Journal of Hand and Microsurgery

Description and validation of an innovative and effective hand-shaped suture-training

model for medical students
--Manuscript Draft--

Manuscript Number: JHAM-D-19-00081

Full Title: Description and validation of an innovative and effective hand-shaped suture-training
model for medical students

Article Type: Ideas and Innovations

Abstract: During medical education, medical students are often frustrated by difficulties in
translating theoretical basic surgical skills (surgical anatomy, suturing, tissue and
instrument handling, local anesthetic administration) into practice due to lack of a low-
cost and easy-to-assemble low fidelity suturing model. A practical and inexpensive pre-
clinical suturing and local anesthesia hand-shaped anatomy training model is
demonstrated. It is addressed to medical students and graduates that wish to get
acquainted with hand anatomy and improve their basic surgical skills.The model
requires only 2 latex gloves, cotton and 2 markers (red and green) per trainee.
Construction requires less than 15 minutes. For validation, eighty students participated
as volunteers in the demonstration course. They evaluated course usefulness and their
own confidence after the course.According to the 5-point Likert scale, the participants’
confidence increased in a statistically significant way (p<0.05). All participants (100%)
stated that their skills were “significantly improved” in terms of instrument handling,
anatomy studying, performing digital anesthesia and suturing technique. Overall
experience was rated as “satisfactory” or above. The proposed modelenables safe
gentle soft-tissue handling and it resembles a realistic human tissue.Low cost,
availability and fast construction are the most important characteristics, making this
validated training model appropriate for acquiring fundamental local anesthesia,
respect for hand neurovascular anatomy and suturing skills.

