Microsurgery is becoming increasingly important in many surgical specialities. In France, it is taught as part of university certificates (UC), which are organised in different ways. A previous study carried out in 2014 highlighted several challenges, particularly in terms of finance and structure. This study aims to update this data ten years later to analyse the evolution of microsurgery teaching in France and identify future challenges related to new practices and constraints.

A descriptive observational survey was performed between January and March 2025 at 28 French university hospitals. The educational referents of the microsurgery university certificates were interviewed using a standardised questionnaire covering teaching methods, hours, assessment methods, registration costs and difficulties encountered. The data collected was compared with that of the 2014 study.

Seventeen centres offered a university certificate in microsurgery, including 14 that already existed in 2014. The average number of hours per year decreased by 24%, while the total number of places offered increased by 86%. Assessment methods remained heterogeneous. The average cost of enrolment in initial training increased by 292 euros. The main challenges identified concerned access to animal models, economic constraints and lack of supervision.

Despite a growing interest in microsurgery training, major disparities persist between university certificates. Standardising programmes, optimising resources and introducing a progressive training pathway could help harmonise practices, while addressing current ethical and logistical issues. We therefore suggest a three-stage model (inert materials, living models, advanced training) to structure learning.

La microchirurgie prend une importance croissante dans de nombreuses spécialités chirurgicales. En France, elle est enseignée dans le cadre de diplômes universitaires (DU), organisés selon des modalités variées. Une précédente étude menée en 2014 avait mis en évidence plusieurs difficultés, notamment d’ordre financier et structurel. Cette étude vise à actualiser ces données dix ans plus tard, afin d’analyser l’évolution de l’enseignement de la microchirurgie en France et d’identifier les défis à venir liés aux nouvelles pratiques et contraintes.

Une enquête observationnelle descriptive a été réalisée entre janvier et mars 2025 auprès de 28 centres hospitalo-universitaires français. Les référents pédagogiques des diplômes universitaires de microchirurgie ont été interrogés à l’aide d’un questionnaire standardisé portant sur les modalités d’enseignement, le volume horaire, les méthodes d’évaluation, les frais d’inscription et les difficultés rencontrées. Les données recueillies ont été comparées à celles de l’étude de 2014.

Dix-sept centres proposaient un diplôme universitaire de microchirurgie, dont 14 existaient déjà en 2014. Le nombre moyen d’heures par an a diminué de 24 %, tandis que le nombre total de places proposées a augmenté de 86 %. Les méthodes d’évaluation restaient hétérogènes. Le coût moyen de l’inscription en formation initiale a augmenté de 292 euros. Les principales difficultés identifiées concernaient l’accès aux modèles animaux, les contraintes économiques et le manque d’encadrement.

Malgré un intérêt croissant pour la formation en microchirurgie, de fortes disparités persistent entre les diplômes universitaires. La standardisation des programmes, l’optimisation des ressources et la mise en place d’un parcours de formation progressif pourraient contribuer à harmoniser les pratiques, tout en répondant aux enjeux éthiques et logistiques actuels. Nous proposons ainsi un modèle en trois étapes (matériaux inertes, modèles vivants, formation avancée) pour structurer l’apprentissage.

# Introduction

Microsurgery is a demanding surgical practice and requires specific specialised training. In France, it is practised by a wide range of specialists, including veterinary surgeons, hand surgeons, vascular surgeons, maxillofacial surgeons, ENT specialists, plastic surgeons, neurosurgeons, dental surgeons and ophthalmologists, among others [1]. Historically, microsurgery was learnt directly in the operating room, in contact with the patient. However, the growing imperatives of safety and quality of care make this method insufficient in the training of young surgeons. Thus, prior training on inert models and animals has become a prerequisite [2], for example to obtain the degree in hand surgery. In France, microsurgery training is mainly based on university certificates (UC). Although widespread, these courses are not standardised and have local specificities, both in their teaching methods and in their evaluation criteria.

The constant growth of microsurgery [3] and in particular supermicrosurgery and robotics applied to microsurgery with platforms such as the Symani® robot, is leading to a growing need for qualified practitioners with expertise in microsurgical techniques [4–6]. The applications of microsurgery are constantly expanding, leading to a growing need for the training of qualified surgical practitioners in this technique.

In 2014, Alzakri et al. assessed the current state of microsurgical teaching in France [7]. They highlighted several challenges for the future, including the financial sustainability of these training programmes.

The aim of this study is to update the data collected by Alzakri et al. ten years later, in order to analyse the evolution of microsurgery teaching in France and to identify future challenges related to new practices but also to the constraints of this type of teaching.

# Methods

This was an observational, descriptive and comparative study aimed at updating the current state of microsurgery teaching in France. A national survey was performed in all French university hospitals and medical schools. The aim was to collect detailed data on the organisation, teaching methods and resources associated with the university certificates (UC) in microsurgery offered at these establishments.

