Controversies in endobronchial ultrasound.

Endobronchial ultrasound (EBUS) is a minimally invasive highly accurate and safe endoscopic technique for the evaluation of mediastinal lymphadenopathy and mediastinal masses including centrally located lung tumors. The combination of transbronchial and transoesophageal tissue sampling has improved lung cancer staging, reducing the need for more invasive and surgical diagnostic procedures. Despite the high level of evidence regarding EBUS use in the aforementioned situations, there are still challenges and controversial issues such as follows: Should informed consent for EBUS and flexible bronchoscopy be different? Is EBUS able to replace standard bronchoscopy in patients with suspected lung cancer? Which is the best position, screen orientation, route of intubation, and sedation/anesthesia to perform EBUS? Is it advisable to use a balloon in all procedures? How should the operator acquire skills and how should competence be ensured? This Pro-Con article aims to address these open questions.

Automated performance metrics and surgical gestures: two methods for assessment of technical skills in robotic surgery.

The objective of this study is to compare automated performance metrics (APM) and surgical gestures for technical skills assessment during simulated robot-assisted radical prostatectomy (RARP). Ten novices and six experienced RARP surgeons performed simulated RARPs on the RobotiX Mentor (Surgical Science, Sweden). Simulator APM were automatically recorded, and surgical videos were manually annotated with five types of surgical gestures. The consequences of the pass/fail levels, which were based on contrasting groups' methods, were compared for APM and surgical gestures. Intra-class correlation coefficient (ICC) analysis and a Bland-Altman plot were used to explore the correlation between APM and surgical gestures. Pass/fail levels for both APM and surgical gesture could fully distinguish between the skill levels of the surgeons with a specificity and sensitivity of 100%. The overall ICC (one-way, random) was 0.70 (95% CI: 0.34-0.88), showing moderate agreement between the methods. The Bland-Altman plot showed a high agreement between the two methods for assessing experienced surgeons but disagreed on the novice surgeons' skill level. APM and surgical gestures could both fully distinguish between novices and experienced surgeons in a simulated setting. Both methods of analyzing technical skills have their advantages and disadvantages and, as of now, those are only to a limited extent available in the clinical setting. The development of assessment methods in a simulated setting enables testing before implementing it in a clinical setting.

Phacoemulsification to MSICS: A transfer of skills study in a simulated environment.: Transfer of phacoemulsification surgical skills to MSICS.

PURPOSE: To investigate if phacoemulsification experience impacts and transfers to the skill acquisition of novices in manual small incision cataract surgery (MSICS) within a simulation environment. SETTING: Copenhagen Academy for Medical Education and Simulation, Denmark. DESIGN: Prospective controlled experimental study. METHODS: The study included 29 residents or specialist in ophthalmology with no prior MSICS experience. Participants were required to either have 1) proficiency on the EyeSi surgical simulator (PG; phaco group) or 2) no prior extensive exposure to the EyeSi simulator or any phacoemulsification surgery experience as a primary surgeon (CG; control group). Possible skill transfer was assessed using a test on the HelpMeSee virtual-reality simulator, including nine modules and 30 steps (points). A pass/fail score was determined at 20 points (out of 30 points). Performance scores were analyzed using independent samples t-tests, pass rates using Fisher's exact test, and individual modules using Fisher-Freeman-Halton analysis. RESULT: The PG performed significantly better in terms of overall performance score (mean SD, PG; 21.8 points 2.3 versus CG; 18.9 points 2.2, p = 0.002, t-value = -3.39) and pass rates (PG; 72 % versus CG; 22%, p = 0.018). The sub-analysis for individual modules demonstrated significant differences exclusively in the capsulorhexis and cortex removal modules. CONCLUSION: The results suggest a positive inter-procedural transfer of skills between phacoemulsification and MSICS. Pretraining and experience in phacoemulsification demonstrated a significant effect on the performance of MSICS within a simulation environment. These findings suggest that phacoemulsification experience provides an advantage before MSICS training in surgical residency programs.

Comparing the impact of surgical expert versus non-ophthalmologist instructors on virtual-reality surgical performance: A randomized controlled trial.

