Self-Practice Program for Beating-Heart Minimally Invasive Coronary Anastomosis Using a Homemade Low-Fidelity Simulator: A Proof of Concept.

OBJECTIVE: We evaluated the effectiveness of a consistent and structured self-practice coronary anastomosis program using a homemade low-fidelity beating-heart simulator. METHODS: An intermediary trainee was subjected to an 8-week structured self-practice program. The program was divided into 2 parts of nonbeating and beating practices with a minimum number of timed anastomoses. Each part was followed by an assessment using an objective skills assessment tool score. The beating-heart simulator was built using motorized toy blocks connected wirelessly to a smartphone application. This was coded to enable rate selection. A junior consultant was compared to the subject at the end of the program. Both were tasked to perform 1 coronary anastomosis for both off-pump coronary artery bypass (OPCAB) and minimally invasive CAB (MICS) setup. The primary outcomes were anastomotic time and score compared with the junior consultant. Secondary outcomes were progression of anastomotic time and score throughout the program. RESULTS: Overall performance of the studied subject approached the performance of the junior consultant in terms of time (OPCAB, 489 vs 605 s; MICS, 712 vs 652 s) and scores (OPCAB, 21 vs 20.7; MICS, 19 vs 20.6). There were inverse correlations between anastomosis time and number of practices for both nonbeating and beating anastomoses. Overall improvement was observed in terms of assessment scoring by 26.6%. CONCLUSIONS: A structured self-practice program using an affordable and accessible simulator was able to help trainees overcome the MICS anastomosis learning curve quicker when introduced earlier. This may encourage earlier adoption of MICS among surgeons.

Simulation training of laparoscopic biliary-enteric anastomosis with a three-dimensional-printed model leads to better skill transfer: a randomized controlled trial.

AIM: A new simulation model and training curriculum for laparoscopic bilioenteric anastomosis has been developed. Currently, this concept lacks evidence for the transfer of skills from simulation to clinical settings. This study was conducted to determine whether training with a three-dimensional (3D) bilioenteric anastomosis model result in greater transfer of skills than traditional training methods involving video observation and a general suture model. METHODS: Fifteen general surgeons with no prior experience in laparoscopic biliary-enteric anastomosis were included in this study and randomised into three training groups: video observation only, practice using a general suture model, and practice using a 3D-printed biliary-enteric anastomosis model. Following five training sessions, each surgeon was asked to perform a laparoscopic biliary-enteric anastomosis procedure on an isolated swine organ model. The operative time and performance scores of the procedure were recorded and compared among the three training groups. RESULTS: The operation time in the 3D-printed model group was significantly shorter than the suture and video observation groups ( P =0.040). Furthermore, the performance score of the 3D-printed model group was significantly higher than those of the suture and video observation groups ( P =0.001). Finally, the goal score for laparoscopic biliary-enteric anastomosis in the isolated swine organ model was significantly higher in the 3D model group than in the suture and video observation groups ( P =0.004). CONCLUSIONS: The utilisation of a novel 3D-printed model for simulation training in laparoscopic biliary-enteric anastomosis facilitates improved skill acquisition and transferability to an animal setting compared with traditional training techniques.

A Simple 3D Printed Model for Intracranial Vascular Anastomosis Practice and the Rochester Bypass Training Score.

BACKGROUND AND OBJECTIVES: Surgical simulation models in cranial neurosurgery are needed to allow affordable, accessible, and validated practice in resident education. Current bypass anastomosis practice models revolve around basic tube tying or complex animal and 3-dimensional models. This study sought to design and validate a 3-dimensional printed model for intracranial anastomosis training. METHODS: A computer-aided design (CAD) generic skull was uploaded into Meshmixer (v.3.5), and a 55-mm opening was created on the right side, mimicking a standard orbitozygomatic craniotomy. The model was rotated 15° upward and 35° left, before a 10-mm square frame was added 80-mm deep to the right orbit. The CAD model was uploaded to GrabCAD and printed using a J750 PolyJet 3D printer before being paired with a vascular anastomosis kit. The model was validated with standardized assessments of residents and attendings by simulating an "M2 to P2" bypass. The Rochester Bypass Training Score (RBTS) was created to assess bypass patency, back wall suturing, and suture quality. Postsimulation survey data regarding the realism and usefulness of the simulation were collected. RESULTS: Five junior residents (Postgraduate Year 1-4), 3 senior residents (Postgraduate Year 5-7), and 2 attendings were participated. The mean operative time in minutes was as follows: junior residents 78, senior residents 33, and attendings 50. The RBTS means were as follows: junior residents 2.4, senior residents 4.0, and attendings 5.0. Participants agreed that the model was realistic, useful for improving operative technique, and would increase comfort in bypass procedures. There are a few different printing options, varying in model infill and printing material used. For this experiment, a mix of Vero plastics were used totaling $309.09 per model; however, using the more common printing material polylactic acid brings the cost to $17.27 for a comparable model. CONCLUSION: This study presents an affordable, realistic, and educational intracranial vascular anastomosis simulator and introduces the RBTS for assessment.

