ТЕХНОЛОГИИ ОБУЧЕНИЯ МИКРОХИРУРГИЧЕСКИМ НАВЫКАМ В ИНСТИТУТЕ МИКРОХИРУРГИИ TRAINING TECHNOLOGIES IN MICROSURGICAL SKILLS IN THE INSTITUTE OF MICROSURGERY

The paper describes the experience of creating a training course on the basics of microsurgery at the Institute of Microsurgery (Tomsk, Russia). The program of the course is provided, developed in accordance with the World trends in teaching microsurgery. The main trends in the development of educational programs are presented.

Microsurgical technology is ubiquitous in the practice of surgical specialties, being a technology that determines the quality of life. In this regard, programs for the training of microsurgery, conducted on the basis of various Medical Centers and Universities, are extremely in demand [1][2][3]. One of the first targeted cycles aimed at popularizing of microsurgical technology was a two-day cycle organized by Academician of the Russian Academy of Medical Sciences N.O. Milanov on the basis of the Russian Scientific Center for Surgery named after Acad. B.V. Petrovsky (Moscow, Russia) together with Carl Zeiss and Aesculap (February 13-14, 2010) (Fig. 1). The participants from the Research Institute of Microsurgery (Tomsk, Russia) were Cand. Med. sci. K.V. Selianinov and A.V. Baytinger. On the initiative of Professor V.F. Baytinger, the first microsurgery training programs in the Siberian Region began at the Institute of Microsurgery in 2011. This became possible with the support of Carl Zeiss (Germany), one of the world leaders in the production of operating microscopes and optical systems . Duration of training is 1 day (10 hours). During the training, the cadets mastered the skills of applying end-to-end vascular anastomoses, nerve sutures on cadaveric and live models (white rats). The implementation of the programs in the early years was carried out jointly with the Department of Plastic Surgery with a Course in Operative Surgery and Topographic Anatomy (headed by Professor V.F. Baytinger), the Siberian State Medical University (Tomsk, Russia  Естественно, что продолжительность цикла была мала и не удовлетворяла полностью потребностей обучающихся в плане более детального освоения микрохирургических навыков. 7 июля 2009 г. Приказом Минздравсоцразвития России была утверждена специальность «Пластическая хирургия». В связи с этим повысился статус Обучающих центров в плане подготовки медицинских кадров для новой специальности. Программа обучения на базе НИИ микрохирургии была скорректирована в направлении увеличения учебных часов с 10 до 36 (6 дней), проведено лицензирование образовательной деятельности по дополнительному профессиональному образованию (лицензия № 2006 от 24.01.2019) (рис. 5).
The duration of the cycle was very short and did not fully satisfy the needs of students in terms of more detailed mastering of microsurgical skills.
The workshop "Introduction to Microsurgery" (Fig. 6), which is actively used in the implementation of the curriculum, was developed and published in 2012 for the purpose of methodological support of the cycle [4]. In addition to the existing equipment (2 operating microscopes from Carl Zeiss, Germany), 4 educational microscopes from Meiji Techno (Japan) (Fig. 7) and consumables (silicone models of vessels) from Wetlab (Japan) were purchased.
Currently, the training program consists of two sections -theoretical and practical parts (Fig. 8).
Theoretical part: -history of the development of microsurgery; -types of vascular sutures; -suture material. Practical part: -acquaintance with the operating microscope and the rules for working; -acquaintance with microsurgical instruments, practicing the skills of suturing on glove rubber; -the imposition of a microsurgical vascular suture on an artificial model of a blood vessel (diameter 1-2 mm), the formation of end to end, end to side vascular anastomoses; -"live surgery" -microsurgical suture of the femoral artery and vein, carotid artery, aorta. The model is a white rat.  (Fig. 9). There was a noticeable increase in students (14 and 24 cadets, respectively) in 2018-2019, which is associated with the greater popularization of microsurgical technology in Russia and the preparation for the approval of the Professional standard "Doctor-plastic surgeon" (approved by order of the Ministry of Labor of Russia in July 31, 2020, No. 482-n) (Fig. 10).
In the last decade, network programs have been widely introduced into the teaching practice of students and residents of Medical Universities, as well as young specialists, allowing them to adopt the experience of leading specialists in Russia and the World in reconstructive and plastic surgery. In 2019, within the framework of the I Microsurgical Summit in Siberia, the Institute of Microsurgery together with Columbia University (New York, USA) are conducted a two-day intensive course on the basics of microsurgery (Fig. 11, 12). There were traumatologists-orthopedists, plastic surgeons from Russia and the countries of the European Union among the participants. The intensive course was accredited in the Continuing Medical Education system.
At the end of each training cycle, an anonymous survey of participants is carried out in order to find out their satisfaction with the quality of training in general, as well as wishes for improving the educational process. It was revealed in the course of an anonymous survey of students, that satisfaction with training in the cycle was 97.6%. The main wishes of the students were: an increase in the duration of the program, the introduction of additional sections on the microsurgical suture of the nerve, the use of autoneural inserts, the imposition of lympho-venular anastomoses, as well as more active involvement of cadets in work in the operating room.
The presence of a training class on the basis of the clinic of the Institute of Microsurgery on a permanent basis allows surgeons to maintain microsurgical skills at an appropriate level. It was repeatedly noted by the leading microsurgeons of Russia and Europe when visiting the Institute (Academician of the Russian Academy of Sciences I.V. Reshetov (Moscow, Russia), Professor M.A. Volokh (St. Petersburg, Russia), Professor M. Ninkovich (Munich, Germany) and others) (Fig. 13). Professor M. Ninkovich noted that it was at the Research Institute of Microsurgery that he first met the opportunity to train microsurgical skills immediately before surgery.

CONCLUSION
Microsurgery training programs allow to form the initial microsurgical skills, which later become the basis for professional growth. Mentors involved in teaching microsurgical skills must take into account the wishes of the cadets and be technologically and professionally prepared to implement them. We see the further development of educational programs in Microsurgery in the introduction of a section on teaching Supermicrosurgery and the involvement of robotic and virtual systems for practicing practical skills.