeding. Synthetic models (e.g. silicone organs), is cost-effective, but they are significantly different from real tissues, making it difficult for trainees to master delicate operations (e.g. controlling the tension of intestinal anastomosis) [ 6 ] . The augmented reality liver resection simulator developed by Strickland et al. [ 5 ] still cannot overcome the authenticity deficit, further highlighting the limitations of virtual training in complex surgeries. Taking the above scenarios into consideration, there is an urgent need in the field of surgical techniques trainingfor an alternative that can avoid ethical controversies, reduce costs, and provide realistic tissue feedback. Ex vivo organ models, with their anatomical authenticity, cost-effectiveness, and ethical friendliness, are gradually emerging as a new option for surgical education. These models utilize discarded organs from slaughtered animals (e.g. pigs used for meat) and simulate blood circulation through perfusion techniques (with a flow rate of 5–10 mL/min), enabling the organs to exhibit mechanical properties close to those of living organisms during training (e.g. intestinal peristalsis and vascular pulsation). Research by Wang et al. [ 1 ] has shown that ex vivo porcine liver model platform, the Smagister, is as effective as live animals in laparoscopic surgical training, with a cost reduction of 60%. However, their study was limited to the training of specialist physicians and did not address the basic skill training of undergraduate students. More importantly, the existing literature rarely discusses the role of ex vivo organs in the development of non-technical skills, such as ethical concerns, teamwork, and dynamic physiological judgment. Therefore, there is an urgent need for systematic research to verify the comprehensive value of ex vivo organs in undergraduate surgical education, especially in balancing ethical costs, operational convenience, and the efficacy of surgical skills practice. This study compares the teaching efficacy, ethical issues, and operational advantages and disadvantages of the Smagister ex vivo organ perfusion system and live animals in undergraduate surgical skill training through a randomized controlled trial. The study aims to provide empirical evidence for optimizing undergraduate surgical training programs with Smagister and laying the foundation for future curriculum design. Methods Study Design and Ethics We designed a two-phase crossover randomized controlled trial (RCT) to control the influence of learning curves and individual differences on the outcomes. The participants were fourth-year medical students majoring in clinical medicine at Sun Yat-sen University School of Medicine, GuangZhou, China (n = 20). They were randomly assigned into the intervention group (n = 10) and the control group (n = 10) using a computer-generated random number table. After the same courses of basic skill training on silicone skin models, when the participants entered advanced training courses, the intervention group used the Smagister ex vivo organ system for training in phase 1 and switched to the live animal model in phase 2, while the control group did the opposite. Competency and ethical distress was assessed at baseline and in follow-up assessments. The core advantage of the crossover design is to eliminate the confounding effects of individual baseline skill differences on the intervention outcomes and to reduce the required sample size [ 1 ] . The study protocol was approved by the Medical Research Ethics Committee of the Eighth Affiliated Hospital of Sun Yat-sen University (Protocol Number: Sun Yat-sen University Affiliated Eighth Hospital Research Ethics [Animal] 2025-014-01) and complied with the requirements of the Declaration of Helsinki and the Guidelines for the Ethical Review of Laboratory Animal Welfare in China. All participants signed written informed consent forms, and it was assured that their data would be used solely for academic research. The live animal experiments adhered to the "3R principles" (Replacement, Reduction, and Refinement). Beagle dogs (weight 10–12 kg, age 1–2 years) were procured from the Laboratory Animal Center of Sun Yat-sen University and used after veterinary health screening, and postoperative euthanasia was performed by a licensed veterinarian to minimize suffering. Equipment and Operating Procedures Ex Vivo Organ System The Smagister ex vivo organ training system consists of three parts: Organ Acquisition and Preprocessing: Fresh whole abdominal organs (including stomach, small intestine, colon, liver, pancreas, spleen, and blood vessels) from slaughtered pigs (breed: Landrace) were obtained from a slaughterhouseand and permitted for educational and research purposes. These organs were perfused with heparinized normal saline (containing 0.9% NaCl and 5000 IU/L heparin sodium) at a flow rate of 5 mL/min through the abdominal aorta at 4℃ to remove residual blood. The organs were then preserved at low temperature (4℃) and transported to the laboratory via cold chain. Circulatory Perfusion Device: A mixture of red ink and gelatin (ratio 1:9) was used to simulate blood. A peristaltic pump maintained the microcirculation pressure of the organs at 60–80 mmHg at a flow rate of 5 mL/min, ensuring that the tissue humidity and mechanical properties were close to those of living organisms [ 1 ] . Surgical Operating Table: The table was equipped with an adjustable shadowless lamp, an abdominal retractor, and a standardized surgical instrument pack (including needle holders, tissue forceps, and hemostatic clamps) to simulate a real surgical environment. Live Animal Model The control group used healthy Beagle dogs. Anesthesia was induced with an intravenous injection of sodium pentobarbital at 30 mg/kg, with a maintenance dose of 5 mg/kg/h. The dogs were fixed on the operating table, with real-time monitoring of heart rate (ECG) and oxygen saturation (SpO₂). The surgical procedures included gastrostomy, gastric perforation repair, small intestine resection, and intestinal anastomosis. Postoperatively, euthanasia was performed by a licensed veterinarian with an intravenous injection of potassium chloride solution at a dose of 1 mmol/kg. Standardized Operating Procedures Both groups followed a unified teaching syllabus (Fig. 1 ): 1. Basic skill training courses (Day 1): Training on silicone skin models for suturing, knot-tying, and cutting sutures, with demonstrations and immediate feedback provided by two senior surgeons. 2. Advanced operating training courses: Including phase 1(Day 3) and phase 2(Day 6). In phase 1, the intervention group utilized Smatristers for animal surgical teaching, while the control group employed Beagle dogs. Accomplishment of gastrostomy, gastric perforation repair, small intestine resection, and intestinal anastomosis on Smagister/live models. Participant trainees exchange the roles of chief surgeon and assistant, with each procedure limited to 30 minutes.In phase 2, two groups exchanged the teaching media( Fig. 5 ). Outcome and assessment tools Primary outcome measure was the difference in Objective Structured Assessment of Technical Skills (OSATS) scores and Basic Technical Skills (BTS) scores between groups. 