The following information was collected:
                        
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                           whether or not there was a UC in the faculty concerned;
                        
                        
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                           speciality of the educational coordinator;
                        
                        
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                           experimental methods proposed in the training: use of inert models (simulators, various materials) and/or living models (rats, pigs, etc.);
                        
                        
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                           hourly volume;
                        
                        
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                           final assessment methods: nature of the exam (practical, theoretical or mixed test), requirement or not to write an examination paper at the end of the training;
                        
                        
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                           capacity: number of places available per year, number of students actually enrolled;
                        
                        
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                           registration cost for initial training;
                        
                        
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                           challenges faced by teaching teams: material, economic, logistical or ethical constraints identified in the organisation and sustainability of training courses.

At the same time, the data collected by Alzakri et al. in 2014 was taken and reanalysed to make a longitudinal comparison between the two audits. The aim of this comparison was to evaluate the changes that have occurred over the last ten years, both in quantitative terms (number of courses, number of hours, number of students, costs, etc.) and qualitative terms (diversification of teaching methods, consideration of ethical issues, changes in constraints).

# Results

Between January and March 2025, a survey was conducted among educational coordinators or representatives of residents in 28 university hospitals and medical schools in France (Fig. 1
                     ). Of these centres, 17 (60%) offered a university certificate in microsurgery at the time of the study. Fourteen of these degree programmes were already in existence in 2014. Since then, 2 university certificates have ceased to run, while 3 new degree programmes have been created.

In terms of the specialities of the teaching staff, 47% were plastic surgeons, 24% orthopaedic surgeons, 18% maxillofacial surgeons and 12% were from other surgical specialities such as otorhinolaryngology or neurosurgery.

Practice on a live model was present in 94% of the training courses surveyed. The other training courses in Strasbourg were limited to inert models or simulators, pending a European certificate in the coming years.

The average overall hourly volume of the training courses was 88hours, a decrease of 24% compared to 2014. The average reduction observed per course was 30hours (85 to 43).

The assessment methods varied according to the courses. Forty per cent of the university diplomas were based on an exclusively practical final exam, 40% combined a practical and theoretical exam and 20% had a continuous assessment system. In 31% of cases, the validation of the university diploma included the writing of a dissertation.

The total intake capacity in France was 275 places per year, which represents an increase of 127 places, or an increase of 86% compared to 2014. On average, faculties with a UC increased their intake capacity by 7.7 places (−2 to 38). The average number of places offered per course was 16 per year. This figure was strongly influenced by the Parisian certificate, which alone offered 60 places per year. Excluding this course, the average number of places per university diploma was 13.

The average cost of registration for initial training was 1314 euros (334–2000). Compared to 2014, this average increase was 292 euros (−750 to 1250).

Finally, several challenges were identified by the educational managers. Five of them mentioned difficulties in accessing animal models (e.g. animal facility constraints, ethical considerations, etc.), and five reported financial obstacles (investment and maintenance of equipment). Two coordinators reported problems related to supervision, particularly due to a lack of availability of trainers.

# Discussion

The teaching of microsurgery in France has evolved over the last ten years. Comparing current data with the results of the study by Alzakri et al. [7], there has been an 86% increase in the number of students in training over the last 10years, despite a 24% reduction in the overall number of hours in the courses offered. All the university hospitals are at maximum capacity, suggesting that the increase in the number of students in training could have been even greater if more places had been available.

This increase in the number of students should be viewed in parallel with an increase in the number of surgical residents over the same period. The number of new surgical residents in France was 686 in 2014, compared to 943 in 2024 (http://www.legifrance.gouv.fr/), an increase of 37%. This increase in the number of surgical residents over this period is therefore less than the increase in the number of students training in microsurgery. There is growing interest in microsurgery training, exceeding the increase in the number of surgical residents over the same period.

The current issues in microsurgery teaching therefore do not relate to the attractiveness of the discipline or the need for training, but rather to structural and economic challenges.

The teaching programmes have to face major financial constraints. One of the main obstacles is the high cost of equipment and consumables. The unavoidable expenses include microsurgical equipment: microscopes, forceps, needle holders, scissors, vascular clamps, which need to be replaced regularly. Animal models: rats, essential for learning microsurgery, cost around €20 each. Consumables: suture threads (8/0, 9/0 and 10/0), costing between €13 and €16 each, anaesthetics (€3 per rat), as well as inert learning models. Assuming a consumption of two wires per practical work, this represents approximately €55 per student for consumables alone during sessions on animals. These costs, although partially offset by registration fees, therefore remain well above the financial resources of students, who are often boarders without specific financial support. The gradual increase in the cost of registration is not enough to balance the budgets, and the teaching programmes are structurally in deficit. These budgetary constraints may explain the reduction in the number of hours of training over the years, or the search for other solutions such as that proposed by Angers, which offers training concentrated over two weeks [8].

