Development of a 3D-printed external ventricular drain placement simulator: technical note

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In this paper, the authors present a physical model developed to simulate accurate external ventricular drain (EVD) placement with realistic haptic and visual feedbacks to serve as a platform for complete procedural training. Insertion of an EVD via ventriculostomy is a common neurosurgical procedure used to monitor intracranial pressures and/or drain CSF. Currently, realistic training tools are scarce and mainly limited to virtual reality simulation systems. The use of 3D printing technology enables the development of realistic anatomical structures and customized design for physical simulators. In this study, the authors used the advantages of 3D printing to directly build the model geometry from stealth head CT scans and build a phantom brain mold based on 3D scans of a plastinated human brain. The resultant simulator provides realistic haptic feedback during a procedure, with visualization of catheter trajectory and fluid drainage. A multiinstitutional survey was also used to prove content validity of the simulator. With minor refinement, this simulator is expected to be a cost-effective tool for training neurosurgical residents in EVD placement.

ABBREVIATIONSEVD = external ventricular drain; ICP = intracranial pressure; VR = virtual reality.

Abstract

In this paper, the authors present a physical model developed to simulate accurate external ventricular drain (EVD) placement with realistic haptic and visual feedbacks to serve as a platform for complete procedural training. Insertion of an EVD via ventriculostomy is a common neurosurgical procedure used to monitor intracranial pressures and/or drain CSF. Currently, realistic training tools are scarce and mainly limited to virtual reality simulation systems. The use of 3D printing technology enables the development of realistic anatomical structures and customized design for physical simulators. In this study, the authors used the advantages of 3D printing to directly build the model geometry from stealth head CT scans and build a phantom brain mold based on 3D scans of a plastinated human brain. The resultant simulator provides realistic haptic feedback during a procedure, with visualization of catheter trajectory and fluid drainage. A multiinstitutional survey was also used to prove content validity of the simulator. With minor refinement, this simulator is expected to be a cost-effective tool for training neurosurgical residents in EVD placement.

Insertion of an external ventricular drain (EVD), or ventriculostomy, is one of the most common neurosurgical procedures, often performed under emergency conditions in intensive care units or trauma centers. Insertion of an EVD is indicated for intracranial pressure (ICP) monitoring or CSF drainage in patients with traumatic brain injury, hemorrhagic stroke, or hydrocephalus. It is often the first neurosurgical procedure that trainees are required to learn and master during residency. The learning curve to perform this surgical procedure is relatively steep. Novice residents may have difficulty appropriately performing the sequence of steps skin-to-skin and may require several catheter passages though the brain before puncturing the ventricle, often leading to higher complications rates.11 According to recent publications, hemorrhagic complication rates of EVD placement can be as high as 30%–40%,15 and documented EVD-related infections have also been reported in as many as 20% of cases.7,10 The high volume of procedures performed every year increases the risk profile of EVD placement, increasing the need for an effective surgical training tool and the need to standardize the evaluation of neurosurgeons who perform this procedure.1 EVD placement is generally performed in emergency situations at unpredictable times, and residents must become proficient early in their training.3 A study by Huyette et al.11 measured the accuracy of freehand catheter placement of EVDs and found that 22% of placement attempts landed the catheter in nonventricular spaces, even after repeated insertions. Repeated attempts can traumatize brain tissue and lead to complications such as infection and hemorrhage.9,20 A study of patient complications associated with EVD placement found that the most serious complications occurred when the surgeon was inexperienced.22

