Microsurgical education for medical students: systematic review

Campos, Michelly Moreira; Tannuri, Ana Cristina Aoun; Montero, Edna Frasson de Souza; Nakamura, Eric Toshiyuki; Ferreira, Giovanna Mattos; Cassino, Pedro Carvalho; Lanchotte, Cinthia; Chinelatto, Lucas Albuquerque; Silva, Filipe Miranda de Oliveira; Galvão, Flavio Henrique Ferreira

doi:10.1590/acb412726

person Michelly Moreira Campos *

Conception and design · Manuscript writing

schoolUniversidade de São Paulo – Faculdade de Medicina – Departamento de Gastroenterologia – São Paulo (SP) – Brazil.schoolUniversidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil.

0009-0007-8695-3900

person Ana Cristina Aoun Tannuri

Technical procedures

schoolUniversidade de São Paulo – Faculdade de Medicina – Departamento de Gastroenterologia – São Paulo (SP) – Brazil.schoolUniversidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil.

0000-0002-5481-032X

person Edna Frasson de Souza Montero

Critical revision

schoolUniversidade de São Paulo – Faculdade de Medicina – Departamento de Gastroenterologia – São Paulo (SP) – Brazil.schoolUniversidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil.

0000-0003-1437-1219

person Eric Toshiyuki Nakamura

Analysis and interpretation of data

schoolUniversidade de São Paulo – Faculdade de Medicina – Departamento de Gastroenterologia – São Paulo (SP) – Brazil.schoolUniversidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil.

0000-0002-9903-7553

person Giovanna Mattos Ferreira

Acquisition of data

schoolUniversidade de São Paulo – Faculdade de Medicina – Departamento de Gastroenterologia – São Paulo (SP) – Brazil.schoolUniversidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil.

0009-0008-2875-357X

person Pedro Carvalho Cassino

Conception and design

schoolUniversidade de São Paulo – Faculdade de Medicina – Departamento de Gastroenterologia – São Paulo (SP) – Brazil.schoolUniversidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil.

0000-0003-2664-0770

person Cinthia Lanchotte

Technical procedures

schoolUniversidade de São Paulo – Faculdade de Medicina – Departamento de Gastroenterologia – São Paulo (SP) – Brazil.schoolUniversidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil.

0000-0002-8139-1458

person Lucas Albuquerque Chinelatto

Technical procedures

schoolUniversidade de São Paulo – Faculdade de Medicina – Departamento de Gastroenterologia – São Paulo (SP) – Brazil.schoolUniversidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil.

0000-0001-6534-5075

person Filipe Miranda de Oliveira Silva

Acquisition of data

schoolUniversidade de São Paulo – Faculdade de Medicina – Departamento de Gastroenterologia – São Paulo (SP) – Brazil.schoolUniversidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil.

0000-0001-7531-7473

person Flavio Henrique Ferreira Galvão

Conception and design · Critical revision · Final approval of the version to be published

schoolUniversidade de São Paulo – Faculdade de Medicina – Departamento de Gastroenterologia – São Paulo (SP) – Brazil.schoolUniversidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil.

0000-0003-1924-3208

person* Corresponding author: emailmichelly.campos@fm.usp.br

Section editor:

Cristina Camargo https://orcid.org/0000-0002-3134-0003

Conflict of interest

Nothing to declare.

