BERKELEY, CA (UroToday Inc.) - The new frontier of surgery is surgical training and education. The limitations of cost, need for highly skilled personnel, one-time only experience, and potential exposure of medical personnel to bovine spongiform encephalopathy (mad cow disease) associated with animal and cadaveric laboratory training experience has engendered increased interest in the development of surgical simulation for minimally invasive surgery teaching. While these simulators are being developed at an exponential rate, there remains a real need for comprehensive validity testing to determine if these devices will be reliable educational formats. The authors of this study are to be commended for this superb example of a well designed, applied and comprehensive validation study of a laparoscopic surgical skills simulator.

Over several years of developing and working with this simulator, the researchers have addressed and studied every aspect of validation. The paper is a concise and comprehensive review of the various definitions of validation. In addition, they have reported their data according to its respective validation evaluation components. As a result, the capabilities of this simulator are clearly understood. One of the more difficult to assess, construct validity, is very nicely studied with impressive results with this MISTELS simulator.

The score on the MISTELS was of highly significant difference in the groups dependent on their laparoscopic surgical experience. In other words, PGY 1 and 2 residents had significantly lower scores than the PGY 3 and 4 residents and the chief residents, fellows, and attending surgeons were, again, significantly better than the PGY 3 and 4 residents. Of equal importance was the ability of the MISTELS score to predict the performance of the resident in the operating room.

It would have been very interesting if they had assessed whether the MISTELS score could be used to correlate the surgeons with laparoscopic clinical experience based on their practice pattern (i.e. the number of laparoscopic cases they perform per month or per year). The discussion that followed the paper highlights some of the important issues in the validation of surgical simulators and the nationwide interest in this area of educational development. This paper should be required reading for anyone interested in surgical simulator education and for all surgeons committed to optimizing education. As Dr. Fried points out in the last portion of the Discussion, the simulator provides an opportunity to learn basic skills in an environment that is more comfortable, under less pressure than the operating room, and does not put patients at risk. Once the foundation of the fundamental skills has been established, then judgment, knowledge and interpretation of what is seen must be learned to create the competent surgeon. Simulators will become an integral part of surgical education programs, but will still require dedicated educators and comprehensive educational curriculae.

Annals of Surgery 240: 518-528, 2004