Neurosurgical residents have few options for practicing EVD placement. Historically, surgical residents have been trained by participating in as many surgeries as possible on live patients while under close supervision. However, although not exclusively for EVD, studies have shown that intraoperative training could often result in longer operation times, higher financial costs, and greater risk of complications.5,17,19,26 Cadavers are not a viable option for EVD placement, because preservation techniques change the tactile properties of brain tissue and the ventricular system tends to be distorted or collapsed, making cadavers an inadequate substitute for a live patient. Using simulators for surgical training allows residents to develop the necessary motor skills safely and realistically, without impacting patient care.6 Most EVD simulators currently on the market are virtual reality (VR)-based. One of the widely used commercial products was developed by Luciano et al.14 That system includes a high-resolution stereoscopic display and a haptic device with head- and hand-tracking capabilities. The user wears stereoscopic goggles that track head movement and adjusts the virtual display accordingly. The user operates on the virtual patient with a haptic stylus in one hand and defines the cutting plane with a tool held in the other hand. The haptic scalpel offers tactile feedback according to the physical characteristics of the tissue being cut; this feature allows the user to get a feel for the different textures of the skin, brain, and bone. Although the VR systems have been validated by neurosurgical residents,3,13 they are still often limited in their ability to mimic the physical properties or phenomena of EVD placement, such as sidewall collisions and limited range of motion.12 In addition, these systems were developed to train the operator on catheter trajectory, leaving aside the other key steps of the procedure. Widespread availability is another major concern for VR simulators, because these devices often cost tens to hundreds of thousands of US dollars.21

For low-cost, high-fidelity simulation to practice EVD placement skin-to-skin, we designed a physical model-based simulator using 3D printing from a stealth head CT scan of a de-identified patient. Three-dimensional printing is a rapidly emerging prototyping technology that enables 3D fabrication with high resolution and customized design. Engineers and surgeons can therefore collaborate to develop the simulator based on clinical needs. The physical simulator provides the same anatomical accuracy as a VR simulator but overcomes the mechanical and procedural limitations. A computer-based simulator adds a level of difficulty for students, as the computer forces the student to translate 3D operating space into an inauthentic 2D space. A physical simulator exists in the “real world” and thus can be used with real surgical tools to create a realistic, immersive simulation environment. In this environment, participants can more easily suspend their disbelief, creating a highly effective learning environment.6 The lessons learned can be perceived as more realistic in comparison with simpler screen-based simulators.18 There exists a 3D-printed simulator for neurosurgery using multimaterial printers, and it has demonstrated the value and feasibility of using a physical model in training.4,25 However, despite the accurate anatomy produced by this method, material selection is limited by the machine and current printing technologies and thus could be inadequate to make realistic phantom tissues. In this study, we used both 3D printing and traditional molding technologies, along with phantom materials, to emphasize the model’s anatomy, tactile feedback, functionalities, and overall durability, aiming for a high-fidelity simulator. We highlight the design of important features needed in EVD training and the process used to evaluate preliminary validity evidence for the simulator.

Methods

Simulator Design

Figure 1 depicts the design of the simulator, which consists of a skull frame, skull cap, replaceable insert, and brain phantom. The skull cap and frame are secured via 3 tabs. Within the skull cavity, the brain phantom is held against a transparent plastic plate in the midline of the skull, allowing for observation and evaluation of catheter placement. The skull cap contains a disposable insert, 40 mm wide and 80 mm long, covering the potential operative region on the skull. This insert is for 1-time use and has an artificial scalp on top of it. The insert size is designed for anatomical accuracy and structural stiffness against the drilling load, while allowing the user some degree of freedom in site selection. The cavity containing the brain is filled with water to mimic pressure conditions inside the human skull. Pressure is controlled by the water reservoir suspended 20 cm above the ventricle, and the water fills the ventricle directly.

FIG. 1.
FIG. 1.

Design of the EVD simulator based on real anatomy. Figure is available in color online only.

The skull frame and cap are manufactured with acrylonitrile butadiene styrene (ABS) plastic using 3D printing. The geometry of the model originates from CT scans of a de-identified patient and is modified to include fastening features using computer-aided design software (Mimics and Magics by Materialise). The skull cavity is made to accommodate a phantom brain. The brain is fabricated using a 3D-printed mold based on 3D scans of a plastinated human brain. To create a realistic texture, the phantom brain is molded with high-acyl gellan gum, a gelatin-like material chosen because of its high gelling efficiency and its ability to mimic the biomechanical properties of human brain tissue.8 The manufactured brain phantom and mold are shown in Fig. 2.