PURPOSE: To compare Manual Small Incision Cataract Surgery (MSICS) microsurgical performance in course participants who received virtual reality simulation-based training by either a surgical expert or a non-ophthalmologist instructor. SETTING: Copenhagen Academy for Medical Education and Simulation, Copenhagen, Denmark. DESIGN: Randomized controlled trial. METHODS: Residents and specialists in ophthalmology with no prior MSICS experience were included to receive virtual reality simulation training in MSICS using the HelpMeSee simulator. The participants were randomly allocated to receive training from either an experienced MSICS surgeon or a non-ophthalmologist, also known as near-peer teaching. The performances of the participants were evaluated at baseline and post-training using a MSICS proficiency-based test with evidence of validity. RESULTS: Thirty participants were included in the study and 29 completed the course. There was no significant difference in final test score between the two groups (p = 0.13). The performance score of both groups of participants increased significantly after receiving the training (p < 0.001). All participants passed the proficiency-based test after receiving the training. CONCLUSION: We found no significant difference in surgical proficiency-level whether the participants were trained by a surgical expert or a non-ophthalmologist instructor for MSICS in a virtual-reality based setting. The findings of this study suggest that near-peer teaching within microsurgical performance potentially could be applied with teaching outcomes comparable to a surgical expert-instructor.

Computer-aided quality assessment of endoscopist competence during colonoscopy: a systematic review.

BACKGROUND AND AIMS: Endoscopists' competence can vary widely, as shown in the variation in the adenoma detection rate (ADR). Computer-aided quality assessment (CAQ) can automatically assess performance during individual procedures. In this review we identified and described different CAQ systems for colonoscopy. METHODS: A systematic review of the literature was done using MEDLINE, EMBASE, and Scopus based on 3 blocks of terms according to the inclusion criteria: colonoscopy, competence assessment, and automatic evaluation. Articles were systematically reviewed by 2 reviewers, first by abstract and then in full text. The methodological quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS: Of 12,575 identified studies, 6831 remained after removal of duplicates and 6806 did not pass the eligibility criteria and were excluded, leaving 25 studies, of which 13 studies were included in the final analysis. Five categories of CAQ systems were identified: withdrawal speedometer (7 studies), endoscope movement analysis (3 studies), effective withdrawal time (1 study), fold examination quality (1 study), and visual gaze pattern (1 study). The withdrawal speedometer was the only CAQ system that tested its feedback by examining changes in ADR. Three studies observed an improvement in ADR, and 2 studies did not. The methodological quality of the studies was high (mean MERSQI, 15.2 points; maximum, 18 points). CONCLUSIONS: Thirteen studies developed or tested CAQ systems, most frequently by correlating it to the ADR. Only 5 studies tested feedback by implementing the CAQ system. A meta-analysis was impossible because of the heterogeneous study designs, and more studies are warranted.

Using neuroimaging to assess brain activity and areas associated with surgical skills: a systematic review.

BACKGROUND: Surgical skills acquisition is under continuous development due to the emergence of new technologies, and there is a need for assessment tools to develop along with these. A range of neuroimaging modalities has been used to map the functional activation of brain networks while surgeons acquire novel surgical skills. These have been proposed as a method to provide a deeper understanding of surgical expertise and offer new possibilities for the personalized training of future surgeons. With studies differing in modalities, outcomes, and surgical skills there is a need for a systematic review of the evidence. This systematic review aims to summarize the current knowledge on the topic and evaluate the potential use of neuroimaging in surgical education. METHODS: We conducted a systematic review of neuroimaging studies that mapped functional brain activation while surgeons with different levels of expertise learned and performed technical and non-technical surgical tasks. We included all studies published before July 1st, 2023, in MEDLINE, EMBASE and WEB OF SCIENCE. RESULTS: 38 task-based brain mapping studies were identified, consisting of randomized controlled trials, case-control studies, and observational cohort or cross-sectional studies. The studies employed a wide range of brain mapping modalities, including electroencephalography, functional magnetic resonance imaging, positron emission tomography, and functional near-infrared spectroscopy, activating brain areas involved in the execution and sensorimotor or cognitive control of surgical skills, especially the prefrontal cortex, supplementary motor area, and primary motor area, showing significant changes between novices and experts. CONCLUSION: Functional neuroimaging can reveal how task-related brain activity reflects technical and non-technical surgical skills. The existing body of work highlights the potential of neuroimaging to link task-related brain activity patterns with the individual level of competency or improvement in performance after training surgical skills. More research is needed to establish its validity and usefulness as an assessment tool.

The bibliometric analysis of extended reality in surgical training: Global and Chinese perspective.