Study	Country	Type of study	Participants	Study design	Result
Mikó et al.¹¹	Hungary	Descriptive methodological study	Medical students, researchers, doctors and specialists	Furka microsurgery course, with 20 hours distributed across five 4-hour classes	15 years of experience demonstrated that the method allows for progressive and structured learning of microsurgery, highlighting the effectiveness of personalized follow-up
Müller et al.¹²	Germany	Cross-sectional observational study	64 medical students	Evaluation of a practical (wet lab) course in microsurgical suturing in ophthalmology with subsequent assessment by questionnaire	There were an increased interest in ophthalmology after the course and strong agreement regarding the desire for more microscopic training
Onoda et al.¹³	Japan	Descriptive observational study	29 medical students	Review of the results of the microsurgery training program	There was a negative correlation between the number of trials in non-animal stages and the number of rats used afterward, suggesting that training first in non-living models reduces the use of animals and allows for effective learning of microsurgery
Liu et al.¹⁴	Canada	Descriptive methodological study	Six medical students, eight residents, and 10 experienced doctors	Multilevel course in ophthalmic microsurgery in a wet lab, with participant feedback collection	The organization, course structure, and positive participant feedback are described, highlighting the viability of multilevel and collaborative programs for surgical training
Deuchler et al.¹⁵	Germany	Prospective observational study	79 medical students	Students underwent training in an ophthalmic microsurgery simulator and were evaluated using objective simulator scores and subjective questionnaires before and after training	The training significantly increased the students' self-perception of microsurgical skills, although there was no association between simulator performance and interest in the specialty
Cole et al.¹⁶	United States of America	Uncontrolled trial	20 medical students	Students participated in a class and performed a wet lab on corneal suturing. Pre- and post-intervention questionnaires	There was a significant increase in comfort with various microsurgical skills, interest in ophthalmology increased, and intrinsic motivation was high
Bastos and Silva¹⁷	Brazil	Descriptive methodological study	Medical students	Development of a synthetic model for basic surgical training made of ethylene-vinyl-acetate plates	The synthetic model has been described as a simple, reproducible, and low-cost alternative for the initial teaching of basic surgical skills to medical students before clinical practice
Kinshoku et al.¹⁸	Brazil	Descriptive methodological study	Medical students	Basic microsurgery training model using Wistar rat cadavers from discarded specimens from other experiments, allowing for microanastomoses	The experimental model enabled safe, low-cost, and ethical microsurgical training
Lin et al.¹⁹	United Kingdom	Descriptive observational study	42 medical students	Practical microsurgical course with specialized supervision. Evaluation conducted through qualitative questionnaires before and after the workshop	There has been progress and increased confidence in microsutures. In total 67٪ considered it important for their future career. Feedback indicated a need for more time and better equipment
Jensen et al.²⁰	United States of America	Longitudinal observational study	12 medical students	Development of low-cost, reusable microsurgery kits using surplus surgical materials. Students performed suturing/anastomosis, evaluated using a performance scale at two time points with a six-week interval	There was an improvement in performance scores and a reduction in time spent on suturing and anastomosis tasks after six weeks, suggesting that the kits are useful educational tools for early introduction to microsurgery
Scholz et al.²¹	Germany	Descriptive observational study	36 medical students	Implementation and evaluation of a microsurgery training program without the use of animal models	The training produced good to excellent results among the students. The animal-free program proved viable for initial microsurgery training and for comparative skill assessment
Pavlidis et al.²²	United States of America	Longitudinal observational study	15 medical students	Informal microsurgical training was conducted weekly for five weeks, with performance analysis by two independent reviewers, including anxiety, workload and sympathetic activation	Sympathetic activation and anxiety levels did not correlate with performance or speed. Training in an informal setting may facilitate skill acquisition by reducing high stress levels
Maluf Junior et al.²³	Brazil	Descriptive methodological study	Medical students	Microsurgical training using pig spleens discarded after splenectomy	The model proved effective for initial learning of vascular microsurgery, at low cost and without the need to sacrifice new animals
Sakamoto et al.²⁴	Japan	Randomized controlled trial	86 medical students	Students were randomized to either hands-on training on a benchtop simulator or video-based learning, followed by 40 minutes of microsuturing practice and subsequent evaluation	The simulator group completed the task in less time than the video group. The final suture quality was higher in the simulator group, but without a significant difference. Practical training on a simulator proved more effective for learning microsuture
Froschauer et al.²⁵	Austria	Randomized experimental study	15 medical students and 15 experienced microsurgeons	Each participant performed two end-to-end anastomoses on a chicken thigh model, one with and one without music	Music had no significant overall effect on run time or performance. However, among experienced surgeons, preferring to work with music was associated with better scores on the Stanford Microsurgery and Resident Training (SMaRT) scale
Al Omran et al.²⁶	United Kingdom	Analytical observational study	40 medical students and six residents	Participants performed consecutive end-to-end microvascular anastomoses; performance was assessed by hand movement analysis and correlated with habitual levels of physical activity	Higher levels of physical activity correlated with worse microsurgical performance among beginners
Sudario-Lumague et al.²⁷	Taiwan	Analytical observational study	578 medical students	Students underwent basic microsurgery training and were evaluated by a senior consultant. Scores between men and women were statistically compared	There was no significant difference in performance between male and female students, indicating similar microsurgical skills between the groups
Hanrahan et al.²⁸	United Kingdom	Analytical observational study	40 medical students	Students performed dural suturing on an ex-vivo porcine model during a neurosurgery course, with evaluations of performance, dexterity, anxiety, and tremor	Physiological tremor was not significantly associated with microsurgical dexterity. Higher subjective perception of anxiety correlated with worse performance
Mücke et al.²⁹	Germany	Prospective comparative study	59 medical students and 19 surgeons	Intensive 14-day microsurgery course, with practical and theoretical evaluation by two independent and blinded examiners for comparison between students and surgeons	Students obtained significantly higher scores than surgeons in practical (13.71 versus 11.73; p < 0.0001) and theoretical (15.27 versus 13.50; p = 0.009) exams and greater course attendance
Teo et al.³⁰	Singapore	Randomized controlled trial	42 medical students (24 in the mass-learning group; 18 in the spaced-learning group)	Students were randomized to either single 8-hour session microsuture training (mass-learning) or weekly 2-hour sessions for four weeks (spaced-learning), with an assessment conducted one month after training	The spaced learning group showed significantly higher scores in suture accuracy after one month, indicating better skill retention