1. The OSATS score, developed by Martin et al. [ 2 ] , includes seven core indicators: (1) Respect for tissue (1–5 points) (2) Time and motion (1–5 points) (3) Instrument handling (1–5 points) (4) Knomledge of instruments (1–5 points) (5) Use of assistants (1–5 points) (6) Flow of operation and forward planning (1–5 points) (7) Knowledge of specific procedure (1–5 points) The total score range from 7 to 35 points. 1. BTS score: Based on suturing speed (uniformity of stitch spacing), suture security (tensile strength test), and accuracy of instrument selection, with a total score of 0-100 points. Every students were scored independently by two expert raters using OSATS and BTS. Secondary outcome measure included ethical distress and teaching efficiency. 1. Ethical Distress Questionnaire: Using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), covering five statements (e.g. "Feeling distressed by the suffering of animals during surgery"), with a total score of 5–25 points. 2. Teaching Efficiency Indicators: At the end of the course, all students completed a survey questionnaire on the advantages and disadvantages of ex vivo organs and live animals in surgical education. The questionnaire included the impact of the two surgical media on surgical skills training in ten aspects: teamwork, tissue vitality judgment, tissue temperature, tissue elasticity, surgical tension, bleeding impact, organ size, biosafety, surgical field, and preparation time. Statistical Analysis The internal consistency reliability of OSATS was calculated using Cronbach’s alpha, and the inter-rater reliability was ensured by calculating Pearson’s r. A mixed model was used to assess the differences between the intervention groups. The type of intervention was considered a fixed effect, and the evaluator was considered a repeated measure to account for the correlation between the scores of the evaluators for each participant. A compound symmetry covariance structure was specified for the within-evaluator variance, assuming that the two evaluators had the same variance and a single covariance measure. Quantitative data that met the normal distribution were expressed as x ± s, and intergroup comparisons were performed using t-tests and one-way ANOVA; a P-value below 0.05 was considered statistically significant. Statistical analysis was performed using SPSS 25.0. Results A total of 20 participants were involved. There were no statistically significant differences between the two groups in terms of age, gender, handedness, and baseline scores of surgical skill assessments( Table 1 ). Table 1 Demographic data of participants. Intervention group Control group Age (mean ± SD) 21.4 ± 0.70 21.3 ± 0.67 Sex ratio (F:M) 6:4 6:4 Handedness (right:left) 9:1 10:0 BTS Score 74.0 ± 8.3 73.3 ± 14.1 Experience in surgery training None None The internal consistency reliability of the OSATS assessment tool was acceptable, with a Cronbach's alpha value of 0.78. The inter-rater reliability was also satisfactory, with a Pearson's r value of 0.76. Figure 2 indicated the differences of basic skill scores,OSATS scores and BTS scores between the interventionand control groups during the two phases of the advanced operating training courses. In phase 1, the intervention group had significantly higher OSATS scores when they practice on Smagister compared to the control group when they practiced on the live animal (23.1 ± 4.5 vs. 19.5 ± 2.5, P = 0.05), with the main advantages being in instrument handling (4.2 ± 0.8 vs. 3.5 ± 0.6) and hemostasis (4.0 ± 0.7 vs. 3.2 ± 0.5). However, the intervention group received lower scores than the control group in BTS scores in phase 2 (81.4 ± 4.6 vs 86.2 ± 4.5, P = 0.029), suggesting that live animals may not necessarily be an advantage in strengthening the practice of basic skills.. Both groups had significantly higher scores in phase 1 of advanced training courses than in the basic skill training courses. The crossover design analysis revealed that the learning effect (Cohen’s d = 0.63) made a significant contribution to the improvement of BTS (P < 0.01). A questionnaire on animal ethical distress was administered to the participating students, after completing phase 1 of the advanced training courses. A total of 20 questionnaires were distributed and all were returned. As shown in Table 3, there was no difference regarding ethical distress between the two groups (Fig. 3 ). Gender, growing environment, and pet ownership experience had no significant influence on the ethical distress scores (p > 0.05), as shown in Table 2 . However, 95% of the students (19/20) believed Smagister system were "more socially ethical" because they avoided the use of live animals and aligned with the concept of resource recycling. Table 2 Univariate Analysis of ethical distress scores by Different Variables Variable Grouping n Mean ± SD F P value Gender Male 12 13.25 ± 4.36 0.12 0.729 Female 8 14.25 ± 4.37 Growing Environment Urban 12 14.08 ± 4.38 0.24 0.787 Suburban 6 12.67 ± 3.50 Rural 2 15.50 ± 4.95 Experience in pet ownership Yes 12 14.58 ± 4.60 0.56 0.461 No 8 12.63 ± 3.70 A questionnaire concerning teaching efficiency was administered after phase 2 of the advanced training courses. A total of 20 questionnaires were distributed and all were returned. As shown in Fig. 4 , the Smagister system stood out in terms of operational convenience and safety, including preparation time, biosafety, and surgical field exposure, as follows, 90% of the students (18/20) believed that Smagister required shorter preparation time (10 minutes vs. 1 hour), which is conducive to improving practice efficiency. 80% of the students (16/20) believed that Smagister provided lower risk of blood contact and reduced burden of operational harm. 80% of the students (16/20) found that the Smagister surgical field was more stable and convenient. In contrast, live animals had advantages in dynamic situation simulation, including teamwork and tissue viability judgement, as follows, 60% of the students (12/20) believed that live animal experiments required more teamwork (anesthesia, life monitoring), which better simulate the real clinical scnarios. . 