Low-fidelity simulation models in urology resident's microsurgery training.

PURPOSE: To evaluate the gain of microsurgical skills and competencies by urology residents, using low-fidelity experimental models. METHODS: The study involved the use of training boards, together with a low-fidelity microsurgery simulator, developed using a 3D printer. The model consists in two silicone tubes, coated with a resin, measuring 10 cm in length and with internal and external diameters of 0.5 and 1.5 mm. The support for the ducts is composed by a small box, developed with polylactic acid. The evaluation of the gain of skills and competencies in microsurgery occurred throughout a training course consisting of five training sessions. The first sessions (S1-S4) took place at weekly intervals and the last session (S5) was performed three months after S4. During sessions, were analyzed: the speed of performing microsurgical sutures in the pre and post-training and the performance of each resident through the Objective Structure Assessment of Technical Skill (OSATS) and Student Satisfaction Self-Confidence tools in Learning (SSSCL). RESULTS: There was a decrease in the time needed to perform the anastomosis (p=0.0019), as well as a progressive increase in the score in the OSATS over during sessions S1 to S4. At S5, there was a slightly decrease in performance (p<0.0001), however, remaining within the expected plateau for the gain of skills and competences. The SSSCL satisfaction scale showed an overall approval rating of 96.9%, with a Cronback alpha coefficient of 83%. CONCLUSIONS: The low-fidelity simulation was able to guarantee urology residents a solid gain in skills and competencies in microsurgery.

Rapid Prototyping Techniques for the Development of a Take-Home Surgical Anastomosis Simulation Model.

OBJECTIVE: The objective of this paper is to describe the techniques and process of developing and testing a take-home surgical anastomosis simulation model. DESIGN: Through an iterative process, a simulation model was customized and designed to target specific skill development and performance objectives that focused on anastomotic techniques in thoracic surgery and consist of 3D printed and silicone molded components. Various manufacturing techniques such as silicone dip spin coating and injection molding have been described in this paper and explored as part of the research and development process. The final prototype is a low-cost, take-home model with reusable and replaceable components. SETTING: The study took place at a single-center quaternary care university-affiliated hospital. PARTICIPANTS: The participants included in the model testing were 10 senior thoracic surgery trainees who completed an in-person training session held during an annual hands- on thoracic surgery simulation course. Feedback was then collected in the form of an evaluation of the model from participants. RESULTS: All 10 participants had an opportunity to test the model and complete at least 1 pulmonary artery and bronchial anastomosis. The overall experience was rated highly, with minor feedback provided regarding the set- up and fidelity of the materials used for the anastomoses. Overall, the trainees agreed that the model was suitable for teaching advanced anastomotic techniques and expressed an interest in being able to use this model to practice skill development. CONCLUSIONS: Developed simulation model can be easily reduced, with customized components that accurately simulate real-life vascular and bronchial components suitable for training of anastomoses technique amongst senior thoracic surgery trainees.

Hand Sewn Anastomosis Skill Acquisition and In Vivo Transfer Using 3D-Printed Small Bowel Simulator.

