The Anatomy of a Lab: Experiences in the Development of an Advanced Digital Microsurgical Training Facility

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(LAST UPDATED 3/17/2020: Professor & Drylab Microscope hardware updated)

Introduction

Microsurgical training is a major component of ophthalmology residency education, and is taught in a progressive manner over the course of a structured three-year curriculum. Given the complex nature of ophthalmic procedures, numerous challenges exist for both students and teachers alike. The implementation of robust simulation-based training is necessitated due to procedural complexity, logistic and ethical concerns for patient safety, and relatively limited case volumes. [1]

The importance of wet lab training in ophthalmic residency has been recognized and mandated by the Accreditation Council of Graduate Medical Education (ACGME) in 2005.[2] Simulation training allows learners to practice the steps of microsurgical procedures, develop coordination, and learn the nuances of instruments and equipment; this has been shown to improve technical proficiency, and even decrease actual surgical complications.[3][4][5] A thoughtfully designed curriculum allows learners to interact with teaching faculty in a relaxed environment. This provides an opportunity for students to best understand technical nuances and expectations, and for educators to assess proficiency and develop a rapport prior to working together in the actual operating theater. Yet, despite this long-standing ACGME requirement, large variability remains among training programs, and best practices are yet to be validated and universally adopted.

A major advancement, and the basis for the curriculum of many training programs, was provided in the publishing of the Iowa Ophthalmology Wet Laboratory Curriculum in 2007[6], along with a step-by-step guideline in establishing a wet lab by Henderson et al. in 2009[7]. The aim of this article is to augment these established fundamentals with a practicum allowing residency training programs to help develop facilities, and integrate simulation training into the core curriculum. This article highlights our experiences in the development of the Ronald M. Burde Microsurgical Simulation Laboratory at Montefiore Hospital, and details how the latest educational technologies were leveraged to optimize the first fourteen stations of the training facility.

Overview of Wet Lab

A total of five student wetlab workspaces (Figure 1A) were created, each with a phacoemulsification platform, Leica operating microscope with integrated video and foot pedal control, and dedicated microsurgical instruments. A sixth “professor station” additionally displays to a 75” Promethean digital whiteboard (Figure 2A), allowing the teacher to not only present traditional didactics, but to furthermore overlay text and “draw” on figures, diagrams, and surgical videos. This digital whiteboard furthermore mirrors the video feed to satellite television monitors throughout the room optimized for viewing angle (Figure 2A&3). This setup allows for teaching faculty to present didactics, perform live demonstrations, and offers tele-education capabilities.

An additional eight stereo microscopes mounted on articulating arms were installed to serve as Drylab stations (Figure 4), each with integrated wireless bluetooth cameras displaying to 12.9” Ipad Pros. These stations together have the capability of creating a “digital classroom”, and allow for video recording and editing, beyond providing a realtime heads-up display for observers and teaching faculty. Additional wetlab and drylab stations will be incorporated in an upcoming phase of development to complete the final stage of expansion.

It is required to have operating microscopes (such as the Leica M620) to perform any major intraocular procedure simulations, as these tasks require multiple planes of focus (phacoemulsification, glaucoma drainage implantation, vitrectomy, angle surgery, etc.).

The stereo microscopes used in the drylab stations (such as the Zeiss Stemi305) are meant for monoplanar tasks which only require magnification and limited depth of focus (corneal suturing, IOL loading, CCC, pupil expansion devices, simple incisions, etc.).

There is a major cost difference between operating and stereo microscopes, with the former being on average at least 5x the cost per unit. We chose to initially outfit our laboratory with 5 operating (wetlab) and 8 stereo (drylab) microscopes to maximize function and the number of stations. This optimizes the space so that students at different levels can all work simultaneously, as we have found that labs run far more effectively and efficiently when an optimal 1:1 ratio of learner:station is achieved. Operating microscopes mounted to articulating arms are an optimal choice if cost and space are not major considerations, and the choices made in this article represent a balance between our desired functionality and budget. Our next slated expansion will likely include 4 more operating microscopes and an additional 4 more stereo microscopes for a total of 10 wetlab and 12 drylab stations.

