Head–neck dissection course during COVID-19 pandemic: challenges, adaptations and how we did it

Abstract

Introduction

Cadaveric dissection courses have come to a standstill since the onset of the COVID-19 pandemic. In addition to limited operative opportunities, cancellation of such courses has severely impacted surgical training, especially in a craft-based specialty such as head–neck surgery. The aim of this educational project was to: (1) study the feasibility of an in-person head–neck cadaveric dissection course during COVID-19 pandemic; and (2) validate the educational benefit of this teaching method to ear, nose and throat (ENT) trainees.

Methods

We developed a 2-day head–neck cadaveric dissection course for ENT trainees. The course programme covered essential head–neck open surgical procedures. Content validity (subjective feedback) was assessed using a 5-point Likert scale. Construct validity (objective usefulness) was evaluated via two pre- and post-course questionnaires, estimating knowledge of head–neck surgical anatomy and self-assessment of levels of confidence with head–neck procedures, respectively.

Results

A risk assessment was conducted and a protocol developed (risk was deemed to be low/tolerable). Content validity showed high satisfaction compared with a median Likert score of 3, ‘average’ (p=0.000002). For construct validity, the mean score per question improved significantly (p=0.001). Overall levels of confidence showed a trend towards improvement (p=0.08). There was significant improvement in laryngectomy (p=0.01) and level I dissection (p=0.01), with an indication of improvement in level II–V dissection (p=0.07).

Conclusions

We demonstrated that a cadaveric dissection course, using thorough risk assessment and protocol, could be safely conducted with high content and construct validation during these unprecedented times. This is an invaluable learning environment that needs to be encouraged despite infection control restrictions.

Introduction

Cadaveric dissection courses form an essential part of surgical training and, until recently, were mandatory for certificate of completion of otolaryngology training in the United Kingdom (UK).¹ Cadaveric dissection has always been the cornerstone of postgraduate anatomy education as well as acquisition of surgical techniques, especially in a complex region such as the head and neck.² Although there is only limited objective evidence for transference of skills to live surgical setting, trainees regard these courses to be of high educational benefit due to the practical skills obtained.³

Cadaveric dissection teaching and courses have come to a standstill since the onset of the COVID-19 pandemic. In addition to limited operative opportunities during this period, the cancellation of such courses has severely impacted surgical training, especially in a craft-based specialty such as head–neck surgery.⁴ With developments in innovative teaching strategies and simulation-based learning, there has been a slow and steady adoption of ‘virtual’ anatomy education.⁵ This process has been expedited during the pandemic, owing to curtailment of face-to-face teaching and inability to meet donor body requirements.⁶

To our knowledge, head–neck dissection courses have not been held in the UK since 23 March 2020. The aim of this educational project is to: (1) study feasibility of in-person head–neck cadaveric dissection course during the COVID-19 pandemic; and (2) validate the educational benefit of this teaching method to ear, nose and throat (ENT) trainees.

Methods

Course development

This course was conducted at a dissection laboratory located in a medical school campus in the UK, with existing COVID secure measures.⁷ Risk assessment for the course was conducted, keeping in line with social distancing measures for in-person teaching. A two-day course programme was developed after consultation with senior head–neck faculty and dissection laboratory management team.

The course was designed to address the following topics:

• • subplatysmal dissection and level V dissection;
• • tracheostomy;
• • submandibular gland/level I dissection;
• • parotidectomy;
• • level II–V dissection;
• • laryngectomy.

Content validity

The course content was validated via anonymised feedback, using a 5-point Likert scale (1=‘very poor’ to 5=‘excellent’). Feedback questions assessed a range of topics, such as course administration, structure, delivery methods, safety, quality of cadavers/instruments, translation to clinical practice and overall satisfaction.

Construct validity

Construct validity was assessed via two pre- and post-course questionnaires: (1) single best answer (SBA) questions relevant to head–neck surgical anatomy; and (2) self-assessment of level of confidence to perform head–neck procedures.

The SBA questions were graded, based on difficulty, as easy (6) and medium-to-hard (14). All topics tested were covered during the duration of the course, via lectures and a dissection manual. The level of confidence was recorded on a 5-point Likert scale (1=‘very low’ to 5=‘very high’).

Statistical analysis

Content validity was analysed by comparing median Likert scores to ‘average’ (Likert score of 3) using Wilcoxon’s signed rank test. For construct validity, responses to SBA questions were analysed by comparing mean score per question in the pre- and post-course evaluation using a paired t-test. Levels of confidence were compared and analysed using Wilcoxon’s signed rank test. A p-value of <0.05 was considered significant. Data analysis was performed using RStudio version 1.3.1093 (RStudio).

