Sim*Dissect
Training Guide
-Dissection SkillsExercises for non-dominant hand performance, coordinated forceps
and scissors cutting, developing tissue planes, and excising simulated
subcutaneous masses and veins
Suggested Exercises and
Homework Assignments
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Sim-Vivo, LLC
Essex, NY
Sim*Dissect
Dissection Skills Learning Module
All surgeons know that a surgical procedure requires skills beyond the ability to cut and sew.
Unfortunately, the human body is not composed of a group of individually packaged tissues that
present themselves like grapes to be removed or repositioned. Most tissues, particularly those
involved in an inflammatory or malignant process, will be tightly adherent to surrounding
structures. In almost all surgical operations, target organs or tumors have to be separated from
surrounding fat, adventia, or scar with a two handed technique combining focal retraction and
tissue spreading or cutting using forceps and scissors. We describe all of these motions as the
process of “dissecting”.
Observing expert surgeons using instruments with both hands in an efficient and fluid manner
will fool us into thinking that the psychomotor skills necessary for dissection are part of our
human genome. As you stumble through your first sebaceous cyst excision or the cleaning of a
saphenous vein, you will find that nothing is farther from the truth. Actually, dissection requires
a coordinated effort of both hands, both dominant and non-dominant, to perform different
movements simultaneously. This can be likened to learning to play the piano using one hand to
play the chords while the other focuses on the melody: competence requires practice and it can’t
be acquired overnight.
If we break down the movements to perform an exceptional dissection, several areas of difficulty
can be identified for the novice. First, the forceps are usually held in the non-dominant hand; the
beginner soon discovers that optimal forceps use requires finger and thumb coordination for
precise grasping and retraction which is essentially the same fine motor control as might be
found with the skill of writing. Try copying this sentence using a pen in your non-dominant
hand … not too easy, huh? Yet, this is the exact level of control needed in delicate dissections.
Secondly, tissue cutting and spreading should be performed with the scissors using very short
motions of the tips. The exact movement of the scissor tips is not so intuitive given the variety
of tissue adhesion that will be encountered in surgery. If the spreading is too broad, the result is
inadvertent damage to surrounding tissue that could result in bleeding or unanticipated injury.
And finally, the coordinated effort of simultaneously retracting and cutting requires integration
of the movements of both hands. These basic skills can actually be learned very quickly to a
level that will allow you to “get through” an operation, but to perform with precision and
efficiency at the level of a master surgeon requires the many years that are devoted to a
residency.
The Sim*Dissect Learning System has been developed to expose you to the skills necessary for
dissection and offer you a framework for further practice. All of the equipment and supplies are
provided in your module and, by following and repeating the suggested exercises proposed in
this booklet and on the training video, you will get off to a good start in learning this skill.
When I operate with learners, almost uniformly at the beginning of each case, I advise them that
“this procedure is not equivalent to a horse race.” The same is true in the completion of this
learning system. The goal should not be how fast you can complete the tasks but how precise
you can make your cuts and spreads to separate out the simulated tissues as cleanly as possible,
and how well you can define the planes between the structures. Anyone can rip tissues out of a
surgical field … only experienced surgeons can remove tissues with minimal blood loss and
surrounding tissue injury! That is our goal.
Let’s get started! When you open your learning system, you will note a number of components
that require a comment on their use:
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The dissection board is composed of simulated fatty tissue that contains several
embedded “tumors” and veins to be dissected and removed. The simulated fat is “selfretracting” which obviates the need for additional instruments. Adherent to the surface
are multiple patches of simulated skin, eschar, or scar that must be debrided and excised
along the appropriate tissue plane.
Metzenbaum scissors – 7 inch. These are the most common type of tissue scissors used
for fine dissection. Note that they are curved and have relatively fine tips that are
rounded at the end.
DeBakey forceps – 7 inch. These are used for atraumatic tissue grasping and retraction.
Careful examination of the tips shows a longitudinal tongue and groove configuration
with transverse serrations that run the length of the forceps.
