AN EDUCATOR’S PERSPECTIVE

JUSTIS P. EHLERS, MD

The field of vitreoretinal surgery is dynamic and exciting, with transformational tools and technologies enabling next-generations surgical techniques and procedures. These technologies range from new visualization systems to imaging platforms to surgical tools and instruments. The last 10 to 15 years have seen dramatic progress in the field, including small-gauge surgery, a broadening platform of handheld instrumentation, 3D surgical theaters, illumination devices, and intraoperative OCT.

The integration of these tools and systems into the operating room, particularly with teaching in mind, requires a careful plan for how to optimize effectiveness of the technology, enhance the surgical procedure, and maintain maximal surgical safety. Both for the surgeon and the trainees, there are several key factors that facilitate this process.

Be Prepared

Preparedness for technology use is likely the most critical factor in maximizing the surgical experience with these new tools. Key opportunities for preparedness include the following:

• Use the technology in a wet-lab or surgical simulation environment. Having this first experience outside of the real-time surgical procedure can reduce stress for that “first-in-hand” surgery.
• Familiarize yourself with the specific features and settings that are relevant to the device. Having to learn these types of features in the midst of the surgery may significantly increase the risk of an overall negative experience with the technology evaluation.
• Take time to learn from experts prior to utilization. This opportunity can include representatives from the company that is developing the technology or from other surgeons who have used the tools previously.
• Test the system functionality, if relevant, on the day of surgery prior to starting surgical procedures.
• Review the plan with the surgical team, particularly with complex platforms: a review of system functionality with the relevant surgical team members for the plan for use, special items that may be needed, room layout, and any potential planned troubleshooting mechanisms if needed.

Surgical Considerations: Plenty of Time and Case Selection

One other key consideration for using new technologies, particularly based on the impact on surgical workflow, is to plan for extra surgical time. This can be achieved through scheduling fewer cases and/or scheduling each case for a slightly longer planned surgical time. This can be helpful to minimize stress that can be created due to unforeseen delays.

Case selection is also critical for evaluating new technologies in an optimal environment. Select technologies may be best evaluated with specific underlying pathologies. Intraoperative optical coherence tomography, for example, has been shown to be particularly useful in cases with complex vitreoretinal interface pathology, such as epiretinal membrane or proliferative diabetic retinopathy. Surgical visualization enhancement systems, such as 3D surgical theaters, may be best initially evaluated on less complex cases and/or macular cases. These efforts for preoperative case selection can be critical not only to reduce surgeon stress but also to maximize the evaluation of the technology in optimal clinical scenarios.

Debrief After Surgery

As with any clinical or surgical challenge, reviewing the process and the experience can play a key role in modifying expectations and optimizing future experience with the technology and the system. Performing a debrief with the entire surgical team can maximize the value of the review experience. Key areas of review include the following:

• Troubleshooting experiences and potential pitfalls,
• Review of the case-specific experience,
• Future approaches to maximize experience, and
• Specific feedback for technology/tool use.

Putting It All Together

The vitreoretinal operating room has become a technologically advanced and rapidly changing theater for state-of-the-art surgical care. Dramatic improvements in computational power, visualization systems, and manufacturing techniques are helping to drive our field forward with emerging tools that will further enable us to care for our patients in new and exciting ways. Similarly to how anti-VEGF therapy transformed utilization of imaging for clinical disease management, new therapeutics (eg, gene therapy) are likely to drive further advancements in surgical techniques and provide new surgical tools and platforms. Adopting these technologies as surgeons and as teachers in a safe and efficient way is critical to preserving surgical safety and care while promoting next-generation education. A careful approach to teaching and learning through preoperative planning, surgical case selection, and postoperative debriefing can help facilitate the process.

A FELLOW’S PERSPECTIVE

DANNY A. MAMMO, MD

“’Does everybody know what time it is?’ ‘Tool time!’” The classic 1990s sitcom Home Improvement humorously makes light of the thrill of using new tools and the massive disasters that can ensue if new tools are improperly used in inexperienced hands. As a vitreoretinal surgical fellow, fellowship is a very exciting time to try out new surgical instruments and viewing devices to hone preferences for life after fellowship. The comfort of having a more knowledgeable attending to guide fellows, much like Al Borland’s role to Tim Taylor, makes fellowship the ideal time to gain exposure to new tools.

At my training program, I am exposed to a wide variety of viewing devices and highly varied surgical instrumentation utilization. When first learning vitreoretinal surgery, this can be overwhelming, because within the same week, I can be operating with a noncontact (Oculus Surgical’s Biom or Zeiss’s Resight) or contact (AVI) viewing system and either under direct microscope visualization or a 3D viewing system, such as the Ngenuity (Alcon) or the Artevo (Zeiss) systems. In addition, with each attending having unique preferences for surgical gauge or instrumentation for macular work, many real-time decisions to correct for various subtle nuances must be made to successfully maintain surgical efficacy. Like any first-year vitreoretinal surgical fellow, I have had my ups and downs when using new surgical instrumentation. Here I share a few tips, from a fellow’s perspective, that I have found useful when using new surgical instruments.

Wet Labs

Taking advantage of a wet lab at your institution can be invaluable in building confidence before entering the operating room. Surgical product representatives are usually more than happy to provide instruments at wet-lab sessions to facilitate comfort with their instruments. When I first started fellowship, we had a variety of wet-lab sessions with multiple attendings to try advanced vitreoretinal surgical techniques, such as bimanual dissection, internal limiting membrane peeling, and lensectomy. This stress-free environment allowed one-on-one instruction regarding the nuances of various forceps, intraocular scissors, and vitreous cutters.

Clear Communication

At a program where multiple different viewing platforms or surgical instruments are being used, be clear with your attendings about your comfort level with a given system. For example, if you have become accustomed to one set of forceps for macular work but seem to be struggling with another pair, often times your attending can give relevant feedback as to the subtle differences between each tool and how one might need to be held or maneuvered differently. For example, when transitioning from a binocular viewing system to a 3D viewing system, the depth/angle at which one holds the light pipe can dramatically affect the visualization during surgery. Having knowledge of not only the new instrument at hand, but also how it differs from some of the other more commonly used instruments, is vital when it comes to safely exploring the technology the operating room.

Watch Closely

Lastly, take every advantage to learn from your time watching your attendings. I have found that attendings switching back to allow the fellow to get a “second chance” after struggling is invaluable in creating positive experiences with new surgical instrumentation. When I first used a vitreoretinal pick, I was able to rapidly become more efficient and adept after watching my attending’s technique on how to approach an adherent membrane and then taking over to tackle a different membrane. This approach to teaching builds confidence for comfort with future encounters with new surgical instruments.

Collaborative Success

Fellowship is a great time to gain exposure to the wide variety of vitreoretinal surgical tools we are lucky to have at our disposal. Doing so in a safe manner to avoid “tool time” challenges, while simultaneously offering the fellow the confidence to continue interfacing with new surgical instruments, relies on critical preparation from the fellow’s side and supportive instruction from mentors. RP