Another contiguous laboratory space was totally remodeled, and a dedicated 10 station multimedia computer laboratory (Figure 5) and conference room was designed to allow for networked didactics and group learning activities among residents. The entire laboratory facility is open and available to residents and students 24-7, and is designed to be conducive to self-directed and group learning, at any convenient opportunity.

Hardware and Specifications of Wet Lab

Figure 1A. A total of 5 wetlab workstations, each consisting of a phacoemulsification platform, Leica operating microscope with integrated video and foot pedal control with integrated fluid management.

Wet Lab Surgical Stations

#5 total (expansion to a total of 10 planned for 2020)

Leica M6220 TableTop Mounted Microscope with Foot Pedal

  1. Integrated Sony video cameras (3CCD Exwave HAD)
    • a. These cameras were purchased refurbished and are discontinued from Sony. Equivalent cameras can be sourced through Leica, and can be HD
    • b. The 3Chip picture quality is beyond adequate for most wetlab purposes, but the newer HD format is superior, but at a cost. An advantage of the newer HD cameras is that they output via more modern adaptors (HDMI as opposed to VGA), and are therefore easier to integrate.
  2. Leica Camera Adaptor (Full HD OptiChrome f=55mm) for
  3. Acer 17” table top display (Model V176L)
    • a. This monitor was sourced for its small footprint and ability to handle VGA input. A more updated HD system would allow use of different options with HDMI input.

Alcon Infiniti Phacoemulsification Unit (#5)

  • Some of the units were donated by the Alcon Foundation, and the remainder purchased during an upgrade to the Centurion Platform
  • Handpieces, BSS Bottles, and Infiniti supplies were donated by Alcon

AMO Whitestar Signature Phacoemulsification Unit (#1)

  • Whitestar Unit, handpieces, and packs were donated by J+J Vision
Figure 1B. A customized wetlab workstation with integrated fluid management.

Custom workstation with integrated fluid management system

(Figure 1B)

  1. The integrated sink allows for fluids to be easily handled right from the surgical station.
  2. A modified shallow bar sink was installed and sourced from a restaurant supply manufacturer (Kegco Drip Tray), and a simple reusable tin painting tray placed over the drainage system provides an extremely cost effective and efficient way to manage fluids and simplify cleanup.
  3. Millwork
    • a. Countertop
      • i. Corian was chosen for cost, durability, ease of maintenance, and customizability. If a wetlab space needs to double as a research laboratory, the choice of countertop material needs to be carefully evaluated to ensure that it meets lab specifications accordingly.
      • ii. The Kegco shallow drip tray (with integrated removable grate designed to prevent solids from falling into the drain) was installed flush with the counter surface in the center of workstation for optimal fluid management. Custom corian sinks were cost prohibitive, and standard basins are generally too deep for use, and will furthermore result in issues with knee clearance under the station.
      • iii. The height of the countertop, knee clearance, and desk width were calibrated with adjustable stool height to optimize foot pedal integration. These specifications are critical to allow for multiple users of different heights to be able to work with optimal ergonomics. The large adjustments in bed, stool, and microscope position in the actual operating room are difficult and resource intensive to recreate in a wetlab environment, and therefore the millwork in the lab required some degree of customization.
    • b. Cabinetry
      • i. Holds supplies for each station/personal items
      • ii. Stores Leica and Sony controller boxes and manages wires
      • iii. Sliding desk extension to increase work surface
    • c. Electrical
      • i. Multiple quad outlets were all connected to a unified switch allowing students to easily power on/off the system. Very important that the microscope lamps are not inadvertently left on after use. There is a very high risk of the system overheating with extended use, and a terminal power switch is critical to make sure that the room is fully off when not in use.