FIG. 2.
FIG. 2.

The phantom brain used in the simulator is manufactured using a 3D-printed mold (left) filled with gellan gum (right). Figure is available in color online only.

The skull cap insert is disposable and intended for 1-time use, and it can simulate a bur scalp incision, holedrilling, dura mater opening, skin closure, and catheter tunneling and anchoring. The insert geometry is extracted from the designated region in the skull cap (Fig. 1) and is 3D printed with plaster composite using a powder-bed machine. The insert is then treated with high-strength epoxy resin on the top and bottom to create a bicortical characteristic, followed by a thin layer of artificial galea and dura, and finally a 4-mm-thick layer of silicone scalp on the exterior surface (Fig. 3).

FIG. 3.
FIG. 3.

The replaceable skull cap insert includes multiple layers to mimic the human skull. Figure is available in color online only.

Figure 4 shows a photograph of the complete simulator setup. The skull is placed on a 30° inclined ramp to mimic the patient’s position during an actual EVD placement. The skull is connected to a water reservoir through a fluid input connector at its base. The simulator’s water reservoir is affixed to a column adjustable to variable heights (0–30 cm above the ventricle) depending on the ICP needed in the different clinical scenarios. Inside the skull cavity, a fluid input tube directs the water into the lateral ventricle of the phantom brain (Fig. 1). Water fills the ventricle, creating pressure inside, allowing for a subtle “pop” sensation when the catheter penetrates the ventricle. On the other side of the skull cap are 2 open windows to observe the ventricle and catheter trajectory (Fig. 4). This feature allows users to correct improper insertion, particularly after multiple attempts.

FIG. 4.
FIG. 4.

Overall EVD model setup, including the inclined ramp, skull insert, and water reservoir (left), and windows to observe catheter trajectory (right). Figure is available in color online only.

Preliminary Validation

The preliminary validation process consisted of evaluation of specific evidence (content validity) and was aligned with best practices defined by the current “Standards” framework offered by the American Educational Research Association, American Psychological Association, and National Council on Measurement in Education.2

Following finalization of the simulator prototype, a sample of neurosurgeons from 3 Michigan-based neurosurgical training programs (University of Michigan, Wayne State University, and Henry Ford Hospital) evaluated the quality of the simulator at their own institutions. Following their placement of an EVD on the simulator, each participant completed a 37-item survey rated on a 4-point rating scale, with 4 being the highest score. A sample of the targeted items from the survey is included in Table 1, in which each point refers to a certain subjective judgment on a specific aspect of the simulator. Based on best practices defined by Seagull and Rooney,23 19 items of the survey were targeted to measure experienced surgeons' opinions regarding the simulator characteristics and features and were organized across 4 domains: physical attributes, realism of experience, value of simulator, and a global (overall) rating. Participant responses were reported as frequencies, with group rating differences analyzed using a many-facet Rasch model. Inter-item reliability of the 19 targeted items was estimated using the Cronbach a test.

TABLE 1.

Example of survey form for evaluating ventriculostomy simulator validity

VENTRICULOSTOMY MODEL EVALUATION
Evaluator Name: ______________________________________________
Approximately how many ventriculostomy procedures have you performed? ______________
Don’t knowNot at all realisticLacks too many key features to be usefulAdequate realism, but could be improvedHighly realistic, no changes needed
(.)(1)(2)(3)(4)
PHYSICAL ATTRIBUTES
Scalp
REALISM OF EXPERIENCE
Identifying skull landmarks
Don’t knowNo relevanceLittle relevanceSome relevanceVery relevant
(.)(1)(2)(3)(4)
PLEASE RATE THE VALUE OF THE SIMULATOR AS A TRAINING TOOL FOR BEGINNERS.
Global— Please check the one statement below with which you most agree:
□ This simulator requires extensive improvements before it can be considered for use in ventriculostomy placement training.
□ This simulator requires minor adjustments before it can be considered for use in ventriculostomy placement training.
□ This simulator can be used in training ventriculostomy placement as is, but could be improved slightly.
□ This simulator can be used in ventriculostomy placement training with no improvements made.

