title: "Blowing up the barriers" in surgical training: exploring and validating the concept of distributed simulation.
abstract: OBJECTIVE
  To 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.
  
  
  BACKGROUND
  Immersive 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.
  
  
  METHODS
  Ten 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.
  
  
  RESULTS
  Face 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).
  
  
  CONCLUSIONS
  DS 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.
authors: Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital Campus, London, United Kingtom. e.kassab@imperial.ac.uk
authors: Eva
authors: E
authors: Kassab
authors: Jimmy Kyaw
authors: JK
authors: Tun
authors: Sonal
authors: S
authors: Arora
authors: Dominic
authors: D
authors: King
authors: Kamran
authors: K
authors: Ahmed
authors: Danilo
authors: D
authors: Miskovic
authors: Alexandra
authors: A
authors: Cope
authors: Bhamini
authors: B
authors: Vadhwana
authors: Fernando
authors: F
authors: Bello
authors: Nick
authors: N
authors: Sevdalis
authors: Roger
authors: R
authors: Kneebone
mesh_terms: D000818:Animals; D001291:Attitude of Health Personnel; D017081:Cholecystectomy, Laparoscopic / Q000193:education*; D002983:Clinical Competence; D003198:Computer Simulation; D004503:Education, Medical, Graduate; D013502:General Surgery / Q000193:education*; D006801:Humans; D008953:Models, Anatomic; D023421:Models, Animal; D011795:Surveys and Questionnaires; D013552:Swine; D014584:User-Computer Interface