Professor Station

AudioVisual

Figure 2a. A professor station with a large 75” touchscreen Promethean monitor with advanced whiteboard capability outputting to 3 large screen monitors.  
  1. A large 75” touchscreen monitor with advanced whiteboard capability (Promethean ActivPanel) mounted to an adjustable height hydraulic stand (Chief X-large FUSION XTM1U)
  1. The Chief Fusion stand allows the Promethean to be easily adjusted to varying heights allowing for optimal ergonomics regardless of the height of the user.
    • a. Promethean ActivPanel have built-in android computers, and have numerous applications and online capabilities built in
  2. Two 75” Samsung Flat panel Television monitors (UN75NU8000F 8 Series)
  3. One 80” Sharp Aquos Television
    • a. The closed-circuit configuration allows for the Promethean Smartpanel to output to large satellite televisions without the need for complex AV system integration, which is a massive cost savings compared to digital AV systems.
    • b. The Promethean panels have a native HDMI output which can be split into multiple signals for simultaneous viewing. Beyond cost, another major advantage of this setup is the ability to output the Promethean whiteboard signal throughout the room, and does not require complicated setup.
  4. Apple Ipad Pro 12.9” mounted in a locking base (Compulock SpaceFlex)
    • a. This Ipad has a dedicated output (USB-C to HDMI) directly to the Promethean/Satellite televisions
    • b. The image from the microscope (Figure 2b) is mirrored to the Promethean/Satellite monitors so everyone in the room has an unobstructed viewing angle
    • c. The Ipad doubles as a document camera (Figure 2b), and allows for live demonstrations of non-microscopic tasks (IOL loading, etc.) without the need for any additional hardware or inputs
  5. Wireless Speaker system (Shure Lavalier WL93 with Yamaha VXC3FW speakers)
    • a. Professor station wirelessly connects lapel microphone to ceiling mounted speakers
    • b. This setup allows professor not only hands free audio amplification, but has the added benefit of allowing the teacher to freely walk around the space
    • c. Crown XLS DriveCore 2 Series XLS 1002 Power Amplifier

Microscope (UPDATED 3/17/2020)

  1. Leica S9i Stereo Greenough Microscope table mounted with an articulating arm
    • Integrated Bluetooth camera with wireless Ipad connectivity
      • Camera has integrated HDMI-out capability
      • We used the wireless option to sync with the Ipad using the Leica imaging app
        • Ipad outputs video image using USB-C/HDMI adaptor to the Promethean
        • Ipad also functions as a table top camera to do macroscopic demonstrations such as showing hand/wrist positioning during suturing
      • Leica A60F articulating arm with table mount option
      • LED Ring illuminator
        • Coaxial positioning allows for uniform illumination and shadow-free
        • No diffuser/polarizer needed, and allows for optimal light intensity
        • Integrated into microscope, so no additional hardware or table top controls needed
    • Fusion Optics allowing for excellent depth of field and large range of magnification
    • Native video output from Leica S9I provides larger field of view than Zeiss Stemi 305
      • Leica S9i does not require reducing lenses to improve field or video output
  • ***Stereo microscopes are NOT designed to focus on multiple surgical planes, such as during phacoemulsification. They can be used to perform basic suturing, CCC, IOL loading, corneal/scleral incision/dissection practice***
  • ***Operating microscopes are well suited for any surgical task, but requires a far more extensive setup. ***


Drylab Stations

Figure 3. An overview of drylab workstations as of 3/2020. Large 80” wall mounted television mirrors the professor station monitors utilizing HDMI splitter

#8 total (UPDATE 03/17/2020:  Expansion of an additional 8 drylab stations planned with Leica S9i Stereo Microscopes mounted using articulating arm- See Professor Station microscope)

Figure 4. A total of 8 drylab stations with stereo microscope, wireless Bluetooth camera control with individual large format iPad integration with digital classroom capability

Hardware

  1. Microscope: Zeiss Stemi305 mounted on Stand-U (Articulating Arm)
    • a. This camera features an integrated wireless Bluetooth camera that connects to a 12.9” Ipad Pro
    • b. The Stand-U articulating arm is a critical piece of the setup, as the traditional Stemi base does not work well with kitaro kits or other simulators.
    • c. A 0.75 reducing lens helps improve the field of view, as the native magnification and working space of the Stemi 305 can be too magnified for many tasks.
    • d. LED Illuminators (#8) Zeiss CL6000 LED Cold-light source
      1. Additional illumination of the surgical field installed at each station with fiber optic coaxial cables
      2. Wire management utilizing Stand U articulating arm

