Evaluation of training models for intraventricular neuroendoscopy

Evaluation of training models for intraventricular neuroendoscopy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of training models for intraventricular neuroendoscopy Sebastian Senger, Magomed Lepshokov, Thomas Tschernig, Guiseppe Cinalli, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4809603/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Nov, 2024 Read the published version in Neurosurgical Review → Version 1 posted 14 You are reading this latest preprint version Abstract Introduction: Structured surgical education has become increasingly important in recent years. Intraventricular neuroendoscopic procedures have been widely established. However, training surgical skills with these techniques is crucial for young residents due to the potential harm to adjacent tissue. Therefore, we evaluated two different training models. Methods: Participants in two different international workshops were trained on a prefixed cadaver model and on a living murine intraabdominal model. Crucial neuroendoscopic techniques such as membrane perforation and tissue biopsy were performed. A blinded questionnaire evaluated both models. Results: Sixty-three participants were trained on the animal model. Forty of these were trained on the cadaver model. The training effect was evaluated almost equally, with 8.5/10 for the animal model and 8.9/10 for the cadaver model. The tissue properties were rated higher regarding realism in the animal model, whereas the anatomic realism was rated higher in the cadaver model. Conclusion: The animal model is a valid alternative to cadaver models for teaching endoscopic neurosurgical skills. This model benefits from the simulation of real surgical tissue properties, including bleeding. The low costs and availability of this technique make it more ubiquitous and can help train further generations of neurosurgeons. neuroendoscopy surgical education murine model cadaver model endoscopy Figures Figure 1 Figure 2 Figure 3 Introduction The first neuroendoscopic procedures were performed more than 100 years ago but soon stopped due to technical and medical limitations [ 6 ]. Neuroendoscopy was revolutionized after the collaboration of Harold Hopkins and Karl Storz in the 1970s [ 20 ]. Endoscopic techniques were restricted to a few specialized centers until the end of the 1980s when well-known neurosurgeons began to take this technique seriously into account [ 9 ]. Endoscopic treatment options include the restoration of the physiological pathway, e.g., with foraminoplasty, or the opening of alternative pathways through fenestrations, e.g., ETV, fenestration of the lamina terminalis or septostomy. In the case of mass lesions, the removal of the lesion must be considered [ 4 , 10 , 13 , 14 ] The goal of international societies is to promote these minimally invasive techniques and teach their application in low-income countries, for instance. However, neuroendoscopy differs slightly from other endoscopic procedures in other surgical fields. General surgeons, orthopedics or urologists, for example, have implemented endoscopic procedures in their daily practice, including different levels of difficulty. Arthroscopic or laparoscopic procedures are well established, and physicians start practicing these procedures early during residency. Courses and training models are available in large numbers. Moreover, the indications for an intraventricular neuroendoscopic procedure are rather rare or are only frequently performed in specialized centers, for instance, for pediatric neurosurgery, or in larger departments with a high number of cases per year. Therefore, compared with other young surgeons, residents might not have the chance to see and practice endoscopic procedures. Although intraventricular procedures are mostly straightforward short procedures and can be performed by unexperienced surgeons under the instruction of an experienced neuroendoscopist, some limitations must be mentioned. First, the knowledge and handling of the endoscope and the instruments must be understood. As mentioned, it might be unfamiliar to young neurosurgeons to look at the screen and not through the microscope. Second, the space in the ventricle system might be limited, and maneuvers can be challenging. Third, the structures adjacent to the ventricle system are very eloquent. Accidental injuries to these structures might cause permanent deficits such as short-term memory deficits (due to Fornix lesions), eye muscle palsy (due to oculomotor nerve lesions) or even hemiparesis (due to thalamic lesions). Injuries to vessels such as the thalamostriate vein or even the basilar artery can result in severe bleeding and even death, as previously reported [ 1 , 5 , 12 , 18 ] These injuries can occur not only by false instrument handling but also, for example, by incorrect coagulation and thermal damage. This emphasizes how important the teaching of these techniques is to avoid complications for the patient. The logical alternatives to train neuroendoscopic procedures on patients are models and simulations. The authors have established annual workshops for neuroendoscopy training over the last 15 and 12 years in two neurosurgical departments. These workshops include lectures, live surgeries and practical hands-on sessions. One model is based on a murine model for the simulation of intraventricular procedures. It was introduced by the authors from the very first edition of their workshop more than 15 years ago, who recalled the experience of Professor Jacques Camaert, who first introduced this model to train in neuroendoscopic procedures in his workshops held for almost 15 years in Ghent, Belgium, until the last edition in 2012. To the best of our knowledge, he has never described or reported his model in the literature. Since then, it has been adopted and described in the literature [ 8 , 11 ]. Given the potential risk of an intraventricular procedure, models simulating this environment might not cover all aspects, such as bleeding or tissue properties. With a live animal model, these aspects should be simulated as intended. The use of animal models is under constant debate, and animal protection laws in many countries encourage scientists and physicians to refine, reduce and/or replace animal experiments. Therefore, the aim of the present study was to evaluate this model in comparison to other models on the learning effect of trainees. Materials and Methods Animal model The procedures were performed under approval by the local governmental animal care committee (registration number TVA 11-2023) and were in accordance with the UKCCCR Guidelines for the Welfare of Animals in Experimental Neoplasia (Br J Cancer 1998; 77:1–10) and the Interdisciplinary Principles and Guidelines for the Use of Animals in Research (New York Academy of Sciences Ad Hoc Committee on Animal Research, NY). Sprague–Dawley rats with a minimum weight of 250 grams were obtained from Charles Rivers Laboratories, Sulzfeld, Germany. The animals were housed in cages at a room temperature of 22–24°C and a relative humidity of 60–65% with a 12-h light/dark cycle. The rats were allowed free access to drinking water and standard laboratory chow (Altromin®, Lage, Germany). The animals were anesthetized by initial