A report about the 10th AOSpine Advanced Level Live Tissue Training Days—the Prevention and Management of Complications in Spine Access Surgery


 by Regula Bleuler, AOSpine Newsletter Editor

On June 30 and July 1, 2016, the AOSpine Advanced Level Tissue Training Days, – The prevention and Management of Complications in Spine Access Injury, was staged in Strasbourg, France, for the tenth time. A total of 68 participants from 21 nations around the world attended the event, which took place at the renowned IRCAD Institute, a world leader in live-tissue education with unmatched facilities for complication simulation and repair techniques training.


AOSpine is one of the few spine societies offering an advanced level live tissue training for the prevention and management of complications in spine access surgery, specifically directed at the management and repair of vascular and visceral injuries particular to spine surgery.


Ratio Table Instructor – Participants: 2:1 – a truly tailor-made learning experience for each participant

With a maximum of only 34 participants per day and a ratio of one table instructor, two participating surgeons, and one experienced ORP per live surgery table, it is more than just an intense one-day training. It is a personal learning experience, tailored to the needs and skills of every participant.


The selected AOSpine table instructors/faculty members are surgeons of the highest repute. Each table instructor is assigned to a designated table for the entire day, to guide and coach the participants through the surgeries. In addition to the table instructor, there are also specialists in vascular, general, urological, and thoracic surgery present, to offer assistance and support on how to find the best and most appropriate approach for each complication the surgeons are facing.


During the training, participants prepare themselves for the worst moments in a surgeon's career - when serious complications happen during a surgery, which the surgeon has never trained before. As faculty member and table instructor Taavi Toomela from Estonia, who has attended these trainings several times already, accurately describes: “It is the moment when something really bad happens during your surgery, when you are with your back against the wall, and you have to take the right decision in a situation of high pressure and tension and act very quickly. This training is great to take away the fear of such emergencies and to give the surgeons confidence in handling such situations."


The morning—lumbar and cervical spine approach

We're off to an early start at 7:15 am. The program starts with a welcome speech by Andreas Korge, the training chairperson, and a long-standing AOSpine faculty member. Afterwards, a short introduction to the anatomy of the pig is given by a veterinary surgeon. Then, it's time to get dressed into scrubs and move up to the third floor to get started. In the OR, everything is ready. Each table is equipped with a screen, displaying the name of the table instructor along with two participants. All of the surgeons take a moment to find their allocated spots, and then receive their final instructions. Soon, the smell of burned skin is in the air. The level of concentration is high, yet the mood is relaxed.


The set-up is extremely professional, not only for the surgeons, but also for the animals. They are treated with dignity and respect. There are always vets around, looking after the animals and making sure that everything is ok with them.


" I'm impressed with the straightforward approach. We are dealing with one complication after another. The set-up, with such a small ratio of table instructor–participants is fantastic. I got to practice a lot and I was taught everything I needed to know, which was a truly unique experience for me. I was also impressed with how much respect the animals were treated. I'd have never expected the training to be such a great experience."

Rita Seen-Hibler, an orthopedic surgeon from Munich

Approach one complication after another, coached and supported by experts

On our designated table, with an anesthetized pig lying on its back, the anterior retroperitoneal approach to the lumbar spine is being trained first. Soon, we are facing the first of many complications that day, an arterial lesion.


Or, to put it bluntly, in that one single moment when the participant is exchanging instruments with the ORP, our table instructor, Robert Morrison, Directing Senior Physician of the Spine Department at Schön Klinik Fürth in Germany, causes an arterial injury, which deliberately catches the trainee at a completely unexpected moment. Quickly, she presses her finger on the wound.


"I'm really impressed. This was much better than what I expected. It was a great learning experience and more than rewarding. The money was very well spent."

Mohammed Salah Eldin, an orthopedic surgeon from Cairo, Egypt

"And now what?" Morrison asks our group. While the finger remains firmly pressed on the artery, various solution proposals are discussed. How can the lesion be treated without causing any additional or potentially worse injury and/or damage? What clamp should be used, and how should it be placed to make sure that we get the best result? Which approach is best, and from what side and angle? Andrej Isaak, a specialist in the area of vascular surgery at Universitätsspital Basel, Switzerland, also joins us at our table. The various approaches are discussed. Each and every one is challenged, and all options are considered until the most appropriate approach to the injury is found and applied.


More training in repair techniques for arterial and venous injuries, as well as visceral and ureteral injuries, follows over the course of the morning. This is all supervised by the table instructor and the various specialists, who constantly support the participants with their skills and expertise to appropriately deal with every challenge given.


Robert Morrison leads us with patience and confidence through the entire surgery. He challenges, supports, assists, and teaches with the highest level of professionalism and a good sense of humor: the ideal combination for a great learning experience. The OR nurse is experienced, and obviously used to work with him, which is an additional advantage.


The discussions are very constructive. The objective is for the participants to get the most out of the experience by showing various perspectives on how to approach a complication, in order to help the surgeons to look at things differently without losing the big picture.


"It's a great opportunity to train in an environment that is very close to a real surgical situation. I believe it's the right way to learn things here, and to be ready and prepared, rather than learning in the field. I recommend this training to anybody, for any level of experience.”

Raffaella Maina, a neurosurgeon from Torino, Italy

If time allows in the morning, participants also have the optional opportunity to train the approach to the anterior cervical spine while dealing with the repair of esophageal and arterial injuries.


Around noon, it's time for a lunch break. Afterwards, a 45 minute "Ask the Specialist" session enables time for questions and answers. Each specialist also holds a short presentation, providing insights into their field of expertise. They give tips, tricks, and advice on how to solve challenging situations, and which equipment to use.


The afternoon—thoracic and thoracolumbar spine

After the presentations conclude, it's time to head back up into the OR. During lunch, everything had been cleaned and set up again. All pigs have been replaced, enabling us all to jump right into the next training session.


This time, the pig is in lateral position, lying on the side with the left side up. We are practicing the approach to the thoracic spine, e.g. the extension of incision and section of diaphragm in the thoraco-abdominal approach, as well as venous, arterial, and pulmonary injuries and their repair techniques.


Again, we train the appropriate approach and instrumentation for the respective type of pathology. We also look at the advantages, disadvantages, and limitations of each approach, all while being carefully guided by the table instructor and the specialists. We continue to learn how to identify and to avoid damage to the important structures that are relevant to an approach, and we practice the vascular, pulmonary, and bowel repair again and again to improve our practical competency until we wrap up at around 6 pm.


An excellent training with fantastic networking opportunities

Course chairman Andreas Korge, Head of Department at the Spine Center Schön Klinik München Harlaching, has been involved in the AOSpine Advanced Live-Tissue Training since the course’s inception.


According to Korge, the live tissue training is so unique because it really is like a real time live surgery with all of the necessary professional equipment. “Training for situations that a surgeon absolutely doesn't want to have happen creates a platform for profound knowledge transfer, and for fruitful discussions. It provides excellent learning and education experiences for all involved,” he shares.


Korge speaks highly of the quality of the AOSpine faculty and the network it provides for him, both professionally and personally. He mentions that he not only has plenty of colleagues he can count on for support if necessary, but that he has also made great friends within the AOSpine network.


Korge highly recommends the training for any surgeon, and especially those who do the approaches themselves, or don't have a specialist nearby they can call. According to the survey conducted among all participating surgeons, is the case for two out of three of them.


The next Advanced Level Live Tissue Training Days—the Prevention and Management of Complications in Spine Access Surgery, will take place on September 28  and 29, 2017. For more information please contact Karin Wandschura, e-mail kwandschura@aospine.org


Newsletter 8 September 2016


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