Letter: Clipping of Intracranial Aneurysms by Neurosurgical Trainees Is Safe and Effective: A Statewide Retrospective Cohort of 614 Consecutive Cases in Queensland, Australia

To the Editor: We read with great interest the recent article “Clipping of Intracranial Aneurysms by Neurosurgical Trainees Is Safe and Effective: A Statewide Retrospective Cohort of 614 Consecutive Cases in Queensland, Australia” by Stuart et al.1 This study provides much needed data regarding the safety of trainee involvement in microsurgical aneurysm clipping. The next most “contemporary” series on this issue was from Christopher Wallace's group, which reported on cases performed between 1993 and 1996 at Toronto Western Hospital.2 Together, these studies demonstrate comparable intraoperative, radiographic, neurological, and functional outcomes between senior residents/fellows and attending neurosurgeons performing aneurysm clipping.1,2 In the Toronto series, 91% of aneurysms were clipped by neurosurgical trainees, whereas only 22% of the cases in the Queensland series designated a trainee as the primary surgeon.1,2 This highlights the impact of the prominent role of endovascular techniques in the modern era, which have led to reduced trainee exposure to microsurgical aneurysm clipping.3 Stuart et al question the generalizability of their findings to other training systems. We write to offer context and outline our institutional approach toward teaching microsurgical aneurysm clipping at the Vancouver General Hospital, the primary adult teaching hospital for the neurosurgical residency program at the University of British Columbia in Vancouver, Canada. Our longstanding philosophy emphasizes that intraoperative experience is irreplaceable in the teaching of aneurysm clipping. While we appreciate attempts to develop high-fidelity training tools such as cadaveric specimens with simulated blood flow, silicone models, and virtual reality simulators, these modalities fall short as comprehensive teaching substitutes.4,5 Notably, they lack the capacity to provide meaningful feedback on tissue handling—particularly dissection around the neck and dome of an aneurysm, which demands exceptional delicacy and precision. Moreover, these simulations fail to replicate the high-stakes environment of cerebrovascular surgery. Although these models can teach the steps of aneurysm clipping to a novice trainee, they are unable to replicate the cognitive demands of intraoperative decision making and the stressors associated with intraoperative complications or aneurysm rupture. The ability to maintain composure and exercise sound judgment in these moments is cultivated only through direct operative exposure. To teach our residents these complex microsurgical skills, we use a four-hand technique in a direct apprenticeship model. We orient the operating microscope's binoculars 180° from each other, allowing both the resident and attending neurosurgeon to operate simultaneously from opposite sides of the patient's head with four instruments in the field. Compared with the Queensland experience, where faculty scrubbed 92.9% of trainee-led cases, our attendings scrub for 100%. This facilitates direct and immediate feedback from the attending neurosurgeon on the resident's technique and decision making. This also enables residents to engage in the technical aspects of the surgical procedure earlier in their training with task delegation possible on a granular basis. Attending neurosurgeons can actively demonstrate specific techniques and immediately intervene in the event of intraoperative complications. This pedagogical framework fosters surgical confidence and technical skill development in trainees and allows for earlier exposure to aneurysm clippings—with our residents typically performing their first clipping by PGY-3 or PGY-4. A recent study from our skull base colleagues supports the safety and potential superiority of this technique over single-surgeon approaches.6 We reviewed logbooks of our senior residents, equivalent to chief residents or senior registrars, from the past two academic years to compile unpublished data on our resident experience with both ruptured and unruptured aneurysm clippings. Our senior residents each participated in a mean of 54 ± 16 aneurysm clipping cases per year and functioned as the primary surgeon in 86% of these cases. The most frequent aneurysm location was anterior communicating artery. Our annualized clipping volume for senior resident aneurysm clipping significantly exceeds the median of 19 (IQR 12-17) reported in American neurosurgical training programs.7 Our high volume is enabled through our role as an academic neurosurgical teaching hospital that is a provincial referral center, with high volumes of open and endovascular aneurysm cases. We echo the sentiment of Burkhart and Lawton that high-volume centers of excellence are essential to provide young neurosurgical trainees with adequate operative exposure.5 Without concentrating aneurysm treatment to high-volume centers, residents in smaller programs or in programs with a strong endovascular bias may not get exposure to “simple” aneurysms appropriate for trainees to clip, such as middle cerebral artery or posterior communicating artery aneurysms. Clipping an aneurysm is an essential skill that all neurosurgical trainees should at minimum be exposed to. The Royal College of Physician and Surgeon Canada lists “performing surgery for patients with an intracranial aneurysm” as a required competency for all neurosurgical residents in Canada.8 Take for instance, a ruptured MCA aneurysm with hematoma and mass effect with a patient in extremis. Future neurosurgeons must be prepared to perform life-saving decompressive craniectomy, clot evacuation, and aneurysm clipping for these patients. Furthermore, application of aneurysm clips may be needed in skull base and oncology neurosurgery in the event of an inadvertent artery injury. For the benefit of future patients, it is the responsibility of senior cerebrovascular neurosurgeons in our field to ensure that the next generation is adequately trained in open microsurgical techniques and that these skills are not lost.

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