80% of the students (16/20) more acknowledged the authenticity of the temperature, elasticity, and bleeding response of live tissues. Regarding the influence of intraoperative bleeding and the psychological tension brought about by surgical operations, the students' opinions were inconsistent. Discussion Surgery techniques training on animals holds irreplaceable value in modern surgery education systems. It effectively cultivates medical students' surgical skills and decision-making abilities by providing realistic tissue feedback and clinical scenario simulation. In Chinese medical schools, dogs are widely used for undergraduate surgical education. According to the questionnaire results, all students believe that live animal surgery course for basic surgical operations is indispensable or irreplaceable by simulators, and 90% of students think that the current animal surgery teaching time should be increased. However, traditional animal experiments face challenges in accessibility, ethical restrictions, and operational repeatability, with the strengthening of ethical standards and the promotion of the 3R principles (replacement, reduction, and refinement) [ 4 , 2 ] . Ex vivo organs, with their highly realistic anatomical structures, cost-effectiveness, and ethical acceptability [ 2 ] , are gradually becoming a necessary supplement to live animal experiments. Our study evaluated the surgical skills, as well as the psychological factors of students when they were trained on Smagister or live animals. BTS improved in both groups without significant differences. This indicates that the Smagister ex vivo organ training system can achieve similar teaching effect regarding basic skills to live animals, which consistent with the findings of Izawa et al. [ 1 ] . OSATS scores, representing the quality of the overall surgical process, were 3.6 score higher (close to significance) in intervention group after phase 1 of advanced training course, which indicated the advantages of Smagister for beginners..Conceivable reasons might be that the Smagister system allows the trainees to reduce the nervousness on the management of bleeding, thereby enabling them to effectively concentrate on fundamental procedural steps. The broader surgical field and larger organs, while maintaining realistic tissue feedback with tissue humidity and mechanical properties under non-life-support conditions, making Smagister more beneficial for beginners than live animals [ 2 , 9 ] . Gromski et al. recommend that beginners should complete at least nine ex vivo surgical procedures before stepping into live animal or supervised human colorectal ESD training [ 10 ] . OSATS also includes assessments of clinical judgement and collaborative skills. [ 2 , 2 ] . Our results demonstrate the advantages of Smagister in training comprehensive abilities. However, our study reveals that the advantages of Smagister are significantly context-dependent. Incomplex operations requiring dynamic teamwork (e.g. anesthesia coordination, vital sign monitoring) and physiological judgment (e.g. bleeding assessment), live animals remain irreplaceable. In phase 2 of advanced training courses, the control group demonstrated significantly higher BTS scores compared to the intervention group (86.2 ± 4.5 vs. 81.4 ± 4.6, P = 0.029). We conducted a survey on ethical cognition and guilt of students concerning animal experiments after the course. The results showed no statistically significant differences between the groups in all indicators. Univariate analysis of variance revealed no significant differences in guilt scores among students with different genders, upbringing environments, or pet-keeping experiences (P > 0.05). In terms of ethical cognition of animal experiments, both groups scored highly (intervention group 16 ± 1.8 vs. control group 15.7 ± 2.5, P = 0.7 ), indicating that students have a good understanding and recognition of the ethical principles of animal experiments, regardless of the teaching method used. This may be related to the widespread strengthening of ethics courses in modern medical education [ 1 ] . Regarding guilt experience, both groups scored moderately (intervention group 13.8 ± 4.9 vs. control group 14.5 ± 3.8, P = 0.7), with no significant differences. This finding is particularly noteworthy, as it suggests that even with the adoption of the supposedly more "humane" teaching method, students' guilt towards animal experiments did not significantly decrease. One plausible interpretation is that students' ethical discomfort may reflect broader concerns about animal welfare rather than being tied to particular intervention procedures [ 2 , 12 ] . Current simulation technologies may lack sufficient realism to meaningfully address trainees' ethical discomfort. Smagister system demonstrated clear advantages in terms of operational convenience and biosafety without contacting the live animals, especially when the beginners are not proficient in surgical operations. Moreover, due to its standardized organ samples, it can achieve a more homogeneous training effect. Smagister system also provided a certain degree of surgical stress simulation, and the two groups of the student's opinions are not significantly different. However, our survey suggested that from the undergraduate students’ perspectives, live animal experiments remain indispensable despite all the advantages of Smagister, including team work, and items requiring indentification of dynamic physiological responses, such as tissue viability and tissue elasticity assessment, which is crucial for developing trainees' clinical judgment skills [ 3 ] . For the critical stage of skill shaping for undergraduate students, unlike previous studies focusing on specialized surgeons [ 2 , 2 , 9 ] , Smagister has its unique adaptability. The operating environment is more stable (no bleeding interference), and the surgical field exposure is more adequate. We can prioritize the use of Smagister in elementary courses, and put the limited live animal resources on advanced teaching, thereby achieving a low-cost, high-efficiency teaching effect.The study has some limitations. Sample size is small and it is a single-center study. Multi-center, large-sample studies, especially students with different cultural backgrounds, are needed. The study assessed immediate skill performance and has not been able to track the skill retention rate of trainees during their clinical internships. Conclusions Our findings establish the idea that Smagister ex vivo platform is educationally non-inferior to live animal models. Smagister exhibited advantages in economic feasibility, ethical acceptability, and biosafety compliance. This evidence supports its adoption as a promising training platform in undergraduate surgical curricula. Smagister might achieve more complex training objectives if incorporated with advanced simulation systems. Declarations Acknowledgements We thank all participants who took part in the study for their time and willingness to engage with the study. Authors’ contributions (I）Concept and design: ZQ L, KC;（II）Acquisition, analysis, or interpretation of data: ZQ L, FS L, BJ, ZS X;（III）Drafting of the manuscript: ZQ L, MY X;（IV）Critical revision of the manuscript for important intellectual content: QY F, FL;（V）Statistical analysis: QT, MY X;（VI）Obtained funding: KC;（VII）Supervision: FL, KC. Funding This work was supported by the Guangdong province New Medical Education Steering Committee's Teaching Reform Initiative (2023) and Teaching Quality Project of the Eighth Affiliated Hospital of Sun Yat-sen University（No：BKXM0035） Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate Ethical approval for this study was obtained from the Medical Research Ethics Committee of the Eighth Affiliated Hospital of Sun Yat-sen University. 