For Trichiasis Surgeons, It Helps to Learn from a Dummy

By Mary Houghton  - May 20, 2016
Removable eye cartridges let trainees examine their work. (Photo: Carla Johnson)

Not long ago, people learning to perform trichiasis surgery practiced their cutting and suturing skills on oranges. From orange rinds, they went straight to live surgery.

With millions of people in Africa and Asia in need of trichiasis surgery to preserve their sight, Emily Gower, an epidemiologist and trachoma expert at the Wake Forest School of Medicine, knew there had to be a better way.

So Gower went to Jim Johnson, executive director of the Wake Forest Center for Applied Learning, who studies how adults learn new skills. As Johnson saw it, the budding trichiasis surgeons needed to practice on something more lifelike. The highly trained special-effects artists at Johnson’s company, Human Analogue Applications, got to work, using silicone and other substances to fashion the anatomical layers of the human eyelid.

The result was HEAD START, a brown-eyed, silicone mannequin that gazes patiently upward as students swath it in sterile drapes and cut into its orbicularis muscle, tarsal plate and conjunctiva. Crucial to the design are the dummy’s removable eyelids, which allow trainees to examine the precision of their work.

“You can take the eye cartridge out and see what the surgery looks like,” explains Gower. “Is the incision at the right height? Is it straight? Is it long enough? Are the sutures evenly spaced? Are they in the right layer of the eyelid?”

Experienced surgeons who tested HEAD START in 2014 were impressed. Even their own advanced skills were improved by operating on the mannequin, they said. Removing HEAD START’s eye cartridges and evaluating their handiwork, many of the surgeons “were surprised by the incompleteness of their incision, its angle or other aspects,” according to a May 2014 International Coalition for Trachoma Control position paper that endorsed the use of HEAD START as a standard procedure in trichiasis surgery training.

A surgeon seeking to become an MMDP Project trainer practices under the supervision of master trainer Amir Bedri, M.D., in Cameroon in September 2015. (Photo: MMDP Project)

Instilling Confidence

Released for use in the field in 2015, the mannequin today is the centerpiece of the training and certification process for anyone seeking to perform trichiasis surgery under the MMDP Project. Even surgeons who have been doing trichiasis operations for years undergo refresher training with HEAD START.

Feedback has been overwhelmingly positive. New surgeons have said that learning on HEAD START gave them confidence and a concrete understanding of what they were doing before they operated on a real human being.

“HEAD START is a tool that is going to revolutionize trichiasis surgical technique because it’s based on a quality-focused approach,” said a trichiasis surgeon who underwent refresher training with the mannequin in Cameroon in September 2015.

In Gower’s view, HEAD START’s biggest value lies in its ability to help trainers accurately judge their students’ skills. She recalled that during a pilot test of HEAD START as a training tool for new surgeons, two of ten trainees failed to gain certification because their instructors could see quite clearly that the trainees’ skills were not up to standard.

“That, to me, is the most important contribution of HEAD START,” says Gower, noting that skills demonstration on the mannequin provides an extra level of assurance that patients will receive high quality surgeries.

As demand for HEAD START grows in government-led trichiasis surgery training programs throughout Africa, the challenge for the mannequin’s makers has shifted to filling the burgeoning orders. Working by hand, a craftsperson at Human Analogue Applications can make just 50 eye cartridges a week. Recently, orders have been arriving in the thousands.

To meet the need, Johnson has turned to a 3-D printing company in Winston-Salem, North Carolina.

That’s good news for the MMDP Project. To date, the project has shipped 18 HEAD START bases and more than 2,700 eye cartridges to Burkina Faso, Cameroon and Ethiopia, where ministries of health are using the innovative tool to ensure state-of-the-art quality in trichiasis surgery training — and aspiring surgeons are seeing how a dummy can sometimes be the best teacher of all.

Mary Houghton is the Communications Specialist for the MMDP Project.