#15 scalpel – This will be available to cut apart tissues that are tightly adhered and may
obliterate tissue planes.
Wire strand and a bag of 12 beads. These will be used to practice coordination and
accuracy of using the forceps in your non-dominant hand
Paper cut-out patterns – Initial practice in retracting and cutting will use these patterns on
paper. You will be asked to hold the paper with forceps while cutting with scissors.
Cloth cut-out patterns – For further practice of using both hands for dissection. Cutting
this flexible sheet will encourage small cuts and frequent repositioning of the forceps.
Guidebook – you are reading it
Exercise 1 – Psychomotor skills with your non-dominant hand
For dissection, you will be using your non-dominant hand to perform precise motions with a skill
that should be about as accurate as your dominant hand. So why not start your practice by
performing a simple task that you do all of the time with your dominant hand: printing your
name. In the center box at the top of the figure below, print your name with your dominant hand.
Now, print your name with the other hand in the remaining 10 boxes. Try to duplicate the
printing as closely as possible. Are you able to make it look about the same as with your
dominant hand? This is an exercise that you can repeat anywhere and anytime. You don’t have
to be completely ambidextrous to be a good surgeon but highly developed psychomotor skills in
your non-dominant hand certainly helps.
Exercise 2 – Beads on a wire
This is an exercise that will allow you to practice precise movements using the DeBakey forceps
with your non-dominant hand. It is not exactly the same as grasping the saphenous vein while
doing a coronary artery anastomosis, but it will allow you to practice without injuring anything.
Put Beads Here
Start by placing 10 the beads in the circle on the piece of paper that is provided (as in
the diagram). You can cheat a little by standing all of the beads on end before you
start which will help you grasp them with forceps, although we will not allow that as
the exercise progresses. Place the blue wire on a flat surface with the long stem
perpendicular to the surface. Why don’t you start by using the forceps with your dominant hand
and stack the beads individually on the wire. Now, take them off and put them back in the circle.
Practice a few times and then time yourself with whatever timer or stopwatch that is on your
smart phone or watch. A good time for this exercise is about 20- 25 seconds without any slipups.
OK … do the same with your non-dominant hand. You can begin with all of the beads upright.
Eventually, you should perform this task with all of the beads lying flat and randomly in the
circle.
We understand that it will get boring practicing this task over and over and over. To avoid this,
you might do it until you get comfortable and then come back to it several times over the next
few days. You should try to achieve the same time as you did with your dominant hand.
Exercise 3 – Paper cut-outs
Now it’s time to use one hand to hold and retract while using the other to cut. We are going to
start with shapes to be cut out of paper as seen in the diagram:
For this exercise, you will grasp the edge of the cut-out with your
DeBakey forceps and cut right down the middle of the dark black
line. No fair grasping the whole diagram with forceps as that
would make it too easy and not realistic to dissecting. You should
hold the paper very close to the area that you are cutting to gain
accuracy. Grasp and cut … grasp and cut … grasp and cut. Move
around the shape with small intervals. When you are finished,
there should remain a small amount of the black line on both sides of the cut-out. One of the
figures has a place to put your name. If you are working in a group with a mentor, this could
facilitate a competition among your colleagues with a prize for the most accurate cut-out. Or,
maybe, it could be used as a final exam of your skills for this exercise. If so …. good luck!
Exercise 4 – Cloth cut-outs
Because the paper is stiff, it really provides some unfair advantage for the previous dissection
exercise. Cutting figures out of the flaccid cloth square will challenge you a bit more. Hold the
cloth with your DeBakey forceps and cut out five circles with different colors: white, pink, red,
blue, and turquoise. Try not to place the grasping tips of the DeBakey within any of the circles
as you cut. Only grasp in the black background area. You will find it easier if you cut over
small distances before re-grasping. When you are done, you should have five circles that have
no black along the edges … and … no color left around the cut-outs.
