Review Article
Kitasato Med J 2013; 43: 99-103　Clinical anatomy as a modern concept for 21st century teaching,
postgraduate education, and research
Bernhard Hirt, Thomas Shiozawa
Institute of Anatomy, Department of Clinical Anatomy, Eberhard Karls University, Tuebingen, Germany
Anatomy faces new challenges in the 21st century. Exponential growth of knowledge, paradigm shifts
in medical education, and the scientific trend to subcellular and molecular research make an impact on
the institutions of today. We described our concept of clinical anatomy as a contemporary and
innovative model for student teaching, postgraduate training, and applied clinical research.
Anatomy can also foster interdisciplinary teaching along with the clinical, especially surgical, professions
to give students a direct link to the application of anatomical knowledge. Furthermore, clinical
students can be relegated to the conceptual framework of basic sciences during their clinical rotations.
Clinical anatomy can provide a unique platform for postgraduate training, because cadaveric human
body specimens can be used as realistic and safe models for practicing even the most complex surgical
procedures. Lastly, the study of clinical anatomy can facilitate applied clinical research, as new
operation techniques and new devices and instruments can be tested and evaluated in a realistic setting.
Therefore, this new concept of the study of clinical anatomy provides a modern, up-to-date model for
teaching anatomy in this day and age.
Key words: clinical anatomy, teaching, dissection, postgraduate surgical training
Background
Clinical Anatomy
A
In Germany, the discussion about anatomy, and how
anatomy related to clinical medicine, peaked at that time
in a well-remembered article by the anatomist Herbert
Lippert about the "Dehumanisation of anatomy and
medicine."2 He called for a more clinical and living,
teaching approach for undergraduate anatomy, resulting
in a broad controversial discussion in the whole medical
community.
This emphasis on clinical anatomy, against the
background of the development of many different medical
technologies, also brought the need for profound
anatomical knowledge back on screen for science and
research and, for the first time, for postgraduate, surgical,
training. The first Center for Clinical Anatomy in
Germany was founded by Bernhard Tillmann, in 1994,
in Kiel, followed by similar institutions in Cologne,
Hanover, Mainz, Muenster, Halle, and Tuebingen. To
date, many anatomical institutes have hosted postgraduate
training courses; however, not many devote themselves
to clinical and macroscopic anatomy as a field of research.
The concept of clinical anatomy in Tuebingen was
natomy is one of the oldest subjects in medicine.
Although having evolved over time, the common
purpose of the scientific field, over decades, and even
centuries, is the explanation of the structure and
morphology of the human body. Traditionally, most
professional anatomists were also clinically trained; and,
therefore, their research was oriented toward the human
structure. However, the vast expanding knowledge in
the second half of the 20th century more and more turned
to sub- and ultrastructure; therefore, the applied and
clinical aspects of anatomy began to fade. This resulted
in the reduction of anatomical content in the curricula
and the decline of clinically qualified anatomists.
However, in the '70s and '80s of the last century the
growing demand in different medical branches for
detailed knowledge of specialized anatomy, e.g., the
development of new technology, was recognized.1 This
rejuvenation was attended by the foundation of the British
and American Association of Clinical Anatomists, in 1977
and 1984, respectively, and also the launch of the journal.
Received 18 February 2013, accepted 2 April 2013
Correspondence to: Bernhard Hirt, Department of Clinical Anatomy, Eberhard Karls University
Elfriede-Aulhorn-Straße 8, 72076 Tuebingen, Germany
E-mail: [email protected]
99
Hirt, et al.
Approbationsordnung, ÄAppO).3 The major alteration
for the preclinical curriculum was the requirement to
integrate more clinical content into the basic sciences.
Therefore, in anatomy, we established a new teaching
format with the Sectio chirurgica, an anatomically
moderated, surgical prosection which is held in parallel
to the dissection course.4 In this course the heads of the
different surgical departments of the University Hospital
perform characteristic and demonstrative operations on
specially embalmed cadavers, moderated by an anatomist.
This interdisciplinary approach helps students to see the
relevance of anatomy for the surgical disciplines, and
highlights the differences of the surgical and anatomical
approach at the same time.
From the start, the acceptance of the medical students
was very good, as it was from the advanced students in
the clinical years. As their interest and the demand
increased, and our lecture hall capacities reached its limits,
we decided to provide the Sectio chirurgica from 2009
on also as an Internet-based live stream. This format
proved even more successful, because students from all
over Germany (and Austria and Switzerland) could
subscribe and view actual surgical operations in real time.
