Microsurgical education in Greece: past, present, and future

The aim of this paper is to provide a brief overview of the history of microsurgery in Greece and how it evolved throughout the years. It is based on published literature as well as anecdotal evidence. It is by no means an exhaustive list of available resources and contributions. Microsurgery in Greece begins with Prof Soucacos who acquired his microsurgical skills in the USA (1970–1974), where he worked as a clinical and research fellow. After gaining invaluable experience, he returned to his home country, Greece, to establish a microsurgery replantation team in 1975. His team gained national recognition soon thereafter thanks to the many successes and innovations they achieved. The tradition is continued with contemporary microsurgical courses in Greece from expert faculty and a busy microsurgical practice in several centers across the country. The experimental educational program in microsurgery includes a blend of synthetic and live animal models, such as rats and rabbits. They include a complete exposure to basic and advanced practical exercises through several days. The simulation training models slowly but surely steadily advance to meet the training standards.


OVERVIEW OF HISTORY OF MICROSURGERY IN GREECE
The history of microsurgery in Greece began with Professor Panayiotis N Soucacos who established microsurgical training in Greece. He acquired his microsurgical skills at the Duke University Medical Center in Durham, North Carolina (1970)(1971)(1972)(1973)(1974) where he worked as a clinical and research fellow under his mentor, Dr. James Urbaniak. After gaining invaluable experience, he returned to his home country, Greece, to establish a microsurgery replantation team in 1975. Until then, several failed replantation attempts had been performed in Greece by various centers (Hippocration Hospital, Diamandis Cassioumis; Laiko Hospital, Panayotis Balas and Anastasios Giannikas; "KAT" Hospital, Athanasios Trabaklos). These failures were attributed to the fact that there was not a dedicated expert microsurgical team to perform these challenging cases [1].
In 1967, Prof Panayiotis Balas, a vascular surgeon, and Anastasios Giannikas, an orthopaedic surgeon, performed the first successful replantation of a total arm amputation at Laiko Hospital, Athens, Greece [2,3]. Nowadays, Prof Balas is considered the father of vascular surgery in Greece. In 1976, he successfully replanted an incomplete non-viable amputation of the distal third of the forearm.
In 1979, Prof Soucacos with the assistance of his resident Stathis Anastasiou, performed the first successful multi-digit replantation in Greece by. In 1984, he established the first microsurgical workshop for orthopaedic and plastic surgeons joined by an internationally renowned faculty, Dr. Julia Terzis (President of the International Microsurgery Society at that time) and his mentor, Dr. Urbaniak from Duke University [1].
In 1989, Prof Soucacos and his team performed the first vascularized free fibula flap in a case of a patient with a type IIIb open tibial fracture. In 1990, the Hellenic Society of Reconstructive Microsurgery was founded. In 1994, the first successful thumb replantation was performed in Greece by Prof Soucacos and his team, including Prof Beris, a resident at the time.
In 1986, the Hand Surgery, Upper extremity and Microsurgery Unit of the "KAT" Hospital in Athens, Greece, was established with Dr. Nikolaos Daoutis as Director and Dr. Nikolaos Gerostathopoulos as Attending surgeon, joined thereafter by many other important microsurgeons. "KAT" hospital remains today a busy trauma center, and major microsurgical and hand trauma cases are being managed. It has a long tradition of teaching micro-surgery courses for almost thirty years and spread the significance of microsurgery in various surgical specialties.
At the General State Hospital of Athens "G. Gennimatas", Prof. Ioannovits established the Department of Microsurgery under the direction of Dr. Stamatopoulos. One of the first clinical cases of the Department was the successful toe-to-hand transfer in 1990 (Dr. K. Stamatopoulos and A. Kepenekidis). This was a benchmark in the evolution of microsurgery with significant contributions in the introduction of the working microscope and flaps for the reconstruction of severe and complex trauma cases. As a result, the field of microsurgery was expanded further across many surgical subspecialties.
The oncological hospital "Agios Savvas" and the Military Hospital of Athens significantly contributed to the development of microsurgery even more. As such Plastic Surgery in Greece was established as the main specialty that applied microsurgery for the management of complex reconstructive cases in relation to other specialties (e.g., ENT, Neurosurgery, Maxillofacial surgery).
Other centers include the "Thriasio General Hospital of Elefsina", St Andreas Hospital of Patra, and University Hospital of Larisa with invaluable contribution in this field. In 1998, with the election of Prof. Malizos as Head of the University Orthopaedic Clinic at the University of Larissa, another center for Microsurgery was established (co-workers Drs Z. Dailiana and S. Varytimidis). Prof. Malizos coming from Prof. Soucacos' "school", having also been trained in the USA close to Prof. Urbaniak has placed his own contribution in the evolution of microsurgery in Greece with clinical, editorial and educational work. In Patra Prof. Elias Lampiris established a Department for surgery of the hand and microsurgery with Drs. M. Tyllianaki and D. Giannika.
The first microsurgery cases in the armed forces were performed at the Athens Veterans' Hospital (417 NIMTS) since 2000 (Dr. P. Spyriounis, Dr. D. Tentis; resident) and later at 401 General Army Hospital in 2010. Dr Tentis, after returning from his microsurgery fellowship in Canada, and with all the other colleagues' contribution and collaboration, a clinical microsurgery practice to be proud of was established.
Ever since, there has been an exponential growth of the field of microsurgery in Greece with novel techniques being introduced in the current clinical practice, such as replantations, revascularization, free tissue transfer, toe-to-hand transfers, nerve grafts, and so forth. Numerous international peer-reviewed papers have been published in reputable Journals [15][16][17].