Results

Risk assessment and protocol

Risk assessment with regards to COVID-19 virus exposure and transmission in-transit to, as well as at, the dissection laboratory was completed. With existing controls, the risk was deemed to be low/tolerable (B) (the scale ranges from very low/trivial (A) to high (D)). The special considerations in protocol for the course were as follows:

• •limitation of attendees (including candidates, organisers and faculty) to 25 within the dissection laboratory (keeping in line with 1 metre plus social distancing while indoors);
• •ensure mechanical ventilation in the dissection laboratory is adequate;
• •one-way system in place within the building and dissection laboratory – in and out through separate doors;
• •all attendees must have taken a lateral flow test and have a negative result, prior to coming onto campus;
• •safety checklist and declaration prior to registration to ensure attendees do not have signs or symptoms of COVID-19 infection, recent close contact with people demonstrating symptoms or live in a household with someone who is shielding;
• •record of sign-in and configuration of pairs at the dissection tables (this will be required for contact tracing should there be any outbreak);
• •use of relevant personal protective equipment (PPE), such as full gowns, goggles, gloves and surgical masks when in the laboratory, and surgical masks at all times in the campus;
• •working in groups of two per cadaver – try to maintain consistent pairings or fixed groupings throughout the course;
• •limited gathering in groups when not dissecting;
• •details of all cadavers were verified and date of death was ascertained to be before January 2020.

Demographics

A total of ten candidates successfully completed the two-day course. All of the candidates were higher surgical ENT trainees at various levels of training (one ST3, three ST4, four ST5 and two ST6) from North and South Thames Deaneries.

Course delivery

Table 1 demonstrates the course programme. The initial pre-course evaluation consisted of 20 SBA questions on head–neck surgical anatomy. This was followed by hands-on cadaveric dissection, interspersed with short lectures (five in total) and live demonstration by faculty, utilising an exoscope to improve visualisation and promote social distancing. The course concluded with a feedback session and post-course evaluation.

Table 1 .

Overview of the course programme

Day 1
09.00–09.30	Registration, safety checks and pre-course evaluation
09.30–09.45	Welcome and introduction
09.45–09.50	First demonstration (sub-platysmal dissection + level V dissection)
09.50–10.45	Dissection (key point finding XI nerve)
10.45–11.00	Coffee
11.00–11.15	Second demonstration (tracheostomy)
11.15–12.00	Dissection (Tracheostomy)
12.00–12.30	Lecture: Emergency airway management
12.30–13.30	Lunch
13.30–13.45	Third demonstration (level I, including submandibular gland dissection)
13.45–14.15	Lecture: Salivary gland surgery
14.30–15.00	Dissection (key points identifying hypoglossal + lingual nerves + SM duct)
15.00–15.15	Fourth demonstration (parotidectomy)
15.15–17.00	Dissection (key point facial nerve and branches)
Day 2
08.30–09.00	Safety checks
09.00–09.15	Fifth demonstration (level II–IV dissection)
09.15–10.00	Dissection
10.00–10.30	Lecture: Neck dissection tips
10.30–10.45	Coffee
10.45–11.45	Continue level II–IV dissection
11.45–12.15	Lecture: Thyroid surgery masterclass
12.30–13.30	Lunch
13.30–14.00	Sixth demonstration and lecture: Laryngectomy
14.00–15.00	Dissection (laryngectomy)
15.00–15.15	Coffee
15.15–15.45	Continue laryngectomy dissection
15.45–16.30	Free dissection
16.30–17.30	Feedback and post-course evaluation

Content validity

Figure 1 shows the responses to 23 feedback questions, recorded on a Likert scale. All questions had a median response of 5, ‘excellent’, except for one question (‘Content of the dissection manual’ which had a median response of 4). This was significantly higher than the expected median Likert response of 3, ‘average’ (p=0.000002).

Figure 1 .

Content validation via responses to feedback questionnaire

Further free-text feedback was received from five candidates (Table 2), and clearly showed high satisfaction with course structure and delivery.

Table 2 .

Summary of feedback comments

Subcategory	Positive feedback	Suggestions for improvement
Structure and delivery	Very happy with balance of lectures, practical dissection and guidance. Good balance between lecture and dissection.	More dissection demonstration if possible. Provision of headlights
Educational benefit	Greatly improved confidence particularly in submandibular gland excision and neck dissection.
Faculty	Top quality faculty. Great faculty and course. Fantastic course	Perhaps one teacher per cadaver for continual assessment

Construct validity

Table 3 lists the results of the pre- and post-course evaluation. There was improvement (18.5%) in the proportion of correct answers among candidates for the SBA questions. The mean score per question improved significantly across candidates (p=0.001). For all questions, there was objective improvement in scores in the post-course evaluation, except for one difficult question on submandibular gland anatomy.

Table 3 .

Frequency of candidates scoring correctly on single best answer questions pre- and post-course

Question topic	Pre-course (n=10)	Post-course (n=10)
Q1: External carotid artery	9	9
Q2: Platysma	5	8
Q3: Sternocleidomastoid muscle	2	4
Q4: Pectoralis major flap	1	2
Q5: Submandibular triangle	9	10
Q6: External branch of superior laryngeal nerve	4	4
Q7: Parotid gland	1	1
Q8: Parathyroid glands	4	7
Q9: Recurrent laryngeal nerve	4	6
Q10: Submandibular gland	9	6
Q11: Facial nerve	5	9
Q12: Total laryngectomy: sequence of steps	4	6
Q13: Total laryngectomy: mobilisation and resection	2	6
Q14: Total laryngectomy: pharyngeal closure	2	6
Q15: Neck dissection	9	10
Q16: Parotidectomy	2	5
Q17: Spinal accessory nerve	1	8
Q18: Levels of cervical lymph nodal groups	7	7
Q19: Hypoglossal nerve	3	6
Q20: Parapharyngeal space	1	1
Total percentage of correct answers	42 (84/200)	60.5 (121/200)

Figure 2 illustrates the level of confidence among candidates to perform various head–neck procedures pre- and post-course. Overall levels of confidence showed a trend towards improvement (p=0.08). There was significant improvement in laryngectomy (p=0.01) and level I dissection (p=0.01), with indication of improvement in level II–V dissection (p=0.07). The results of construct validity proved the effectiveness of our delivery methods.