Results

Based on the design described above, a simulator prototype along with many inserts and phantom brains was built for evaluation. The simulator is designed to perform skin-to-skin EVD placement, by which participants would have a chance to practice the entire procedure, including tunneling and suturing (Fig. 5). A total of 17 surgeons (12 residents, 1 fellow, and 4 faculty neurosurgeons) from the 3 Michigan-based neurosurgical training programs evaluated preliminary validity evidence of the simulator. Overall, surgeon evaluator responses showed average ratings of 3.4, 3.3, 3.9, and 2.5 (on a 4-point scale) for physical attributes, realism of experience, value of the simulator as a training tool, and global (overall) domains, respectively. The highest score of 3.9 was obtained for “value of simulator as a training tool for novice neurosurgeons,” indicating this model had high potential for serving as a training tool. The survey details, corresponding scores, and comments are listed in Table 2. Faculty evaluators had higher overall averaged scores (mean = 3.4) than the fellow (mean = 3.3) or residents (mean = 3.0; p < 0.05). A deeper analysis indicated no rating differences at the item level (p > 0.05). Six (35.3%) of 17 evaluators indicated the simulator was useful in its current form and indicated, “This simulator can be used in training ventriculostomy placement as is, but could be improved slightly.” Ten (58.8%) of 17 evaluators indicated, “This simulator requires minor adjustments before it can be considered for use in ventriculostomy placement training.” The Cronbach a for the targeted items was estimated to be high (19 items, a = 0.90).

FIG. 5.
FIG. 5.

Images from a representative EVD simulator evaluation showing scalp incision (a), bone drilling (b), catheter placement (c), and tunneling and suturing (d). Figure is available in color online only.

TABLE 2.

Survey results from 17 experienced neurosurgeons and residents

Survey ItemsMean Score (SD)Major Comments
Physical attributes
 Scalp3.1 (0.44)Skin is rubbery
 Bone3.4 (0.62)
 Dura thickness2.9 (0.71)Dura is a little too tough
 Brain tissue texture3.4 (0.72)
 Visualization of skull landmarks3.0 (0.72)Additional landmarks (ears) are needed
 Location of insert for drilling3.6 (0.50)
 Size of the insert for drilling3.9 (0.47)Insert could be a little larger anteriorly
 CSF flow (rate) to confirm placement3.6 (0.77)
Realism of experience
 Identifying skull landmarks3.2 (0.55)Needs skin landmarks in addition to bone
 Incision and retraction of skin3.1 (0.87)
 Drilling bone3.3 (0.84)
 Opening dura2.6 (0.95)
 Inserting ventriculostomy3.3 (0.69)
 Water flowing from catheter & visual confirmation of trajectory3.4 (0.79)
 Tunneling of ventriculostomy3.4 (0.62)Tunneling resistance is not so realistic
 Placement of retaining stitches3.7 (0.50)
 Scalp closure3.5 (0.52)
Value of simulator as a training tool3.9 (0.25)
Global rating2.5 (0.48)This simulator requires minor adjustments before it can be considered for use in ventriculostomy placement training

