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Keywords:

  • anatomy;
  • cadavers;
  • medical education;
  • embalming;
  • clinical anatomy;
  • anatomical models;
  • surgical training;
  • Thiel solution

Abstract

  1. Top of page
  2. Abstract
  3. ANATOMICAL-SURGICAL TRAINING COURSES ON CADAVERS
  4. USE OF ANATOMICAL MODELS
  5. CONCLUSIONS
  6. LITERATURE CITED
  7. Biographical Information

The invention of new techniques for surgery and interventional radiology demand improved training for ongoing specialists. The Anatomical Institutes in Switzerland support these requirements by establishing hands-on practical training courses by using new procedures for cadaver embalming and model construction. Improvements allow courses to provide students with more realistic simulations of both established and experimental surgical methods. Through these changes, the value of in-depth gross anatomy is enhanced as a topic of fundamental importance for the postgraduate medical and surgical curriculum. The web site http://www.unifr.ch/sgahe/snga.html contains information on courses using the Thiel embalming solution. Details about training courses in Switzerland using anatomical models are available at http://www.heartlab.org, http://www.vascular-international.org, and http://www.elastrat.com. Anat Rec (New Anat) 265:254–256, 2001. © 2001 Wiley-Liss, Inc.

Gross anatomy is one of the fundamental topics in medical education. By learning gross anatomy, medical students get a first impression about the structure of the normal human body, which is the basis for understanding pathologic and clinical problems. Dissection courses still play an important role in learning gross anatomy, in addition to lectures and seminars. Also, training courses for imaging (x-ray, magnetic resonance imaging, computed tomography, sonography) as well as computer-assisted learning environments are part of a student's gross anatomy curriculum. However, the anatomical knowledge acquired during medical school is usually not sufficient for postgraduate training as a physician, in particular, as a surgeon or radiologist. Here, a more profound training in gross anatomy is necessary. Therefore, the Anatomical Institutes in Switzerland recently started a program for postgraduate training of ongoing specialists. In collaboration with university hospitals, but also with district hospitals and various foundations, numerous interdisciplinary-training courses were established.

The anatomical knowledge acquired during medical school is usually not sufficient for postgraduate training as a surgeon or radiologist. Here, a more profound training in gross anatomy is necessary.

The program focuses on practical anatomical courses using either cadavers or anatomical models. To come as close as possible to clinical reality, we introduced new techniques for embalming and casting, which allow simulating established or even new surgical methods.

ANATOMICAL-SURGICAL TRAINING COURSES ON CADAVERS

  1. Top of page
  2. Abstract
  3. ANATOMICAL-SURGICAL TRAINING COURSES ON CADAVERS
  4. USE OF ANATOMICAL MODELS
  5. CONCLUSIONS
  6. LITERATURE CITED
  7. Biographical Information

Cadavers fixed by conventional procedures by using mainly formalin for conservation are only of limited use for practical surgical courses due to profound changes of color, strength, and fragility of organs and tissues.

Recently, new protocols for embalming cadavers have been established by using 4-chloro-3-methylenphenol as well as various salts for fixation, boric acid for disinfecting, and ethylene glycol for preservation of tissue plasticity (Thiel, 1991). Two stem solutions are prepared. Solution I contains boric acid 3% (w/v), (mono-) ethylene glycol 30% (v/v), ammonium nitrate 20% (w/v), and potassium nitrate 5% (w/v). Solution II consists of (mono-) ethylenglycol 10% (v/v), and 4-chloro-3-methylphenol 1% (v/v).

The cadavers are perfused by means of femoral or carotid artery with a solution containing 14,300 ml of stem solution I plus 500 ml of stem solution II and adding 700 g of sodium sulfite as well as 300 ml of formalin. In the original study, additional infusions of the lungs by using a tracheal tube, of the intestine by using a gastric tube, and of the brain by means of superior sagittal sinus have been described. These procedures seem not to be necessary for cadavers used for surgical training courses. The cadavers are stored for approximately 4 weeks in a solution containing boric acid 3% (w/v), (mono-) ethylene glycol 10% (v/v), ammonium nitrate 10% (v/v), potassium nitrate 5% (w/v), stem solution-II 2% (v/v), sodium sulfite 7% (w/v), and formalin 2% (v/v). Thereafter, the bodies are kept in plastic bags, which are closed with a zipper. The cadavers may be used for months or even years.