INTRODUCTION: General surgery residents need to master the hand-sewn bowel anastomosis (HSBA) technique. However, practice opportunities outside of the operating room are rare, and commercial simulators are often costly. The objective of this study is to assess the efficacy of a new, affordable silicone small bowel simulator, made with a three-dimensional (3D) printed mold, as a training tool to learn this technique. METHODS: This was a single-blinded pilot randomized controlled trial comparing two groups of eight junior surgical residents. All participants completed a pretest using an inexpensive, custom developed 3D-printed simulator. Next, participants randomized to the experimental group practiced the HSBA skill at home (eight sessions), while those randomized to the control group did not receive any hands-on practice opportunities. A posttest was done using the same simulator as for the pretest and practice sessions, and the retention-transfer test was performed on an anesthetized porcine model. Pretests, posttests and retention-transfer tests were filmed and graded by a blinded evaluator using assessments of technical skills, quality of final product, and tests of procedural knowledge. RESULTS: The experimental group significantly improved after practicing with the model (P = 0.01), while an equivalent improvement was not noted in the control group (P = 0.07). Moreover, the experimental group's performance remained stable between the posttest and the retention-transfer test (P = 0.95). CONCLUSIONS: Our 3D-printed simulator is an affordable and efficacious tool to teach residents the HSBA technique. It allows development of surgical skills that are transferable to an in vivo model.

The tale of the "unlucky" 13 errors in the "journey" towards an outstanding end -product in microvascular anastomosis training.

In microsurgery training, where the first steps occur in a safe simulated environment, we believe there is a lack of emphasis on well reflected commonly occurring mistakes; education manuals provide stepwise instructions on performing tasks but do not list common mistakes and ways to avoid them. It is well acknowledged that the majority of vascular anastomotic complications are attributed to technical errors, however the validated global rating scales that are used to assess microsurgical competency do not address errors and how to avoid making them - potentially preventing devastating failures. Our aim is to improve and streamline constructive feedback in microsurgical education by use of an error-based learning resource. By referring to our '13 errors' graphic, teachers and students can refer to specific errors they have made, and quickly revise these with error-specific feedback, with and without supervision. The '13 errors' table enables identification errors, explanation as to why these may have occurred, and constructive feedback in order to rectify the mistake.

Do Skills Naturally Transfer Between Multiport and Single-Port Robotic Platforms? A Comparative Study in a Simulated Environment.

Introduction and Objective: With introduction of the da Vinci single-port (SP) system, we evaluated which multiport (MP) robotic skills are naturally transferable to the SP platform. Methods: Three groups of urologists: Group 1 (5 inexperienced in MP and SP), Group 2 (5 experienced in MP without SP experience), and Group 3 (2 experienced in both MP and SP) were recruited to complete a validated urethrovesical anastomosis simulation using MP followed by SP robots. Performance was graded using both GEARS and RACE scales. Subjective cognitive load measurements (Surg-TLX and difficulty ratings [/20] of instrument collisions camera and EndoWrist movement) were collected. Results: GEARS and RACE scores for Groups 1 and 3 were maintained on switching from MP to SP (Group 3 scored significantly higher on both systems). Surg-TLX and difficulty scores were also maintained for both groups on switching from MP and SP except for a significant increase in SP camera movement (+7.2, p = 0.03) in Group 1 compared to Group 3 that maintained low scores on both. Group 2 demonstrated significant lower GEARS (-2.9, p = 0.047) and RACE (-5.1, p = 0.011) scores on SP vs MP. On subanalysis, GEARS subscores for force sensitivity and robotic control (-0.7, p = 0.04; -0.9, p = 0.02) and RACE subscores for needle entry, needle driving, and tissue approximation (-0.9, p = 0.01; -1.0, p = 0.02; -1.0, p < 0.01) significantly decreased. GEARS (depth perception, bimanual dexterity, and efficiency) and RACE subscores (needle positioning and suture placement) were maintained. All participants scored significantly lower in knot tying on the SP robot (-1.0, p = 0.03; -1.2, p = 0.02, respectively). Group 2 reported higher Surg-TLX (+13 pts, p = 0.015) and difficulty ratings on SP vs MP (+11.8, p < 0.01; +13.6, p < 0.01; +14 pts, p < 0.01). Conclusions: The partial skill transference across robots raises the question regarding SP-specific training for urologists proficient in MP. Novices maintained difficulty scores and cognitive load across platforms, suggesting that concurrent SP and MP training may be preferred.

Smartphone-Based DIY Home Microsurgical Training with 3D Printed Microvascular Clamps and Japanese Noodles.

