• Eva Kassab, Jimmy Kyaw Tun, Sonal Arora, Dominic King, Kamran Ahmed, Danilo Miskovic, Alexandra Cope, Bhamini Vadhwana, Fernando Bello, Nick Sevdalis, and Roger Kneebone.
• Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital Campus, London, United Kingtom. e.kassab@imperial.ac.uk
• Ann. Surg. 2011 Dec 1;254(6):1059-65.

ObjectivesTo explore face, content and construct validity of Distributed Simulation (DS), an innovative approach to low-cost, high-fidelity surgical simulation and compare technical performance in the DS with that on a standard surgical box trainer.BackgroundImmersive simulation is widely accepted as an important modality for surgical education. However, access and cost limit the uptake of full-scale simulation training. DS is a portable, simulated clinical environment aiming at widening access to immersive simulation.MethodsTen novice and 10 expert surgeons performed a laparoscopic cholecystectomy on a porcine model in the DS and on a box trainer. Face and content validity were measured using 6-point Likert-type questionnaires. Construct validity was rated using the Objective Structured Assessment of Technical Skills (OSATS). Comparison of technical performance between DS and box trainer was measured using the Wilcoxon test.ResultsFace validity was rated as 5.1 (SD = 0.54) by novices and 4.8 (SD = 0.64) by experts.Content validity was rated as 5.2 (SD = 0.40) by novices and 5.1 (SD = 0.56) by experts. Experts performed significantly better than novices in the DS (16.3 vs. 27.3, P < 0.001) demonstrating construct validity. Experts' technical performance did not differ between DS and box trainer (26.5 vs. 27.3, P > 0.84) whereas novices performed better on the box trainer (19.8 vs. 16.3, P < 0.01). Qualitative data analysis demonstrated that surgeons felt able to behave as if in a real operating room (OR).ConclusionDS offers a valid, low-cost, accessible environment for training and assessing surgeons. This approach has major implications for surgical education and for the widespread implementation of immersive simulation at a time of increasing financial austerity.

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