Multiuse of Disposable Microsurgical Instruments as a Cost-Efficient Alternative for Training and Research

Supplemental Digital Content is available in the text.

Summary:

Microsurgery demands significant preclinical training, often hampered by the high costs of the required microsurgery instruments. We hypothesized that recently available disposable microsurgery instruments provide sufficient quality and significantly reduced costs. In a comparative analysis with standard reusable instruments, participants performed equally with both instrument sets and recommended the disposable instruments for microsurgery training and research applications.

INTRODUCTION

Microsurgery is important in many surgical specialties and increasingly used in small animal research models.^1,2 Consequently, the acquisition of microsurgery skills is essential to a growing population of residents and researchers but hampered by the costs of training models and instruments.

Therefore, a large number of cost-efficient and readily available training models have been developed for microsurgical training.^1,3–6 However, the high costs of standard microsurgical instruments and their fragility remain challenging for microsurgery training. Recently, disposable microsurgery instruments have been introduced to provide low case-load practices with inexpensive instruments. From an ecological aspect, these single-use instruments and their subsequent disposal are questionable. However, for microsurgery training and experimental microsurgery animal models, these instruments could provide a low-cost alternative to conventional instruments. For these applications, a sufficient sterilization would be possible; however, no experience exists whether or not these instruments are of sufficient quality.

In this study, we analyzed the application of single-use microsurgery instruments compared with conventional instruments in a standardized training environment. Thirty surgeons and researchers conducted standardized timed tests and questionnaires comparing the quality, handling, and size of single-use to reusable instruments. In summary, combined with long-term experience from research use, our results suggest that single-use microsurgery instruments provide a cost-efficient alternative for small microsurgery training and research programs.

METHODS

Thirty participants with different microsurgical experience (microsurgery trainee to experienced microsurgeon), ranging from 1 month to over 10 years, compared single-use to reusable instruments. Participants received a set of disposable microsurgical instruments (Malosa Medical, England) and a set of standard reusable microsurgical instruments (S&T, Neuhausen, Switzerland) containing forceps, scissors, and a needle holder (Fig. 1). A timed test was used to quantify handling and material quality. Here, participants were instructed to perform 5 single knots with 9/0 sutures (Prolene, Ethicon, Johnson and Johnson Medical Care, Austria) on a nonviable tissue membrane to provide standardized conditions. As previously described,⁵ a surgical glove was fixed on a custom-made rack with a standardized horizontal incision. The required time was recorded for 2 runs using both sets of instruments. Additionally, standard training situations in in vitro and in vivo models were conducted by the participants while using both sets for direct comparison. Thereafter, a questionnaire assessed instrument-related factors such as size, weight, quality, and handling using a 1–10 scale (see pdf, Supplemental Digital Content 1, which displays a questionnaire for single-use instruments for microsurgical training, http://links.lww.com/PRSGO/A439) Furthermore, participants were asked to evaluate the price-performance ratio and if they would recommend disposable instruments for microsurgical training or research applications.

Fig. 1.

Image of the reusable instruments on the left and the single-use instruments on the right. From left to right the forceps, scissors, and the needle holders are shown.

RESULTS

The practical microsurgery exercise showed no significant difference (P = 0.615; 2-sided t test) between reusable instruments (436 ± 144 seconds) and disposable instruments (457 ± 162 seconds). The utilized single-use instruments were slightly heavier (22.8 g for the single-use needle holder versus 18.6 g; 28.7 g for single-use forceps versus 19.4 g; 21.1 g for single-use scissors versus 17.2 g) but weight was rated optimal at 5.16 ± 1.26 (scale: 1, too light; 5, optimal; 10, too heavy). The size was rated almost optimal at 5.7 ± 1.56 (scale: 1, too small; 5, optimal; 10, too big) (Fig. 2). Handling was rated at 5.67 ± 1.85 and quality at 5.61 ± 2.13 (scale: 1, worst; 10, best). The price-performance ratio of the single-use instruments was rated at 6.82 ± 2.08 (scale: 1, poor quality; 10, best quality for the price; Fig. 3). Although reusable microsurgery instruments were rated better than single-use instruments in direct comparison (6.87 ± 2.44; 1, single-use better; 5, equal; 10, reusable instruments better), participants highly recommended (7.74 ± 2.32; 1, no recommendation; 10, strong recommendation) the disposable instruments for microsurgery training or research (Fig. 4).

Fig. 2.

After a practical test and several training applications, participants were asked to rate the single-use instruments compared with the standard reusable instruments. Weight of the single-use instruments was rated 5.16 ± 1.26 and size 5.7 ± 1.56 (median equal to first quartile for size) on a 1–10 scale (1, too light or too small; 5, optimal; 10, too heavy or too large).

Fig. 3.

Handling of the single-use instruments was rated at 5.67 ± 1.85 and quality at 5.61 ± 2.13 (scale: 1, worst; 10, best). The price-performance ratio of the single-use instruments was rated at 6.82 ± 2.08 (scale: 1, worst; 10, best) based on a 1:4 price ratio compared with standard instruments.

Fig. 4.

Standard reusable instruments were rated better in terms of overall quality than single-use instruments (6.87 ± 2.44; 1, single-use better; 5, equal; 10, reusable instruments better). Nevertheless, participants highly recommended the significantly cheaper single-use microsurgery instruments for microsurgical training (7.74 ± 2.32; 1, no recommendation; 10, strong recommendation).

DISCUSSION

Many surgeons and researchers require microsurgical training; however, training is often limited due to the high costs of providing fragile microsurgery instruments to trainees.^2,7,8 Recently introduced single-use microsurgery instruments may, therefore, if sufficiently reusable and of high quality, provide a cost-efficient solution to this problem.

In this study, we systematically compared disposable instruments for microsurgical training with standard reusable instruments. For this purpose, we designed a practical test to quantify the function of the instruments and surveyed microsurgical trainees of different skill levels on their opinion. Our hypothesis was that disposable instruments are sufficiently reusable and sufficiently high in quality to permit a cost-efficient alternative to standard instruments. The single-use instruments used in this study were approximately 4 times cheaper (set prize approximately 300€) compared with the reusable instruments traditionally used at our institution (approximately 1,200€). Combined with the easily available training models such as surgical gloves or the chicken leg model, they provide an affordable and easily available training opportunity.^1,3–5 The disposable instruments were chemically and heat sterilized with standard research devices.

Our results suggest that disposable and reusable instruments differ in relevant handling properties (e.g., 22.8 g for the single-use needle holder compared with 18.6 g for the reusable).

However, the practical test showed no significant difference in the handling of the instruments. From our personal experience and other work groups using these instruments for training and research, sufficient sterilization can be achieved, and long-term application is possible over the course of several months. Furthermore, the mishandling or accidental drops of microsurgery instruments by trainees is less problematic due to the significantly lower price of renewing single-use instruments.

Most importantly, despite the slightly inferior quality rating, the 75% cheaper disposable instruments were highly recommended for microsurgical training and research.

Many studies suggest early microsurgical training to facilitate fast skill acquisition, which could be more likely with affordable training resources.^8,9 Although the principle of single-use instruments for clinical purposes is ecologically questionable, their repeatable use combined with in vitro training models provides a widely available and cost-efficient access to young trainees.

Supplementary Material

gox-5-e1320-s001.pdf ^{(51.5KB, pdf)}