inhalation of isoflurane. Anesthesia was induced by intraperitoneal injection of 90 mg/kg bodyweight ketamine (Ketavet®, Parke Davis; Freiburg, Germany) and 8 mg/kg bodyweight xylazine (Rompun®, Bayer; Leverkusen, Germany). All animals received 5 mg/kg body weight carprofen (Vetranal™, Sigma‒Aldrich; St. Louis, USA) subcutaneously in addition to pain relief. The animals were fixed in the supine position, and the limbs were fixed with tape. The anesthesia was constantly evaluated, and additional ketamine was applied if necessary. A median skin incision was made to access the peritoneal space. An endoscope was inserted, and the skin was closed with a circular suture. There are two options: the model can be applied under water and constant irrigation with Ringer’s solution or under air conditions. The authors suggest the use of antifogging fluids to avoid forging of the lenses if the second method is used. The surgical steps were demonstrated to the trainees by the tutor on videos or pictures before the surgery. The following surgical steps were performed by the trainee. First, the endoscope is introduced, and an inspection of the abdominal space is performed. Second, the liver lobes are identified, and coagulation at the rim of the liver lobe is performed. Then, the coagulated tissue was removed with biopsy forceps. Possible bleeding from the parenchyma can be stopped with a bipolar probe. After this step, the endoscope can be rotated 180 degrees to expose the bladder. This procedure simulates tumor removal. The attaching ligaments can be cut with scissors, and the bladder can be removed with grasping forceps. Then, the endoscope is turned again and moves up to the upper part of the liver and the diaphragm. As a next step, the ligamentum falciforme is exposed and can be cut. The last step is fenestration of the diaphragm. Here, coagulation is performed, the diaphragm is perforated with blunt perforating forceps, and the stoma is enlarged with balloon catheters. This simulates an ETV. The animal was then euthanized with a lethal dose of pentobarbital as it otherwise died due to collapse of the lung. Cadaver model The endoscopic procedures can also be trained on cadaver models. The Institute of Anatomy and Cell Biology of the Saarland University provides the human cadavers. The education of physicians was performed under approval by the local governmental ethic committee (registration number 245/22). In general, these fresh frozen or prefixed cadavers allow surgical procedures, including borehole trepanation, endoscopic puncture of the ventricle and inspection and perforating steps. The trainees were instructed to perform a ventricle puncture 2.5 cm parasagittal and before the coroner suture by themselves under instructions. Then, the ventricles were inspected with different angled optics. They then perform ETV. As a next step, a more lateral base hole was cut 4–5 cm parasagittally, and a septostomy was performed. Evaluation form A questionnaire, as added to the supplemental section, was distributed to the participants at the end of the workshop. The questionnaire included general questions regarding age, educational level, and experience in neuroendoscopy. The model was subsequently rated concerning the handling, realism and overall learning effect. The trainees were also asked for their desired qualities of an ideal training model for neuroendoscopy. Statistical analysis The questionnaires were transferred to SPSS (IBM, Armonk, USA). The results were analyzed by the chi-square test and likelihood test. A level of statistical significance was assumed at p ≤ 0.05. The data are presented as the mean and standard error of the mean. Results Overall, 63 trainees participated in the workshop events. Twenty-six were residents, and 37 were consultants. Years of practice were categorized as follows: 1–5 years (n = 21); 5–10 years (20); 10–15 years (n = 16); and more than 15 years (n = 6). Twenty-eight participants had not previously undergone ETV. The remaining 35 participants had performed 1.8 ± 0.1 ETVs and were almost exclusively consultants. They frequently use neuronavigation (80%) and balloon catheters (94%). Laser techniques are only applied in 11% of cases. A total of 97% of the participants evaluated the animal model as “very realistic” or “what is realistic” regarding surgical handling, 90% regarding anatomy, 97% regarding tissue properties and 98% in general. The cadaver model was evaluated by 95% of the participants as “very realistic” or “what is realistic” regarding surgical handling, 100% regarding anatomy, 80% regarding tissue properties and 100% in general. These data are summarized in Table 1 . Table 1 summarizes the evaluation of the realism of the murine training model and the cadaver model in terms of “handling”, “anatomy”, “tissue properties” and “overall impression”. Murine Model Handling [n] Murine Model Anatomic realism [n] Murine Model Tissue Properties [n] Murine Model Overall Impression [n] Cadaver Model Handling [n] Cadever Anatomic Realism [n] Cader Tissue Properties [n] Cader Overall Impression [n] very realistic 35 27 36 37 24 29 13 23 kind of realistic 24 29 24 25 14 11 19 17 more unrealistic 0 4 2 1 2 0 6 0 unrealistic 1 1 0 0 0 0 2 0 don’t know 4 2 1 0 0 0 0 0 The learning effect was assessed on an asset scale from low = 1 to high = 10. The animal model was evaluated with a mean score of 8.5 ± 0.2, and the cadaver model had a mean score of 9.0 ± 0.2. Residents and consultants evaluated the models nearly identically (8.4 ± 0.3 vs 8.6 ± 0.3 and 8.9 ± 0.3 vs. 9.0 ± 0.3). There was no statistically significant difference between the groups. The trainees were asked about their confidence in performing an ETV after performing the training model. A total of 74.0% of the participants were confident after the animal model was established, and 87.5% of the participants were confident after the cadaver model was established. After each model, the consultants felt more confident than did the residents (89% vs 58% and 96% vs. 71%, respectively). In addition, the trainees were asked about the requirements of an ideal training model. The participants “strongly agreed” or “agreed” in 100% with realistic simulation of anatomical structures, 98% with realistic simulation of tissue strength, 80% with realistic simulation of pulsation, 78% with realistic simulation of complications, 76% with realistic simulation of bleeding and 71% with a realistic simulation of an OR setting. Table 2 summarizes the expected requirements for an ideal training model by the participants. Same Instruments like in the OR [n] Same Setting like in the OR [n] Realistic Anatomical Structures [n] Realistic Tissue Properties Regarding Resistance [n] Realistic Bleeding Conditions [n] Realistic Pulsation [n] Simulation of Complications [n] strongly agree 49 17 44 41 31 23 24 agree 14 34 19 21 17 23 19 neither nor 0 5 0 1 5 6 6 disagree 0 1 0 0 4 5 6 Discussion This study showed that a low-cost murine model can achieve training effects comparable to those of cadaveric models for neuroendoscopic procedures. More experienced surgeons feel comparable confidence in performing an ETV after bypassing such a model in comparison to a cadaver hands-on session. Young colleagues also rated the model as an adequate learning method. A limitation of the murine model is surely that it cannot help to teach the intra- and paraventricular anatomy of the human brain. Simulating the anatomy was one of the most important requirements for an ideal model in our poll. Other training models may overcome this problem, as cadaver models are not ubiquitously available all over the world or are restricted by shortages or low prices. 