Objectives: The prospect of extended reality (XR) being integrated with surgical training curriculum has attracted scholars. However, there is a lack of bibliometric analysis to help them better understand this field. Our aim is to analyze relevant literature focusing on development trajectory and research directions since the 21st century to provide valuable insights. Methods: Papers were retrieved from the Web of Science Core Collection. Microsoft Excel, VOSviewer, and CiteSpace were used for bibliometric analysis. Results: Of the 3337 papers published worldwide, China contributed 204, ranking fifth. The world's enthusiasm for this field has been growing since 2000, whereas China has been gradually entering since 2001. Although China had a late start, its growth has accelerated since around 2016 due to the reform of the medical postgraduate education system and the rapid development of Chinese information technology, despite no research explosive period has been yet noted. International institutions, notably the University of Toronto, worked closely with others, while Chinese institutions lacked of international and domestic cooperation. Sixteen stable cooperation clusters of international scholars were formed, while the collaboration between Chinese scholars was not yet stable. XR has been primarily applied in orthopedic surgery, cataract surgery, laparoscopic training and intraoperative use in neurosurgery worldwide. Conclusions: There is strong enthusiasm and cooperation in the international research on the XR-based surgical training. Chinese scholars are making steady progress and have great potential in this area. There has not been noted an explosive research phase yet in the Chinese pace. The research on several surgical specialties has been summarized at the very first time. AR will gradually to be more involved and take important role of the research.

How experienced robotic nurses adapt to the Hugo™ RAS system.

No studies have reported on the impact at team level of the Medtronic Hugo™ RAS system. We described the work patterns and learning curves of an experienced robotic nurse team adapting to the new robotic system. We prospectively recorded the robotic nurse team's preoperative, perioperative, and postoperative tasks on the first 30 robotic procedures performed. The data were descriptively analyzed, and Gantt Charts were created for a timeline overview of the work patterns. We compared the operative times between the Medtronic Hugo™ RAS and the Davinci® system. The preoperative phase seemed to improve with a median time of 94 min (IQR 81-107). After 20 surgeries, the work pattern became more consistent where the scrub and circulating nurses worked simultaneously. There was no noticeable improvement for the perioperative and postoperative phases with a stable median time of 170 min (IQR 135-189) and 26 min (IQR 22-31). We found that the work pattern seemed to stabilize after 20 surgeries but with a continued decrease in preoperative time without a learning curve plateau. The robotic nurse team suffered from few breaks and long working hours because only a few nurses at our facility were trained in the Hugo™ system.

Variable practice is superior to self-directed training for laparoscopic simulator training: a randomized trial.

BACKGROUND: Mastering laparoscopy is challenging-it requires specific psychomotor skills which are difficult to obtain in the operating room without potentially compromising patient safety. Proficiency-based training programs using virtual reality simulators allow novices to practice and develop their skills in a patient-safe learning environment. Variable practice leads to stronger retention and skills transfer in a non-surgical setting. The objective of this trial was to investigate if variable practice was superior to self-directed training. METHODS: A randomized trial where participants (n = 36) were randomized to proficiency-based laparoscopic simulator training of basic skills using either variable practice or self-directed training, followed by a transfer test with proficiency-based training on a procedural task (a salpingectomy). All participants returned after a period of 3-5 weeks to perform a retention test. RESULTS: The mean time to proficiency for the basic skills tasks were 119 min (SD: 93) for the variable practice group versus 182 min (SD: 46) for the self-directed training group (p = 0.015). The time to reach proficiency during the transfer test was 103 min (SD: 57) versus 183 min (SD: 64) for the variable practice group versus the self-directed training group, respectively (p < 0.001). The mean time to proficiency for the retention test was 51 min (SD: 26) and 109 min (SD: 53) for the variable practice group and self-directed training group, respectively (p < 0.001). CONCLUSION: Variable practice is superior to self-directed training for proficiency-based laparoscopic training. With variable time to practice proficiency is reduced, there is higher transfer to a procedural task, and retention is improved.

Training and assessment for colorectal surgery and appendicectomy- a systematic review.

AIM: There is currently an increased focus on competency-based training, in which training and assessment play a crucial role. The aim of this systematic review is to create an overview of hands-on training methods and assessment tools for appendicectomy and colon and rectal surgery procedures using either an open, laparoscopic or robot-assisted approach. METHOD: A systematic review of Medline, Embase, Cochrane and Scopus databases was conducted following the PRISMA guidelines. We conducted the last search on 9 March 2023. All published papers describing hands-on training, evaluation of performance data and development of assessment tools were eligible. The quality of studies and the validity evidence of assessment tools are reported. RESULTS: Fifty-one studies were identified. Laparoscopic assessment tools are abundant, but the literature still lacks good-quality assessment tools for open appendicectomy, robotic colectomy and open rectal surgery. Overall, there is a lack of discussion regarding the establishment of pass/fail standards and the consequences of assessment. Virtual reality simulation is used more for appendicectomy than colorectal procedures. Only a few of the studies investigating training were of acceptable quality. There is a need for high-quality studies in open and robotic-assisted colon surgery and all approaches to rectal surgery. CONCLUSION: This review provides an overview of current training methods and assessment tools and identifies where more research is needed based on the quality of the studies and the current validity evidence.

