title: Evaluation of Three Sources of Validity Evidence for a Synthetic Thoracoscopic Esophageal Atresia/Tracheoesophageal Fistula Repair Simulator.
abstract: OBJECTIVE
  Thoracoscopic esophageal atresia (EA)/tracheoesophageal fistula (TEF) repair is technically challenging. We have previously reported our experiences with a high-fidelity hybrid model for simulation-based educational instruction in thoracoscopic EA/TEF, including the high cost of the tissue for these models. The purposes of this study were (1) to create a low-cost synthetic tissue EA/TEF repair simulation model and (2) to evaluate the content validity of the synthetic tissue simulator.
  
  
  METHODS
  Review of the literature and computed tomography images were used to create computer-aided drawings (CAD) for a synthetic, size-appropriate EA/TEF tissue insert. The inverse of the CAD image was then printed in six different sections to create a mold that could be filled with platinum-cured silicone. The silicone EA/TEF insert was then placed in a previously described neonatal thorax and covered with synthetic skin. Following institutional review board-exempt determination, 47 participants performed some or all of a simulated thoracoscopic EA/TEF during two separate international meetings (International Pediatric Endosurgery Group [IPEG] and World Federation of Associations of Pediatric Surgeons [WOFAPS]). Participants were identified as "experts," having 6-50 self-reported thoracoscopic EA/TEF repairs, and "novice," having 0-5 self-reported thoracoscopic EA/TEF repairs. Participants completed a self-report, six-domain, 24-item instrument consisting of 23 5-point rating scales and one 4-point Global Rating Scale. Validity evidence relevant to test content and response processes was evaluated using the many-facet Rasch model, and evidence of internal structure (interitem consistency) was estimated using Cronbach's alpha.
  
  
  RESULTS
  A review of the participants' ratings indicates there were no overall differences across sites (IPEG versus WOFAPS, P=.84) or experience (expert versus novice, P=.17). The highest observed averages were 4.4 (Value of Simulator as a Training Tool), 4.3 (Physical Attributes-chest circumference, chest depth, and intercostal space), and 4.3 (Realism of Experience-fistula location). The lowest observed averages were 3.5 (Ability to Perform-closure of fistula), 3.7 (Ability to Perform-acquisition target trocar sites), 3.8 (Physical Attributes-landmark visualization), 3.8 (Ability to Perform-anastomosis and dissection of upper pouch), and 3.9 (Realism of Materials-skin). The Global Rating Scale was 2.9, coinciding with a response of "this simulator can be considered for use in neonatal TEF repair training, but could be improved slightly." Material costs for the synthetic EA/TEF inserts were less than $2 U.S. per insert.
  
  
  CONCLUSIONS
  We have successfully created a low-cost synthetic EA/TEF tissue insert for use in a neonatal thoracoscopic EA/TEF repair simulator. Analysis of the participants' ratings of the synthetic EA/TEF simulation model indicates that it has value and can be used to train pediatric surgeons, especially those early in their learning curve, to begin to perform a thoracoscopic EA/TEF repair. Areas for model improvement were identified, and these areas will be the focus for future modifications to the synthetic EA/TEF repair simulator.
authors.affiliation: 1 Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago , Chicago, Illinois.|2 Departments of Surgery and Medical Education, Northwestern University Feinberg School of Medicine , Chicago, Illinois.
authors.forename: Katherine A
authors.initials: KA
authors.lastname: Barsness
authors.affiliation: 3 Department of Learning Health Sciences, University of Michigan Medical School , Ann Arbor, Michigan.
authors.forename: Deborah M
authors.initials: DM
authors.lastname: Rooney
authors.affiliation: 4 Innovations Laboratory, Northwestern Simulation, Center for Education in Medicine, Northwestern University Feinberg School of Medicine , Chicago, Illinois.
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Davis
authors.affiliation: 4 Innovations Laboratory, Northwestern Simulation, Center for Education in Medicine, Northwestern University Feinberg School of Medicine , Chicago, Illinois.
authors.forename: Ellie
authors.initials: E
authors.lastname: O'Brien
mesh_terms: D001291:Attitude of Health Personnel; D017076:Computer-Aided Design; D004867:Equipment Design; D004933:Esophageal Atresia / Q000601:surgery*; D004947:Esophagus; D005260:Female; D006801:Humans; D010372:Pediatrics / Q000193:education*; D066330:Printing, Three-Dimensional; D012272:Ribs; D012828:Silicones; D000066908:Simulation Training / Q000191:economics; D013906:Thoracoscopy / Q000193:education* / Q000379:methods; D014132:Trachea; D014138:Tracheoesophageal Fistula / Q000601:surgery*; D014481:United States
chemical_list: D012828:Silicones