3D-printed models are helpful for teaching anatomy and might help to encourage medical students to choose neurosurgery at all; however, training manual skills effectively is doubtable [ 7 , 17 ]. Various computer simulations have been developed and have shown fair results concerning anatomical learning effects. Nonetheless, as this technology was promoted more than 15 years ago, it is still not routinely implemented [ 2 ]. A major drawback of virtual reality is the inadequate simulation of force sensing and tissue properties. The importance of this simulation aspect has also been shown in our evaluation. Emerging technologies might overcome this problem in the near future toward establishing low-cost, high-performance MIS force sensors, such as promising piezoelectric sensors. Recent rapid advances in computer vision and machine learning have drawn increasing attention to imaging-based tactile sensing, also known as vision-based sensing [ 16 ]. Augmented or virtual reality will continue to result in rapid advancements in operative planning, intraoperative navigation, and neurosurgical training [ 19 ]. Interestingly, complication simulation was only important for 76% of all trainees. In our opinion, this aspect is common in neuroendoscopic intraventricular procedures, as complications are major risks for patients [ 1 , 12 ]. In particular, hemorrhages might be challenging to handle and need immediate proper measures [ 15 ]. Models could be improved by testing the effects on the manual skills and knowledge of the participants. However, standardized evaluation methods are lacking and should be developed by surgical societies regardless of the proper model type [ 3 ]. To evaluate the current status of neurosurgical models with other surgical fields, we performed a PubMed search for the “Laparoscopic training model”, “Arthroscopic training model” and “neuroendoscopic training model”. This simple keyword search revealed 21537 papers concerning laparoscopic training models, 5656 papers concerning arthroscopic training models and only 194 papers concerning neuroendoscopic training models. These results emphasize how underrepresented this topic is in the neurosurgical community and should be further supported to ensure proper education of future generations of neuroendoscopists. Abbreviations CSF cerebral spine fluid ETV endoscopic third ventriculostomy Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing interests The authors do not have any financial or non-financial interests that are directly or indirectly related to the work submitted. Author Contributions Author contributions to the study and manuscript preparation include the following. Conception and design: Sebastian Senger, Thomas Tschernig, Joachim Oertel, Guiseppe Cinalli Acquisition of data: Sebastian Senger, Magomed Lepshokov Analysis and interpretation of data: Sebastian Senger, Thomas, Tschernig, Joachim Oertel, Guiseppe Cinalli Drafting the article: Sebastian Senger Critically revising the article: Joachim Oertel, Guiseppe Cinalli Reviewed the final version of the manuscript and approved it for submission: Sebastian Senger, Joachim Oertel, Guiseppe Cinalli Study supervision: Joachim Oertel, Guiseppe Cinalli Ethics approval All animal experiments were performed under approval by the local governmental animal care committee (registration number TVA 11-2023). The education of physicians on cadavers were performed under approval by the local governmental ethic committee (registration number 245/22). References Abtin K, Thompson BG, Walker ML (1998) Basilar artery perforation as a complication of endoscopic third ventriculostomy. Pediatr Neurosurg 28:35–41 Alaraj A, Lemole MG, Finkle JH, Yudkowsky R, Wallace A, Luciano C et al (2011) Virtual reality training in neurosurgery: Review of current status and future applications. Surg Neurol Int 2:52 Chawla S, Devi S, Calvachi P, Gormley WB, Rueda-Esteban R (2022) Evaluation of simulation models in neurosurgical training according to face, content, and construct validity: a systematic review. Acta Neurochir 164(4):947–966. 10.1007/s00701-021-05003-x Epub 2022 Feb 4. PMID: 35122126; PMCID: PMC8815386 Cinalli G, Spennato P, Savarese L, Ruggiero C, Aliberti F, Cuomo L, Cianciulli E, Maggi G (2006) Endoscopic aqueductoplasty and placement of a stent in the cerebral aqueduct in the management of isolated fourth ventricle in children. J Neurosurg 104(1):21–27 Cinalli G, Spennato P, Ruggiero C, Aliberti F, Trischitta V, Buonocore MC, Cianciulli E, Maggi G (2007) Complications following endoscopic intracranial procedures in children. Childs Nerv Syst 23(6):633–644 Decq P, Schroeder HW, Fritsch M, Cappabianca P (2013) A history of ventricular neuroendoscopy. World Neurosurg 79(2 Suppl):S14e1–S14e6 Efe IE, Çinkaya E, Kuhrt LD, Bruesseler MMT, Mührer-Osmanagic A (2023) Neurosurgical Education Using Cadaver-Free Brain Models and Augmented Reality: First Experiences from a Hands-On Simulation Course for Medical Students. Medicina (Kaunas). Oct 9;59(10):1791. 10.3390/medicina59101791 . PMID: 37893509; PMCID: PMC10608257 Fernandez-Miranda JC, Barges-Coll J, Prevedello DM, Engh J, Snyderman C, Carrau R, Gardner PA, Kassam AB (2010) Animal model for endoscopic neurosurgical training:technical note. Minim Invasive Neurosurg. Oct;53(5–6):286-9. 10.1055/s-0030-1269927 . Epub 2011 Feb 7. PMID: 21302201 Grunert P, Gaab MR, Hellwig D, Oertel JM (2009) German neuroendoscopy above the skull base. Neurosurg Focus 27(3):E7 Hellwig D, Grotenhuis JA, Tirakotai W, Riegel T, Schulte DM, Bauer BL, Bertalanffy H (2005) Endoscopic third ventriculostomy for obstructive hydrocephalus. Neurosurg Rev 28(1):1–38 Jaimovich SG, Bailez M, Asprea M, Jaimovich R (2016) Neurosurgical training with simulators: a novel neuroendoscopy model. Child’s Nerv Syst 32(2):345–349 McLaughlin MR, Wahlig JB, Kaufman AM, Albright AL (1997) Traumatic basilar aneurysm after endoscopic third ventriculostomy: case report. Neurosurgery 41:1400–1404 Oertel JM, Schroeder HW, Gaab MR (2009) Endoscopic stomy of the septum pellucidum: indications, technique, and results. Neurosurgery 64:482–493 Oertel JM, Vulcu S, Schroeder HW, Konerding MA, Wagner W, Gaab MR (2010) Endoscopic transventricular third ventriculostomy through the lamina terminalis. J Neurosurg 113(6):1261–1269 Oertel J, Linsler S, Strohm L, Senger S (2022) Management of severe intraoperative hemorrhage during intraventricular neuroendoscopic procedures: the dry field technique. Acta Neurochir 164(10):2551–2557 Othman W, Lai ZA, Abril C, Barajas-Gamboa JS, Corcelles R, Kroh M, Qasaimeh MA (2022) Tactile Sensing for Minimally Invasive Surgery: Conventional Methods and Potential Emerging Tactile Technologies. Front Robot AI 8:705662. 10.3389/frobt.2021.705662 PMID: 35071332; PMCID: PMC8777132 Petrone S, Cofano F, Nicolosi F, Spena G, Moschino M, Di Perna G, Lavorato A, Lanotte MM, Garbossa D (2022) Virtual-Augmented Reality and Life-Like Neurosurgical Simulator for Training: First Evaluation of a Hands-On Experience for Residents. Front Surg 9:862948. 