Hello, this is Dr. Satoshi Kuroda from University of Toyama, Toyama, Japan. In this lecture, I present the structure, limitation, and future perspective of neurosurgical training in Japan, especially at my institute, Department of Neurosurgery, Toyama University Hospital. In Japanese education system, we go to primary school for six years, junior high school for three years, and high school for three years. Then we start a six-year curriculum for medical university. After we get an MD degree, we start a residency in general for two years, and a residency for neurosurgery for four years. Finally, we can be a board-certified neurosurgeon when we pass the board certification examination. In Japan, there are totally 94 residency programs for neurosurgery. The term board-certified neurosurgeons refers to the physicians who possess a certificate for having undergone a training based on the board certification program established in 1966, having passed the severe examination, and continuing lifelong learning. Target disease for neurosurgery include emergency disease, stroke, and cranial nerve wounds, brain tumors, functional diseases such as epilepsy, Parkinson's disease, trigeminal neuralgia, facial spasm, and pediatric disease, and spinal cord, spinal, and peripheral nerve diseases. Board-certified neurosurgeons are physicians having comprehensive and specialized knowledge and medical skills, as well as the ability to properly judge the necessity to transfer the patient to other specialists as appropriate for prevention, diagnosis, emergent cures, surgery, non-surgical treatment, or rehabilitation of these diseases. Board-certified members are obligated to keep on learning the latest knowledge and techniques even after being certified, and the certificate must be renewed every five years. The lifelong learning committee adopted the credit registration system, which scores learning and research activities for assessment. Activity approved for credit includes participation in our presentation at an academic meeting, publication of our paper on the academic journal. In addition, board-certified members must attend the training program in medical ethics, medical safety, medical accidents, and medical jurisprudence approved by Japan Neurosurgical Society at least once during the five-year certification period. I strongly believe that we neurosurgeons are required to obtain the abilities of not only excellent technique but also profound knowledge and insight to care of a patient with neurosurgical disorders. For this purpose, I consider that the following five items are essential in neurosurgical training, including good education, intense learning, clear-cut thinking, good experience, and intellectual ability. These five items would lead us to be excellent neurosurgeons with excellent technique and profound knowledge and insight. Such neurosurgeons would be able to not only treat the patient in front of us but also improve the outcome of the patient over the world by developing a novel surgical technique and diagnosis method. At Toyama University Hospital, I strongly recommend all medical students to try to simulate bypass surgery under a surgical microscope using a silicon tube. I also recommend my resident and staff doctors to repeat to simulate deep-seated bypass surgery such as STM-2 anastomosis using the model of skull and brain. At our department, bypass boot camp is open to the medical students, residents, and staff doctors every six months. They simulate various kinds of bypass surgery according to their surgical skills. Chicken wing is very useful to simulate STMCA bypass in a fresh condition. Catabatic dissection course is also open to resident and staff doctors every year. They can simulate a variety of surgical approaches according to their surgical experience and skills. Furthermore, Toyama Microsurgical Training School is open to resident and staff doctors every year. They are the students here and present their surgery using unedited video. Master surgeons advise them to improve the quality of their surgery. At Toyama University Hospital, we prefer the rooftile-style training for residents. For example, when we operate on the patient with non-ruptured aneurysm, junior resident starts surgery including skin incision and craniotomy under the direction of senior resident. When junior resident falls into difficulty during the dissection of sylvian fissure, senior resident takes over to further dissect sylvian fissure. But when senior resident cannot dissect the aneurysm from the surrounding tissue, staff doctor or professor finally completes neck clipping of aneurysm. We call such step-by-step education system as the rooftile-style education. Residents are supported by their older colleagues to establish the safety of surgery. We prefer to employ a three-dimensional computer graphic and 3D printing before surgery for complex vascular or tumor region. It is very easy for experienced neurosurgeons to imagine a three-dimensional structure of these regions. But it is sometimes difficult for medical students and residents to do it. However, this technology is quite useful as the education tools to obtain the same imagination for experienced neurosurgeons, residents, and medical students. This example of 3DCG shows a giant pterous meningioma, a dumbbell-type schwannoma, temporal lobe AVM, and a curinoidal meningioma. This is an example of 3DCG and intraoperative finding in a patient with a thoracic dural AV fistula. In this patient with temporal lobe AVM, we created a 3D printing model of AVM and its vascular architecture. This 3D model was quite useful during surgery by identifying the deep-seated feeding artery. We are also using an iPad covered by a sterile bag during surgery to refer patients' images without walking to an on-wall display in the operating room. It's quite useful. I also believe that it is quite useful for everyone, including students, residents, and staff doctors, to draw operative findings from the viewpoint of education. These illustrations are drawn by Professor Sugita from Shinshu University and by Professor Kamiyama from Sapporo, respectively. This is an example of my drawing after surgery for AV fistula at the craniocervical junction. This is another example of my drawing after surgery for vestibular schwannoma. But it is a little bit difficult to draw operative findings when we operate on the patient with a complex brain tumor and so on. Therefore, I recently started to use an iPad to draw operative findings with digital technology. This is an example of digital drawing for microvascular decompression for trigeminal neuralgia. It is quite easy to draw the shadow and arachnoid trabecula on iPad. This is another example of digital drawing of a large cranioidal meningioma. Digital drawing makes us unable to express a complex 3D structure by using a transparent technology that was impossible with manual drawing. This is a third example of digital drawing for right SDA, SDA, A3 anastomosis. In conclusion, I briefly overviewed the current situation of neurosurgery training and education in Japan, especially at Department of Neurosurgery, Tohema University Hospital. I strongly believe that we should train and educate young doctors to be skillful and also scientific neurosurgeons patiently with a warm heart for a long time. For this purpose, we should employ everything, including analog and digital technologies. Thank you very much.

neurosurgical training

Japan

board-certified neurosurgeon

continuous learning

surgical planning