Introduction
Recent challenges for UK surgical trainees, including changes to the training model, staff shortages, service provision, doctor’s pay restoration strikes and post-coronavirus disease 2019 pandemic effects, have affected trainees’ operating theatre time.Reference Robinson, Luton, Mellor, James, Hopkins and Powell1, 2 Rapid resolution of these issues is essential given the current issues with National Health Service provision.
It is crucial that each operating theatre opportunity is maximised in terms of quality for trainees to gain optimal surgical proficiency,Reference Rupani, Evans and Iqbal3 thus an emphasis on simulation training of basic surgical skills, outside of the operating theatre environment, has been promoted to enhance operating theatre time.
Tonsillectomy and tonsil tying are often the first surgical techniques learnt by ENT trainees.4 The National Tonsillectomy Audit recommended that all trainees must be competent in tonsillar ties before learning other techniques,4 therefore the use of simulation training has become an invaluable tool for learning early skills in the ligation of vessels without compromising patient safety, to enhance productivity in operating theatre time and the training opportunities available.
Simulators for tonsil tying exist, for example basic skills models focusing on tonsil tying (Cardiff cup,Reference Al-Hussaini, Addams-Williams and Tomkinson5 tissue box,Reference Wasson, de Zoysa and Stephens6 Birmingham shoeReference Street, Beech and Jennings7), those of higher fidelity (Nottingham tonsillectomy haemostasis simulator,Reference Ross, Jaiswal and Jones8 Yorick’s skull,Reference Raja, Haneefa and Chidambaram9 Telford,Reference Douglas, Senior, Scott and Douglas10 Bhat, Kaliavaradan, Muruganidhi and Sethu modelsReference Bhat, Kaliavaradan, Muruganidhi and Sethu11) and some with intrinsic objective feedback mechanisms.Reference Evans and Owens12 Some simulators are more complex, requiring time and skills to assemble. Some require modification of other non-simulation models (e.g. AirSim Bronchi from TruCorp,Reference Douglas, Senior, Scott and Douglas10 model skullReference Raja, Haneefa and Chidambaram9, Reference Evans and Owens12) or equipment that may be difficult to locate and require time and skill to create circuits.Reference Evans and Owens12 The models focusing on tonsil tying are simple and effective, but may not provide feedback on tension because of tying to paperclips or wires.
We present the TonsillectomEase trainer, a simple, low-cost and effective model for tonsil tying that incorporates a degree of objective self-directed feedback on artery ligation tension, is depth modifiable as the trainee’s level of skill progresses and offers training to both dominant and non-dominant hands.
Materials and methods
Equipment
This TonsillectomEase trainer requires the following equipment: urine bottle, strawberry laces confectionary (thick and thin), headlight, tonsillectomy instruments (silk or cotton tie, Boyle–Davis gag, Negus knot pusher, curved scissors, curved Negus forceps, Birkett’ tonsillar artery forceps), endotracheal tube and tape (optional), cotton ball or gauze (optional) and Hibiscrub (optional).
Easy two-step assembly
Step 1
Two holes are made with the curved scissors to the lateral walls of the urinary bottle. The size of the hole depends on the width of the strawberry laces used and the optional use of cotton wool and/or gauze, both of which are inserted into the holes.
Step 2
The Boyle–Davis gag is applied. Optional endotracheal tubing can be taped to the superior inner aspect of the urinary bottle, thereby simulating the need to apply the Boyle–Davis gag whilst being mindful of the airway. See Video for demonstration of assembly and use of the Cardiff TonsillectomEase Trainer (available in the online journal https://www.dropbox.com/scl/fi/rruc7t3z41zopthbmxdlq/The-TonsillectomEase-Trainer-dropbox.mov?rlkey=hnuzmmt691ajpev0eczmrv955&st=l27mwjml&dl=0).
Results
Ready to practice
TonsillectomEase trainer should be taped to a table or held on the lap. The strawberry laces simulate the texture and delicacy of the arterial vessels. As the trainee advances, thinner arteries (thinner strawberry laces) and greater depth of the artery placements can be introduced. Eventually, cotton gauze or wool soaked in HibiScrub can be placed around the artery to simulate a bleeding artery and its slippery texture.
Objective feedback
Trainees will need to apply appropriate tension without (1) cheese wiring the artery, which indicates that tension is too high; (2) losing the artery as the cotton wool simulating the tonsillar tissue is introduced; and (3) slipping off the artery as the HibiScrub is introduced.
Adjustment for progressing beginners
We suggest the following parameters for trainees: (1) beginners: 3 cm depth, large strawberry laces; (2) intermediate: 6 cm depth, thin strawberry laces; (3) advanced: cotton wool or gauze soaked in HibiScrub wrapped around the artery.
The TonsillectomEase trainer can be used to practice at work between operating theatre cases or in home environments.
Conclusion
The TonsillectomEase trainer allows trainees to practice their manual dexterity, and knot tying with tension and texture. This objective feedback potentially allows more rapid acquisition of skills training than its subjective only counterparts. It is simple, easy to make and affordable as it does not require extra equipment. As this model’s objective feedback is very rudimentary , there is the potential for more sophisticated audio and visual feedback, which would increase the build complexity.
• With wider issues in healthcare (staff shortages, strikes and the coronavirus disease 2019 pandemic), opportunities to develop surgical skills are limited
• A simple, low-cost and effective tonsil knot-tying trainer was constructed with materials found in the hospital setting
• The trainer is modifiable for the progressing trainee with a degree of objective feedback
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S0022215125102764.
Competing interests
None declared.