10.3389/fsurg.2022.862948 PMID: 35662818; PMCID: PMC9160654 Schroeder HW, Oertel J, Gaab MR (2004) Incidence of complications in neuroendoscopic surgery. Childs Nerv Syst 20:878–883 Scott H, Griffin C, Coggins W, Elberson B, Abdeldayem M, Virmani T, Larson-Prior LJ, Petersen E (2022) Virtual Reality in the Neurosciences: Current Practice and Future Directions. Front Surg 8:807195. 10.3389/fsurg.2021.807195 Zada G, Liu C, Apuzzo ML (2013) Through the looking glass: optical physics, issues, and the evolution of neuroendoscopy. World Neurosurg 79(2 Suppl):S3–13 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Nov, 2024 Read the published version in Neurosurgical Review → Version 1 posted Editorial decision: Revision requested 24 Aug, 2024 Reviews received at journal 20 Aug, 2024 Reviews received at journal 16 Aug, 2024 Reviewers agreed at journal 16 Aug, 2024 Reviewers agreed at journal 15 Aug, 2024 Reviewers agreed at journal 14 Aug, 2024 Reviews received at journal 12 Aug, 2024 Reviewers agreed at journal 12 Aug, 2024 Reviewers agreed at journal 12 Aug, 2024 Reviewers agreed at journal 11 Aug, 2024 Reviewers invited by journal 10 Aug, 2024 Editor assigned by journal 10 Aug, 2024 Submission checks completed at journal 29 Jul, 2024 First submitted to journal 26 Jul, 2024 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4809603","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":344678247,"identity":"6b392576-5cf1-41af-b5a3-207876f83c94","order_by":0,"name":"Sebastian Senger","email":"","orcid":"","institution":"Medical School of Saarland University","correspondingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Senger","suffix":""},{"id":344678248,"identity":"7f80e653-6286-46c1-84da-2daa901fe830","order_by":1,"name":"Magomed Lepshokov","email":"","orcid":"","institution":"Medical School of Saarland University","correspondingAuthor":false,"prefix":"","firstName":"Magomed","middleName":"","lastName":"Lepshokov","suffix":""},{"id":344678249,"identity":"06c68a3a-c9eb-462c-b365-00a7056966ef","order_by":2,"name":"Thomas Tschernig","email":"","orcid":"","institution":"Medical School of Saarland University","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Tschernig","suffix":""},{"id":344678250,"identity":"0c06c368-9f5b-46e9-9f4e-06034fbc36d0","order_by":3,"name":"Guiseppe Cinalli","email":"","orcid":"","institution":"Santobono-Pausilipon Children’s Hospital, AORN","correspondingAuthor":false,"prefix":"","firstName":"Guiseppe","middleName":"","lastName":"Cinalli","suffix":""},{"id":344678251,"identity":"396ad1f0-e3e1-43ec-b935-a63142521e57","order_by":4,"name":"Joachim Oertel","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIie2QsQrCMBRFE4R0eW3nUqi/8CTg91SEdhI6OjhUCk5xr19jRUiXfoBbK4KugoOCIkZER9NRMGdKHvdwk0eIwfCzJCyw0vel0OdpSpBxeCWxtUIGorXiWvNDc0QnFv56tUvGN+KU6XfFE2VvmiMbCSca8rxC4lWaGtxENAOlLAH6vj1DNQk1Sr2n2Q1ZDOCer/ZdKXWja2E0UxsLAYB17PTZ8t1Qf4noQiDrCWDcB8nBqzQPcy1Jjpex7AJ0tieYBIFTFpqaF/JzglZ5xaRt0GAwGP6RB9lhPTJFCqjZAAAAAElFTkSuQmCC","orcid":"","institution":"Medical School of Saarland University","correspondingAuthor":true,"prefix":"","firstName":"Joachim","middleName":"","lastName":"Oertel","suffix":""}],"badges":[],"createdAt":"2024-07-26 17:21:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4809603/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4809603/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10143-024-03082-9","type":"published","date":"2024-11-11T15:56:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63886034,"identity":"e0bd3eca-c7d6-4436-af23-6ab9385956f4","added_by":"auto","created_at":"2024-09-03 11:27:42","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":100407,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative screenshots of the ventricular system. Endoscopic view with the 0-degree optic inside the right lateral ventricle. The right foramen of Monro is in the center. The choroid plexus (\u003cstrong\u003e1\u003c/strong\u003e) runs through it to the roof of the 3\u003csup\u003erd\u003c/sup\u003e ventricle. The thalamostriate vein (\u003cstrong\u003e2\u003c/strong\u003e) runs on the right. The fornix forms the medial and upper parts of the foramen. The thalamus forms the lateral part. The 3\u003csup\u003erd\u003c/sup\u003e floor can be identified through the foramen of Monro (\u003cstrong\u003eA\u003c/strong\u003e). Viewing through the 3\u003csup\u003erd\u003c/sup\u003e ventricle, the endoscope was carefully moved through the foramen. The optic chiasm can be identified at the top (\u003cstrong\u003e3\u003c/strong\u003e), followed by the infundibular recess (\u003cstrong\u003e4\u003c/strong\u003e), the clivus at the floor (\u003cstrong\u003e5\u003c/strong\u003e) and the mammillary bodies (\u003cstrong\u003e6\u003c/strong\u003e) (\u003cstrong\u003eB\u003c/strong\u003e). The 3\u003csup\u003erd\u003c/sup\u003e ventricle was viewed after ETV. The lamina terminalis (\u003cstrong\u003e7\u003c/strong\u003e) and the optic chiasm (\u003cstrong\u003e3\u003c/strong\u003e) can be identified. The bony clivus can be seen through the newly formed stoma (\u003cstrong\u003e9\u003c/strong\u003e) (\u003cstrong\u003eC\u003c/strong\u003e). A 30-degree optic view was used for comparison. The lamina terminalis, optic chiasm and anterior commissure can be identified more precisely (\u003cstrong\u003eD\u003c/strong\u003e). Screenshot of the stoma after ETV with identification of the basilar artery (\u003cstrong\u003e10\u003c/strong\u003e) (\u003cstrong\u003eE\u003c/strong\u003e). Inspection through the stoma to ensure communication of the CSF and exclude Lillequist’s membrane (\u003cstrong\u003eF\u003c/strong\u003e). The posterior part of the third ventricle was viewed using angled optics. The triangularly shaped sylvian aqueduct (\u003cstrong\u003e11\u003c/strong\u003e), posterior commissure (\u003cstrong\u003e12\u003c/strong\u003e), pineal body (\u003cstrong\u003e13\u003c/strong\u003e), habenular commissure (\u003cstrong\u003e14\u003c/strong\u003e) and choroid plexus (\u003cstrong\u003e15\u003c/strong\u003e) can be identified (\u003cstrong\u003eG\u003c/strong\u003e). A flexible endoscope was used to view the entrance of the aqueduct (\u003cstrong\u003eH\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4809603/v1/9786b11939fbd46ad2017be3.jpg"},{"id":63886036,"identity":"e7bea9bb-2fd6-4326-b9d8-3c53fe1f68e5","added_by":"auto","created_at":"2024-09-03 11:27:43","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58287,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of the cadaver model. After the trocar is introduced, the third ventricle is identified, and perforation is performed between the mammillary bodies and the infundibular recess (\u003cstrong\u003eA\u003c/strong\u003e). Enlargement of the stoma with the balloon catheter (\u003cstrong\u003eB\u003c/strong\u003e). The stoma was viewed to identify the basilar artery and perforating vessels on both sides (\u003cstrong\u003eC, D\u003c/strong\u003e). Inspection of the dorsal part of the third ventricle with the entrance of the aqueduct (\u003cstrong\u003eE\u003c/strong\u003e). Visualization of the triangular-shaped aqueduct (\u003cstrong\u003eF\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4809603/v1/842bc5e6f5abc9d06164e639.jpg"},{"id":63887045,"identity":"be74ad31-f710-440a-84dd-f7a7bf366976","added_by":"auto","created_at":"2024-09-03 11:35:42","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":125079,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of the murine model. The rat was placed in the supine position (\u003cstrong\u003eA\u003c/strong\u003e), and the abdominal wall was opened (\u003cstrong\u003eB\u003c/strong\u003e). The liver was identified (\u003cstrong\u003eC\u003c/strong\u003e). The biopsy was performed with biopsy forceps (\u003cstrong\u003eD\u003c/strong\u003e). The falciform ligament is identified (\u003cstrong\u003eE\u003c/strong\u003e) and cut with scissors (\u003cstrong\u003eF\u003c/strong\u003e). The diaphragm was identified and perforated with perforating forceps (\u003cstrong\u003eG\u003c/strong\u003e, \u003cstrong\u003eH\u003c/strong\u003e). The balloon catheter was inflated, and the stoma was enlarged (\u003cstrong\u003eI\u003c/strong\u003e). The stoma can be inspected, and the procedure ends with a lethal dose of pentobarbital (\u003cstrong\u003eJ\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4809603/v1/fae604a2d94e4e551030c8f2.jpg"},{"id":69274738,"identity":"6597fd05-edac-45d5-aef7-ca145ab1a0af","added_by":"auto","created_at":"2024-11-18 16:19:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":777499,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4809603/v1/cda14dc6-ba44-4eb2-a061-2db179b6a187.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of training models for intraventricular neuroendoscopy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe first neuroendoscopic procedures were performed more than 100 years ago but soon stopped due to technical and medical limitations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Neuroendoscopy was revolutionized after the collaboration of Harold Hopkins and Karl Storz in the 1970s [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Endoscopic techniques were restricted to a few specialized centers until the end of the 1980s when well-known neurosurgeons began to take this technique seriously into account [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEndoscopic treatment options include the restoration of the physiological pathway, e.g., with foraminoplasty, or the opening of alternative pathways through fenestrations, e.g., ETV, fenestration of the lamina terminalis or septostomy. In the case of mass lesions, the removal of the lesion must be considered [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe goal of international societies is to promote these minimally invasive techniques and teach their application in low-income countries, for instance. However, neuroendoscopy differs slightly from other endoscopic procedures in other surgical fields. General surgeons, orthopedics or urologists, for example, have implemented endoscopic procedures in their daily practice, including different levels of difficulty. Arthroscopic or laparoscopic procedures are well established, and physicians start practicing these procedures early during residency. Courses and training models are available in large numbers. Moreover, the indications for an intraventricular neuroendoscopic procedure are rather rare or are only frequently performed in specialized centers, for instance, for pediatric neurosurgery, or in larger departments with a high number of cases per year. Therefore, compared with other young surgeons, residents might not have the chance to see and practice endoscopic procedures. Although intraventricular procedures are mostly straightforward short procedures and can be performed by unexperienced surgeons under the instruction of an experienced neuroendoscopist, some limitations must be mentioned. First, the knowledge and handling of the endoscope and the instruments must be understood. As mentioned, it might be unfamiliar to young neurosurgeons to look at the screen and not through the microscope. Second, the space in the ventricle system might be limited, and maneuvers can be challenging. Third, the structures adjacent to the ventricle system are very eloquent. Accidental injuries to these structures might cause permanent deficits such as short-term memory deficits (due to Fornix lesions), eye muscle palsy (due to oculomotor nerve lesions) or even hemiparesis (due to thalamic lesions). Injuries to vessels such as the thalamostriate vein or even the basilar artery can result in severe bleeding and even death, as previously reported [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] These injuries can occur not only by false instrument handling but also, for example, by incorrect coagulation and thermal damage. This emphasizes how important the teaching of these techniques is to avoid complications for the patient. The logical alternatives to train neuroendoscopic procedures on patients are models and simulations.\u003c/p\u003e \u003cp\u003eThe authors have established annual workshops for neuroendoscopy training over the last 15 and 12 years in two neurosurgical departments. These workshops include lectures, live surgeries and practical hands-on sessions. One model is based on a murine model for the simulation of intraventricular procedures. It was introduced by the authors from the very first edition of their workshop more than 15 years ago, who recalled the experience of Professor Jacques Camaert, who first introduced this model to train in neuroendoscopic procedures in his workshops held for almost 15 years in Ghent, Belgium, until the last edition in 2012. To the best of our knowledge, he has never described or reported his model in the literature. Since then, it has been adopted and described in the literature [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the potential risk of an intraventricular procedure, models simulating this environment might not cover all aspects, such as bleeding or tissue properties. With a live animal model, these aspects should be simulated as intended.\u003c/p\u003e \u003cp\u003e The use of animal models is under constant debate, and animal protection laws in many countries encourage scientists and physicians to refine, reduce and/or replace animal experiments. Therefore, the aim of the present study was to evaluate this model in comparison to other models on the learning effect of trainees.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAnimal model\u003c/h2\u003e \u003cp\u003e The procedures were performed under approval by the local governmental animal care committee (registration number TVA 11-2023) and were in accordance with the UKCCCR Guidelines for the Welfare of Animals in Experimental Neoplasia (Br J Cancer 1998; 77:1\u0026ndash;10) and the Interdisciplinary Principles and Guidelines for the Use of Animals in Research (New York Academy of Sciences Ad Hoc Committee on Animal Research, NY). Sprague\u0026ndash;Dawley rats with a minimum weight of 250 grams were obtained from Charles Rivers Laboratories, Sulzfeld, Germany. The animals were housed in cages at a room temperature of 22\u0026ndash;24\u0026deg;C and a relative humidity of 60\u0026ndash;65% with a 12-h light/dark cycle. The rats were allowed free access to drinking water and standard laboratory chow (Altromin\u0026reg;, Lage, Germany). The animals were anesthetized by initial inhalation of isoflurane. Anesthesia was induced by intraperitoneal injection of 90 mg/kg bodyweight ketamine (Ketavet\u0026reg;, Parke Davis; Freiburg, Germany) and 8 mg/kg bodyweight xylazine (Rompun\u0026reg;, Bayer; Leverkusen, Germany). All animals received 5 mg/kg body weight carprofen (Vetranal\u0026trade;, Sigma‒Aldrich; St. Louis, USA) subcutaneously in addition to pain relief.