Developing a phantom for simulating robotic-assisted complete mesocolic excision using 3D printing and medical imaging.

BACKGROUND: Robotic-assisted complete mesocolic excision is an advanced procedure mainly because of the great variability in anatomy. Phantoms can be used for simulation-based training and assessment of competency when learning new surgical procedures. However, no phantoms for robotic complete mesocolic excision have previously been described. This study aimed to develop an anatomically true-to-life phantom, which can be used for training with a robotic system situated in the clinical setting and can be used for the assessment of surgical competency. METHODS: Established pathology and surgical assessment tools for complete mesocolic excision and specimens were used for the phantom development. Each assessment item was translated into an engineering development task and evaluated for relevance. Anatomical realism was obtained by extracting relevant organs from preoperative patient scans and 3D printing casting moulds for each organ. Each element of the phantom was evaluated by two experienced complete mesocolic excision surgeons without influencing each other's answers and their feedback was used in an iterative process of prototype development and testing. RESULTS: It was possible to integrate 35 out of 48 procedure-specific items from the surgical assessment tool and all elements from the pathological evaluation tool. By adding fluorophores to the mesocolic tissue, we developed an easy way to assess the integrity of the mesocolon using ultraviolet light. The phantom was built using silicone, is easy to store, and can be used in robotic systems designated for patient procedures as it does not contain animal-derived parts. CONCLUSIONS: The newly developed phantom could be used for training and competency assessment for robotic-assisted complete mesocolic excision surgery in a simulated setting.

Lack of stereopsis does not reduce surgical performance but prolongs the learning curve of vitreoretinal surgery.

PURPOSE: To investigate whether individuals with long-term reduced stereopsis were able to obtain the same level of surgical skills in simulated vitreoretinal surgery on the Eyesi Surgical Simulator as individuals with normal stereopsis. METHODS: Twenty-four medical students were recruited and divided into two groups according to their degree of stereopsis: Group 1 (n = 12) included subjects with normal stereopsis (60 arcsec or lower) and Group 2 (n = 12) included subjects with reduced stereopsis (120 arcsec or higher). Stereopsis was tested using the TNO test (Lameris Ootech BV, Nieuwegein, the Netherlands). The participants were trained in virtual reality-simulated vitreoretinal surgery and continuously measured using a test with solid validity evidence and a pre-defined pass-fail score. All data were analysed using the Wilcoxon rank sum test. RESULTS: We observed no differences in overall performance scores for any of the four modules. The participants with reduced stereopsis used 5.8 more attempts in bimanual training (p = 0.04), 8.8 more attempts in removal of posterior hyaloid (p = 0.04), 9.1 more attempts in navigation training (p = 0.20) and 0.3 fewer attempts in removal of internal limiting membrane (p = 0.69). CONCLUSION: The final performance scores on the Eyesi Surgical Simulator were independent of the degree of stereopsis. However, the number of attempts to achieve the pre-defined pass-fail score increased significantly with reduced stereopsis in two of four modules. These results indicate that a high degree of stereopsis is not necessary to become proficient in microsurgery but may prolong the learning curve.

Surgical gestures can be used to assess surgical competence in robot-assisted surgery : A validity investigating study of simulated RARP.

To collect validity evidence for the assessment of surgical competence through the classification of general surgical gestures for a simulated robot-assisted radical prostatectomy (RARP). We used 165 video recordings of novice and experienced RARP surgeons performing three parts of the RARP procedure on the RobotiX Mentor. We annotated the surgical tasks with different surgical gestures: dissection, hemostatic control, application of clips, needle handling, and suturing. The gestures were analyzed using idle time (periods with minimal instrument movements) and active time (whenever a surgical gesture was annotated). The distribution of surgical gestures was described using a one-dimensional heat map, snail tracks. All surgeons had a similar percentage of idle time but novices had longer phases of idle time (mean time: 21 vs. 15 s, p < 0.001). Novices used a higher total number of surgical gestures (number of phases: 45 vs. 35, p < 0.001) and each phase was longer compared with those of the experienced surgeons (mean time: 10 vs. 8 s, p < 0.001). There was a different pattern of gestures between novices and experienced surgeons as seen by a different distribution of the phases. General surgical gestures can be used to assess surgical competence in simulated RARP and can be displayed as a visual tool to show how performance is improving. The established pass/fail level may be used to ensure the competence of the residents before proceeding with supervised real-life surgery. The next step is to investigate if the developed tool can optimize automated feedback during simulator training.