Discussion

The use of 3D printing technology in the field of surgical simulation has led to many innovations, particularly for customized design and patient-specific simulation. Along with molding techniques to shape tissue-mimicking phantoms, physical models are expected to be more practical than VR simulators. In the particular case of EVD placement simulators, VR models focus on trajectory training, while our physical model was designed and developed as a comprehensive training tool for all the steps involved in EVD placement. Specifically, our model allows identification of surface anatomy and skin incision, skin retraction, bur-hole drilling, sharp opening of dura, catheter passage into the brain, skin closure, and subcutaneous catheter tunneling and catheter anchoring. One major advantage of our model over the existing products is that it provides immediate realistic visual feedback of EVD placement by observing CSF flow in the proximal end of the catheter and allows troubleshooting during various steps of the procedure, imitating (with high fidelity) problems found in “real-world” scenarios, such as: lack of CSF flow caused by malposition of the catheter, air locks, and a low-pressure system; occlusion of the catheter by debris; excessively tight anchoring stitches; and damage to the catheter while suturing skin. In addition, skull windows in the left hemicranium offer real-time visualization of the position and trajectory of the catheter within the intracranial compartment, with realistic depth and trajectory range through the bur hole. The simulator also allows the novice operator to become familiar with the surgical instruments needed to place an EVD, which generally varies among institutions. Finally, our physical simulator has all the necessary features for training in ICP monitor placement, including an intracranial compartment pressurized by a height-adjustable water reservoir. With the flexibility of 3D printing, modifications for distorted anatomy or patient-specific features can be added to the current model.

Manufacturing costs and ancillary technology required to use the existing VR ventriculostomy simulators is a major concern, particularly for the initial investment, which ranges from several tens to hundreds of thousands of US dollars.21 The manufacturing cost of a physical EVD simulator is significantly lower (estimated to be within $1000), and it can be used extensively by replacing the multilayer insert after each use, and the phantom brain after approximately 10 EVD placements. The brain phantom can hold its integrity for 10 or more passes because of the water pressure and material used. Catheter insertion is also not affected by the previous pathways created inside the brain phantom. This feature turns our simulator into a very cost-effective training tool, and it is easily accessible to training programs in third-world countries.

Although favorable, preliminary findings indicate areas of the simulator that could be improved prior to implementation into a curriculum. All comments received from the evaluators can be addressed in a refined model. Specifically, dura thickness can be adjusted by the number of layers of the membrane material, and skin resistance can be reduced by mixing 5%–10% mineral oil into Dragon Skin silicone (Smooth-on Inc.).24 Additional landmarks, such as ears, can be produced by 3D printing onto the existing model. The survey is strongly favorable, but there are a number of limitations that should be considered at this time. First, although the study was multiinstitutional, data were collected from a convenience sample of volunteer participants in southeastern Michigan. Second, the sample evaluated to date is relatively small and may not reflect the opinions of a larger sample. Further research will clarify if the feedback from these evaluators is different from those of a broader sample of neurosurgeons across a variety of regions. Finally, we have only examined preliminary validity evidence from this prototype model, and further simulator refinement and deeper evaluation of different kinds of validity evidence will be required to maximize the fidelity of our simulator in the training of EVD placement. Our future line of research includes evaluating the simulator’s utility for measuring surgeon EVD performance, or to better define mastery of the procedure by distinguishing novice from proficient practitioners. Next, a performance rating instrument will need to be created to align all steps of the EVD with a global rating matrix using the Objective Structured Assessment of Technical Skill (OSATS) tool.16 Based on those findings, training protocols and evaluation standards, such as the minimum score before a resident can operate on a live patient, will be developed.

Conclusions

In this paper we present a newly developed physical simulator based on 3D printing and molding technologies for EVD placement and report survey results used to evaluate validity evidence relevant to content validity. Survey results from 17 surgeons with a range of expertise strongly support the use of this model for EVD training. With minor refinement, this simulator is expected to improve training experiences in neurosurgery, thereby leading to better patient care. The capability to measure and improve an individual’s performance has not yet been fully studied. Following the recommended refinements and future study, we ultimately expect to incorporate this simulator into a comprehensive curriculum to train residents in EVD placement.