We have recently incorporated simple modifications of the konjac flour noodle model to enable DIY home microsurgical training by (i) placing a smartphone on a mug to act as a microscope with at least ×3.5-5 magnification, and (ii) rather than cannulating with a 22G needle as described by others, we have found that cannulation with a 23G needle followed by a second pass with an 18G needle will create a lumen (approximately 0.83 mm) without an overly thick and unrealistic "vessel" wall. The current setup, however, did not allow realistic evaluation of anastomotic patency as the noodles became macerated after application of standard microvascular clamps, which also did not facilitate practice of back-wall anastomoses. In order to simulate the actual operative environment as much as possible, we introduced the use of 3D-printed microvascular clamps. These were modified from its previous iteration (suitable for use in silastic and chicken thigh vessels), and video recordings were submitted for internal validation by senior surgeons. A "wet" operative field where the konjac noodle lumen can be distended or collapsed, unlike other nonliving models, was noted by senior surgeons. With the 3D clamps, the noodle could now be flipped over for back-wall anastomosis and allowed patency testing upon completion as it did not become macerated, unlike that from clinical microvascular clamps. The perceived advantages of this model are numerous. Not only does it comply with the 3Rs of simulation-based training, but it can also reduce the associated costs of training by up to a hundred-fold or more when compared to a traditional rat course and potentially be extended to low-middle income countries without routine access to microsurgical training for capacity development. That it can be utilized remotely also bodes well with the current limitations on face-to-face training due to COVID restrictions and lockdowns.

Microtools: A systematic review of validated assessment tools in microsurgery.

BACKGROUND: Microsurgery is a technically demanding aspect of surgery that is integral to a variety of sub-specialties. Microsurgery is required in high-risk cases where time is limited and pressure is high, so there is increasing demand for skills acquisition beforehand. The aim of this review was to analyse the available literature on validated microsurgical assessment tools. METHODS: Covidence was used to screen papers for inclusion. Keywords included 'microsurgery', 'simulation', 'end-product assessment' and 'competence'. Inclusion criteria specified simulation models which demonstrate training and assessment of skill acquisition simultaneously. Tools which were used for training independently of technical assessment were excluded and so were tools which did not include a microvascular anastomosis. Each assessment tool was evaluated for validity, bias, complexity and fidelity and reliability using PRISMA and SWiM guidelines. RESULTS: Thirteen distinct tools were validated for use in microsurgical assessment. These can be divided into overall assessment and end-product assessment. Ten tools assessed the 'journey' of the operation, and three tools were specifically end-product assessments. All tools achieved construct validity. Criterion validity was only assessed for the UWOMSA1 and GRS.2 Interrater reliability was demonstrated for each tool except the ISSLA3 and SAMS.4 Four of the tools addressed demonstrate predictive validity.4-7 CONCLUSION: Thirteen assessment tools achieve variable validity for use in microsurgery. Interrater reliability is demonstrated for 11 of the 13 tools. The GRS and UWOMSA achieve intrarater reliability. The End Product Intimal Assessment tool and the Imperial College of Surgical Assessment device were valid tools for objective assessment of microsurgical skill.

Reduction of the Number of Live Animals Used for Microsurgical Skill Acquisition: An Experimental Randomized Noninferiority Trial.

BACKGROUND: Live animals have been used for decades as one of the many training models for developing surgical skills. Microsurgery in particular relies on training for skill acquisition and maintenance, using live animal models, especially rats (murine models). Efforts are underway to reduce the number of rats sacrificed to achieve this objective. METHODS: A group of students with minimal microsurgical experience, after having gone through a basic microsurgical course, were randomly split into three equal groups, all three groups following a 24-week standard training program based on low- and medium-fidelity training models with standardized murine training days. In addition to the standard training regimen, each participant performed supplementary training on live rats every 4, 6, or 8 weeks. According to the training program, the procedures have been performed on chicken legs, flower petals, and rats, each procedure being blindly assessed and evaluated using validated models and scales. The primary evaluated outcome was the Stanford Microsurgery and Resident Training (SMaRT) scale result of the final rat anastomosis performed by each group, for which the tested hypothesis was one of noninferiority. The secondary outcomes were represented by the final rat anastomosis time, final chicken leg anastomosis result and time, and the final petal score. RESULTS: After the 24th week, no differences were observed between the three groups regarding their microsurgical skills, as measured by the aforementioned surgical outcomes. All participants improved significantly during the study (mean [standard deviation] 19 ± 4 points on the SMaRT scale), with no significant differences between the groups, p < 0.001 for noninferiority. CONCLUSION: A training regimen based on low- and moderate-fidelity models, with the addition of training on a live rat every 8 weeks was noninferior to a training regimen that used a live rat every 6 weeks and also noninferior to a training regimen that used a live rat every 4 weeks.

