Intentional enterotomies: validation of a novel robotic surgery training exercise

While laparoscopic simulation-based training is a well-established component of general surgery training, no such requirement or standardized curriculum exists for robotic surgery. Furthermore, there is a lack of high-fidelity electrocautery simulation training exercises in the literature. Using Messick's validity framework, we sought to determine the content, response process, internal content and construct validity of a novel inanimate tissue model that utilizes electrocautery for potential incorporation in such curricula. A multi-institutional, prospective study involving medical students (MS) and general surgery residents (PGY1-3) was conducted. Participants performed an exercise using a biotissue bowel model on the da Vinci Xi robotic console during which they created an enterotomy using electrocautery, followed by approximation with interrupted sutures. Participant performance was recorded and then scored by crowd-sourced assessors of technical skill, along with three of the authors. Construct validity was determined via difference in Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and total number of errors between the two cohorts. Upon completion of the exercise, participants were surveyed on their perception of the exercise and its impact on their robotic training to determine content validity. 31 participants were enrolled and separated into two cohorts: MS + PGY1 vs. PGY2-3. Time spent on the robotic trainer (0.8 vs. 8.13 h, p = 0.002), number of bedside robotic assists (5.7 vs. 14.8, p < 0.001), and number of robotic cases as primary surgeon (0.3 vs. 13.1, p < 0.001) were statistically significant between the two groups. Differences in GEARS scores (18.5 vs. 19.9, p = 0.001), time to completion (26.1 vs. 14.4 min, p < 0.001), and total errors (21.5 vs. 11.9, p = 0.018) between the groups were statistically significant as well. Of the 23 participants that completed the post-exercise survey, 87% and 91.3% reported improvement in robotic surgical ability and confidence, respectively. On a 10-point Likert scale, respondents rated the realism of the exercise 7.5, educational benefit 9.1, and effectiveness in teaching robotic skills 8.7. Controlling for the upfront investment of certain training materials, each exercise iteration cost ~ $30. This study confirmed the content, response process, internal structure and construct validity of a novel, high-fidelity and cost-effective inanimate tissue exercise which successfully incorporates electrocautery. Consideration should be given to its addition to robotic surgery training programs.