Organic bench model applied to surgical suture training

Veterinary and human medicine students should be trained in skills necessary to perform surgical procedures. Regarding the practice of surgical sutures, the methods used include the use of various materials such as fabric device, sponge, pieces of the animals and pieces of ethylene vinyl acetate. This article proposes to use banana and eggplant to train surgical suture techniques. The work was carried out by monitors from the veterinary surgical technical discipline. These monitors performed sutures in the vegetables (green banana and eggplant) and completed a questionnaire on the method. All monitors agreed that vegetables are easy to handle. Most stated that it was a pleasant experience for not using live animals. An advantage of using vegetables is handling, including storage and disposal. Besides, they do not transmit diseases. Animal materials such as bovine tongue, and swine parts that are widely used in suture teaching, present the risk of zoonosis transmission. The proposed organic bench model (banana and eggplant) may be indicated as a complementary alternative to advanced surgical sutures training. In addition, the model in question avoids the use of animals, while respecting ethical and legal issues.

Orange Biopsy, suture, incision Allows to analyze different 'layers' Table 1 presents the main vegetables and their indications for teaching techniques used to handle and suture tissues. Such vegetables represent a good option in this type of teaching because they are accessible, cheap and easy to dispose of (without prejudice to the environment) and without the possibility of transmitting diseases as can happen with animal parts also used in this type of teaching.

Methodology
In order to carry out this study, a qualitative field experimentation was carried out as described by Pereira et al. (2018). The data obtained were submitted to descriptive statistics.
The following items were used to make the model: a medium density fiberboard (MDF) measuring seven centimeters in length, seven centimeters in width and half a centimeter in height pierced by two sets of four nails (2.70 centimeters by 0.48 mm) for positioning and fixing the material, preventing its movement.
Two vegetables were used as pieces for suture training, green banana variety Prata and eggplant (Musa spp. And Solanum melongena L., respectively). For the experiment, the surgical instruments used were blunt-thin surgical scissors, a Mayo-Hegar needle holder, anatomical forceps with a rat tooth, a Bard-Parker scalpel handle number 4 and a scalpel Development, v. 9, n. 10, e3939108614, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i10.8614 6 blade number 24. The suture was made using 3-0 Nylon threads with 3/8 circumference triangular needle and 3-0 Catgut thread with 3/8 circumference blunt needle, mono and multifilament suture materials, respectively ( Figure 1).  The vegetables were cut along their longitudinal axis, providing two halves that were fixed to the wooden supports, with the convex face facing upwards. Two incisions measuring fifteen centimeters in length each with an internal spacing of two centimeters and a depth of one and a half centimeters were made in the eggplant, forming a detachable flap. In the banana, incisions were made from seven to ten centimeters in length ( Figure 2). Research, Society and Development, v. 9, n. 10, e3939108614, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i10.8614  Research, Society and Development, v. 9, n. 10, e3939108614, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i10.8614  After performing the sutures, the evaluators were asked to complete a questionnaire with questions regarding the use of the proposed method, using the Likert scale to assess psychometric responses. This scale allows to analyze the acceptance of the proposed model through qualitative attributions previously established, and thus to verify the attitude and the degree of conformity of the interviewee (Silva Júnior & Costa, 2014). The data obtained in the questionnaire were evaluated using percentage frequencies.
To assess suture patterns singly, the evaluators descriptively commented on the ability to make the knot. Resistance and tissue approximation also were evaluated, and finally, the final aspect of the suture pattern. Research, Society and Development, v. 9, n. 10, e3939108614, 2020 (CC BY 4.