With a chat option, the Internet viewers can also take an
active part by asking the surgeons questions. To date,
about 20% of all medical students in Germany have
registered for the Sectio chirurgica. The last season,
with 12 operations on living patients ranged from a kidney
excision and transplantation to an implantation of an
artificial heart, was seen by approximately 25,000
students.
The Sectio chirurgica shows an excellent way to
integrate clinical content into a traditional medical
curriculum. The interdisciplinary approach proves very
useful in producing a coherent anatomical and surgical
course curriculum, supplementing the very valuable,
traditional dissection course. Using modern broadcasting
technology, the conspicuity and impact of anatomy on
the clinical education increased enormously, even far
over the borders of Tuebingen.
Furthermore, we are not only engaged in preclinical
teaching. Anatomy may also play a relevant role in
clinical education, especially when talking about
complications of interventional procedures. In the
initiation phase of the local skills lab, the department of
internal medicine asked us to cooperate with them by
teaching practical skills. Martin et al. reported that
residents who underwent a structured, anatomy-based
training on central venous line placement produce
significantly fewer pneumothoraces than did their
untrained colleagues.5 Based on these findings, we
originally proposed by Prof. Ulrich Drews, former chair
of the Anatomy Department of Experimental
Embryology. As the gap at the end of the last century
between anatomical research and the education of medical
doctors widened, Prof. Drews sought the solution in
bringing the study of anatomy back to the clinical and,
especially, the surgical sciences. Coincidentally, the
Institute of Anatomy was planning a new building at that
time, which was then constructed as a new teaching
building on the clinical campus (Figure 1). The basic
layout was then designed to provide a setting for teaching
clinical anatomy, as well, and this was the nucleus for
what the department is today.
Concept and development in Tuebingen
The development of the Department of Clinical Anatomy
in Tuebingen started with the new teaching building.
The requirement was a new facility for the dissection
course and cadaver processing, the outcome was an
innovative and visionary concept for teaching anatomy
and clinical anatomy.
Student teaching
The study of medicine in Germany requires 6 years. The
first 2 years mainly cover the basic sciences (anatomy,
biochemistry, and physiology) leading up to the first state
examination. Three clinical years are followed by a
practical year, after which the second state examination
concludes the medical studies.
The Medical Faculty of Tuebingen University applies
this traditional 2-step curricular structure; however, the
curriculum was always remodeled with small but
constitutive changes. The most impacting external
regulatory requirement was a new federal legislation on
medical education in 2002 (Ärztliche
Figure 1. Department of Clinical Anatomy, teaching building,
established in 2000
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Clinical anatomy as a modern concept
developed an anatomical training session with emphasis
on the neck, regarding the catheter placement technique
and possible complications.6 This became a required
module in the internal medicine skills training, which
actually takes place in the anatomical dissection hall. As
a second means of educating medical students in a realistic
surgical environment, we initiated a course teaching
endoscopic anatomy. Students were trained to analyze
anatomy via endoscopic views on cadavers. They learned
to use endoscopes dynamically to search for specific
structures. We recognized that this educational concept
is able to longitudinally connect basic anatomical
knowledge with clinical relevance.
with an OR table, operation microscope, ultrasonic device,
and laparoscopy tower, was already included. Over the
years, we acquired more equipment. Now we offer 11
workplaces with OR tables (Trumpf Merkur, Trumpf
GmbH + Co. KG, Ditzingen, Germany), High definition
(HD) laparoscopic/arthroscopic tower (Karl Storz GmbH
& Co. KG, Tuttlingen, Germany), basic surgical
instruments (Aesculap AG, Tuttlingen, Germany; KLS
Martin Group, Tuttlingen, Germany; Karl Storz), and
LED (light-emitting diodes) surgical operating lamps
(KLS Martin Group). After beginning with live (real
time) surgery transmissions in 2008, we established one
Karl Storz OR1 master workplace (Karl Storz) for
demonstrations (Figure 3). Several HD camera systems
provide high quality overview and insights for telemedial
purposes. In 2011, a livestream broadcast studio was
added. We established technical architecture to combine
the existing OR1 master workplace including the Karl
Storz AIDA (Karl Storz) documentation system with a
TricasterTM 855 live production system (NewTek Inc.,
San Antonio, TX, USA). Sound processing is facilitated
with a Sennheiser Integrated System (Sennheiser
Electronic GmbH & Co. KG, Wedemark, Germany).