Figure 2 .

Pre- and post-course level of confidence with head–neck procedures among candidates (n=10)

Discussion

This was the first in-person cadaveric head–neck dissection course held in the UK since the onset of the COVID-19 pandemic. The tests of content and construct validity demonstrate a high level of satisfaction with course delivery methods as well as significant educational benefit from this course.

Implications for surgical training

Surgical simulation has been severely curtailed across the globe, with social distancing regulations and a shortage of PPE.⁸ In the UK and Republic of Ireland, surgical trainees reported cancellation of 80% of courses during the first wave of the pandemic.⁴ The current cohort of surgical trainees is expected to achieve the same level of competencies as previous generations with limited elective surgeries, restrictions to the number of surgical assistants in theatre and increasing demand for service provision.⁹ Simulation platforms, such as cadaveric dissection or virtual reality (VR) systems, enable understanding of three-dimensional anatomy, acquisition of surgical skills and improvement in competency without compromising patient safety. A recent systematic review proved that cadaveric simulation induces short-term skill acquisition by objective means.¹⁰ However, there is limited evidence regarding long-term skills retention or transference of skills from cadaveric training to live operating setting. Through construct validation, we demonstrated statistically significant improvement in understanding of head–neck surgical anatomy as well as subjective level of confidence in procedures such as neck dissection and laryngectomy. As we progress to the recovery phase of the pandemic, it is vital to focus on training gaps. Surgical simulation, in the form of cadaveric courses, would provide an effective and safe alternative not just to trainees to develop their skills, but also to trainers to revisit their techniques in this period of limited operative exposure.¹¹

Challenges and adaptations

Multiple obstacles were encountered in the planning and conduct of this course. First, the course was postponed twice due to lockdown restrictions imposed nationally. Thereafter, the dissection laboratory had to be prioritised for medical students, because social distancing measures meant up to four times the number of sessions were required for the same module compared with pre-COVID times.⁶ Second, the safety of all attendees as well as residents of the campus had to be ensured. The resumption of undergraduate teaching, presence of time-tested COVID secure measures in the campus and rollout of vaccinations helped from the safety perspective. Apart from human-to-human transmission, the unknown risk of transmission of the virus from dead bodies to humans was considered.¹² Cadavers were chosen from before the onset of the pandemic and their causes of death were confirmed to be not related to COVID-19. With detailed risk assessment and use of standard universal precautions, risk of transmission of Hazard Group 3 organisms, such as COVID-19, is minimal to staff involved in autopsy/cadaveric dissection.¹³ Candidate feedback (content validity) corroborated the safety measures in place during the course (90% ‘excellent’ and 10% ‘good’ ‘Safety measures with regards to COVID-19’).

Future developments

The results of content validation demonstrated avenues to improve the course in the future, such as revision of the dissection manual and the provision of headlights to individual candidates. To maximise learning for future candidates, pre-course material could be sent out in advance and a live faculty demonstration of parotidectomy be arranged (in view of poor scores in the SBA exam and limited improvement in level of confidence).

Factors, such as the availability of cadavers and safety concerns with regards to COVID-19 transmission may continue to shift the balance towards VR-based simulation in the future.¹⁴

Human cadaveric dissection, with its relative affordability and accurate depiction of surgical anatomy, is an invaluable resource for surgical training across all specialities.¹⁵ Although there is no proven difference in knowledge acquired between VR and traditional cadaveric dissection, trainees and faculty can vouch for better surgical skill development with cadavers because they offer more realistic tissue handling.¹⁵ As COVID-19 related restrictions are expected to continue in the foreseeable future, our protocol for a COVID-safe cadaveric dissection course could be implemented not just in the UK but also internationally across all surgical specialities to help alleviate training gaps.

Conclusions

The COVID-19 pandemic has severely compromised surgical training in the UK and its ripple effects will be felt in the coming years. There needs to be emphasis on surgical simulation courses, such as cadaveric dissection, to consolidate techniques and accelerate skills acquisition for surgical trainees. Our statistically significant course feedback shows the dramatic improvement in confidence and understanding that a cadaveric dissection course has on surgical trainee operative technique. This is an invaluable learning environment that needs to be encouraged despite infection control restrictions. We demonstrated that a cadaveric dissection course, using thorough risk assessment and protocol, could be safely conducted with high content and construct validation during these unprecedented times.

Conflicts of interest

None.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.