Exercise 5 – Creating tissue planes
One of the important principles of dissection is to find natural planes between tissues and
proceed with the dissection through tissues that offer the least resistance and have minimal
bleeding. These “tissue planes” usually are found between tissues of differing density or
anatomic configurations. Typical examples are the planes between fascia and subcutaneous
tissue, gallbladder and liver, or adhered omentum onto mesentery (a particularly difficult plane
to define). Once these areas of natural separation are found, the goal of dissection is to further
expand laterally on these planes by using sharp or blunt separation to open up the operative field.
This requires the use of the forceps to elevate one side of the tissue while dividing bluntly or
cutting sharply with the scissors. As with our other exercises, it is extremely important to
maintain traction with the forceps as closely as possible to the action of the scissors in order to
impart the force of the forceps directly to the spot that you are cutting. If the forceps are too far
from the focus of dissection, then the force for retraction will dissipated through the elasticity of
the tissues. Action of the scissors should be in relatively short cuts or spreads.
In the box, you will find a model that provides an opportunity to practice this skill. The yellow
material simulates subcutaneous tissue and fat. Attached to the surface is a piece of material
measuring about 4 inches in width and is adherent to the simulated fat. Let’s pretend that this is
a fascia or a skin layer. On top of this are several pieces of red solid and mesh material which
represent tissue adherent the fascia. It might be eschar, scar, infected mesh or any other tissue
that you would like to separate away. Your task is to carefully remove the surface material off of
the fascia by developing and enlarging the tissue plane between the two simulated tissues …
after which, you will remove the simulated fascia from the underlying fat. To get started, you
will have to carefully retract small portions of the material to be removed while separating and
cutting away the underlying tissue. We would suggest that you start with the mesh material
because that is the easiest and less adherent plane. When you get to the area where the mesh is
attached to the red material it might get a little harder. Once you have completed the removal of
the mesh then remove the red layer of simulated tissue from the fascia. You may have to use
scalpel dissection as referenced in the next paragraph. After the fascia has been cleaned, grab
your scalpel and incise it vertically to yield 3 or 4 sections. Then, carefully dissect (see, now you
have the skills to use that word now!) these pieces from the underlying layer. The goal will be to
leave “no fascia behind” while taking away very little of the yellow “fat”. Of course, you could
just grab the stuff and rip it away, but that wouldn’t be fair, would it? Remember, as we stated
earlier, speed is not the concern here … accurate dissection is! Separating small areas by
spreading the scissor tips and then cutting is the best approach to this task.
There may be situations in which you encounter adhesion planes that are just too firm or tight to
use the scissors. They just won’t work! You might ask yourself the question: “What now?” The
answer is simple: “It’s time for the knife.” Scalpel dissection is certainly an alternative for very
dense tissue, and the technique is the same as for the scissors. The tissue is retracted with the
forceps thus placing tension on the area to be cut. Holding the scalpel like a pencil, the cutting
edge of the scalpel near the tip is brought through the center of the tissue dissection plane with
small strokes. At times, this can be scary since little is known of the tissue that lies just deep to
the surface but, in this case, the classic dogma applies: “You gotta do what you gotta do!”
When the tissue planes begin to open up again, you can always go back to using the scissors.
Scalpel dissection will be useful for the small pieces of the red mesh that are adherent to the
corners of the red patch. The trick here is to leave the patch attached to the underlying surface so
as to provide a firmer base from which you can dissect the mesh off. Try to do this with both the
scalpel and the scissors to get an idea of which will better. This situation is very similar to an
abdomen “socked in” with tight adhesions. What a nightmare! But patience and persistence will
win the day even with the worst scar and adhesions.
Exercise 6 – Excising soft tissue masses.
Now it is time for real surgery! Once the surface of
the board has been debrided and cleaned of the red
patches and fascia, you will be able to palpate several
simulated masses just under the surface. If they were
exposed, they would look like the picture:
But, of course, they are buried in the simulated
subcutaneous tissue … and you have to “dissect”
them out. A diagram is included in the box.