Almeland et al.³¹	Norway	Randomized controlled trial	46 medical students randomized into two groups	The intervention group received training in macro and microsurgery; the control group received only microsurgery training. After training, all participants performed macrosurgical suturing tasks and were evaluated	The intervention group showed worse macrosurgical performance
Jensen et al.³²	United States of America	Randomized controlled trial	24 medical students (12 in the LazyBox simulator group; 12 in the control group)	Students undergo longitudinal practice on a low-fidelity microsurgery simulator (LazyBox) (group 1) or no additional practice (group 2). Assessments are performed before and six weeks after the intervention	Both groups showed improvement in the tasks, with no statistically significant differences. The use of the LazyBox simulator did not demonstrate any significant additional benefit
Nemeth et al.³³	Hungary	Descriptive study	470 residents e medical students	Summary of 50 years of experience in microsurgical education, with emphasis on individualized training, standardization, skills assessment, and structured feedback	Experience showed that early and progressive exposure improves performance in subsequent residencies. The importance of adequate duration, individualized training and objective assessment is highlighted
Galvão et al.³⁴	Brazil	Prospective observational study	38 medical students	Description of a microsurgical training course in rat intestinal transplantation	Low completion rate attributed to lack of time, patience, frustration, or technical difficulty. Medical students showed a low completion rate in complex microsurgical models
Zhang et al.³⁵	United States of America	Descriptive observational study	Medical students	Review of institutional experience in creating microsurgery research programs for medical students	Microsurgery research programs for students provided high-quality technical training, contributed to scientific output and influenced career choices in surgical fields
Climov et al.³⁶	Romania	Comparative experimental study	One medical student and one microsurgeon	Comparison of the performance between a student and an experienced microsurgeon in performing hemifacial transplantation in rats, analyzing the learning curve	The student showed a progressive reduction in operating time and ischemia, approaching the performance of a specialist after nine transplants
Beier et al.³⁷	Germany	Descriptive observational study	44 medical students	Implementation of an extracurricular microsurgery course for medical students with training in end-to-end arterial anastomosis in chicken thigh, with evaluation conducted through questionnaires before and after the course	The course led to a significant improvement in self-assessment of microsurgical skills, a high level of participant satisfaction, and 82٪ reported a positive influence on their future choice of specialty
Couceiro et al.³⁸	United States of America	Experience report	Medical students	Description of a continuous microsurgery training regimen using non-living animal models (chicken thighs and wings)	The training regimen using non-living tissues has proven to be accessible, economical, useful for developing microsurgical skills, and avoids the use of live animals in training
Bhandarkar et al.³⁹	United States of America	Pilot feasibility study	Medical students	Reproduction and implementation of a low-cost microsurgical training system (smartphone for magnification + "Lazy Glasses") for performing tasks	The simulation system was easy to assemble, low cost (< $ 50) and viable for microsurgical training in medical students, with the potential to expand access to microsurgical training
Haran et al.⁴⁰	New Zealand	Prospective observational study	Nine medical students and 11 residents	Four-hour dry lab course for training in basic microsurgical skills. Subjective assessment of skills before and after the course using a Likert scale	There was a significant improvement in self-assessment of microsurgical skills. Early exposure increases confidence and perceived ability
Zyluk et al.⁴¹	Poland	Experimental study	10 medical students	Students performed a microsuture test (“six-stitches test”) on a latex glove before and after exposure to three conditions: caffeine consumption, ingestion of a small dose of alcohol, and physical exercise	Caffeine had a significant positive effect on performance. Physical exercise performed immediately before the task had a negative effect. A small dose of alcohol had a minimal effect on performance
Micko et al.⁴²	Austria	Experimental study	10 medical students and 10 neurosurgery residents	Each participant performed a microsurgical task in the NeuroTouch virtual reality simulator under two conditions: well-rested (baseline) and after a sleep interruption at night (stress test)	After sleep interruption, the total score improved significantly (45.1 → 48.7; p = 0.048), the execution time remained stable, and excessive force varied by hand, but self-assessment worsened
Fulton et al.⁴³	United States of America	Case study	One medical student	Individual microsurgical training with knot tying and anastomosis practice on synthetic vessels, under the supervision of an experienced instructor	The participant achieved a technical level equivalent to a third-year surgical resident. Early exposure can develop adequate microsurgical skills
Kaplan et al.⁴⁴	United States of America	Randomized trial	10 medical students and 10 residents	Randomization into two groups: control (endoscopic dissection on a silicone anatomical specimen) and intervention (prior training in microvascular dissection on a chicken wing model). Single-blind assessment of time to complete the task and dissection quality	Prior microsurgical training significantly improved the time and quality of dissection in all groups, with the greatest benefit observed in medical students
Neudert et al.⁴⁵	Germany	Randomized trial	30 medical students and six otosurgeons	Group 2 underwent ossicular and tympanic membrane reconstruction on days 1, 7, 14, and 21; group 1 underwent reconstruction on days 1 and 21 and only observed on days 7 and 14. The results were evaluated in comparison with otolaryngologists	The group with more frequent training showed significant improvement, but it did not reach the specialists' level. The training increased the students' interest in the surgical specialty
Ilgner et al.⁴⁶	Germany	Descriptive observational study	Medical students	Implementation of training in ontological microsurgery using a plastic ear model and a high-definition stereoscopic video system coupled to a surgical microscope	Students improved their visuomotor coordination and gained greater confidence in their manual skills. The system facilitated group feedback and sparked interest in microsurgical specialties
Furka et al.⁴⁷	Hungary	Retrospective observational study	263 medical students	Training courses in suturing/microsurgery, with initial and final evaluation of time, safety, knot stability, and suture thread integrity	There was a significant reduction in knot tying time after training. Individualized training is more suitable than mass training for teaching microsurgery
von Reibnitz et al.⁴⁸	Switzerland	Preclinical prospective trial	13 participants: medical students, residents, and attending physicians	In three training sessions, each participant performed nine microvascular anastomoses using a robotic system. Videos of the anastomoses were blindly evaluated by a specialist	There were a significant reduction in anastomosis time and an improvement in scores throughout the sessions. Prior surgical experience initially correlated with better performance, but this difference disappeared in the last session
Sakamoto et al.⁴⁹	Japan	Non-randomized controlled experimental study	25 medical students and nine neurosurgeons	Students trained in microanastomosis for eight weeks. One group received weekly feedback from a specialist via video call, and the other group practiced self-study using DVDs, with a final practical exam blindly evaluated by two specialists; performance was also compared with neurosurgeons	The group that received expert feedback achieved significantly higher scores in anastomosis than the self-learning group. This group also scored higher than the neurosurgeons

