Hugh Greenwood BAPS Neonatal Surgical Skills Workshop
Course Director Anthony Lander PhD FRCS(Paed) DCH
A team of surgeons from the UK, funded partly from monies donated by a Philanthropist called Hugh Greenwood, have delivered a number of Neonatal Surgical Skills Courses/Workshops principally in Africa.
In December 2017 BAPS ran the first one day Neonatal Surgical Skills Workshop in association with the ASEAN Society of Paediatric Surgeons (ASPS). The workshop was held in Manila and 30 trainees from the Philippines, Indonesia, Malaysia, Vietnam and Thailand attended. The course was hosted at the newly constructed Advanced Surgical Centre in Manila and was supported by Johnson & Johnson.
Content: This is a hands-on one-day surgical skills course in which registrants spend a significant amount of the day operating. The skills we cover include neonatal small bowel anastomoses, open Stamm gastrostomy, neonatal stoma formation, duodenal atresia repair and oesophageal atresia repair. The models use animal tissue.
Small bowel anastomosis: The warm up exercise is an interrupted extra-mucosal anastomosis in a length of porcine small intestine. This is unlike neonatal bowel but has important challenges that develop skills. The layers of the bowel wall are harder to handle than neonatal tissues. This model allows lots of suturing and is an excellent first exercise. Discussions include suture types, placement of sutures, use of assistants, physical properties and the handling of instruments. The exercise also allowed registrants to relax and get to know faculty and other surgeons.
Figure 1. An anastomosis in a loop of porcine bowel.
Stamm gastrostomy: An open gastrostomy can be performed in a porcine bladder acting as a stomach. This has proved a useful exercise and is not always as easy as some think.
Figure 2. Two purse strings in a Stamm gastrostomy in a porcine bladder.
Stoma formation: This exercise uses chicken intestine inside a neonatal abdomen made from a porcine bladder. This is an excellent model for stoma formation as shown below.
Figure 3. A porcine bladder is used for an abdomen with chicken intestine inside. A double barrel stoma is illustrated.
If the porcine bladders are large enough the bladder used for the gastrostomy can be reused as an abdomen for the fashioning of various types of stoma. Importantly, this model requires minimal preparation yet allows lots of teaching.
Duodenal atresia: This model has been used on a number of courses with success. The model sits on a supportive jig with a loop of porcine intestine for the proximal duodenum and a length of chicken intestine for the distal duodenum. A diamond anastomosis is fashioned. Porcine ureter can be used for the distal duodenum. The models are prepared in advance and stored in a fridge.
Figure 4. Pig intestine used for a proximal duodenum and chicken intestine for the distal duodenum. Left: incisions. Middle: a completed diamond anastomosis. Right: An anastomosis opened for inspection.
Oesophageal atresia: An opaque paper cup is used as a thorax with a pre-prepared thoracotomy window.
Figure 5. Paper cups used for a neonatal thorax with thoracotomy access.
The upper oesophagus is either pig urethra or chicken intestine. The trachea and fistula can be constructed from part of the bladder and ureter from a pig, or from the ileocoloc region of the chick with its paired caeca.
Figure 6. Left: OA TOF seen through a thoracotomy. Middle: piecemeal division of fistula. Right: separation of common wall between oesophageal upper pouch and trachea.
Figure 7. Left: Posterior sutures in place. Right: Transanastomotic tube passed before front wall sutures.