The formalin content of the fixation solution is drastically reduced with a final concentration of 0.8%. The low-odor embalming technique results in well preserved organs and tissues concerning color, consistency, and transparency. The procedure affords high standards of preservation with good disinfecting efficacy and without releasing harmful substances into the environment. The suitability of the cadavers may be improved by injection of colored silicon (m-polymer) into the large arteries, veins, or both (Figure 1). The label enters even small vessels (up to 1 mm diameter), depending on pressure, injection volume, and fluidity of silicon solution. The excellent quality of preservation is also visualized in a photographic atlas of practical anatomy published by Thiel (1997).

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Figure 1. Anatomical specimen (right arm, cubital region) fixed with Thiel-solution and injected with red silicon. Note the flexibility of the muscles and the perfect filling of the arteries.

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The new fixation procedure offers the advantage that organs and tissues retain their flexibility and plasticity. The articular joints remain freely movable, and the color of the organs is very similar to the in vivo condition. Thus, the cadavers can be used for training of both conventional and new surgical procedures, including laparoscopic surgery of thorax, abdomen, and pelvis, as well as arthroscopy.

Within recent years, numerous hands-on courses using cadavers fixed with Thiel solution have been performed in the Anatomical Institutes in Switzerland. Examples include skull base surgery, microsurgery of paranasal sinuses, rhinoplasty and facial plastic surgery, otology and temporal bone surgery, neurosurgery of the middle and posterior cranial fossa, endoscopic surgery of the abdomen and pelvis, interventional neuroradiology. A complete list of the courses can be obtained at the site (http://www.unifr.ch/sgahe/snga.html) of the Swiss Network for Gross Anatomy (SNGA), which is a subgroup of the Swiss Society for Anatomy, Histology, and Embryology (SSAHE).

Some courses are held once or twice a year; other courses are offered even more frequently. Weekly hands-on courses for ongoing orthopedic surgeons have been established in some Anatomical Institutes, where all standard approaches are taught. Surgical preparation of cadavers is now part of the final graduate examination for orthopedic surgeons.

The success of the courses depends on planning, infrastructure, and didactic concept. Both clinicians and anatomists are closely working together. The institutes offer the rooms for dissection and seminars as well as for the storage of the cadavers. Anatomists usually demonstrate cadaver specimens or models, which show the regions of interest. Well-experienced and highly motivated clinicians work as tutors and give intensive instructions before the participants start with hands-on dissection. The groups are kept small to facilitate practical work for each participant and to guarantee optimal supervision by the tutors. Industrial companies usually sponsor the surgical instruments. Finally, seminars demonstrating state of the art surgical procedures complete the courses.

USE OF ANATOMICAL MODELS

  1. Top of page
  2. Abstract
  3. ANATOMICAL-SURGICAL TRAINING COURSES ON CADAVERS
  4. USE OF ANATOMICAL MODELS
  5. CONCLUSIONS
  6. LITERATURE CITED
  7. Biographical Information

In recent years, new techniques for building anatomical models have been established by using various resins such as polyurethane and elastomers. Usually, a negative cast is made from a cadaver specimen, which then is transformed by several intermediate steps into a perfect model showing detailed anatomy (Figure 2). The models are characterized by their flexibility and tear stress resistance. Therefore, they can be used for training of various surgical and interventional procedures (Gailloud et al., 1999; von Segesser et al., 1999).

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Figure 2. Anatomical model of the abdomen and femoral region used for training of bypass surgery.

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In the Anatomical Institutes of Zurich and Geneva, training models have been developed and successfully used since 1996 for the following procedures: aorto-iliaco bypass surgery, less invasive aortic and mitral valve replacement, coronary bypass surgery on the beating heart, interventional radiology on aortic aneurysm, interventional radiology on head and neck arteries.

