Simulation

Tissue Handling and Dissection

Simulation

Model 1: Pelvic Sidewall Dissection

- Heavy duty grouting sponge (7.5x 5.25-inch x 2.25 inch)
- Freeze pops (Fla-Vor-Ice)
- Cotton bunting
- Spray adhesive (Flex Seal Clear)
- 3/8-inch diameter rope
- Multipurpose sealing wrap (Glad Press’n seal)
- Corkboard or plastic platform
- Plastic spring clips
1. Cut sponge in half to create base of pelvic sidewall.
2. Wrap one freeze pop in press-n-seal wrap (“artery”).
3. Place two freeze pops (one wrapped “artery” and one regular freeze pop “vein”) at junction of sponge (Figure 1).
4. Cover “vessels” with cotton bunting (Figure 2).
5. “Ureter” preparation: rope placed between two layers of heavy duty press-n-seal saran wrap (Figure 3).
6. Spray cotton bunting with adhesive and place ureter preparation over vessels/pelvic sidewall (Figure 4).
7. Use clips to secure saran wrap to sponge and secure sponge to platform (Figure 5).
Figure 1 - Freeze pop vessels placed on “pelvic sidewall” sponge.

Figure 2 - Cotton bunting placed over “vessels.”

Figure 3 - Ureter/peritoneal preparation (shown prior to placement of second piece of press-n-seal).

Performance

Techniques are demonstrated in the following images:
- “Grasp and tent”
- “Push and spread”
- “Gentle teasing/blunt dissection”
- “MM by MM” sharp dissection
- “Skeletonization”
- Demonstration of venous injury with leak from freeze pop vessel
Figure 4 - Ureter with peritoneum placed over sidewall.

Figure 5 - “Peritoneum” layer secured to sponge sidewall; sponge secured to platform.

Image A: “Grasp and tent” technique demonstrated to open “peritoneum."

Image B: “Push and spread” technique to expose “ureter” under peritoneum and connective tissue.

Image C: “Gentle teasing/blunt dissection” to expose ureter on medial leaf of peritoneum.

Image D: “Mm by mm” sharp dissection of peritoneum/connective tissue to mobilize ureter.

Image E: “Skeletonization” to further mobilize “ureter” from underlying “vessels.”

Image F: Demonstration of venous injury with leak from freeze pop vessel.

Model 2: Anterior Vaginal Wall Dissection

- 8-inch diameter plastic planting pot
- Heavy-duty scrub sponge (Scotch-Brite 4.5x2.7-inch by 0.6 inch)
- Corkboard or plastic platform
- Plastic spring clips
1. Cut parallel slits on side of plastic planter pot (Figure 1)
2. Secure sponge to side of planter pot using clips (Figure 2)
3. Secure pot to corkboard base (Figure 2)
4. Secure base to table top (Figure 2)
5. Sponge can be moistened with spray bottle to simulate tissue moisture (Figure 3)
Image A: Learner can be assessed based on accuracy of dissection between darker “epithelium” and lighter “connective tissue.” In this image, dissection is too deep on the upper left and too superficial on the lower right.
Image B: Midline incision into “epithelial” layer.
Image C: “Push and spread” blunt dissection.
Image D: “Mm by mm” sharp dissection of epithelium from underlying connective tissue.
Image E: “Traction-counter-traction,” where learner directs assistant to achieve optimal traction/counter-traction effect during dissection.

References

Birkmeyer JD, Finks JF, O'Reilly A, Oerline M, Carlin AM, Nunn AR, et al. Surgical skill and complication rates after bariatric surgery. Michigan Bariatric Surgery Collaborative. N Engl J Med 2013;369:1434-42.
Rogers RM Jr, Taylor RH. The core of a competent surgeon: a working knowledge of surgical anatomy and safe dissection techniques. Obstet Gynecol Clin North Am 2011;38:777-88.

Contributing Authors

Jeffrey Cornella, MD, Mayo Clinic - Scottsdale, Arizona
Marlene Corton, MD, Professor of Obstetrics and Gynecology - University of Texas Southwestern Medical Center
Rajiv Gala, MD, Ochsner Health System
Oz Harmanli, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine
Jamie Bashore Long, MD, Director, Center for Pelvic Health and Chief of Urogynecology, Reading Health System - Pennsylvania
Doug Miyazaki, MD, Novant Health - North Carolina
Michael Moen, MD, Professor of Obstetrics and Gynecology, Chicago Medical School/Rosalind Franklin University
Mikio Nihira, MD, Professor, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center
Amy O’ Boyle, MD, Captain, USN, MC, Fellowship Director Female Pelvic Medicine and Reconstructive Surgery, Walter Reed National Military Medical Center
John Riggs, MD, Associate Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas Health Science Center at Houston (UTHealth)
Robert Rogers, MD, Kalispell Regional Medical Center - Montana
Carmen Sultana, MD, Professor of Clinical Obstetrics and Gynecology, Weill Cornell Medical College

Tissue Handling and Dissection

Simulation

Model 1: Pelvic Sidewall Dissection

Model 2: Anterior Vaginal Wall Dissection

References

Contributing Authors

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