\u003c/p\u003e \u003cp\u003eThe animals were fixed in the supine position, and the limbs were fixed with tape. The anesthesia was constantly evaluated, and additional ketamine was applied if necessary. A median skin incision was made to access the peritoneal space. An endoscope was inserted, and the skin was closed with a circular suture. There are two options: the model can be applied under water and constant irrigation with Ringer\u0026rsquo;s solution or under air conditions. The authors suggest the use of antifogging fluids to avoid forging of the lenses if the second method is used. The surgical steps were demonstrated to the trainees by the tutor on videos or pictures before the surgery. The following surgical steps were performed by the trainee.\u003c/p\u003e \u003cp\u003eFirst, the endoscope is introduced, and an inspection of the abdominal space is performed. Second, the liver lobes are identified, and coagulation at the rim of the liver lobe is performed. Then, the coagulated tissue was removed with biopsy forceps. Possible bleeding from the parenchyma can be stopped with a bipolar probe.\u003c/p\u003e \u003cp\u003eAfter this step, the endoscope can be rotated 180 degrees to expose the bladder. This procedure simulates tumor removal. The attaching ligaments can be cut with scissors, and the bladder can be removed with grasping forceps.\u003c/p\u003e \u003cp\u003eThen, the endoscope is turned again and moves up to the upper part of the liver and the diaphragm. As a next step, the ligamentum falciforme is exposed and can be cut.\u003c/p\u003e \u003cp\u003eThe last step is fenestration of the diaphragm. Here, coagulation is performed, the diaphragm is perforated with blunt perforating forceps, and the stoma is enlarged with balloon catheters. This simulates an ETV. The animal was then euthanized with a lethal dose of pentobarbital as it otherwise died due to collapse of the lung.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eCadaver model\u003c/h2\u003e \u003cp\u003eThe endoscopic procedures can also be trained on cadaver models. The Institute of Anatomy and Cell Biology of the Saarland University provides the human cadavers. The education of physicians was performed under approval by the local governmental ethic committee (registration number 245/22). In general, these fresh frozen or prefixed cadavers allow surgical procedures, including borehole trepanation, endoscopic puncture of the ventricle and inspection and perforating steps. The trainees were instructed to perform a ventricle puncture 2.5 cm parasagittal and before the coroner suture by themselves under instructions. Then, the ventricles were inspected with different angled optics. They then perform ETV. As a next step, a more lateral base hole was cut 4\u0026ndash;5 cm parasagittally, and a septostomy was performed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEvaluation form\u003c/h2\u003e \u003cp\u003eA questionnaire, as added to the supplemental section, was distributed to the participants at the end of the workshop. The questionnaire included general questions regarding age, educational level, and experience in neuroendoscopy. The model was subsequently rated concerning the handling, realism and overall learning effect. The trainees were also asked for their desired qualities of an ideal training model for neuroendoscopy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe questionnaires were transferred to SPSS (IBM, Armonk, USA). The results were analyzed by the chi-square test and likelihood test. A level of statistical significance was assumed at p\u0026thinsp;\u0026le;\u0026thinsp;0.05. The data are presented as the mean and standard error of the mean.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOverall, 63 trainees participated in the workshop events. Twenty-six were residents, and 37 were consultants. Years of practice were categorized as follows: 1\u0026ndash;5 years (n\u0026thinsp;=\u0026thinsp;21); 5\u0026ndash;10 years (20); 10\u0026ndash;15 years (n\u0026thinsp;=\u0026thinsp;16); and more than 15 years (n\u0026thinsp;=\u0026thinsp;6). Twenty-eight participants had not previously undergone ETV. The remaining 35 participants had performed 1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1 ETVs and were almost exclusively consultants. They frequently use neuronavigation (80%) and balloon catheters (94%). Laser techniques are only applied in 11% of cases.\u003c/p\u003e \u003cp\u003eA total of 97% of the participants evaluated the animal model as \u0026ldquo;very realistic\u0026rdquo; or \u0026ldquo;what is realistic\u0026rdquo; regarding surgical handling, 90% regarding anatomy, 97% regarding tissue properties and 98% in general.\u003c/p\u003e \u003cp\u003eThe cadaver model was evaluated by 95% of the participants as \u0026ldquo;very realistic\u0026rdquo; or \u0026ldquo;what is realistic\u0026rdquo; regarding surgical handling, 100% regarding anatomy, 80% regarding tissue properties and 100% in general. These data are summarized in 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\u003esummarizes the evaluation of the realism of the murine training model and the cadaver model in terms of \u0026ldquo;handling\u0026rdquo;, \u0026ldquo;anatomy\u0026rdquo;, \u0026ldquo;tissue properties\u0026rdquo; and \u0026ldquo;overall impression\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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=\".\" 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=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\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\u003eMurine Model Handling\u003c/p\u003e \u003cp\u003e[n]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMurine Model\u003c/p\u003e \u003cp\u003eAnatomic realism\u003c/p\u003e \u003cp\u003e[n]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMurine Model Tissue Properties\u003c/p\u003e \u003cp\u003e[n]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMurine Model\u003c/p\u003e \u003cp\u003eOverall Impression\u003c/p\u003e \u003cp\u003e[n]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCadaver Model Handling\u003c/p\u003e \u003cp\u003e[n]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCadever\u003c/p\u003e \u003cp\u003eAnatomic Realism\u003c/p\u003e \u003cp\u003e[n]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCader Tissue Properties\u003c/p\u003e \u003cp\u003e[n]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCader Overall\u003c/p\u003e \u003cp\u003eImpression\u003c/p\u003e \u003cp\u003e[n]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003every realistic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ekind of realistic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emore unrealistic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eunrealistic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edon\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\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=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\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 learning effect was assessed on an asset scale from low\u0026thinsp;=\u0026thinsp;1 to high\u0026thinsp;=\u0026thinsp;10. The animal model was evaluated with a mean score of 8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2, and the cadaver model had a mean score of 9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2. Residents and consultants evaluated the models nearly identically (8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 vs 8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 and 8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 vs. 9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3). There was no statistically significant difference between the groups.