The use of animals in microsurgical training poses a major ethical challenge. Although practice on inert models has become a required stage at the beginning of training, we believe that the transition to live models is still essential to acquire complete proficiency in vascular suture techniques.

The pedagogical effectiveness of the different learning models has not yet been clearly established [9]. Some studies suggest that progressive training, without the use of living models, could be considered in certain cases [10]. However, the biological and rheological reality of a vascular suture cannot be fully reproduced on an inert model or in virtual reality. Nevertheless, these technologies can limit the use of animal models by optimising the preparation of students beforehand. The introduction of virtual reality could facilitate the transition between simulation and training on living models thanks to a more precise evaluation of the evolution of students’ skills despite uncertainty as to the reliability of the measurements [1,11].

One way to rationalise the use of live models would be to introduce a system of prior certification: only students who have validated skills on inert models and in advanced simulation would have access to animal training. This approach would reduce the number of animals used while guaranteeing quality learning.

A major challenge in microsurgery training in France is the lack of standardisation. Currently, each university course is structured according to the choices of its educational coordinator, resulting in significant disparities in terms of hours (some reaching up to 175hours of practice), assessment methods and registration costs. Internationally, accreditation bodies such as the Accreditation Council for Graduate Medical Education (ACGME) in the United States impose precise standards for training and skills assessment [12]. In France, the issue of standardisation had already been raised by Alzakri et al. in 2014 [7], but no significant progress has been made since then. The introduction of standardised assessment scores could be an interesting avenue for guiding training and identifying students requiring additional support [13,14]. These scores would make it possible to objectify the skills acquired and to better structure the national recognition of training courses. Thus, it would be pertinent to define standardised training programmes with clear prerequisites to validate each stage of learning.

A three-stage approach could be considered:
                        
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                           initial training: learning on inert materials and simulation. This phase would enable students to develop precise movements and familiarise themselves with the instruments;
                        
                        
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                           intermediate training on a live model: acquisition of fundamental skills with clear objectives: dissection, basic techniques in experimental microsurgery and end-to-end sutures on vessels of different diameters;
                        
                        
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                           advanced training: access to complex procedures, such as end-to-side sutures, vascular bypasses and the creation of microsurgical flaps. This phase would allow students to perfect their skills and prepare them for clinical management.

This structured training model would ensure coherent educational progression, optimise the use of resources (particularly animal models), and guarantee that each student acquires an appropriate level of competence before moving on to the next stages. Moreover, not all students have the same objectives depending on their speciality, and the complex procedures that may be offered in advanced training only concern a few specialities.

Finally, it is essential to remember that microsurgery is not based solely on technical skills. Decision-making, communication and teamwork are fundamental elements that cannot be acquired solely through practice on experimental models. Mentoring in the operating room remains an important part of microsurgical training, allowing for learning, self-assessment and reflection on individual progress that comes with experience and not only during university education [15].

# Conclusion

The teaching of microsurgery in France has seen a growing demand for microsurgery training. However, this expansion is accompanied by significant disparities and persistent challenges, particularly of a financial, logistical and ethical nature. The structuring of training courses into progressive pathways and national standardisation appear to be priority strategies, to ensure the long-term survival and further improvement of learning in this specific discipline.

# Authors’ contributions

TD: writing – original draft – investigation resources data curation.

PL: resources – validation.

NB: conceptualization – writing validation – project administration – review and editing – methodology.

All authors have read and agreed to the published version of the manuscript.

# Declaration of generative AI and AI-assisted technologies in the writing process

No use of any generative AI or AI-assisted technologies to write this manuscript.

# Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The authors would like to thank all those involved in the teaching of microsurgery in France, and more specifically, all the academic coordinators who provided us with the essential data for the completion of this study. A special thanks to Clément Rosière, Guillaume Adam, Amarante Orieux, Ali Mojallal, Sybille Facca, Pierre Guerreschi, Vianney Bastit, Jordan Turpin, Mayeul Dumarty, Francois Dap, Francois Loisel, Arnaud Pare, Ophélie Simon, Vincent Pinsolle, Anaïs Delgove, Tanguy Perraudin, Nathalie Pham Dang, Baptiste Bertrand, Dominique Casanova, Béatrice Mordret, Nicolas Vari, Isabelle Auquit Ackbur, Elise Lupon, Virgil Gerset, Solène Feyel, Laurine Cafarelli, Romain Huguet, Olivier Camuzard, Christian Herlin, Michel Chammas, Francois Thuau, Boris Laure, Sephanie Delclaux.