Skills transfer from the DaVinci® system to the Hugo™ RAS system.

PURPOSE: Recently, the robotic surgical system, Hugo™ was approved for clinical use. The transfer of skills is important for understanding the implementation of surgical innovation. We explored the transfer of skills from the DaVinci® to the Hugo™ by studying the learning curve and short-term patient outcomes during radical prostatectomy (RARP). METHODS: We examined the transfer of skills from one surgeon performing RARP from the first case with the Hugo™ system in April 2022. The surgeon had previously performed > 1000 RARPs using DaVinci®. Perioperative and clinical outcomes were collected for procedures on both Hugo™ and DaVinci®. Patient follow-up time was 3 months. RESULTS: Nineteen Hugo™ cases and 11 DaVinci® cases were recorded. No clinically relevant difference in procedure time was found when transferring to Hugo™. Patients operated using Hugo™ had more contacts postoperatively compared to the DaVinci®, all Clavien-Dindo (CD) grade 1 (53% vs 18%). Three patients from the Hugo™ group were re-admitted within 30 days with catheter malfunction (CD grade 1), infection without a focus (CD grade 2), and ileus due to a hernia in the port hole (CD grade 3b). The 3-month follow-up showed similar results in prostate-specific antigen levels (PSA) and erectile dysfunction between the two robotic systems, but a higher incidence of incontinence was found for the Hugo™. CONCLUSION: We observed that the skills of an experienced robotic surgeon are transferable from DaVinci® to Hugo™ when performing RARP. No obvious benefits were found for using Hugo™ compared to DaVinci® for RARP although this needs confirmatory studies.

First experience with the Hugo™ robot-assisted surgery system for endometriosis: A descriptive study.

INTRODUCTION: The Medtronic Hugo™ Robot-assisted Surgery (RAS) system was recently approved for clinical use. We explored the safety and feasibility of this system for endometriosis surgery. The primary outcome was safe case completion without major surgical complications (Clavien-Dindo grade ≤2) and no conversion to open surgery or laparoscopy. MATERIAL AND METHODS: Surgeries for endometriosis performed at the Department of Gynecology, Rigshospitalet, on the Medtronic Hugo™ RAS system were included. Two experienced robotic surgeons performed all surgeries with their usual robotic team. The variables included were patient demographics, peri- and postoperative data, complications and 30-day readmission rate. We used the IDEAL framework 1/2a for surgical innovation in this descriptive study. RESULTS: The first 12 patients were included. All cases were completed without intraoperative complications or conversion. Four patients experienced Clavien-Dindo grade 1 postoperative complications. No patients were re-admitted within 30 days. Median docking time (17 minutes), console time (87.5 minutes), blood loss (40 mL) and length of hospital stay (1 day) were acceptable compared with previous literature. CONCLUSIONS: In this pilot study, we found the Medtronic Hugo™ RAS system safe and feasible for robot-assisted surgery for endometriosis. The advent of new robotic systems is welcomed to accelerate the development of technology that will advance surgical care for patients across the globe.

No difference between using short and long intervals for distributed proficiency-based laparoscopy simulator training: a randomized trial.

BACKGROUND: Simulation-based training is increasingly used to acquire basic laparoscopic skills. Multiple factors can influence training, e.g., distributed practice is superior to massed practice in terms of efficiency. However, the optimal interval between training sessions is unclear. The objective of this trial was to investigate if shorter intervals between sessions are more efficient than longer intervals during proficiency-based laparoscopy simulator training. METHODS: A randomized simulation-based trial where medical students (n = 39) were randomized to proficiency-based training with either 1-2 days (intervention group) or 6-8 days (control group) between training sessions. Both groups practiced a series of basic tasks and a procedural module until proficiency level on the LapSim® simulator. Both groups were given instructor feedback upon request. After reaching proficiency, participants were invited back for a retention test 3-5 weeks later and practiced the same tasks to proficiency again. RESULTS: The mean time to reach proficiency during training was 291 (SD 89) and 299 (SD 89) min in the intervention and control group, respectively (p = 0.81). During the retention test, the mean time to reach proficiency was 94 (SD 53) and 96 (SD 39) minutes in the intervention and control groups, respectively (p = 0.91). CONCLUSION: We found no difference whether practicing with shorter intervals or longer intervals between training sessions when examining time to proficiency or retention.

