Construct validation of the ProMIS simulator using a novel laparoscopic suturing task K. R. Van Sickle, D. A. McClusky III, A. G. Gallagher, C. D. Smith Emory Endosurgery Unit, Emory University School of Medicine, 1364 Clifton NE, Atlanta, GA 30322, USA Received: 20 November 2004/Accepted: 28 March 2005/Online publication: 21 July 2005 Abstract Background: Theuseofsimulationforminimallyinvasive surgery (MIS) skills training has many advantages over currenttraditionalmethods.Oneadvantageofsimulation is that it enables an objective assessment of technical performance. The purpose of this study was to determine whether the ProMIS augmented reality simulator could objectively distinguish between levels of performance skills on a complex laparoscopic suturing task. Methods: Ten subjects — five laparoscopic experts and five laparoscopic novices — were assessed for baseline perceptual, visio-spatial, and psychomotor abilities using validated tests. After three trials of a novel laparoscopic suturing task were performed on the simulator, measures for time, smoothness of movement, and path distance were analyzed for each trial. Accuracy and errors were evaluated separately by two blinded reviewers to an in- terrater reliability of >0.8. Comparisons of mean per- formance measures were made between the two groups using a Mann-Whitney U test. Internal consistency of ProMIS measures was assessed with coefficient a. Results: The psychomotor performance of the experts was superior at baseline assessment (p < 0.001). On the laparoscopic suturing task, the experts performed sig- nificantly better than the novices across all three trials (p < 0.001). They performed the tasks between three and four times faster (p < 0.0001), had three times shorter instrument path length (p < 0.0001), and had four times greater smoothness of instrument movement (p < 0.009). Experts also showed greater consistency in their performance, as demonstrated by SDs across all mea- sures, which were four times smaller than the novice group. Observed internal consistency of ProMIS mea- sures was high (a = 0.95, p < 0.00001). Conclusions: Preliminary results of construct validation efforts of the ProMIS simulator show that it can dis- tinguish between experts and novices and has promising psychometric properties. The attractive feature of Pro- MIS is that a wide variety of MIS tasks can be used to train and assess technical skills. Key words: Surgical simulator — Virtual reality — Laparoscopic suturing — Psychomotor skills — Objective assessment — Construct validity Continued advances in computer technology and the growing need for training in advanced laparoscopic skills outside the operating room environment have led to growing interest in the development of virtual reality (VR) simulators. Simulation technology is well estab- lished in the sphere of aviation and military training, and the application of this technology to surgical lapa- roscopy training was first proposed over a decade ago [10]. Nevertheless, the integration of VR simulation into surgical training has evolved relatively slowly. Initial resistance was due primarily to a lack of val- idation studies that could provide an evaluation the use of simulation for the training of laparoscopic skills. However, after considerable research the validity of several VR-based simulators, including the Minimally Invasive Surgical Trainer — Virtual Reality (MIST- VR), the GI Mentor from Simbionix, and the Xitact SA, has recently been demonstrated [4]. Although most of them are still in the validation phase(s), a recent article by Schijren and Jakimowicz identified at least eight different surgical simulators in use to varying degrees around the world [12]. The use of simulation in surgical training curricula is becoming more widely accepted, for several reasons. First, VR training has been shown to enhance the acquisition of laparoscopic skills [16]. Second, most simulators are able to provide objective assessment and feedback of the subjectsÕ performance during the train- ing phase, allowing for continuous skills refinement. Finally, two recent randomized, controlled, double- blinded clinical trials have demonstrated that the oper- ating room performance of subjects receiving VR training is better than that of control subjects [5, 13]. Correspondence to: C. D. Smith Surg Endosc (2005) 19: 1227–1231 DOI: 10.1007/s00464-004-8274-6 Ó Springer Science+Business Media, Inc. 2005