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Virtual Reality Simulator Training for Laparoscopic Colectomy: What Metrics Have Construct Validity?

Shanmugan, Skandan M.D.1; Leblanc, Fabien M.D.2; Senagore, Anthony J. M.D.3; Ellis, C. Neal M.D.4; Stein, Sharon L. M.D.1; Khan, Sadaf M.D.1; Delaney, Conor P. M.D., Ph.D.1; Champagne, Bradley J. M.D.1

doi: 10.1097/DCR.0000000000000031
Original Contributions: Benign Colorectal Disease

BACKGROUND: Virtual reality simulation for laparoscopic colectomy has been used for training of surgical residents and has been considered as a model for technical skills assessment of board-eligible colorectal surgeons. However, construct validity (the ability to distinguish between skill levels) must be confirmed before widespread implementation.

OBJECTIVE: This study was designed to specifically determine which metrics for laparoscopic sigmoid colectomy have evidence of construct validity.

DESIGN: General surgeons that had performed fewer than 30 laparoscopic colon resections and laparoscopic colorectal experts (>200 laparoscopic colon resections) performed laparoscopic sigmoid colectomy on the LAP Mentor model. All participants received a 15-minute instructional warm-up and had never used the simulator before the study. Performance was then compared between each group for 21 metrics (procedural, 14; intraoperative errors, 7) to determine specifically which measurements demonstrate construct validity. Performance was compared with the Mann-Whitney U-test (p < 0.05 was significant).

RESULTS: Fifty-three surgeons; 29 general surgeons, and 24 colorectal surgeons enrolled in the study. The virtual reality simulators for laparoscopic sigmoid colectomy demonstrated construct validity for 8 of 14 procedural metrics by distinguishing levels of surgical experience (p < 0.05). The most discriminatory procedural metrics (p < 0.01) favoring experts were reduced instrument path length, accuracy of the peritoneal/medial mobilization, and dissection of the inferior mesenteric artery. Intraoperative errors were not discriminatory for most metrics and favored general surgeons for colonic wall injury (general surgeons, 0.7; colorectal surgeons, 3.5; p = 0.045).

LIMITATIONS: Individual variability within the general surgeon and colorectal surgeon groups was not accounted for.

CONCLUSIONS: The virtual reality simulators for laparoscopic sigmoid colectomy demonstrated construct validity for 8 procedure-specific metrics. However, using virtual reality simulator metrics to detect intraoperative errors did not discriminate between groups. If the virtual reality simulator continues to be used for the technical assessment of trainees and board-eligible surgeons, the evaluation of performance should be limited to procedural metrics.

See related article on p. 141

1Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio

2Department of Digestive Surgery, University Hospitals of Bordeaux, Bordeaux, France

3Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California

4Division of Colorectal Surgery, Veterans Administration Gulf Coast Veterans Health Care System, Biloxi, Mississippi

Financial Disclosures: None reported.

Presented at the Research Forum at the meeting of The American Society of Colon and Rectal Surgeons, Phoenix, AZ, April 27 to May 1, 2013.

Correspondence: Skandan Shanmugan, M.D., Division of Colorectal Surgery, University of Pennsylvania, 800 Walnut St, 20th Floor, Philadelphia, PA 19107-5109. E-mail:

© 2014 The American Society of Colon and Rectal Surgeons