Furniture

(4 “Islands” each with 4 Stations)

  1. Millwork (#4) (Figure 4)
    • a. Each island designed to hold 4 drylab stations Power management for 4 Ipads and 4 microscopes with LED cold-source requires extended power strips (#2), each with 8 outlet capability with surge protection (Tripp-Lite)
  2. Sink Integration
    • a. 2 deep basin sinks with telescoping faucets with integrated sprayer per island
      • i. Sprayer attachments allow for instruments to be cleaned after sessions when animal eyes are used
      • ii. Acrylic guard/backsplash to protect microscopes and LED illuminators
  3. Stools
    • a. Actual surgical stools designed for OR use can be cost prohibitive, and the decision to purchase standard office exam chairs (Brewer New-Matic with backrest ST0OT1020BBLFG) with extended vertical excursion was made. This choice is important to optimize ergonomics for short and tall users given microscope positioning and working distance of the microscopes and needs to be calibrated to the desk height.
    • b. Real operating room chairs offer wheel locks and the benefit of being ergonomically identical to the OR setting, and are preferred if cost is not an issue, and the style/height/footprint of the OR stool is appropriate for the simulation station.
  4. Audio-Visual
    • a. IPad Pro (12.9”) mounted in Compulock Flexible Security Stand
    • b. Stemi305 Integrated Wireless bluetooth camera controls
    • c. Zeiss App downloaded to each Ipad with 1:1 local connection using native SSID Wifi from microscopes
    • d. Tripp-Lite Power management system- 8 Outlet x 2 for total of 16/island
      • i. Allows constant charging of Ipad
      • ii. Allows for LED Cold-Source and Stemi 305 powering
Figure 5. A digital conference facility for didactics, networking and group learning activities

Conference Room

  1. 10 computer stations
    • MiniDell computer terminals
  2. Promethean Active Panel (70”) Touchscreen
  3. Conferencing hardware
    • Lifestyle module
    • ClickShare integration
  4. 3-D printer
  5. Podium
    • Alienware desktop computer with Oculus Rift head mounted design
    • Olympus BH2 glass-slide microscope with video integration

Acknowledgments

We would like to thank our leadership, engineering and design teams, support staff, and countless donors and alumni for their incredible dedication and support to our training program and residents. 

References

  1. Neufeld A, Hanson LL, Pettey J. Teaching in the operating room: trends in surgical skills transfer in ophthalmology. Ann Eye Sci. 2017;2:41.
  2. ACGME Program Requirements for Graduate Medical Education in Ophthalmology, available at https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/240-Ophthalmology_2019_TCC.pdf?ver=2018-08-02-083941-257
  3. Rogers GM, Oetting TA, Lee AG, et al. Impact of a structured surgical curriculum on ophthalmic resident cataract surgery complication rates. J Cataract Refract Surg. 2009;35:1956-1960.
  4. Staropoli PC, Gregori NZ, Junk AK, et al. Surgical Simulation Training Reduces Intraoperative Cataract Surgery Complications Among Residents. Simul Healthc. 2018; 13(1):11-15.
  5. Pantanelli SM, Papachristou G, Callahan C, et al. Wet Lab-Based Cataract Surgery Training Curriculum for the PGY 2/PGY 3 Ophthalmology Resident. MedEdPORTAL. 2018;14:10782.
  6. Lee AG, Greenlee E, Oetting TA, et al. The Iowa opthalmology wet laboratory curriculum for teaching and assessing cataract surgical competency. Ophthalmology. 2007;144(7):e21-6.
  7. Henderson BA, Grimes KJ, Fintelmann RE, Oetting TA. Stepwise approach to establishing an ophthalmology wet laboratory. J Cataract Refract Surg. 2009;35(6):1121-8.