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Supplementary Files SurveyQuestionnaire.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 03 Jan, 2026 Reviewers agreed at journal 28 Dec, 2025 Reviewers invited by journal 06 Nov, 2025 Editor assigned by journal 09 Sep, 2025 Submission checks completed at journal 08 Sep, 2025 First submitted to journal 08 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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07:29:51","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101408,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7370321/v1/2cc21cc31b2413f57e41bff1.html"},{"id":96159100,"identity":"e65f0679-6221-4d4b-abf7-008894c4ce9d","added_by":"auto","created_at":"2025-11-18 08:40:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":68310,"visible":true,"origin":"","legend":"\u003cp\u003eStudy Grouping and Intervention Flowchart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7370321/v1/4defc3ac591e12a10c520a55.png"},{"id":96249880,"identity":"d7d4f804-eea5-4098-afda-1e3c4de4d72c","added_by":"auto","created_at":"2025-11-19 07:36:36","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":64702,"visible":true,"origin":"","legend":"\u003cp\u003eScores of Students at Different Phases\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7370321/v1/d077b4639501413dd578e6cb.jpg"},{"id":96159101,"identity":"ef6f9862-e350-4738-b317-f8a5c7a59b7c","added_by":"auto","created_at":"2025-11-18 08:40:20","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":46479,"visible":true,"origin":"","legend":"\u003cp\u003eSurvey on Animal Ethical Distress\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7370321/v1/771db6287f0c65bb0eaed325.jpg"},{"id":96251869,"identity":"f43296f7-874b-429b-9521-c58871af0d88","added_by":"auto","created_at":"2025-11-19 07:40:09","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":34282,"visible":true,"origin":"","legend":"\u003cp\u003eSurvey on the Advantages and Disadvantages of the Smagister Ex Vivo Organ Training System Compared to Live Animals in Surgical Education\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7370321/v1/853c115cc4cf6f01a2022f73.png"},{"id":96159108,"identity":"fe690a6b-0da3-44aa-9a3b-420d4805d98f","added_by":"auto","created_at":"2025-11-18 08:40:20","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":973002,"visible":true,"origin":"","legend":"\u003cp\u003eComponents and Surgical Scenarios of the Smagister Ex Vivo Organ System: A. Peristaltic Pump and Perfusion Fluid Pathway. B. Gross View of Abdominal Organs. C. Gastrointestinal Anastomosis. D. Small Intestine Anastomosis. E. Gastrostomy Procedure. F. Student Operating Conditions.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7370321/v1/ff5808b1c5ab53a89a2a1c7c.png"},{"id":96257103,"identity":"6e036c6d-bce1-4d62-a77c-bc5718362c63","added_by":"auto","created_at":"2025-11-19 07:51:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2201729,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7370321/v1/dfcebbc4-9973-4753-aad5-8253d517b68b.pdf"},{"id":96159098,"identity":"e6a1b3ca-069d-4d66-a465-fc4e7d1ffde5","added_by":"auto","created_at":"2025-11-18 08:40:20","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18307,"visible":true,"origin":"","legend":"","description":"","filename":"SurveyQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-7370321/v1/81a6baf51a9611e544746441.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"An alternative ex-vivo live multivisceral training simulator Smagister for animal labs in Undergraduate Surgical Education: Balancing Technical Competence and Ethical Constraints","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe traditional mode of using live animal experiments has long been employed in the teaching of surgical operations. However, the issues such as animal ethical controversies, high costs associated with animal breeding, anesthesia, and operating room construction, as well as biosafety risks, are becoming increasingly disturbing. There is a growing need for alternative approaches \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. For example, in the case of using dogs for teaching purposes, a single session can cost approximately \u003cspan\u003e$\u003c/span\u003e500 (including anesthesia, feeding, and postoperative care), and the ethical approval process for animal experiments can take as long as 3\u0026ndash;6 months in some of the Chinese institutes, which severely limiting the efficiency of teaching \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. In some countries, the use of live animals for surgical education is even prohibited. To reduce the use of live animals, alternative solutions such as virtual reality (VR) and synthetic models have been widely explored \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. However, VR technology fails to replicate key physiological feedbacks in open surgery, such as tissue elasticity and dynamic bleeding. Synthetic models (e.g. silicone organs), is cost-effective, but they are significantly different from real tissues, making it difficult for trainees to master delicate operations (e.g. controlling the tension of intestinal anastomosis) \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. The augmented reality liver resection simulator developed by Strickland et al.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e still cannot overcome the authenticity deficit, further highlighting the limitations of virtual training in complex surgeries. Taking the above scenarios into consideration, there is an urgent need in the field of surgical techniques trainingfor an alternative that can avoid ethical controversies, reduce costs, and provide realistic tissue feedback.\u003c/p\u003e\u003cp\u003eEx vivo organ models, with their anatomical authenticity, cost-effectiveness, and ethical friendliness, are gradually emerging as a new option for surgical education. These models utilize discarded organs from slaughtered animals (e.g. pigs used for meat) and simulate blood circulation through perfusion techniques (with a flow rate of 5\u0026ndash;10 mL/min), enabling the organs to exhibit mechanical properties close to those of living organisms during training (e.g. intestinal peristalsis and vascular pulsation). Research by Wang et al.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e has shown that ex vivo porcine liver model platform, the Smagister, is as effective as live animals in laparoscopic surgical training, with a cost reduction of 60%. However, their study was limited to the training of specialist physicians and did not address the basic skill training of undergraduate students. More importantly, the existing literature rarely discusses the role of ex vivo organs in the development of non-technical skills, such as ethical concerns, teamwork, and dynamic physiological judgment. Therefore, there is an urgent need for systematic research to verify the comprehensive value of ex vivo organs in undergraduate surgical education, especially in balancing ethical costs, operational convenience, and the efficacy of surgical skills practice.