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lack of haptic feedback a surgeon receives when directly controlling laparoscopic
instruments. Furthermore, RALS necessitates training with millions of dollars of
equipment that is often tied to the operating room (OR) and therefore is available in
only a limited capacity for initial skill acquisition and rehearsal. As a result, these
techniques require specialized training and assessment beyond the scope of tradi-
tional methods.
This chapter provides an overview of current assessment methods for both lapa-
roscopic and RALS skills, both during simulation and operative procedures. Some
of the most exciting means of doing so are virtual reality simulators that automati-
cally output scores, but they are far from the only option. Laparoscopic surgery
features an extensively accepted testing and certification process, called the
Fundamentals of Laparoscopic Surgery. This multistep curriculum later became the
basis for a similar program in RALS, the Fundamentals of Robotic Surgery. As MIS
continues to grow, the importance of specialty-specific and indeed procedure-
specific simulation and testing has been highlighted. Further development of these
curriculums is ongoing.
Smaller scale and more individualized means of assessment are also available,
including global rating scales, motion tracking devices and software, technology-
based data export, idle time analysis, and combined analysis of technical and non-
technical skills.
Validation and Training
Past models of medical training revolved around students rehearsing skills on actual
patients – a questionable process that has since been largely jettisoned. The
Halsteadian model of medical education was introduced in the early twentieth cen-
tury as a way for experience to be gradually gained from patients under the supervi-
sion of experienced physicians. The advent of medical simulation presents a viable
alternative to this practice. Suturing can be rehearsed with artificial tissue models,
intubation can be practiced on life sized manikins, and entire surgical procedures
can be simulated in virtual reality. The patient can thus be safely removed from the
technical aspect of training.
Specifically for minimally invasive surgery, there are countless training options
ranging from homemade box trainers adapted from a shoebox to six-figure virtual
reality simulators. With such a wide range, surgical educators must determine how
best to train and assess students based on a variety of factors, not the least of which
is cost. Traditionally, options are set as the “gold standard,” a broadly accepted and
validated objective that can be reproduced at most sites. Validation includes several
factors. Face validity, how realistic, or how a method feels, and content validity,
how applicable of an instructional tool it is, are both subjective – meaning that they
are at mercy to the assessor’s opinions and beliefs. Commercial simulators often
rely heavily on face validity, using the realism of their product as a selling point.
In the old dictum, objective measures of validity which are those independent of
personal influence, were defined as construct, concurrent, and predictive. Research
E.I. George et al.