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 Description and validation of an innovative and effective hand-shaped
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2 suture-training model for medical students
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9 Authors: Aristeidis Zibis1, Apostolos Fyllos2, Zoe Dailiana2
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1Department of Anatomy, Faculty of Medicine, University of Thessaly
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15 2Department of Orthopedic Surgery, Faculty of Medicine, University of
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24 Corresponding author:
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27 Zoe H. Dailiana, MD, PhD, Professor
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30 Department of Orthopaedic Surgery, Faculty of Medicine, University of Thessaly, 3
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32 Panepistimiou St, Biopolis 41110 Larissa, Greece.
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36 e-mail: dailiana@med.uth.gr, phone: +302413502722, Fax: +302413501011
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3 Keywords: suture training; model; hand-shaped model; hand anatomy;
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6 medical education; effectiveness of hand anatomy education; self-made
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8 training model.
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 Introduction
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3 Suturing expertise and experience remains one of the most significant
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6 and frequently used skills not only in the surgical field but also as a basic skill
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8 for the general practitioner, and it should be an integral part of the curriculum
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10 in medicine. Previously, formal training in basic surgical skills was not part of
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13 the curriculum and most medical students had their first lessons by observing
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15 and then practicing their skills on patients, using the formula “see one, do one,
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18 teach one”.1 This constitutes a practice which could raise medicolegal and
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20 ethical issues.2 One of the most substantial prerequisites for successful
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23 suturing skills is thoughtful and adequate training.
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26 There are various models for preclinical suture courses. High fidelity
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28 models are as close to reality as possible (animal skin, cadaver training), but
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31 they have disadvantages such as limited availability, high cost, storage
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33 difficulties, risk of infections, and ethical issues. By contrast, low fidelity models
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(foam, self-made models, fruit skin) are easily available, low cost materials and
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38 can be repeatedly used. Most of them however, present certain disadvantages,
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40 such as finite life, difficult acquisition and storage and are difficult to reproduce
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43 at home. It has been found that training on low-fidelity simulators was similar to
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45 training on high-fidelity simulators.3
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48 Although textbooks and videos that demonstrate suturing techniques are
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51 available everywhere nowadays, it is the translation of this theoretical
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53 knowledge to practical performance in clinical cases that agitates medical
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56 students and future residents. Medical students and young doctors feel
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58 inexperienced, stressed and technically unconfident, and are intrigued by
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 hands-on and tool-using experiences.4 Thus, the use of a teaching model,
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5 realistic circumstances, is necessary. This paper describes the construction of
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7 an ethical, practical, realistic, reproducible, and cost-effective suturing model
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10 for preclinical training, without using animal or human tissues, with satisfactory
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12 validating results.
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Materials and methods
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22 This self-made training model requires materials of daily use, including
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24 2 latex surgical gloves of the same size, cotton, and 2 board markers (red and
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green). For suture-practicing a needle holder, forceps, scissors and 3/0 sutures
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29 are required. At first, one of the gloves is stuffed with cotton so as to give the
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31 impression of a human hand. On this structure, the arterial (red) and nervous
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34 (green) network of palmar and dorsal surface of the hand are outlined by the
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36 students with the use of the two board markers, based on an anatomical atlas
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39 and with the aid of a supervisor (Figure 1a). Then, the second latex glove is
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41 placed over the hand-made construction. The two gloves are tied together at
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their proximal parts. The training model is ready for use and this requires
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46 approximately 10-15 minutes to complete. Simultaneously, sites for safe use of
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48 local anesthetic injection are also demonstrated. An incision is created on the
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51 upper layer and suturing process begins (Figure 1b), with particular attention to
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53 avoid suturing the underlying glove and outlined neurovascular structures.
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56 The training protocol was evaluated by 80 first- and second-year medical
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59 students with no surgical skills background (novices) that volunteered to take
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 part in the study, from a single academic center, after signing a consent form.
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2 The questionnaire on the suturing skills and trainees’ comfort level was handed
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5 before and after the course. Students rated their confidence on a 5-point Likert
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7 scale with the lowest rating (very unconfident) being 1 and the highest rating
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10 being 5 (very confident).5 In addition, the participants were asked to rate their
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12 satisfaction with the model, and to provide self-assessment of their own
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15 eligibility. All 80 study participants completed pre- and post-training
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17 questionnaires in order to measure self-perceived confidence in performing
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simple interrupted sutures and digital anesthesia block.
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23 On the day of the course, all participants were instructed how to use
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25 surgical instruments and what was expected of them on the glove model by
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means of an instructional video presentation. A supervisor was assigned for
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30 every 5 students, in order to directly address and resolve any questions and
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32 errors. A task specific checklist was met by every participant, including incision,
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35 proper tissue and instrument handling, suture passing, knot tying, and
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37 performing a digital block. The total cost of materials (80 pairs of latex gloves,
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40 enough cotton to fill them,12 board markers, sutures) for 80 students was 50
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42 euro. Student’s t-test in Microsoft Excel for Mac was used for statistical analysis
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of questionnaire results.
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51 Results
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54 Increased confidence (p<0.05) after training was found from the
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56 comparison of pre- and post-training self-evaluation forms. According to the 5-
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 1.2, range from 1 to 2), while their confidence increased at the end of the course
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2 in a statistically significant way (p<0.05, mean: 4.325, range from 3 to 5).
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6 Of 80 participants, 85% (n=68) were “very satisfied” with the course
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8 experience, while the remaining 15% (n=12) rated their experience as
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13 usefulness.
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16 The absolute majority of participants (100%) upon completion of their
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self-evaluation forms after the course, stated that their skills were “significantly
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21 improved” in terms of instrument handling, hand anatomy studying, and
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23 performing digital anesthesia and suturing technique.
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30 Discussion
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33 The proposed teaching model is simple and stands out in terms of
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35 availability of materials and practical applications. Cotton is an easy to find and
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38 safe material that resembles the deeper connective tissue and the gloves are
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40 similar to the subcutaneous cellular tissue. The superficial glove simulates the
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texture of skin and offers acceptable resistance to the passage of a suture
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45 needle with no significant effort. As the incision is placed over a curved surface,
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47 the incised wound gapes, which reflects a realistic situation leading to
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50 understanding the wound tension and the need for adequate suture placing. A
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52 variety of incisions (straight versus curved versus Z-type) apart from suturing
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55 technique can also be practiced, as well as different plasty-techniques for more
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 extensively and gain confidence before they enter the emergency department
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6 Simulation is an instructional strategy used to teach technical skills,
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8 procedures, and operations, by presenting learners with situations that
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13 advantages such as allowing the student/doctor to acquire surgical skills before
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15 operating on a patient and receiving an objective evaluation of his efficiency by
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18 the supervisors. According to our results, this model allows the trainee to
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20 increase the speed, efficiency, automaticity, and precision through practicing
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23 and refining skills.6 Low-fidelity models, in comparison to actual skin on a
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training opportunities, adding to the medical education and not jeopardizing it.7,8
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31 This bench model offers improved clinical perception of underlying
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actually resembles a specific anatomic site, the hand. The sketched
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40 anatomy. Furthermore, the self-practice can reduce the length of supervised
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43 training and can offer continued practice with periods of rest, in contrast to
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45 single, once-a-year exposure.
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48 A major limitation of this study is the lack of direct comparison and cross-
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51 reference with other teaching models, to highlight its advantages or
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53 disadvantages. In our medical school, lack of availability of high fidelity models
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 We feel that the proposed bench-model could be complementary or
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5 replacing them. The simplicity of materials creates the possibility of mass
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7 production. Models prepared in this manner can be stored and preserved for
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10 several months. The availability, usefulness and cost-effective nature of the
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12 glove model, together with fast preparation time, makes this suturing simulator
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15 suitable when an affordable alternative is desired for preclinical education.
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24 Funding
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27 None
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Conflict of interest
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 References
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 Figure legends
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3 Figure 1a: First glove, stuffed with cotton, with neurovascular anatomy outlined.
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6 Figure 1b: Glove model of 2 layers: suturing of superficial glove layer while the
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8 underlying neurovascular anatomy is easily identified.
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Figure 1 Click here to download Figure FIGURE1ab.tiff
LETTER TO THE EDITOR

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Supplementary Material
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