Postgraduate training
Having started with loose cooperation with several clinical
partners in the university hospital, the contribution of the
Department of Clinical Anatomy to postgraduate
education has also changed tremendously over the last
years. The building and basic hardware proved a perfect
setting for surgical training courses to many disciplines.
Starting with anesthesiology and orthopaedic surgery,
soon training courses in neurosurgery, ear, nose, and
throat (ENT) surgery, maxillofacial surgery, gynecology,
and trauma surgery followed. The present infrastructure
allows us to host training courses of varying size (Figure
2). In 2012, we hosted 60 national and international
training course events, training about 1,000 surgeons from
12 different disciplines.
Infrastructure
The floor plan is centered around the semicircular shaped
dissection hall on the ground floor, the first floor
comprises seminar rooms and a histology lecture hall.
The basic hardware: operating room (OR) equipment
Cadaver processing
For the dissection course, formalin (4%) fixation is used.
For the training of surgical procedures, an alcoholglycerol mixture, as described previously,7 proved very
valuable. Advantages are the authentic haptics of the
soft tissue, which allow full mobility of joints for
arthroscopy and CO2 insufflation of the abdomen for
laparoscopy. Limitations to these fixation methods are
the preservation of the brain and the relatively fast
evaporation time of the fixation fluids. The latter requires
a more intensive maintenance of the specimen if stored
Figure 2. Example setting of a postgraduate training course in
the Department of Clinical Anatomy
Figure 3. Karl Storz OR1 system integrated in the dissection
hall of the Department of Clinical Anatomy
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Hirt, et al.
with the study of clinical anatomy, we provide a platform
for companies to test their newly developed implants
and for surgeons to test and/or practice new surgical
approaches. For example, the first retinal microchip
allowing blind patients to see again18 was first tested for
the surgical procedure and fitting of the implant on a
cadaveric specimen in our facility.
and used over a longer period of time.
Applied anatomy research
The cooperation with various clinical disciplines and
medical devices companies naturally suggests scientific
cooperation. In a clinical anatomy department, the
possibilities and limitations of new surgical techniques
can be tested under safe conditions on the most realistic
model−the human cadaveric body.
Special ties exist to the departments of neurosurgery,
ENT, obstetrics andgynecology, and hand and plastic
surgery. In neurosurgery, several new approaches were
described, with a focus on endoscopy versus microscopy
(Figure 4). The endoscopic extension of the retrosigmoid
suprameatal approach optimizes the visualization of the
sellar and parasellar regions.8 First usability testing of
different new prototype endoscope systems were
performed in an anatomical setting to check usability in
neurosurgical standard approaches like the anterolateral
or retrosigmoidal,9 as well as for a ventriculoscopic
approach,10 and visualization for aneurysm surgery.11
A special challenge in gynecology is pelvic floor
surgery, because the numbers of patients increase rapidly
and many new, mainly minimal invasive operation
techniques arise. As the pelvis presents an anatomically
highly complex and three-dimensionally challenging
region, we evaluated several new pelvic floor repair
systems. The anatomical conditions for different mesh
applicators like the Gynecare TVT-O, 12 Gynecare
PROLIFT 13 and Gynecare PROSIMA14 were first
implanted in anatomical cadavers to evaluate the requisite
surgical procedures. This was clearly foresighted because
nowadays many of these products are viewed critically
because of the increasing occurrences of complications.
Surgical cadavers were also used to develop new
surgical measures for free flap transplantations in the
field of plastic and reconstructive surgery.15-17 Moreover,
Discussion
The 21st century is a great challenge for anatomy because
the settings change with new educational paradigms,
technological advances, and the demands of the various
institutions and societies. Against this background, the
need for a sound anatomical education is now more
important than ever.19 The surgical disciplines involved
have already expressed their concerns about the quality
of anatomical education.20,21 In 2009, the German Society
of Surgery even made "Anatomia − quo vadis?"