\u003c/p\u003e\u003cp\u003eThis study compares the teaching efficacy, ethical issues, and operational advantages and disadvantages of the Smagister ex vivo organ perfusion system and live animals in undergraduate surgical skill training through a randomized controlled trial. The study aims to provide empirical evidence for optimizing undergraduate surgical training programs with Smagister and laying the foundation for future curriculum design.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy Design and Ethics\u003c/h2\u003e\n\u003cp\u003eWe designed a two-phase crossover randomized controlled trial (RCT) to control the influence of learning curves and individual differences on the outcomes. The participants were fourth-year medical students majoring in clinical medicine at Sun Yat-sen University School of Medicine, GuangZhou, China (n\u0026thinsp;=\u0026thinsp;20). They were randomly assigned into the intervention group (n\u0026thinsp;=\u0026thinsp;10) and the control group (n\u0026thinsp;=\u0026thinsp;10) using a computer-generated random number table. After the same courses of basic skill training on silicone skin models, when the participants entered advanced training courses, the intervention group used the Smagister ex vivo organ system for training in phase 1 and switched to the live animal model in phase 2, while the control group did the opposite. Competency and ethical distress was assessed at baseline and in follow-up assessments. The core advantage of the crossover design is to eliminate the confounding effects of individual baseline skill differences on the intervention outcomes and to reduce the required sample size\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Medical Research Ethics Committee of the Eighth Affiliated Hospital of Sun Yat-sen University (Protocol Number: Sun Yat-sen University Affiliated Eighth Hospital Research Ethics [Animal] 2025-014-01) and complied with the requirements of the Declaration of Helsinki and the Guidelines for the Ethical Review of Laboratory Animal Welfare in China. All participants signed written informed consent forms, and it was assured that their data would be used solely for academic research. The live animal experiments adhered to the \"3R principles\" (Replacement, Reduction, and Refinement). Beagle dogs (weight 10\u0026ndash;12 kg, age 1\u0026ndash;2 years) were procured from the Laboratory Animal Center of Sun Yat-sen University and used after veterinary health screening, and postoperative euthanasia was performed by a licensed veterinarian to minimize suffering.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eEquipment and Operating Procedures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eEx Vivo Organ System\u003c/h2\u003e\n\u003cp\u003eThe Smagister ex vivo organ training system consists of three parts:\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003e\n\u003cp\u003eOrgan Acquisition and Preprocessing: Fresh whole abdominal organs (including stomach, small intestine, colon, liver, pancreas, spleen, and blood vessels) from slaughtered pigs (breed: Landrace) were obtained from a slaughterhouseand and permitted for educational and research purposes. These organs were perfused with heparinized normal saline (containing 0.9% NaCl and 5000 IU/L heparin sodium) at a flow rate of 5 mL/min through the abdominal aorta at 4℃ to remove residual blood. The organs were then preserved at low temperature (4℃) and transported to the laboratory via cold chain.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eCirculatory Perfusion Device: A mixture of red ink and gelatin (ratio 1:9) was used to simulate blood. A peristaltic pump maintained the microcirculation pressure of the organs at 60\u0026ndash;80 mmHg at a flow rate of 5 mL/min, ensuring that the tissue humidity and mechanical properties were close to those of living organisms\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eSurgical Operating Table: The table was equipped with an adjustable shadowless lamp, an abdominal retractor, and a standardized surgical instrument pack (including needle holders, tissue forceps, and hemostatic clamps) to simulate a real surgical environment.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ol\u003e\n\u003c/div\u003e\n\u003ch3\u003eLive Animal Model\u003c/h3\u003e\n\u003cp\u003eThe control group used healthy Beagle dogs. Anesthesia was induced with an intravenous injection of sodium pentobarbital at 30 mg/kg, with a maintenance dose of 5 mg/kg/h. The dogs were fixed on the operating table, with real-time monitoring of heart rate (ECG) and oxygen saturation (SpO₂). The surgical procedures included gastrostomy, gastric perforation repair, small intestine resection, and intestinal anastomosis. Postoperatively, euthanasia was performed by a licensed veterinarian with an intravenous injection of potassium chloride solution at a dose of 1 mmol/kg.\u003c/p\u003e\n\u003ch3\u003eStandardized Operating Procedures\u003c/h3\u003e\n\u003cp\u003eBoth groups followed a unified teaching syllabus (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e):\u003c/p\u003e\n\u003cp\u003e1. Basic skill training courses (Day 1): Training on silicone skin models for suturing, knot-tying, and cutting sutures, with demonstrations and immediate feedback provided by two senior surgeons.\u003c/p\u003e\n\u003cp\u003e2. Advanced operating training courses: Including phase 1(Day 3) and phase 2(Day 6).\u003c/p\u003e\n\u003cp\u003eIn phase 1, the intervention group utilized Smatristers for animal surgical teaching, while the control group employed Beagle dogs. Accomplishment of gastrostomy, gastric perforation repair, small intestine resection, and intestinal anastomosis on Smagister/live models. Participant trainees exchange the roles of chief surgeon and assistant, with each procedure limited to 30 minutes.In phase 2, two groups exchanged the teaching media( Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eOutcome and assessment tools\u003c/h2\u003e\n\u003cp\u003ePrimary outcome measure was the difference in Objective Structured Assessment of Technical Skills (OSATS) scores and Basic Technical Skills (BTS) scores between groups.\u003c/p\u003e\n\u003cp\u003e1. The OSATS score, developed by Martin et al.\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e, includes seven core indicators:\u003c/p\u003e\n\u003cp\u003e(1) Respect for tissue (1\u0026ndash;5 points)\u003c/p\u003e\n\u003cp\u003e(2) Time and motion (1\u0026ndash;5 points)\u003c/p\u003e\n\u003cp\u003e(3) Instrument handling (1\u0026ndash;5 points)\u003c/p\u003e\n\u003cp\u003e(4) Knomledge of instruments (1\u0026ndash;5 points)\u003c/p\u003e\n\u003cp\u003e(5) Use of assistants (1\u0026ndash;5 points)\u003c/p\u003e\n\u003cp\u003e(6) Flow of operation and forward planning (1\u0026ndash;5 points)\u003c/p\u003e\n\u003cp\u003e(7) Knowledge of specific procedure (1\u0026ndash;5 points)\u003c/p\u003e\n\u003cp\u003eThe total score range from 7 to 35 points.