6th Instructional course on Peripheral Nerve Surgery (Basic)

This will be a 1 ½ day course consisting of a one-day workshop on skill acquisition on nerve repair and another half instructional day on advances in nerve surgery. 

Format : Lectures, videos, case-based discussions and hands-on practical. Online resources will be made available for pre-reading. There will be twelve stations with bench operating microscope and fresh frozen cadaveric specimen. Two participants per station. Each station is equipped with basic surgical instruments and two sets of complimentary surgical loupes with headlights and 3 piece micro instruments.

Application for 12 CME points by Singapore Medical Council to be made.

Target Participants (limited to max of 24) : Senior residents/Consultants in hand /ortho /plastic surgery

Prerequisites: All participants will be required to have attended a microsurgery course prior. They must be familiar with loupe dissection and neurorrhaphy using microscopes. 

Course fees (SGD): Full Participant $ 900 (inclusive of 3 micro instruments, operating loupes and headlight).     

Special Rates:

  *Please contact the Course Secretary for the Promo Codes.

**Note: On 16 March 2018, the afternoon sessions of the Advanced course overlaps with the Basic course: The Advanced participants will be in the lab doing their practical, while the Basic participants will be at the lecture rooms. For participants who have signed up for both courses, please skip the Basic lectures to attend the Advanced practical.

 The lectures for the course will be made available to you on a USB stick. 

 Course Secretary:  Ms Agnes Chua email : chua.agnes.lf@ktph.com.sg   ; Mr Toh Yew Chin email : toh.yew.chin@ktph.com.sg

PROGRAMME

Day 1 Instructional Course

Aim:  An overview of the recent advances in nerve injury, healing, repair and rehabilitation.

1300 – 1345   Microanatomy of the nerve LBH
At the end of the lecture the participant will be able to:

1. Describe the structure of the peripheral nerve fiber and name its major components
2. Identify the microstructure of the peripheral nerve and its relevance in nerve repair and regeneration
3. Describe the topography of major peripheral nerves of the upper limb

1345 - 1430 Biology of nerve injury and repair AC
At the end of the lecture the participant will be able to:
1. Understand the intracellular and extracellular processes that occur after a nerve injury, including Wallerian degeneration
2. Describe the classification of peripheral nerve injuries in relation to management and prognosis
3. Understand the physiology of nerve regeneration and its implication in modern nerve surgery including allografts and nerve conduits.
4. Describe the effects of peripheral nerve injury on distal structures (Motor and sensory end organs)

1430 - 1515 Principles of nerve repair SJS KIV WEE (Lecture and Video)
At the end of the lecture the participant will be able to:
1. Outline the indications for surgery after a nerve injury
2. Understand the rationale for timing for surgery
3. Prepare the patient and the nerve bed for surgery
4. List the apparatus and instruments required in the surgery
5. List and describe the types of peripheral nerve repair
6. Describe in detail the surgical techniques of repair
7. Identify possible difficulties in repair and strategies to overcome them

1515 - 1530 Coffee break

1530 - 1600 Techniques and tips in micro surgical repair JT
At the end of the lecture the participant will be able to:
1. List and describe the types of peripheral nerve repair
2. Describe in detail the surgical techniques of repair
3. Identify possible difficulties in repair and strategies to overcome them

1545 – 1615 Review of allografts /conduits/wraps SS
At the end of the lecture the participant will be able to:
1. Understand the principles and biology of nerve grafts/conduits and wraps in current nerve surgery
2. Describe the indications and guidelines for nerve allografts, conduits and wraps
3. Describe the procedure for each of the materials in nerve repair and reconstruction
 
1615 - 1645 Postoperative management of nerve repair AY
At the end of the lecture the participant will be able to:
1. Describe the principles of splinting in nerve repair
2. Describe and perform qualitative assessment of nerve recovery
3. Understand the role of the brain in nerve recovery and rehabilitation 
4. Develop a management strategy for sensory and motor rehabilitation post repair
5. Identify poor outcomes early and describe principles of management