Acknowledgments

We would like to thank the Department of Neurosurgery at both Henry Ford Hospital and Wayne State University for participating in the survey.

Author Contributions

Conception and design: Tai, Shih, Savastano. Acquisition of data: Tai, Stephenson, Liao, Savastano. Analysis and interpretation of data: Tai, Rooney. Drafting the article: Tai, Savastano. Critically revising the article: Sagher, Tai. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Sagher. Administrative/technical/material support: Stephenson, Liao. Study supervision: Sagher, Tai, Shih.

References

  • 1

    Alaraj ATobin MKBirk DMCharbel FTSimulation in neurosurgery and neurosurgical procedures. Levine AIDeMaria S JrSchwartz ADSim AJ: The Comprehensive Textbook of Healthcare Simulation New YorkSpringer2013. 415423

  • 2

    American Educational Research Association: Standards for Educational and Psychological Testing Washington, DCAmerican Educational Research Association2014

  • 3

    Banerjee PPLuciano CJLemole GM JrCharbel FTOh MY: Accuracy of ventriculostomy catheter placement using a head- and hand-tracked high-resolution virtual reality simulator with haptic feedback. J Neurosurg 107:5155212007

  • 4

    Bova FJRajon DAFriedman WAMurad GJHoh DJJacob RP: Mixed-reality simulation for neurosurgical procedures. Neurosurgery 73:Suppl 11381452013

  • 5

    Bridges MDiamond DL: The financial impact of teaching surgical residents in the operating room. Am J Surg 177:28321999

  • 6

    Bryson EOLevine AI: The simulation theater: a theoretical discussion of concepts and constructs that enhance learning. J Crit Care 23:1851872008

  • 7

    Chatzi MKarvouniaris MMakris DTsimitrea EGatos CTasiou A: Bundle of measures for external cerebral ventricular drainage-associated ventriculitis. Crit Care Med 42:66732014

  • 8

    Chen RKShih AJ: Multi-modality gellan gum-based tissue-mimicking phantom with targeted mechanical, electrical, and thermal properties. Phys Med Biol 58:551155252013

  • 9

    Guyot LLDowling CDiaz FGMichael DB: Cerebral monitoring devices: analysis of complications. Acta Neurochir Suppl 71:47491998

  • 10

    Hoefnagel DDammers RTer Laak-Poort MPAvezaat CJ: Risk factors for infections related to external ventricular drainage. Acta Neurochir (Wien) 150:2092142008

  • 11

    Huyette DRTurnbow BJKaufman CVaslow DFWhiting BBOh MY: Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans. J Neurosurg 108:88912008

  • 12

    Lemole GM JrBanerjee PPLuciano CNeckrysh SCharbel FT: Virtual reality in neurosurgical education: part-task ventriculostomy simulation with dynamic visual and haptic feedback. Neurosurgery 61:1421492007

  • 13

    Lemole MBanerjee PPLuciano CCharbel FOh M: Virtual ventriculostomy with ‘shifted ventricle’: neurosurgery resident surgical skill assessment using a high-fidelity haptic/graphic virtual reality simulator. Neurol Res 31:4304312009

  • 14

    Luciano CBanerjee PLemole GM JrCharbel F: Second generation haptic ventriculostomy simulator using the ImmersiveTouch system. Stud Health Technol Inform 119:3433482006

  • 15

    Maniker AHVaynman AYKarimi RJSabit AOHolland B: Hemorrhagic complications of external ventricular drainage. Neurosurgery 59:4 Suppl 2ONS419ONS4252006

  • 16

    Martin JARegehr GReznick RMacRae HMurnaghan JHutchison C: Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 84:2732781997

  • 17

    Moon HHKim JHKang HIMoon BGLee SJKim JS: Brain injuries during intraoperative ventriculostomy in the aneurysmal subarachnoid hemorrhage patients. J Korean Neurosurg Soc 46:2152202009

