Development of synthetic simulators for endoscope-assisted repair of metopic and sagittal craniosynostosis

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Endoscope-assisted repair of craniosynostosis is a safe and efficacious alternative to open techniques. However, this procedure is challenging to learn, and there is significant variation in both its execution and outcomes. Surgical simulators may allow trainees to learn and practice this procedure prior to operating on an actual patient. The purpose of this study was to develop a realistic, relatively inexpensive simulator for endoscope-assisted repair of metopic and sagittal craniosynostosis and to evaluate the models’ fidelity and teaching content.


Two separate, 3D-printed, plastic powder–based replica skulls exhibiting metopic (age 1 month) and sagittal (age 2 months) craniosynostosis were developed. These models were made into consumable skull “cartridges” that insert into a reusable base resembling an infant’s head. Each cartridge consists of a multilayer scalp (skin, subcutaneous fat, galea, and periosteum); cranial bones with accurate landmarks; and the dura mater. Data related to model construction, use, and cost were collected. Eleven novice surgeons (residents), 9 experienced surgeons (fellows), and 5 expert surgeons (attendings) performed a simulated metopic and sagittal craniosynostosis repair using a neuroendoscope, high-speed drill, rongeurs, lighted retractors, and suction/irrigation. All participants completed a 13-item questionnaire (using 5-point Likert scales) to rate the realism and utility of the models for teaching endoscope-assisted strip suturectomy.


The simulators are compact, robust, and relatively inexpensive. They can be rapidly reset for repeated use and contain a minimal amount of consumable material while providing a realistic simulation experience. More than 80% of participants agreed or strongly agreed that the models’ anatomical features, including surface anatomy, subgaleal and subperiosteal tissue planes, anterior fontanelle, and epidural spaces, were realistic and contained appropriate detail. More than 90% of participants indicated that handling the endoscope and the instruments was realistic, and also that the steps required to perform the procedure were representative of the steps required in real life.


Both the metopic and sagittal craniosynostosis simulators were developed using low-cost methods and were successfully designed to be reusable. The simulators were found to realistically represent the surgical procedure and can be used to develop the technical skills required for performing an endoscope-assisted craniosynostosis repair.

ABBREVIATIONS CAD = Canadian dollars; PGY = postgraduate year.

Article Information

Correspondence Kyle W. Eastwood: The Hospital for Sick Children, Toronto, ON, Canada.

INCLUDE WHEN CITING Published online June 1, 2018; DOI: 10.3171/2018.2.PEDS18121.

Disclosures Aesculap, Inc. loaned the endoscopy equipment free of charge for the model assessment. Medtronic, Inc. loaned the drills used in the simulations free of charge for the model assessment. Lumitex, Inc. loaned the lighted retractors used in the simulations free of charge for the model assessment.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    The 3D surface model of metopic skull segmented from DICOM using Mimics software (A), assembly of reusable model base and cartridge using Magics software (B), and final metopic model assembled (C). Figure is available in color online only.

  • View in gallery

    Skull insert component of cartridge showing dura (A). Skull insert with periosteum secured to the superficial surface (B). Skull insert and cartridge base assembled with water-filled balloon (scalp not shown) (C). Fully assembled metopic model with partial dissection displaying tissue layers (D). Figure is available in color online only.

  • View in gallery

    Photographs of metopic craniosynostosis simulator showing stages of procedure: planning and initial incision (A); subgaleal dissection and dissection of periosteum (B); placement of burr hole (C and D); expansion of burr hole with punches/rongeurs (E); placement of endoscope (F); and endoscopic view showing dissection of dura from inferior skull surface and excision of bone (G). Figure is available in color online only.

  • View in gallery

    Photographs of sagittal craniosynostosis simulator showing various stages of the procedure, including planning the incision (A); initial anterior incision, subgaleal dissection, and dissection of periosteum (B); placement of anterior burr hole (C); posterior incision and subgaleal dissection (D); expansion of anterior burr hole (E); and endoscopic view depicting dissection of dura from inferior surface of skull (F). Figure is available in color online only.



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