\u003c/p\u003e \u003cp\u003eThe trainees were asked about their confidence in performing an ETV after performing the training model. A total of 74.0% of the participants were confident after the animal model was established, and 87.5% of the participants were confident after the cadaver model was established. After each model, the consultants felt more confident than did the residents (89% vs 58% and 96% vs. 71%, respectively).\u003c/p\u003e \u003cp\u003eIn addition, the trainees were asked about the requirements of an ideal training model. The participants \u0026ldquo;strongly agreed\u0026rdquo; or \u0026ldquo;agreed\u0026rdquo; in 100% with realistic simulation of anatomical structures, 98% with realistic simulation of tissue strength, 80% with realistic simulation of pulsation, 78% with realistic simulation of complications, 76% with realistic simulation of bleeding and 71% with a realistic simulation of an OR setting.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003esummarizes the expected requirements for an ideal training model by the participants.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSame Instruments\u003c/p\u003e\n\u003cp\u003elike in the OR\u003c/p\u003e\n\u003cp\u003e[n]\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSame Setting\u003c/p\u003e\n\u003cp\u003elike in the OR\u003c/p\u003e\n\u003cp\u003e[n]\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRealistic Anatomical Structures\u003c/p\u003e\n\u003cp\u003e[n]\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRealistic Tissue Properties Regarding Resistance\u003c/p\u003e\n\u003cp\u003e[n]\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRealistic Bleeding Conditions\u003c/p\u003e\n\u003cp\u003e[n]\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRealistic Pulsation\u003c/p\u003e\n\u003cp\u003e[n]\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSimulation of\u003c/p\u003e\n\u003cp\u003eComplications\u003c/p\u003e\n\u003cp\u003e[n]\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003estrongly agree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eagree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eneither nor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003edisagree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed that a low-cost murine model can achieve training effects comparable to those of cadaveric models for neuroendoscopic procedures. More experienced surgeons feel comparable confidence in performing an ETV after bypassing such a model in comparison to a cadaver hands-on session. Young colleagues also rated the model as an adequate learning method. A limitation of the murine model is surely that it cannot help to teach the intra- and paraventricular anatomy of the human brain. Simulating the anatomy was one of the most important requirements for an ideal model in our poll. Other training models may overcome this problem, as cadaver models are not ubiquitously available all over the world or are restricted by shortages or low prices. 3D-printed models are helpful for teaching anatomy and might help to encourage medical students to choose neurosurgery at all; however, training manual skills effectively is doubtable [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVarious computer simulations have been developed and have shown fair results concerning anatomical learning effects. Nonetheless, as this technology was promoted more than 15 years ago, it is still not routinely implemented [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A major drawback of virtual reality is the inadequate simulation of force sensing and tissue properties. The importance of this simulation aspect has also been shown in our evaluation. Emerging technologies might overcome this problem in the near future toward establishing low-cost, high-performance MIS force sensors, such as promising piezoelectric sensors. Recent rapid advances in computer vision and machine learning have drawn increasing attention to imaging-based tactile sensing, also known as vision-based sensing [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Augmented or virtual reality will continue to result in rapid advancements in operative planning, intraoperative navigation, and neurosurgical training [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterestingly, complication simulation was only important for 76% of all trainees. In our opinion, this aspect is common in neuroendoscopic intraventricular procedures, as complications are major risks for patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In particular, hemorrhages might be challenging to handle and need immediate proper measures [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eModels could be improved by testing the effects on the manual skills and knowledge of the participants. However, standardized evaluation methods are lacking and should be developed by surgical societies regardless of the proper model type [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo evaluate the current status of neurosurgical models with other surgical fields, we performed a PubMed search for the \u0026ldquo;Laparoscopic training model\u0026rdquo;, \u0026ldquo;Arthroscopic training model\u0026rdquo; and \u0026ldquo;neuroendoscopic training model\u0026rdquo;. This simple keyword search revealed 21537 papers concerning laparoscopic training models, 5656 papers concerning arthroscopic training models and only 194 papers concerning neuroendoscopic training models. These results emphasize how underrepresented this topic is in the neurosurgical community and should be further supported to ensure proper education of future generations of neuroendoscopists.