Simulator training in aneurysm clipping

Ruptured vascular malformations are considered to be a neurosurgical emergency, and rapid evaluation and management might be live-saving. There are various options in aneurysms treatment including endovascular procedures such as coiling and stenting, and then traditional surgical approach using “open” craniotomy followed by a treatment of aneurysm itself, most often by clipping. Currently, endovascular methods are dominating and surgery is limited to a small number of cases when there is a ruptured aneurysm located on middle cerebral artery, usually associated with an expanding intracerebral hematoma, which requires evacuation during the procedure as well. There is another limitation considering “open” surgery – antiplatelet or anticoagulant therapy, which is, on the other hand, necessary for endovascular treatment.

Aneurysm clipping remains a challenge for residents and attending neurosurgeons as well. Due to a low number of aneurysm clippings in our daily neurosurgical practice as endovascular treatment is increasing, neurosurgical training is considered to be very important. A resident can come across this kind of surgery as an assistant or by operating under a supervision in the advanced phase of residence program (1; 2). Regarding the limited number of surgeries performed, there is a lack of opportunity to get familiar with this complex procedure.

Aiming to gain microsurgical skills in aneurysm clipping, lots of different types of simulation activities have been introduced. Various kinds of static simulators, virtual-reality based simulation techniques, and 3D models are most commonly described in aneurysm clipping training. Each of these methods has its own benefits and drawbacks, in general the most limiting disadvantage is a lack of realistic conditions (3; 4). A recent study by Joseph et al. (5) highlighted functional simulators, being able to display realistic anatomy and physiology with blood flow and pulsatility based on obtained image data by specific patients. For successful neurosurgical training in aneurysm clipping, the ideal simulator should be able to provide a detailed anatomy of the brain and vascular structures, and also replicate the possible surgery pitfalls, namely periprocedural aneurysm rupture (6; 7).

We got an opportunity to use an AneurysmBox from UpSurgeon. This 3D model contains a white base with skull, a pre-existing standard pterional craniotomy, surgical tools – loupes with LED light, clips applicator, spatula, bayonet, and 4 clips of various shapes. The model mimics realistic vascular anatomy with 5 aneurysms localized on different cerebral arteries. Our goal was to identify and treat all the aneurysms with a proper clip placement, concurrently evaluating the simulator design. Due to a low number of residents at our neurosurgical department, no questionnaires or further research were performed.

In general, we consider this type of training especially beneficial for residents in the first years of their practice. From our point of view the biggest advantage of the use of AneurysmBox is the vascular anatomy highly resembling realistic conditions (congenital vascular anomalies as atypical branching are not displayed). Having more shapes of clips enables choosing the most suitable one aiming to secure appropriate aneurysm closure (Fig. 1, 2).

Fig 1

Due to various aneurysm locations, a resident is able to train reaching different arterial location and get familiar with surrounding anatomy (Figure 2).

Fig 2

On the other hand, the model lacks the properties of potential realistic perioperative complications such as aneurysm rupture or clip malposition resulting in inadequate occlusion. Another limitation could be the material used for the brain model itself, as it does not reflect the softness of tissues and vessels, so inappropriate rough manipulation which would in vivo lead to a vessel damage has basically no impact on the simulator.

To summarize, we would definitely recommend AneurysmBox as a means of aneurysmal clipping training for residents. The biggest benefits appreciated are in getting familiar with surgical approach and vascular anatomy and learning how to manipulate with specific surgical tools.