Generating a Prioritized List of Operative Procedures for Simulation-based Assessment of General Surgery Trainees Through Consensus.

OBJECTIVE: To develop appropriate content for high-stakes simulation-based assessments of operative competence in general surgery training through consensus. BACKGROUND: Valid methods of summative operative competence assessment are required by competency-based training programs in surgery. METHOD: An online Delphi consensus study was conducted. Procedures were derived from the competency expectations outlined by the Joint Committee on Surgical Training Curriculum 2021, and subsequent brainstorming. Procedures were rated according to their perceived importance, perceived procedural risk, how frequently they are performed, and simualtion feasibility by a purposive sample of 30 surgical trainers and a 5-person steering group. A modified Copenhagen Academy for Medical Education and Simulation Needs Assessment Formula was applied to the generated data to produce ranked procedural lists, which were returned to participants for re-prioritization. RESULTS: Prioritized lists were generated for simulation-based operative competence assessments at 2 key stages of training; the end of 'phase 2' prior to the development of a sub-specialty interest, and the end of 'phase 3', that is, end-of-training certification. A total of 21 and 16 procedures were deemed suitable for assessments at each of these stages, respectively. CONCLUSIONS: This study describes a national needs assessment approach to content generation for simulation-based assessments of operative competence in general surgery using Delphi consensus methodology. The prioritized procedural lists generated by this study can be used to further develop operative skill assessments for use in high-stakes scenarios, such as trainee progression, entrustment, and end-of-training certification, before subsequent validity testing.

Artificial Intelligence Improves Novices' Bronchoscopy Performance: A Randomized Controlled Trial in a Simulated Setting.

BACKGROUND: Navigating through the bronchial tree and visualizing all bronchial segments is the initial step toward learning flexible bronchoscopy. A novel bronchial segment identification system based on artificial intelligence (AI) has been developed to help guide trainees toward more effective training. RESEARCH QUESTION: Does feedback from an AI-based automatic bronchial segment identification system improve novice bronchoscopists' end-of-training performance? STUDY DESIGN AND METHODS: The study was conducted as a randomized controlled trial in a standardized simulated setting. Novices without former bronchoscopy experience practiced on a mannequin. The feedback group (n = 10) received feedback from the AI, and the control group (n = 10) trained according to written instructions. Each participant decided when to end training and proceed to performing a full bronchoscopy without any aids. RESULTS: The feedback group performed significantly better on all three outcome measures (median difference, P value): diagnostic completeness (3.5 segments, P < .001), structured progress (13.5 correct progressions, P < .001), and procedure time (-214 seconds, P = .002). INTERPRETATION: Training guided by this novel AI makes novices perform more complete, more systematic, and faster bronchoscopies. Future studies should examine its use in a clinical setting and its effects on more advanced learners.

Assessing Chest Tube Insertion Skills Using a Porcine Rib Model-A Validity Study.

INTRODUCTION: Assessments require sufficient validity evidence before their use. The Assessment for Competence in Chest Tube Insertion (ACTION) tool evaluates proficiency in chest tube insertion (CTI), combining a rating scale and an error checklist. The aim of this study was to collect validity evidence for the ACTION tool on a porcine rib model according to the Messick framework. METHODS: A rib model, consisting of a porcine hemithorax that was placed in a wooden frame, was used as simulator. Participants were recruited from the departments of surgery, pulmonology, and emergency medicine. After familiarization with the rib model and the equipment, standardized instructions and clinical context were provided. They performed 2 CTIs while being scored with the ACTION tool. All performances were assessed live by 1 rater and by 3 blinded raters using video recordings. Generalizability-analysis was performed and mean scores and errors of both groups on the first performance were compared. A pass/fail score was established using the contrasting groups' method. RESULTS: Nine novice and 8 experienced participants completed the study. Generalizability coefficients where high for the rating scale (0.92) and the error checklist (0.87). In the first CTI, novices scored lower than the experienced group (38.1/68 vs. 47.1/68, P = 0.042), but no difference was observed on the error checklist. A pass/fail score of 44/68 was established. CONCLUSION: A solid validity argument for the ACTION tool's rating scale on a porcine rib model is presented, allowing formative and summative assessment of procedural skills during training before patient contact.