A review of surgical simulation with attention to validation methodology.

The use of simulation technology for teaching and evaluating surgical skills has gained considerable attention in recent years. This is driven by interest in quality of care, concerns over increasing operative complexity, constraints on the use of animal models, limited available patient material, medicolegal pressures, and fiscal mandates for cost-effective performance. Traditional mechanical models are yielding to techniques dependent on electronic technology, including virtual reality. Data to support the validity of simulation techniques for surgical training, assessment, and certification represent only a fraction of the literature available on the subject. Literature searches were conducted in MEDLINE and ERIC, covering the period from 1966 to the present. The electronic and bioengineering literature was not surveyed due to the extensive literature on technology development, distinct from assessment of context specific validity. The search results and the bibliographies of key review articles were examined to identify articles that contained original data, measured performance between cohorts, defined performance measures, and described a standard against which performance was compared. Most of the literature pertaining to simulation techniques for surgical training has been published within the past 5 years and consist of review, opinion, and feasibility articles. There is an emerging body of evidence to establish the validity of simulation techniques for assessing surgical skills. Further refinement of simulation techniques, identification of specific performance measures, longitudinal evaluations, and comparison to practice outcomes are still needed to establish the validity and the value of surgical simulation for teaching and assessing surgical skills prior to considering implementation for certification purposes.