  • 18

    Okuda YBryson EODeMaria S JrJacobson LQuinones JShen B: The utility of simulation in medical education: what is the evidence?. Mt Sinai J Med 76:3303432009

  • 19

    Puram SVKozin EDSethi RAlkire BLee DJGray ST: Impact of resident surgeons on procedure length based on common pediatric otolaryngology cases. Laryngoscope 125:9919972015

  • 20

    Roitberg BZKhan NAlp MSHersonskey TCharbel FTAusman JI: Bedside external ventricular drain placement for the treatment of acute hydrocephalus. Br J Neurosurg 15:3243272001

  • 21

    Schirmer CMElder JBRoitberg BLobel DA: Virtual reality-based simulation training for ventriculostomy: an evidence-based approach. Neurosurgery 73:Suppl 166732013

  • 22

    Schroeder HWNiendorf WRGaab MR: Complications of endoscopic third ventriculostomy. J Neurosurg 96:103210402002

  • 23

    Seagull FJRooney DM: Filling a void: developing a standard subjective assessment tool for surgical simulation through focused review of current practices. Surgery 156:7187222014

  • 24

    Wang YTai BLYu HShih AJ: Silicone-based tissue-mimicking phantom for needle insertion simulation. J Med Devices 8:0210012014

  • 25

    Waran VNarayanan VKaruppiah ROwen SLAziz T: Utility of multimaterial 3D printers in creating models with pathological entities to enhance the training experience of neurosurgeons. J Neurosurg 120:4894922014

  • 26

    Wilson TSahu AJohnson DSTurner PG: The effect of trainee involvement on procedure and list times: A statistical analysis with discussion of current issues affecting orthopaedic training in UK. Surgeon 8:15192010

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Article Information

Correspondence Oren Sagher, Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Dr., Rm. 3552 TC, Ann Arbor, MI 48109-5338. email: osagher@med.umich.edu.

INCLUDE WHEN CITING Published online June 26, 2015; DOI: 10.3171/2014.12.JNS141867.

DISCLOSURE Funding for this project was received from the Blue Cross Blue Shield Michigan Foundation (A.J.S., B.L.T., D.R., and O.S.), and the Clinical Simulation Center at the University of Michigan (B.L.T.).

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Design of the EVD simulator based on real anatomy. Figure is available in color online only.

  • View in gallery

    The phantom brain used in the simulator is manufactured using a 3D-printed mold (left) filled with gellan gum (right). Figure is available in color online only.

  • View in gallery

    The replaceable skull cap insert includes multiple layers to mimic the human skull. Figure is available in color online only.

  • View in gallery

    Overall EVD model setup, including the inclined ramp, skull insert, and water reservoir (left), and windows to observe catheter trajectory (right). Figure is available in color online only.

  • View in gallery

    Images from a representative EVD simulator evaluation showing scalp incision (a), bone drilling (b), catheter placement (c), and tunneling and suturing (d). Figure is available in color online only.

References

1

Alaraj ATobin MKBirk DMCharbel FTSimulation in neurosurgery and neurosurgical procedures. Levine AIDeMaria S JrSchwartz ADSim AJ: The Comprehensive Textbook of Healthcare Simulation New YorkSpringer2013. 415423

2

American Educational Research Association: Standards for Educational and Psychological Testing Washington, DCAmerican Educational Research Association2014

3

Banerjee PPLuciano CJLemole GM JrCharbel FTOh MY: Accuracy of ventriculostomy catheter placement using a head- and hand-tracked high-resolution virtual reality simulator with haptic feedback. J Neurosurg 107:5155212007

4

Bova FJRajon DAFriedman WAMurad GJHoh DJJacob RP: Mixed-reality simulation for neurosurgical procedures. Neurosurgery 73:Suppl 11381452013

5

Bridges MDiamond DL: The financial impact of teaching surgical residents in the operating room. Am J Surg 177:28321999