("Anatomy−where to go?") a main topic of their annual
congress. There is also amounting data supporting a
decline of anatomical knowledge in the recent years.22,23
Our concept of teaching clinical anatomy tries to
counteract this development, taking effect on several
levels:
・The undergraduate teaching concept connects basic
sciences and clinical application. With the Sectio
chirurgica, we have succeeded in creating an
innovative, transdisciplinary, nationwide, combined
anatomical and surgical lecture course. It is clearly
necessary to discuss how this approach may be
transferable to other institutions. And we also clearly
see a need to teach anatomy clinically applied in the
preclinical phase, and then to review anatomy during
clinical studies so that students remember it and we
can point out its relevance, e.g., to help avoid
complications.
・Anatomy can take a major part in postgraduate
education, because we can exclusively provide the
most realistic training model there is−the human body,
with all its anatomical variants. With modified fixation
procedures and sufficient OR equipment, we can offer
an up-to-date surgical training environment, including
audio and video technology for telemedial
transmissions via the Internet accessible from
anywhere in the world.
・To further support the development of medical
technology and surgical science, the study of clinical
anatomy can play a key role for interdisciplinary
cooperation and scientific exchange, providing a
platform for cutting-edge applied research. The
Figure 4. Clinical anatomical research setting: evaluation of
different surgical visualization techniques in skull base surgery
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Clinical anatomy as a modern concept
11. Ebner FH, Marquardt JS, Hirt B, et al. Broadening
horizons of neuroendoscopy with a variable-view
rigid endoscope: an anatomical study. Eur J Surg
Oncol 2010; 36: 195-200.
12. Reisenauer C, Kirschniak A, Drews U, et al.
Transobturator vaginal tape inside-out. A minimally
invasive treatment of stress urinary incontinence:
surgical procedure and anatomical conditions. Eur J
Obstet Gynecol Reprod Biol 2006; 127: 123-9.
13. Reisenauer C, Kirschniak A, Drews U, et al.
Anatomical conditions for pelvic floor reconstruction
with polypropylene implant and its application for
the treatment of vaginal prolapse. Eur J Obstet
Gynecol Reprod Biol 2007; 131: 214-25.
14. Reisenauer C, Shiozawa T, Huebner M, et al.
Anatomic study of prolapse surgery with
nonanchored mesh and a vaginal support device. Am
J Obstet Gynecol 2010; 203: 590.e1-7.
15. Rahmanian-Schwarz A, Spetzler V, Amr A, et al. A
composite osteomusculocutaneous free flap from the
medial femoral condyle for reconstruction of complex
defects. J Reconstr Microsurg 2011; 27: 251-60.
16. Rahmanian-Schwarz A, Rothenberger J, Hirt B, et
al. A combined anatomical and clinical study for
quantitative analysis of the microcirculation in the
classic perfusion zones of the deep inferior epigastric
artery perforator flap. Plast Reconstr Surg 2011;
127: 505-13.
17. Rahmanian-Schwarz A, Schiefer J, Amr A, et al.
Vascularized tendon incorporated in reverse
homodigital and heterodigital island flaps for the
reconstruction of dorsal digital defects. Microsurgery
2012; 32: 178-82.
18. Zrenner E, Bartz-Schmidt KU, Benav H, et al.
Subretinal electronic chips allow blind patients to
read letters and combine them to words. Proc Biol
Sci 2011; 278: 1489-97.
19. Older J. Anatomy: a must for teaching the next
generation. Surg J R Coll Surg Edinb Irel 2004; 2:
79-90.
20. Monkhouse WS. Anatomy and the medical school
curriculum. Lancet 1992; 340: 834-5.
21. Waterston SW, Stewart IJ. Survey of clinicians'
attitudes to the anatomical teaching and knowledge
of medical students. Clin Anat 2005; 18: 380-4.
22. McKeown PP, Heylings DJ, Stevenson M, et al. The
impact of curricular change on medical students'
knowledge of anatomy. Med Educ 2003; 37: 95461.
23. Prince KJ, Scherpbier AJ, van Mameren H, et al. Do
students have sufficient knowledge of clinical
anatomy? Med Educ 2005; 39: 326-32.
accelerating technological advances are also realities
in medicine; and novel surgical devices, innovative
procedures, and ground-breaking, new approaches
provide a great opportunity for clinical anatomy to be
in the vanguard of this great technological evolution.
We believe this concept to be a beacon for a 21st
century study of clinical anatomy and would encourage
other institutions to follow on this path. It may lead this
magnificent academic field back to clinical recognition,
to expedite the applied sciences, and to a better quality of
medical and health care for the next generation.
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