Results and Discussion
Considering suturing as a fundamental phase of the surgical procedure, such sutures are procedures of extreme relevance in everyday medical practice. Its accomplishment requires, in addition to theoretical foundation, the development of manual dexterity that allows the apprentice surgeon to perform basic surgical maneuvers (Tudury & Potier, 2008). However, most students do not develop basic and satisfactory surgical skills during their academic training. Thus, it is necessary to complement the undergraduate curriculum teaching about small surgical procedures (Marcondes et al., 2014). In this context, suture training is of fundamental importance for the acquisition of psychomotor skills (Matera, 2009), with several training models described in the literature, such as the fabric device for suture training Costa Neto et al., 2011) pieces of post-mortem animal Franco et al., 2008;Otoch et al., 2012), EVA plaques (Bastos & Silva, 2011; and organic models (Denadai & Souto, 2012;Denadai, Saad-Hossne & Souto, 2013), avoiding the use of vivisection for this purpose.
The use of alternative methods for teaching sutures is well accepted by many students, and in a study comparing the teaching of specific suture for the intestine (Gambee suture) in cadaver and in artificial simulator it was demonstrated that the level of learning was equal (Caston et al., 2016).
Among the materials proposed for training medical and surgical practices are vegetables (Denadai & Souto, 2012;Wang et al., 2015). To our knowledge, a limited number of studies evaluate the application of vegetables as organic bench models and their standardization. The choice of vegetables was substantiated by the related literature (Denadai & Souto, 2012;Denadai et al., 2014), which cite banana and eggplant as the most used vegetables for training in surgical suture. The choice to use the green banana variety Prata is due to its coarser ecotexture that causes less tissue damage. Most works do not specify the variety to be chosen (Valliyate et al., 2012). The acquisition of the vegetables used in the training was quite easy since such vegetables are easily found in supermarkets and other places that sell these products.
One of the most used materials for suture training is the bovine tongue (Carniatto, 2017, Franco et al., 2008Otoch et al., 2012). In a quick survey by phone in butchers in the region, the price of bovine tongue was around $ 2.50 (Kg). Therefore, the cost of vegetables is much lower, making them preferred materials for teaching sutures from an economic point of view.
Low cost is one of the advantages of using simulators in teaching (Smeak, 1999).
To use the model, the plant must be fixed on a support that prevents its movement of the nylon used made visibly difficult to perform sutures in the eggplant due to the absence of contrast between the thread and the vegetable.
We chose to use needles with the same circumference size (3/8) for both wires.
However, a traumatic needle was used for the monofilament thread, and a blunt needle for the multifilament thread. The proportion of trauma caused to the tissues, mainly the superficial one, was lower when using a blunt needle, indicated in the literature for friable tissues because it provides less tissue damage (Arruda & Viana, 2014).
The subjective analysis of the data obtained in the questionnaire applied to student monitors of the discipline Veterinary Surgical Technique allowed to verify that all the evaluators (100%) agreed on the ease in handling the vegetables used, providing a pleasant experience for not using live animals in the development of skills basic regarding surgical sutures (75%), in addition to allowing the application of theoretical concepts related to surgical sutures (75%). The values found corroborate with other alternative methods (Costa Neto et al., 2011;Martins Filho, 2015).
Regarding the development of psychomotor skills, the dexterity with which the movements were performed was superior in eggplant when compared to banana (50% and 25%, respectively). Most respondents (75%) agreed that both vegetables allow repetition of training and recommend them for training in surgical sutures. These data make it possible to observe that the organic bench model meets the ideological conception of the principles of the 3R (Herrmann, Pistollato & Stephens, 2019), aiming at reducing the use of animals for teaching surgical sutures, in addition to repetition and ability gain.
As for the technical realization of the suture patterns, tissue penetration and approximation were adequately verified in eggplant (100% and 75% respectively), while tissue resistance was better verified in banana (75%). Regarding the patterns performed, the observed result was impartial between patterns interrupted as continuous, with no predilection among of the vegetal.
Another advantage of using vegetables is handling, including storage and disposal, being a portable and easy to use material. Given these characteristics, the student can carry out training both in the classroom and in the home environment. The vegetable must be used quickly because it is a perishable product and must be stored outside the refrigeration environment, allowing the top layer (peel) not to become friable. In this work, after the training was performed, the suture materials (surgical threads) were removed and the vegetables were destined for animal feed, avoiding waste. Other alternative materials such as animal parts require disposal as hospital material, which can make the process more Development, v. 9, n. 10, e3939108614, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i10.8614 13 expensive. Disposal of plastic materials also requires care since many have an environmental impact as they are difficult to degrade. The disposal of the vegetables proposed in this study is quite simple and can be done in common garbage and is considered organic, bringing little impact on the environmental point of view.
An under-mentioned advantage for the use of vegetables is that such materials are inert from the point of view of disease transmission in the teaching of suture techniques. Products from animals such as bovine tongue and pig parts are widely used in teaching sutures Denadai et al., 2013;Franco et al., 2008;Otoch et al., 2012). However, there is a risk of transmission of diseases such as brucellosis detected in Brazil in bovine tongue (Lima et al., 2015) and in pigs (Leite et al., 2014). Tuberculosis has also been recorded in bovine tongue in the country (Herrmann et al., 2019) as well as leptospirosis in pigs (Rigo et al., 2013). Therefore, the use of vegetables does not require the use of individual protective equipment. In addition, as they are perishable material, animal parts may give off an unpleasant smell after handling for a certain time and release liquids. This fact is not discussed in the literature, but it can be important for learning. The unpleasant odor and the release of liquids can cause rejection of the method by the students.
Although it is considered as a low-fidelity material, the use of vegetables does not present differences in learning when compared to other high-fidelity methods (those of higher cost, including synthetic models, anatomical models, cadaver or live animals) that are more attractive to students (Denadai & Souto, 2012;Denadai et al., 2014;Otoch et al., 2012;Pereira et al., 2016;Rodrigues, Mendes & Silva, 2013;Tudury & Potier, 2008).
Although it is considered as a low-fidelity material, the use of vegetables does not present differences in learning when compared to other high-fidelity methods (those of higher cost, including synthetic models, anatomical models, cadaver or live animals) that are more attractive to students (Denadai & Souto, 2012;Denadai et al., 2014;Otoch et al., 2012;Pereira et al., 2016;Rodrigues, Mendes & Silva, 2013;Tudury & Potier, 2008).
Analyzing the use of the different materials proposed in the literature, including vegetables, it is concluded that all can be used in teaching techniques for handling and tissue suture. Based on advantages and disadvantages, the selection must be based on criteria of familiarity of the professional with the material, availability, cost and level of learning intended.

Final Considerations
The proposed organic bench model (banana and eggplant) has low cost, practicality, easy availability, storage, handling and disposal, being indicated as a complementary alternative to advanced surgical sutures training, allowing the student to develop important psychomotor skills for the surgical experience.
In addition, the model in question makes it possible not to use animals in practical classes, either live animals or in cadavers, respecting legal ethical issues.
Other studies may demonstrate that diverse vegetables and different materials can be used to teach tissue handling techniques. Several naneuvers can be included in these studies, like as medication administration, substance infiltration in sites with lesions and other indications.