In view of these recent developments in general surgery on the one hand and the high incidence of vascular injuries in modern wars on the other, the German Army Medical Service recognized that their general surgeons required additional training in vascular trauma surgery before going on military deployment. As it was obvious that these skills could not be learned and maintained within the scope of civilian surgical practice in the military hospitals in Germany, a special vascular trauma skills training program needed to be developed. In the preceding years, trauma surgery skills courses using simulation models had emerged as an effective alternative to overcome limited open operative experience [16]. Therefore, a vascular trauma surgery course for non-vascular surgeons using established vascular surgery simulation models was developed in cooperation with the Vascular International School, Switzerland [17, 18]. Meanwhile, this course is mandatory for every German military surgeon together with concomitant courses in damage control surgery (DCS) in anaesthetized swine and a course on surgical skills for exposure in trauma using human cadavers. Together, these courses aim to fill the gap in lacking proficiency in open surgical treatment for major vascular trauma.

The vascular trauma surgery skills program is divided into two separate courses: the basic course focusses on open vascular surgical techniques in general and extremity vascular trauma, while the advanced course concentrates on truncal and neck trauma. In each two-day course, seven tutors, all experienced vascular surgeons from major vascular surgery departments in Germany, Austria, and Switzerland, instruct no more than 24 participants, ensuring intensive feedback for each participant at all times. Each exercise is demonstrated and explained step by step by one of the tutors and the participants follow the demonstration on the monitors next to their workstations (Fig. 1). Thereafter, the participants perform the exercise themselves, closely observed and corrected, if necessary, by the tutors.

Two tutors explain and demonstrate the exercise step by step while the participants watch carefully on their monitors. Thereafter, each participant repeats the exercise under supervision of the tutors

Both courses are performed in the Military Hospital in Ulm, Germany, in cooperation with the Vascular International School, Switzerland. The hands-on courses are based on the well-established setting and the life-like models developed by the Vascular International School. The value of these models with pulsatile vessels for improvement of surgical skills in vascular surgery has been proven [19, 20]. Deliberately, only few, easy-to-remember suture techniques are taught for direct sutures, patch angioplasty, and end-to-side and end-to-end anastomosis. Instead of introducing several different techniques, these few basic procedures are repeatedly performed by the participants, steadily increasing the level of difficulty from working in an open box (Fig. 2) up to performing an anastomosis deep in the abdomen (Fig. 3) or in an uncomfortable supragenual exposure of the leg (Fig. 4). Next to arterial and venous reconstructions with autologous and alloplastic grafts, adjacent techniques indispensable for vascular trauma management such as thrombectomy with a Fogarty catheter are introduced as well. Based on military requirements, a further focus lies on damage control surgery with direct suture techniques as well as placement and safe fixation of a temporary intravascular shunt. In addition to the dominating hands-on training, two brief lectures introduce special features of vascular trauma management and basic tactical considerations for the approach of these severe injuries.

Participants performing an interpositional graft in a box with pulsatile artery

A tutor giving tips for direct sutures of the inferior cava vein in the abdominal model

Participant performing an anastomosis to the supragenual popliteal artery using a leg model. As in all Vascular International models, the artery has a pulsatile flow

As the course intends to give all surgeons, irrespective of their specialization, a vascular surgical tool kit easily available in every situation, it concentrates on open vascular surgery. The only endovascular technique introduced in the advanced course is resuscitative endovascular balloon occlusion of the aorta (REBOA), as practical knowledge of this procedure is mandatory for all military surgeons and frequently asked for among civilian trauma surgeons. The participants learn vascular access via inguinal puncture, placement, and handling of the balloon as well as the indications for and complications of REBOA [21].

At the end of every course the participants have to complete an evaluation form (Table 1). The vast majority of participants feel more confident and well prepared for daily practice, deployment, or work in a trauma center. Most participants would recommend the course to colleagues and voted for a repetition every 3 years. However, the benefit of the latter approach has not yet been proven and is subject to an ongoing study reevaluating the skills after several years. The main criticism of the courses is the missing training in vascular surgical exposure. However, this important aspect is element of another course.