Microsurgical skills training course and impact on trainee confidence and workload.

INTRODUCTION: Our objective was to measure the impact of a basic microsurgery training course on trainees' confidence and workload in performing microsurgery. METHODS: A prospective study of participants in an accredited 5-day microsurgery course over a 3-month period. The confidence and workload of the participants were assessed after the first and final day. The workload was assessed using the validated NASA Task Load Index composed of 6 subscales scored on a 20-point visual analog scale (VAS). Confidence was assessed over 5 dimensions on a 5-point VAS for anastomosis performance, vessels preparation, knot tying, training effectiveness, and future practice of microsurgery. RESULTS: A total of 31 participants completed the study with 55% reporting some previous microsurgery experience. All confidence dimensions improved significantly after completing the course, regardless of prior experience (p<0.01). Those with prior experience started and finished the course at higher confidence levels in anastomosis performance and vessel preparation than the non-experienced group (p<0.05). Overall workload showed a downward trend (improvement) at the end of the course, but no significant changes in the experienced and non-experienced groups (p>0.05). Most participants scored above the 50% "sustainability threshold" for mental demand, both before (71%) and after the course (73%), however, perceived physical demand significantly reduced, p = 0.01. CONCLUSION: The microsurgery course teaches fundamental skills and principles; therefore, it has merit in those who will utilize these skills in their future practice. Although there is increased confidence in skill acquisition, the impact on perceived workload during a short 5-day basic microsurgery course did not significantly change.

Development, manufacture and initial assessment of validity of a 3-dimensional-printed bowel anastomosis simulation training model.

BACKGROUND: It is critical that junior residents be given opportunities to practise bowel anastomosis before performing the procedure in patients. Three-dimensional (3D) printing is an affordable way to provide realistic, reusable intestinal simulators. The aim of this study was to test the face and content validity of a 3D-printed simulator for bowel anastomosis. METHODS: The bowel anastomosis simulator was designed and assembled with the use of desktop 3D printers and silicone solutions. The production cost ranges from $2.67 to $131, depending on which aspects of the model one prefers to include. We incorporated input from a general surgeon regarding design modifications to improve the realism of the model. Nine experts in general surgery (6 staff surgeons and 3 senior residents) were asked to perform an anastomosis with the model and then complete 2 surveys regarding face and content validity. Items were rated on a 5-point Likert scale ranging from 1 ("strongly disagree") to 5 ("strongly agree"). RESULTS: The overall average score for product quality was 3.58, indicating good face validity. The average score for realism (e.g., flexibility and texture of the model) was 3.77. The simulator was rated as being useful for training, with an overall average score of 3.98. In general, the participants agreed that the simulator would be a valuable addition to current simulation-based medical education (average score 4.11). They commented that the model would be improved by adding extra layers to simulate mucosa. CONCLUSION: Experts found the 3D-printed bowel anastomosis simulator to be an appropriate tool for the education of surgical residents, based on the model's texture, appearance and ability to undergo an anastomosis. This model provides an affordable way for surgical residents to learn bowel anastomosis. Future research will focus on proving educational efficacy, effectiveness and transfer that can be adapted for laparoscopic anastomosis training, hand-sewing and stapling procedures.

Learning microvascular anastomosis: Analysis of practice patterns.

