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Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 81-82

Newer training tool in cleft lip and palate surgery

Department of Burns, Plastic and Maxillofacial Surgery, VM Medical College and Safdarjung Hospital, New Delhi, India

Date of Web Publication11-Aug-2017

Correspondence Address:
Karoon Agrawal
T-23, First Floor, Green Park Main, New Delhi - 110 016
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_44_17

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How to cite this article:
Agrawal K. Newer training tool in cleft lip and palate surgery. J Cleft Lip Palate Craniofac Anomal 2017;4:81-2

How to cite this URL:
Agrawal K. Newer training tool in cleft lip and palate surgery. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2020 May 25];4:81-2. Available from: http://www.jclpca.org/text.asp?2017/4/2/81/212840

Cleft lip and palate (CLP) remains my heart and soul. Being a general plastic and reconstructive surgeon even though I see, operate, and manage almost all varieties of patients in plastic surgery, CLP remains the first priority in my clinical practice. As an educator and mentor, I am also involved in training programs through workshops, updates, continuing educational programs, and conferences in addition to regular classroom teaching. Even though I participate in teaching the whole of plastic surgery, teaching and training in the field of cleft and craniofacial anomalies give me a special joy and satisfaction. Cleft surgery is the basic surgical skill expected to be learned during plastic surgery training at least in India. The classroom teaching of the anomaly and surgical procedure is an integral part of every training module. Theory questions on CLP are essential part of every plastic surgery exit examination. In practical examination too, the trainees are grilled on the surgical steps of CLP repair.

When discussing with cleft surgeons globally, I have known that the teaching and training in cleft surgery are becoming more and more difficult, especially skill development in performing primary corrective surgery. The CLP repair surgeries are performed in infants <1 year of age. One is always concerned about the handling of delicate tiny tissues in these small babies. And yet on joining clinical practice, trainees are expected to perform the surgery independently. What about the practical training and operative skill development? Is it adequate? In one of the conferences, a debate exposed the inadequacy of training and skill development for various plastic surgical procedures including cleft surgery, microvascular procedures, and craniofacial reconstructions in the Indian curriculum. Till the end of the last century, all cleft surgeries were performed in teaching institutions. There was enough exposure to primary cleft surgeries during the training period. Toward the end of training, most of the trainees would get substantial hands-on experience on CLP surgeries under the supervision of the experienced teachers. There were few workshops and other training opportunities. Virtual surgical teaching did not exist.

There has been a major shift in the training and skill development in the field of cleft surgeries. New technology has made inroads in skill development in many surgical fields including cleft. The situation is a little different in the field of cleft vis-à-vis other surgeries, for example, laparoscopic surgery. The emergence of nongovernmental organizations helping cleft surgery turned the table. Most of the clefts shifted from training institutions to nonteaching centers for the reasons known to all. Now there is a dearth of clefts in most of the training centers. Unfortunately, there is a lack of understanding between the training centers and the cleft care centers for training and teaching. Effectively, adequate exposure to cleft surgery is lacking during training. The hands-on training is practically a dream now. Apart from the nonavailability of the patients, one is concerned about the risk of complications in these small babies inviting litigation. There are ethical considerations too.

During our residency, we were given a cup with narrow mouth with two rubber strips placed side by side to practice suturing at a depth akin to intraoral surgery. We were introduced to this device as “palate trainer.” People used different devices to practice suturing at depths mimicking cleft palate repair. Smile train developed virtual surgery simulator. This is a web-based technology tool which allows real-time interaction with three-dimensional (3D) surgical simulation.[1] This is aided by high-definition intraoperative video and voice-over. However, this has its limitation in hands-on skill development and does not seem to be popular.

One needs to ponder over this training gap and find a way out. One needs to innovate to overcome these shortcomings. This is the era of technology and newer technology has answer to every such issue. It is just a question of being open to this technology and using it to our benefit. With time we have learned that “warm simulators” are becoming difficult in training cleft surgery.[2] Animal and cadaveric training have their limitation because of nonavailability of cleft model. Hence, there is emergence of manikin based and virtual reality simulators in the field of CLP. I am amazed at the pace of technology development in the field of simulator technology for CLP surgery.

Now 3D printing technology is turning the table. With the use of this technology, a CLP trainer has been developed by a medical resident under the guidance and supervision of a group of senior plastic surgeons. I had an opportunity to interact with the innovator and his marketing team in New York recently. I was impressed with the quality of manikin prepared. This simulator is unique. One can practice any technique of CLP repair. However, I was skeptical about its cost. At present, the simulator is in the developing stage. Once it goes for mass production, it is envisaged that the cost will significantly come down. This is important, especially for developing countries, where it is likely to be used in larger number. This is a cartridge-based simulator. I also suggested making the cartridge reusable to reduce the cost.

I am also aware of an ongoing development of a 3D virtual reality simulator for CLP surgeries. The one which is in process of development has haptic feedback with visual and voice feedback. This is expected to be ready by the end of this year and is being developed by an India-based company.

These simulators will allow the trainees to repeatedly practice the surgical steps in a low-stress environment without causing risk to the patients. These simulators record the procedure performed which can be replayed to provide a feedback.

This is the era of rapidly developing technology in all fields of human endeavor, including surgical and medical training.[2] Today, the traditional teaching may not be suitable for skill development in primary CLP surgery. The virtual surgical videos may teach but may not train adequately. The newer generation of surgical simulators for CLP is improving in leaps and bounds in terms of educational content and realism. These newly emerging simulators are likely to transform the training methodology in cleft surgeries as is happening in other surgical specialties as the “task trainers” are the in-thing. It may not be an exaggeration to say that in the future, these simulators will replace the traditional training in cleft surgery.

  References Top

Oliker A, Cutting C. The role of computer graphics in cleft lip and palate education. Semin Plast Surg 2005;29:286-93.  Back to cited text no. 1
Chittoria RK, Pai DR. Robotics, simulation and telemedicine relevant to plastic surgery. In: Agrawal K, editor. Text Book of Plastic, Reconstructive and Aesthetic Surgery. Vol. I. New Delhi: Thieme; 2017. p. 493-516.  Back to cited text no. 2


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