\u003c/p\u003e\n\u003cp\u003e1. BTS score: Based on suturing speed (uniformity of stitch spacing), suture security (tensile strength test), and accuracy of instrument selection, with a total score of 0-100 points.\u003c/p\u003e\n\u003cp\u003eEvery students were scored independently by two expert raters using OSATS and BTS.\u003c/p\u003e\n\u003cp\u003eSecondary outcome measure included ethical distress and teaching efficiency.\u003c/p\u003e\n\u003cp\u003e1. Ethical Distress Questionnaire: Using a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree, 5\u0026thinsp;=\u0026thinsp;strongly agree), covering five statements (e.g. \"Feeling distressed by the suffering of animals during surgery\"), with a total score of 5\u0026ndash;25 points.\u003c/p\u003e\n\u003cp\u003e2. Teaching Efficiency Indicators: At the end of the course, all students completed a survey questionnaire on the advantages and disadvantages of ex vivo organs and live animals in surgical education. The questionnaire included the impact of the two surgical media on surgical skills training in ten aspects: teamwork, tissue vitality judgment, tissue temperature, tissue elasticity, surgical tension, bleeding impact, organ size, biosafety, surgical field, and preparation time.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n\u003cp\u003eThe internal consistency reliability of OSATS was calculated using Cronbach\u0026rsquo;s alpha, and the inter-rater reliability was ensured by calculating Pearson\u0026rsquo;s r. A mixed model was used to assess the differences between the intervention groups. The type of intervention was considered a fixed effect, and the evaluator was considered a repeated measure to account for the correlation between the scores of the evaluators for each participant. A compound symmetry covariance structure was specified for the within-evaluator variance, assuming that the two evaluators had the same variance and a single covariance measure. Quantitative data that met the normal distribution were expressed as x\u0026thinsp;\u0026plusmn;\u0026thinsp;s, and intergroup comparisons were performed using t-tests and one-way ANOVA; a P-value below 0.05 was considered statistically significant. Statistical analysis was performed using SPSS 25.0.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 20 participants were involved. There were no statistically significant differences between the two groups in terms of age, gender, handedness, and baseline scores of surgical skill assessments( Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic data of participants.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex ratio (F:M)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6:4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6:4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHandedness (right:left)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9:1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10:0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBTS Score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73.3\u0026thinsp;\u0026plusmn;\u0026thinsp;14.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExperience in surgery training\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe internal consistency reliability of the OSATS assessment tool was acceptable, with a Cronbach's alpha value of 0.78. The inter-rater reliability was also satisfactory, with a Pearson's r value of 0.76. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e indicated the differences of basic skill scores,OSATS scores and BTS scores between the interventionand control groups during the two phases of the advanced operating training courses. In phase 1, the intervention group had significantly higher OSATS scores when they practice on Smagister compared to the control group when they practiced on the live animal (23.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 vs. 19.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5, P\u0026thinsp;=\u0026thinsp;0.05), with the main advantages being in instrument handling (4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 vs. 3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6) and hemostasis (4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 vs. 3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5). However, the intervention group received lower scores than the control group in BTS scores in phase 2 (81.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 vs 86.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5, P\u0026thinsp;=\u0026thinsp;0.029), suggesting that live animals may not necessarily be an advantage in strengthening the practice of basic skills.. Both groups had significantly higher scores in phase 1 of advanced training courses than in the basic skill training courses. The crossover design analysis revealed that the learning effect (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.63) made a significant contribution to the improvement of BTS (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eA questionnaire on animal ethical distress was administered to the participating students, after completing phase 1 of the advanced training courses. A total of 20 questionnaires were distributed and all were returned. As shown in Table\u0026nbsp;3, there was no difference regarding ethical distress between the two groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Gender, growing environment, and pet ownership experience had no significant influence on the ethical distress scores (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. However, 95% of the students (19/20) believed Smagister system were \"more socially ethical\" because they avoided the use of live animals and aligned with the concept of resource recycling.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUnivariate Analysis of ethical distress scores by Different Variables\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrouping\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e13.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.729\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e14.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eGrowing Environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e14.08\u0026thinsp;\u0026plusmn;\u0026thinsp;4.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.787\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSuburban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e12.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e15.50\u0026thinsp;\u0026plusmn;\u0026thinsp;4.95\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eExperience in pet ownership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e14.58\u0026thinsp;\u0026plusmn;\u0026thinsp;4.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.461\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e12.63\u0026thinsp;\u0026plusmn;\u0026thinsp;3.70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA questionnaire concerning teaching efficiency was administered after phase 2 of the advanced training courses. A total of 20 questionnaires were distributed and all were returned. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the Smagister system stood out in terms of operational convenience and safety, including preparation time, biosafety, and surgical field exposure, as follows,\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e90% of the students (18/20) believed that Smagister required shorter preparation time (10 minutes vs. 1 hour), which is conducive to improving practice efficiency.\u003c/p\u003e\u003cp\u003e80% of the students (16/20) believed that Smagister provided lower risk of blood contact and reduced burden of operational harm.\u003c/p\u003e\u003cp\u003e80% of the students (16/20) found that the Smagister surgical field was more stable and convenient.\u003c/p\u003e\u003cp\u003eIn contrast, live animals had advantages in dynamic situation simulation, including teamwork and tissue viability judgement, as follows,\u003c/p\u003e\u003cp\u003e60% of the students (12/20) believed that live animal experiments required more teamwork (anesthesia, life monitoring), which better simulate the real clinical scnarios. .\u003c/p\u003e\u003cp\u003e80% of the students (16/20) more acknowledged the authenticity of the temperature, elasticity, and bleeding response of live tissues.\u003c/p\u003e\u003cp\u003eRegarding the influence of intraoperative bleeding and the psychological tension brought about by surgical operations, the students' opinions were inconsistent.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSurgery techniques training on animals holds irreplaceable value in modern surgery education systems. It effectively cultivates medical students' surgical skills and decision-making abilities by providing realistic tissue feedback and clinical scenario simulation. In Chinese medical schools, dogs are widely used for undergraduate surgical education. According to the questionnaire results, all students believe that live animal surgery course for basic surgical operations is indispensable or irreplaceable by simulators, and 90% of students think that the current animal surgery teaching time should be increased. However, traditional animal experiments face challenges in accessibility, ethical restrictions, and operational repeatability, with the strengthening of ethical standards and the promotion of the 3R principles (replacement, reduction, and refinement)\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Ex vivo organs, with their highly realistic anatomical structures, cost-effectiveness, and ethical acceptability\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e, are gradually becoming a necessary supplement to live animal experiments.\u003c/p\u003e\u003cp\u003eOur study evaluated the surgical skills, as well as the psychological factors of students when they were trained on Smagister or live animals. BTS improved in both groups without significant differences. This indicates that the Smagister ex vivo organ training system can achieve similar teaching effect regarding basic skills to live animals, which consistent with the findings of Izawa et al.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. OSATS scores, representing the quality of the overall surgical process, were 3.6 score higher (close to significance) in intervention group after phase 1 of advanced training course, which indicated the advantages of Smagister for beginners..Conceivable reasons might be that the Smagister system allows the trainees to reduce the nervousness on the management of bleeding, thereby enabling them to effectively concentrate on fundamental procedural steps. The broader surgical field and larger organs, while maintaining realistic tissue feedback with tissue humidity and mechanical properties under non-life-support conditions, making Smagister more beneficial for beginners than live animals\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Gromski et al. recommend that beginners should complete at least nine ex vivo surgical procedures before stepping into live animal or supervised human colorectal ESD training\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. OSATS also includes assessments of clinical judgement and collaborative skills.\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Our results demonstrate the advantages of Smagister in training comprehensive abilities.\u003c/p\u003e\u003cp\u003eHowever, our study reveals that the advantages of Smagister are significantly context-dependent. Incomplex operations requiring dynamic teamwork (e.g. anesthesia coordination, vital sign monitoring) and physiological judgment (e.g. bleeding assessment), live animals remain irreplaceable. In phase 2 of advanced training courses, the control group demonstrated significantly higher BTS scores compared to the intervention group (86.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 vs. 81.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6, P\u0026thinsp;=\u0026thinsp;0.029).\u003c/p\u003e\u003cp\u003eWe conducted a survey on ethical cognition and guilt of students concerning animal experiments after the course. The results showed no statistically significant differences between the groups in all indicators. Univariate analysis of variance revealed no significant differences in guilt scores among students with different genders, upbringing environments, or pet-keeping experiences (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In terms of ethical cognition of animal experiments, both groups scored highly (intervention group 16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 vs. control group 15.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5, P\u0026thinsp;=\u0026thinsp;0.7 ), indicating that students have a good understanding and recognition of the ethical principles of animal experiments, regardless of the teaching method used. This may be related to the widespread strengthening of ethics courses in modern medical education\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Regarding guilt experience, both groups scored moderately (intervention group 13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 vs. control group 14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8, P\u0026thinsp;=\u0026thinsp;0.7), with no significant differences. This finding is particularly noteworthy, as it suggests that even with the adoption of the supposedly more \"humane\" teaching method, students' guilt towards animal experiments did not significantly decrease. One plausible interpretation is that students' ethical discomfort may reflect broader concerns about animal welfare rather than being tied to particular intervention procedures\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Current simulation technologies may lack sufficient realism to meaningfully address trainees' ethical discomfort.