CURRENT STATUS OF MICROSURGICAL TRAINING IN GREECE
Nowadays, thanks to Prof Soucacos initial efforts to establish standardized training microsurgical centers around Greece, there is a variety of educational courses and opportunities. The nationally recognized state-of-the-art Experimental Research and Training Center at "ELPEN", Athens, Greece is a pioneering Institute. The first basic and advanced microsurgical course for plastic surgeons took place at the "ELPEN" training center organ- At the ELPEN center, several hands-on microsurgical -both basic and advanced -workshops occur annually until recent unprecedented restrictions due to COVID-19 pandemic. Through expert faculty one-on-one instruction on practical exercises and lectures, participants complete a series of microsurgical exercises with an increasing difficulty. The basic and advanced experimental model is the live wistar rat and rabbit, respectively, which both offer an unparalleled experience for trainees. A veterinary anesthesiologist with his designated crew of assistants provides sedation and analgesia for the animals. The participants of the course practice their skills through a series of practical exercises with increasing difficulty after having been introduced to fundamental concepts through video-based lectures.
Step-by-step techniques are being taught, such as end-to-end, end-to-side anastomoses of femoral vessels, neurorrhaphy, interposition vein graft, bypass graft, free groin flap, aorta dissection, and auricular replantation [18] ( Fig. 1-3).  • Joint annual symposium co-organized by the Hellenic Society for Reconstructive Microsurgery and the Hellenic Society for Surgery of the Hand, held in Thessaloniki. There are training sessions incorporated in the symposium program with lectures on surgical anatomy, flap anatomy and dissection techniques.
Yearly course in microsurgery organized by the Orthopaedic Clinic of University of Ioannina since 1984.
• 3-month practical training in microsurgery organized at the research center "Th. Garofalidis" at KAT hospital since 1989 with co-direction by the Hand and Microsurgery Clinic, the Research Center and the University Orthopaedic Clinic of KAT.
• Microsurgery week organized by the University Orthopaedic Clinic of Ioannina University since 1989 (Professors Beris, Korompilias and Vekris).
• Course for flap dissection on living tissues (rabbits-pigs): organized by the Dept. of Plastic Reconstructive and Aesthetic Surgery of "YGEIA" Hospital (chief scientific organizing faculty member Dr. Aikaterini Vlastou) and the Dept. of Plastic Surgery and Burns Center of Ioannina University (Dept. Head and co-organizing faculty member Prof. Efstathios Lycoudis).
• Microsurgery training organized by the Plastic Surgery Clinic of Evangelismos Hospital (scientific organising faculty member Dr. George Charkiolakis).
Until today, orthopaedic and plastic surgery residents rotate through several major teaching public hospitals across the country to further gain exposure to hand trauma and microsurgical training alongside experienced faculty. Notably, microsurgery is also being performed in private sector hospitals in major cities in Greece.

OBJECTIVE ASSESSMENT TOOLS FOR MICROSURGICAL TRAINING
Different objective assessments tools and scoring systems to determine the quality of the training provided to trainees. International consensuses on minimum standards for microsurgical courses [19,20], minimum microsurgery case requirements [21] and several validated training models with objective structured assessment of technical skills (OSATS) have been devised to evaluate the trainers' performance in microsurgery [22][23][24][25].
The development of assessment tools for Robot-Assisted Microsurgery (RAMS) skills is still in progress [26][27][28][29]. All of these innovative grading tools are comprehensive and reliable for assessing the students' progress throughout a microsurgical course [30,31]. However, they focus solely on the technical aspects [32], such as manual dexterity, hand-eye coordination, meticulous suture placement [33,34], speed, operative flow, motion 35, and patency of the anastomosis based on taskspecific checklists [36][37][38][39][40]. On the other hand, nontechnical skills (NTS) are equally important. Nontechnical skills include five broad categories: leadership, situation awareness, decision-making, communication, and teamwork. The integration of these skills in the microsurgical curricula is a work in progress [41]. Last but not least, studies show that expert instruction is pivotal in achieving timely and significant progress in microsurgical courses compared to courses which do not have a designated instructor [42].
The educational ethic of spreading the knowledge for the development of new microsurgeons is reflected today in current microsurgical training; innovative methods are being employed by faculty for residents to be able to expand their technical skills with the elevation of anterolateral thigh flaps under Attending supervision [43]. Contemporary experimental microsurgical research is being conducted in several fields, such as nerve regeneration with an epineurial flap can be used to bridge a nerve defect [44].
Some drawbacks in the microsurgical training are the short residency period of four years and the lack of a robust official rotational training in head and neck, craniofacial, breast, upper and lower limb subspecialties during residency.

FUTURE PERSPECTIVES
Due to COVID-19, the face and shape of the microsurgical training has shifted towards virtual training worldwide. Ιn order to abide by the new regulations, researchers and policy creators have begun to recognize and started to turn to alternative educational modalities, such as nonliving models, virtual/augmented reality (VR/AR) and three-dimensional tools for microvascular anastomosis training [45]. A myriad of novel synthetic [46] (e.g., silicone) and biological training models have been devised over the years. As a result, select microsurgery courses at the University of Ioannina School of Medicine, Greece, have proposed modernized curricula consisting of a blend of both live and virtual learning experiences, and advocated the evaluation of the trainee should be added in the training programs [47].
In conclusion, the history of microsurgery in Greece reflects the long tradition in this field with ongoing contribution from contemporary passionate researchers and physicians.