6

Bryson EOLevine AI: The simulation theater: a theoretical discussion of concepts and constructs that enhance learning. J Crit Care 23:1851872008

7

Chatzi MKarvouniaris MMakris DTsimitrea EGatos CTasiou A: Bundle of measures for external cerebral ventricular drainage-associated ventriculitis. Crit Care Med 42:66732014

8

Chen RKShih AJ: Multi-modality gellan gum-based tissue-mimicking phantom with targeted mechanical, electrical, and thermal properties. Phys Med Biol 58:551155252013

9

Guyot LLDowling CDiaz FGMichael DB: Cerebral monitoring devices: analysis of complications. Acta Neurochir Suppl 71:47491998

10

Hoefnagel DDammers RTer Laak-Poort MPAvezaat CJ: Risk factors for infections related to external ventricular drainage. Acta Neurochir (Wien) 150:2092142008

11

Huyette DRTurnbow BJKaufman CVaslow DFWhiting BBOh MY: Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans. J Neurosurg 108:88912008

12

Lemole GM JrBanerjee PPLuciano CNeckrysh SCharbel FT: Virtual reality in neurosurgical education: part-task ventriculostomy simulation with dynamic visual and haptic feedback. Neurosurgery 61:1421492007

13

Lemole MBanerjee PPLuciano CCharbel FOh M: Virtual ventriculostomy with ‘shifted ventricle’: neurosurgery resident surgical skill assessment using a high-fidelity haptic/graphic virtual reality simulator. Neurol Res 31:4304312009

14

Luciano CBanerjee PLemole GM JrCharbel F: Second generation haptic ventriculostomy simulator using the ImmersiveTouch system. Stud Health Technol Inform 119:3433482006

15

Maniker AHVaynman AYKarimi RJSabit AOHolland B: Hemorrhagic complications of external ventricular drainage. Neurosurgery 59:4 Suppl 2ONS419ONS4252006

16

Martin JARegehr GReznick RMacRae HMurnaghan JHutchison C: Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 84:2732781997

17

Moon HHKim JHKang HIMoon BGLee SJKim JS: Brain injuries during intraoperative ventriculostomy in the aneurysmal subarachnoid hemorrhage patients. J Korean Neurosurg Soc 46:2152202009

18

Okuda YBryson EODeMaria S JrJacobson LQuinones JShen B: The utility of simulation in medical education: what is the evidence?. Mt Sinai J Med 76:3303432009

19

Puram SVKozin EDSethi RAlkire BLee DJGray ST: Impact of resident surgeons on procedure length based on common pediatric otolaryngology cases. Laryngoscope 125:9919972015

20

Roitberg BZKhan NAlp MSHersonskey TCharbel FTAusman JI: Bedside external ventricular drain placement for the treatment of acute hydrocephalus. Br J Neurosurg 15:3243272001

21

Schirmer CMElder JBRoitberg BLobel DA: Virtual reality-based simulation training for ventriculostomy: an evidence-based approach. Neurosurgery 73:Suppl 166732013

22

Schroeder HWNiendorf WRGaab MR: Complications of endoscopic third ventriculostomy. J Neurosurg 96:103210402002

23

Seagull FJRooney DM: Filling a void: developing a standard subjective assessment tool for surgical simulation through focused review of current practices. Surgery 156:7187222014

24

Wang YTai BLYu HShih AJ: Silicone-based tissue-mimicking phantom for needle insertion simulation. J Med Devices 8:0210012014

25

Waran VNarayanan VKaruppiah ROwen SLAziz T: Utility of multimaterial 3D printers in creating models with pathological entities to enhance the training experience of neurosurgeons. J Neurosurg 120:4894922014

26

Wilson TSahu AJohnson DSTurner PG: The effect of trainee involvement on procedure and list times: A statistical analysis with discussion of current issues affecting orthopaedic training in UK. Surgeon 8:15192010

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