Study	Clear aim	Appropriate methodology	Aims addressed by the study design	Adequate recruitment	Reliable data collection	Bias controlled	Ethical consideration	Accurate data analysis	Clear statement of findings	Relevance	Overall risk
Mikó et al.¹¹	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Müller et al.¹²	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Onoda et al.¹³	Partial	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Liu et al.¹⁴	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Deuchler et al.¹⁵	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Cole et al.¹⁶	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Bastos and Silva¹⁷	Yes	Yes	Yes	Can't tell	Yes	Yes	Yes	Yes	Yes	Yes	Low
Kinshoku et al.¹⁸	Yes	Yes	Yes	Can't tell	Yes	Yes	Yes	Yes	Yes	Yes	Low
Lin et al.¹⁹	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Jensen et al.²⁰	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Scholz et al.²¹	Yes	Yes	Yes	Yes	Yes	Partial	Yes	Yes	Yes	Yes	Low
Pavlidis et al.²²	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Partial	Low
Maluf Junior et al.²³	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Sakamoto et al.²⁴	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Froschauer et al.²⁵	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Al Omran et al.²⁶	Yes	Yes	Yes	Yes	Yes	Can't tell	Yes	Yes	Yes	Yes	Low
Sudario-Lumague et al.²⁷	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Hanrahan et al.²⁸	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Mücke et al.²⁹	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Teo et al.³⁰	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Almeland et al.³¹	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Partial	Low
Jensen et al.³²	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Nemeth et al.³³	Partial	Yes	Yes	Yes	Partial	Yes	Yes	Yes	Yes	Yes	Moderate
Galvão et al.³⁴	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Zhang et al.³⁵	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Climov et al.³⁶	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Beier et al.³⁷	Yes	Yes	Yes	Yes	Yes	Can't tell	Yes	Yes	Yes	Yes	Low
Couceiro et al.³⁸	Yes	Yes	Yes	Yes	Partial	Yes	Yes	Yes	Yes	Yes	Low
Bhandarkar et al.³⁹	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Haran et al.⁴⁰	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Partial	Partial	Yes	Moderate
Zyluk et al.⁴¹	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Micko et al.⁴²	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Partial	Low
Fulton et al.⁴³	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Kaplan et al.⁴⁴	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Neudert et al.⁴⁵	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Ilgner et al.⁴⁶	Yes	Yes	Yes	Yes	Partial	Yes	Yes	Partial	Partial	Yes	Moderate
Furka et al.⁴⁷	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
von Reibnitz et al.⁴⁸	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Partial	Partial	Yes	Moderate
Sakamoto et al.⁴⁹	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low

[1] Source: Elaborated by the authors.