So, let’s begin with one of the small red masses across the top. It could be a sebaceous cyst, a
lipoma, a fibroma, or something similar that is firmly adherent to the surrounding tissue. First of
all, palpate the mass through the subcutaneous tissue and then begin cutting with your scissors
through the yellow simulated fat in a vertical direction. Note that this material is self-retracting.
You might occasionally have to push it out of the way, but in general, it will stay out of the field.
Once you visualize the red mass, gently grasp the exposed surface and retract it straight out of
the field. With gentle spreading and cutting using small bites of the scissors, try and develop a
plane around the mass. You will have to re-grasp the mass several times on all sides to gently
rotate it out of the wound while you continue the dissection. With this exercise, you are going to
quickly discover that your retracting forceps are as important as your scissors. It is key to expose
the tissues to be cut or separated, and this only can be done with the appropriately applied
retraction in the correct direction (which is usually away from the focus of the dissection).
Remember, that the goal is to leave as little of the simulated subcutaneous tissue as possible on
the mass to be excised. You may also find that if you try to cut big chunks of the simulated
subcutaneous tissue, the scissors just won’t hack it (excuse the pun). You may think that the
scissors are defective but that isn’t the case. These Metzenbaum scissors are not designed to cut
large lumps of tissues as that is the function of the larger Mayo scissors. Dissecting scissors are
designed for dissecting which means small cuts and spreads.
Once you have removed, the first mass, set it aside. We anticipate that you will get so good that
future excised masses will have less remaining adherent tissue on them. The task is simple now
… remove the rest of the palpable masses leaving as little tissue on them as possible.
For the blue simulated veins, the goal will be the same. Eventually, the entire anterior surface of
the vein will need to be exposed. Removing it requires gentle dissection circumferentially
around the structure. There are no rules here – you can start removing it from the center going in
both directions or from the ends meeting in the center.
So how did you do? Look at the “specimens.” Are they intact? Is there a lot of simulated fat
remaining on them? The big question, however, is how comfortable you feel with your
dissection skills at the end of all of these exercises? You should continue to practice the
exercises that focus on using the forceps with your non-dominant hand such as bead transfer and
cutting designs out of paper or cloth. Hopefully, when you get to the OR, you will do a great job
with dissection!!
We believe that Sim*Vivo has created a novel learning system for learning and practicing
dissection skills. Of course, we are always open for suggestions to improve this module. If you
can think of any improvements, please pass them on to us at [email protected]. We will
certainly get back you to discuss any changes that we might make. Thanks!
©Sim*Vivo, LLC
Revised on 7/20/2016, JBF
... In the hands of the learner!
Sim*Vivo, LLC
30 Albee Lane
Essex, NY 12936
518-963-7640
www.sim-vivo.com
Sim*Vivo
learning modules, including Sim*Dissect, are available on our website:
Sim*Suture – for practice of suturing techniques: interrupted, running, mattress,
subcuticular. All supplies included to practice to competence.
Sim*Tie – supplies and a board to learn two-handed and one-handed ties
Sim*Cath – an inexpensive complete central venous catheter kit to facilitate the
placement of central lines in all available manikins.
Sim*Supply -
a single source supplier of surgical simulation materials
Sutures – 3-0, 4-0 nylon; 2-0, 3-0 silk; #1 nylon
Ties – 3-0 silk, 0 nylon, 6-0 nylon
Suture kits – Hegar needle driver, Adson forceps, suture scissors, scalpel, and
assorted sutures and needles without the simulated skin board
Sim*Bandage – 4x4’s, ABD pads, kerlix gauze roll for bandaging practice
Surgical instruments – Hegar needle driver; Adson, DeBakey, and Gerald forceps;
Castroviejo vascular needle driver; Metzenbaum, suture, and iris scissors
Sim*Pad – a realistic suturing board with integrated guidelines to assist in novice
education and practice
Simulated bowel – a piece of realistic bowel for the practice of enterotomy closure
and intestinal anastomosis.