\u003c/p\u003e\u003cp\u003eSmagister system demonstrated clear advantages in terms of operational convenience and biosafety without contacting the live animals, especially when the beginners are not proficient in surgical operations. Moreover, due to its standardized organ samples, it can achieve a more homogeneous training effect. Smagister system also provided a certain degree of surgical stress simulation, and the two groups of the student's opinions are not significantly different. However, our survey suggested that from the undergraduate students\u0026rsquo; perspectives, live animal experiments remain indispensable despite all the advantages of Smagister, including team work, and items requiring indentification of dynamic physiological responses, such as tissue viability and tissue elasticity assessment, which is crucial for developing trainees' clinical judgment skills \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFor the critical stage of skill shaping for undergraduate students, unlike previous studies focusing on specialized surgeons\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, Smagister has its unique adaptability. The operating environment is more stable (no bleeding interference), and the surgical field exposure is more adequate. We can prioritize the use of Smagister in elementary courses, and put the limited live animal resources on advanced teaching, thereby achieving a low-cost, high-efficiency teaching effect.The study has some limitations. Sample size is small and it is a single-center study. Multi-center, large-sample studies, especially students with different cultural backgrounds, are needed. The study assessed immediate skill performance and has not been able to track the skill retention rate of trainees during their clinical internships.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings establish the idea that Smagister ex vivo platform is educationally non-inferior to live animal models. Smagister exhibited advantages in economic feasibility, ethical acceptability, and biosafety compliance. This evidence supports its adoption as a promising training platform in undergraduate surgical curricula. Smagister might achieve more complex training objectives if incorporated with advanced simulation systems.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all participants who took part in the study for their time and willingness to engage with the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(I）Concept and design: \u003cstrong\u003eZQ L,\u0026nbsp;\u003c/strong\u003eKC;（II）Acquisition, analysis, or interpretation of data: \u003cstrong\u003eZQ L,\u0026nbsp;\u003c/strong\u003eFS L, BJ, ZS X;（III）Drafting of the manuscript: \u003cstrong\u003eZQ L,\u0026nbsp;\u003c/strong\u003eMY X;（IV）Critical revision of the manuscript for important intellectual content:\u0026nbsp;QY F, FL;（V）Statistical analysis:\u0026nbsp;QT, MY X;（VI）Obtained funding:\u0026nbsp;KC;（VII）Supervision:\u0026nbsp;FL, KC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Guangdong province New Medical Education Steering Committee\u0026apos;s Teaching Reform Initiative (2023) and Teaching Quality Project of the Eighth Affiliated Hospital of Sun Yat-sen University（No：BKXM0035）\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Medical Research Ethics Committee of the Eighth Affiliated Hospital of Sun Yat-sen University. Each participant pro-vided written consent before entering the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIzawa Y, Hishikawa S, Muronoi T, Yamashita K, Maruyama H, Suzukawa M, et al. Ex-vivo and live animal models are equally effective training for the management of a penetrating cardiac injury[J]. 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Surgery. 2014;156(3):676\u0026ndash;88. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.surg.2014.04.044\u003c/span\u003e\u003cspan address=\"10.1016/j.surg.2014.04.044\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ex vivo training, Surgical skills education, Alternatives to animal use, Medical ethics, Simulation fidelity, Undergraduate medical education","lastPublishedDoi":"10.21203/rs.3.rs-7370321/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7370321/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eTraditional live animal surgical training requires urgent alternatives due to mounting ethical concerns and substantial cost burdens. However, current simulation modalities (e.g., virtual reality platforms) remain limited in their capacity to replicate the critical haptic feedback and tissue responsiveness characteristic of open surgical procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eA randomized crossover trial (n=20) was conducted to compare the teaching effects of the intervention group (Smagister ex vivo organ perfusion system) and the control group (live Beagle dogs) in an undergraduate surgical skills course. The primary endpoints were Basic Technical Skills (BTS) and Objective Structured Assessment of Technical Skills (OSATS) scores, while secondary endpoints included ethical distress and teaching experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eThere was no significant difference in basic skills scores between the two groups (P\u0026gt;0.05). The intervention group had significantly higher OSATS scores in the first phase than the live group (23.1±4.5 vs. 19.5±2.5, P=0.05), and also had certain advantages in preparation time, surgical field, and biosafety. The control group had advantages in team collaboration (recognized by 12/20) and tissue viability assessment (16/20), but there was no difference in ethical distress levels between the two groups ( P=0.7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions \u003c/strong\u003eThe Smagister system achieves parity with live animal training in educational outcomes while offering superior cost, ethical, and safety profiles, making it an optimal choice for undergraduate surgical education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e The study was registered with Medical Research Ethics Committee of the Eighth Affiliated Hospital of Sun Yat-sen University (Protocol Number: Sun Yat-sen University Affiliated Eighth Hospital Research Ethics [Animal] 2025-014-01)\u003c/p\u003e","manuscriptTitle":"An alternative ex-vivo live multivisceral training simulator Smagister for animal labs in Undergraduate Surgical Education: Balancing Technical Competence and Ethical Constraints","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-18 08:40:15","doi":"10.21203/rs.3.rs-7370321/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-04T00:11:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16012397407451896716370478012660327312","date":"2025-12-28T05:46:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-06T05:26:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-09T04:41:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-09T03:50:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-09-08T15:32:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9f04feaa-8372-4ed1-adc9-663845a41ec9","owner":[],"postedDate":"November 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-18T08:40:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-18 08:40:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7370321","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7370321","identity":"rs-7370321","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}