Compared with cadavers, the anatomical models offer the advantages that they can be produced in large numbers and used multiple times. Furthermore, courses using anatomical models can be held outside of the anatomical institutes in conference centers or hotels, locations often favored by surgeons. For example, courses for basic techniques in vascular surgery are held yearly in a Conference Center in Pontresina, where specific models with intravascular pressure simulation are used. Further details about training courses in Switzerland using anatomical models may be obtained from the Internet at the following addresses: http://www.heartlab.org, http://www.vascular-international.org, and www.elastrat.com.

Compared with cadavers, the anatomical models offer the advantages that they can be produced in large numbers and used multiple times.

CONCLUSIONS

  1. Top of page
  2. Abstract
  3. ANATOMICAL-SURGICAL TRAINING COURSES ON CADAVERS
  4. USE OF ANATOMICAL MODELS
  5. CONCLUSIONS
  6. LITERATURE CITED
  7. Biographical Information

The demand for educational programs in gross anatomy has substantially changed within the past years. Most medical schools teach students only basic training in anatomy because other disciplines, such as cell and molecular biology, have been expanded according to their importance to modern medicine. On the other hand, more detailed anatomical knowledge is necessary for many other medical disciplines, in particular, orthopedics, surgery, and radiology. Hands-on anatomical training courses organized by the Swiss Anatomical Institutes using newly established techniques for cadaver embalming and new anatomical models have been found to be very helpful in postgraduate training of ongoing specialists. The courses reflect just part of the clinical reality and, therefore, have a virtual character, but they prepare the clinicians for the daily work and, thus, improve the quality of postgraduate training. In this context, cooperation between anatomists and clinicians is absolutely necessary and plays an important role for the future.

LITERATURE CITED

  1. Top of page
  2. Abstract
  3. ANATOMICAL-SURGICAL TRAINING COURSES ON CADAVERS
  4. USE OF ANATOMICAL MODELS
  5. CONCLUSIONS
  6. LITERATURE CITED
  7. Biographical Information
  • Gailloud P, Muster M, Piotin M, Mottu F, Murphy KJ, Fasel JHD, Rüfenacht DA. 1999. In vitro models of intracranial arteriovenous fistulas for the evaluation of new endovascular treatment materials. Am J Neuroradiol 20: 291295.
  • Thiel W. 1991. Die Konservierung ganzer Leichen in natürlichen Farben. Ann Anat 174: 185195.
  • Thiel W. 1997. Photographic atlas of practical anatomy 1. Berlin, Heidelberg, New York: Springer.
  • von Segesser LK, Westaby St, Pomar J, Loisance D, Groscurth P, Turina M. 1999. Less invasive aortic valve surgery: rationale and technique. Eur J Cardiothorac Surg 15: 781785.

Biographical Information

  1. Top of page
  2. Abstract
  3. ANATOMICAL-SURGICAL TRAINING COURSES ON CADAVERS
  4. USE OF ANATOMICAL MODELS
  5. CONCLUSIONS
  6. LITERATURE CITED
  7. Biographical Information

Dr. Groscurth is head of the Institute Anatomy in Zurich, Dean for Student Affairs at the Medical Faculty of the University of Zurich, and president of the Swiss Society for Anatomy, Histology, and Embryology (SSAHE). His research is focused on cell and immune biology. Dr. Eggli is head of the Department of Topographical Anatomy and Neuroanatomy at the Institute of Anatomy in Bern. His scientific interests are the composition and organization of brain extracellular matrix and the further development of kryofixation techniques for electron microscopy. Dr. Kapfhammer is professor of Anatomy and head of Neural Development at the Anatomical Institute in Basel. His research focuses on mechanisms of neuronal regeneration and dendritic development. Dr. Rager is ordinary professor of Anatomy and Director of the Institute of Anatomy and Special Embryology at the University of Fribourg. His research interest is the developmental neurobiology. Dr. Hornung is codirector of the “Institut de Biologie Cellulaire et de Morphologie,” coordinator of the gross anatomy teaching and president of the Department of Neurosciences of the University of Lausanne. His research projects are in the field of developmental neurobiology. Dr. Fasel is head of the Clinical Anatomy Research Group at the University in Geneva. His research is focused on interventional neuroradiology, hepatic, and orthopedic surgery.