1645 – 1730 Case discussions MMC

 
Day 2 Workshop on Micro neural repair 

0830 – 0835 Health & Safety – Dr. Mohan

0835 – 0845 Practical 1 Use of the microscope & Instrument handling AC

You should be able

• To hold and manipulate a jewelers forceps, micro needle holder and scissors comfortably.
• Care for the fine tips of the micro instruments
• Mount and dismount a 8/0 needle on the needle holder
• Manipulate a suture with a jewelers forceps

0845 – 0915 Practical 2 Micro suturing practices LBH - Orlando
You should be able
• Place a 9/0 needle at various angles through a cut in the rubber glove
• Place a 9/0 needle using a back hand technique
• Perform a double throw on a 9/0 suture followed by a single throw and ensure the knots are square and locked in full engaged position.

0915 – 1000 Practical 3 Nerve Dissection WEE
You should be able
• Dissect the digital nerve in the cadaveric hand using the microscope with jewelers forceps and curved micro scissors
• Dissect the fascicles apart and clean then of the adventitia
• Manipulate the fascicles under the microscope

Tea 1000 - 1015

Practical 4 1015 – 1100  
To understand the concept of tensegrity in nerve (DP)
Aim: In this practical, participants, will learn about the intrinsic tension within nerves and the role of allografts and conduits in restoring nerve continuity in truly tension free way.
Observation on tensegrity
Expose the common digital nerve in the palm via a transverse incision through the proximal palmar crease. Divide the 1st common digital nerve and then note the distance of retraction of the cut ends. Repair the nerve with 2 sutures, 180 degrees apart with 9/0 epi perineural sutures. Move the MP joint of the index and middle finger and note the gapping at the repair site.

Practical 5 1100 – 1145 Fascicular Repair JT
You should be able
• Place a 9/0 needle through the perineurium of the cut fascicle
• Co apt the two ends accurately based on the micro structure
• Tie the knot of the suture sufficiently tight to bring the ends together without causing tension or redundant nerve material at the suture site
• Plan and place the sutures circumferentially around the repair site without crowding of sutures

Practical 6 1145 – 1230 Grouped Fascicular repair (SRN or median) AY
You should be able
• Place a 9/0 needle through the epi- and perineurium of the cut group fascicle
• Ensuring that the suture includes the appropriate group fascicles epi and perineurium
• Co apt the two ends accurately based on the micro structure ensuring fascicle to fascicle cooptation
• Tie the knot of the suture sufficiently tight to bring the ends together without causing tension or escaping fascicles at the suture site
• Plan and place the sutures circumferentially around the repair site without crowding of sutures

Lunch 1230 -1330

Practical 7 1330 – 1430 -Allograft practice OM
Next perform an interposition allograft of 1 cm following division of the 2nd common digital nerve. Note the repair site with MP joint movement of the middle and ring finger.
Practical 8 1430 – 1530 Conduit practice OM
Next perform an interposition conduit with at least a 5-mm gap between nerve ends following division of the 3rd common digital nerve. Note the repair site with MP joint movement of the ring and little finger.

Tea 1530 - 1545

Practical 9 1545 – 1630 Nerve grafting DP
You should be able
• Create a defect in the model nerve by excising a segment
• Use the segment as a cable graft
• Place a 9/0 needle through the epi and perineurium of the cut group fascicle on one end of the graft and the recipient nerve stump
• Co apt the two ends accurately based on the micro structure
• Tie the knot of the suture sufficiently tight to bring the ends together without causing tension or redundant nerve material at the suture site
• Plan and place the sutures circumferentially around the repair site without crowding of sutures
• Repeat the process at the other end of the graft and nerve stump

Feedback and Wrap up 1630 – 1700

At the end of each practical the finished task will be assessed by the faculty and the quality discussed with the candidate by immediate feed back and any remedial teaching is performed immediately. The candidate will not progress to the next stage till he has completed the prior stage satisfactorily.