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecerebral spine fluid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eETV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eendoscopic third ventriculostomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors do not have any financial or non-financial interests that are directly or indirectly related to the work submitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor Contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor contributions to the study and manuscript preparation include the following. Conception and design: Sebastian Senger, Thomas Tschernig, Joachim Oertel, Guiseppe Cinalli\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Acquisition of data: Sebastian Senger, Magomed Lepshokov\u003c/p\u003e\n\u003cp\u003eAnalysis and interpretation of data: Sebastian Senger, Thomas, Tschernig,\u003c/p\u003e\n\u003cp\u003eJoachim Oertel, Guiseppe Cinalli\u003c/p\u003e\n\u003cp\u003eDrafting the article: Sebastian Senger\u003c/p\u003e\n\u003cp\u003eCritically revising the article: Joachim Oertel, Guiseppe Cinalli\u003c/p\u003e\n\u003cp\u003eReviewed the final version of the manuscript and approved it for submission: Sebastian Senger, Joachim Oertel, Guiseppe Cinalli\u003c/p\u003e\n\u003cp\u003eStudy supervision: Joachim Oertel, Guiseppe Cinalli\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll animal experiments were performed under approval by the local governmental animal care committee (registration number TVA 11-2023). The education of physicians on cadavers were performed under approval by the local governmental ethic committee (registration number 245/22).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbtin K, Thompson BG, Walker ML (1998) Basilar artery perforation as a complication of endoscopic third ventriculostomy. Pediatr Neurosurg 28:35\u0026ndash;41\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlaraj A, Lemole MG, Finkle JH, Yudkowsky R, Wallace A, Luciano C et al (2011) Virtual reality training in neurosurgery: Review of current status and future applications. Surg Neurol Int 2:52\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChawla S, Devi S, Calvachi P, Gormley WB, Rueda-Esteban R (2022) Evaluation of simulation models in neurosurgical training according to face, content, and construct validity: a systematic review. Acta Neurochir 164(4):947\u0026ndash;966. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00701-021-05003-x\u003c/span\u003e\u003cspan address=\"10.1007/s00701-021-05003-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2022 Feb 4. PMID: 35122126; PMCID: PMC8815386\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCinalli G, Spennato P, Savarese L, Ruggiero C, Aliberti F, Cuomo L, Cianciulli E, Maggi G (2006) Endoscopic aqueductoplasty and placement of a stent in the cerebral aqueduct in the management of isolated fourth ventricle in children. J Neurosurg 104(1):21\u0026ndash;27\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCinalli G, Spennato P, Ruggiero C, Aliberti F, Trischitta V, Buonocore MC, Cianciulli E, Maggi G (2007) Complications following endoscopic intracranial procedures in children. Childs Nerv Syst 23(6):633\u0026ndash;644\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDecq P, Schroeder HW, Fritsch M, Cappabianca P (2013) A history of ventricular neuroendoscopy. World Neurosurg 79(2 Suppl):S14e1\u0026ndash;S14e6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEfe IE, \u0026Ccedil;inkaya E, Kuhrt LD, Bruesseler MMT, M\u0026uuml;hrer-Osmanagic A (2023) Neurosurgical Education Using Cadaver-Free Brain Models and Augmented Reality: First Experiences from a Hands-On Simulation Course for Medical Students. Medicina (Kaunas). Oct 9;59(10):1791. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/medicina59101791\u003c/span\u003e\u003cspan address=\"10.3390/medicina59101791\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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World Neurosurg 79(2 Suppl):S3\u0026ndash;13\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":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"neuroendoscopy, surgical education, murine model, cadaver model, endoscopy","lastPublishedDoi":"10.21203/rs.3.rs-4809603/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4809603/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eStructured surgical education has become increasingly important in recent years. Intraventricular neuroendoscopic procedures have been widely established. However, training surgical skills with these techniques is crucial for young residents due to the potential harm to adjacent tissue. Therefore, we evaluated two different training models.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eParticipants in two different international workshops were trained on a prefixed cadaver model and on a living murine intraabdominal model. Crucial neuroendoscopic techniques such as membrane perforation and tissue biopsy were performed. A blinded questionnaire evaluated both models.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Sixty-three participants were trained on the animal model. Forty of these were trained on the cadaver model. The training effect was evaluated almost equally, with 8.5/10 for the animal model and 8.9/10 for the cadaver model. The tissue properties were rated higher regarding realism in the animal model, whereas the anatomic realism was rated higher in the cadaver model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe animal model is a valid alternative to cadaver models for teaching endoscopic neurosurgical skills. This model benefits from the simulation of real surgical tissue properties, including bleeding. The low costs and availability of this technique make it more ubiquitous and can help train further generations of neurosurgeons.\u003c/p\u003e","manuscriptTitle":"Evaluation of training models for intraventricular neuroendoscopy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-03 11:27:37","doi":"10.21203/rs.3.rs-4809603/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-25T01:55:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-20T19:43:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-16T10:06:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151516199778530380692163506445183497463","date":"2024-08-16T09:52:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60622446106075271741917351156147406378","date":"2024-08-16T00:39:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106420869268923658029578753380624328427","date":"2024-08-14T18:41:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-12T15:17:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"331461203317021841589706356535509033926","date":"2024-08-12T14:55:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277802948530996974976481359602990716954","date":"2024-08-12T14:36:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259780843003150203285249174312937590724","date":"2024-08-11T08:56:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-10T20:21:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-10T20:20:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-30T02:10:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurosurgical Review","date":"2024-07-26T17:20:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bfdaf7a7-88b8-45c5-8163-5fcc32690901","owner":[],"postedDate":"September 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-18T15:59:05+00:00","versionOfRecord":{"articleIdentity":"rs-4809603","link":"https://doi.org/10.1007/s10143-024-03082-9","journal":{"identity":"neurosurgical-review","isVorOnly":false,"title":"Neurosurgical Review"},"publishedOn":"2024-11-11 15:56:55","publishedOnDateReadable":"November 11th, 2024"},"versionCreatedAt":"2024-09-03 11:27:37","video":"","vorDoi":"10.1007/s10143-024-03082-9","vorDoiUrl":"https://doi.org/10.1007/s10143-024-03082-9","workflowStages":[]},"version":"v1","identity":"rs-4809603","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4809603","identity":"rs-4809603","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}