BACKGROUND: Performing a successful microsurgical vascular anastomosis (MVA) is challenging and requires lots of practice. However, the most efficient practice protocol is yet to be found. We aimed to compare and analyze two major practice patterns for fine motor tasks as applied to learning MVA: distributed and mass practice protocols. Ten neurosurgeons with comparable experience in microsurgery (but no experience in vascular anastomosis) were randomized to practice MVA either using a distributed (1 session/day) or a mass practice (6 sessions/day) protocol. A total of 24 sessions of practice and 2 recall test sessions were given. Anastomosis score, time to complete a single stitch and the total time to complete an anastomosis were recorded. Mass practice protocol caused a clear fatigue effect observed toward the end of each mass practice trial block. Statistical comparison using one-way analysis of variance showed significantly higher anastomosis scores and shorter times to place a single stitch as well as to complete the anastomosis in distributed practice group for the last 3 acquisition practice trials, and the 2 recall tests (p < 0.05). The relative advantage of the distributed practice protocol could be attributed to forgetting/spacing effect. Although mass practice protocol resulted in worse performance, it still showed a gradual improvement trend in performance from beginning to the end. Therefore, certain adjustments to a mass practice protocol (such as increasing the number of practice blocks) could potentially lead to an eventual performance level comparable to a distributed protocol. This point is a subject of further investigation.

A novel "video-game" simulator for training fetoscopic laser coagulation of anastomoses in twin-to-twin transfusion syndrome.

 : We have developed a high-fidelity interactive "video-game" simulator in order to teach fetoscopic laser ablation of placental anastomoses for twin-twin transfusion syndrome This simulator may be used by teachers in order to provide metrics-based simulator education to multiple trainees, in both hands-on and distanced learning settings WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: The use of simulation improves training of the fetoscopic laser techniques utilized in the treatment of twin-twin transfusion syndrome A number of mannequins have been developed to aid this education WHAT DOES THIS STUDY ADD?: Two new simulators are described for twin-twin transfusion syndrome training-silicone and digital The digital simulator is a novel digital video game virtual format This new format has enhanced interactivity and has the potential to enable distance learning.

Implementation of the ACS/ APDS Resident Skills Curriculum reveals a need for rater training: An analysis using generalizability theory.

BACKGROUND: The American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) Resident Skills Curriculum includes validated task-specific checklists and global rating scales (GRS) for Objective Structured Assessment of Technical Skills (OSATS). However, it does not include instructions on use of these assessment tools. Since consistency of ratings is a key feature of assessment, we explored rater reliability for two skills. METHODS: Surgical faculty assessed hand-sewn bowel and vascular anastomoses in real-time using the OSATS GRS. OSATS were video-taped and independently evaluated by a research resident and surgical attending. Rating consistency was estimated using intraclass correlation coefficients (ICC) and generalizability analysis. RESULTS: Three-rater ICC coefficients across 24 videos ranged from 0.12 to 0.75. Generalizability reliability coefficients ranged from 0.55 to 0.8. Percent variance attributable to raters ranged from 2.7% to 32.1%. Pairwise agreement showed considerable inconsistency for both tasks. CONCLUSIONS: Variability of ratings for these two skills indicate the need for rater training to increase scoring agreement and decrease rater variability for technical skill assessments.

Coronary Anastomosis Simulation: Directed Interventions to Optimize Success.

BACKGROUND: The role of simulation-based training in coronary artery bypass grafting remains undefined. Barriers to simulator use include clinical and personal obligations, insufficient materials, and lack of mentorship. The purpose of this study was to implement a longitudinal, residency-wide coronary anastomosis simulation curriculum. METHODS: A prospective observational study was conducted from 2018 to 2019 at a single academic center. All residents of the Thoracic Surgery training program participated. Each participant was provided a low-fidelity coronary anastomosis simulator, high-quality instruments, and faculty mentor. Formal assessments were held quarterly, and residents were encouraged to practice alone and with their mentor. Baseline and follow-up metrics were compared with simple descriptive statistics. RESULTS: Seventeen residents and 12 faculty participated in the study. Residents demonstrated increased use of the simulator, with 21% participating in independent practice at baseline and 82% in the fourth quarter (P = .02). The median score on the Thoracic Surgery Directors Association Vessel Anastomosis Assessment improved from 42 out of 65 at baseline to 54 out of 65 in the fourth quarter (P = .04), and mean anastomosis time was reduced by 5 minutes 6 seconds (P = .02). Over 12 months, junior residents demonstrated a mean reduction in anastomosis time of 6 minutes 36 seconds, and senior residents decreased anastomosis time by 3 minutes 6 seconds (P = .02). CONCLUSIONS: Providing residents with a low-fidelity coronary anastomosis trainer with high-quality instruments and a faculty mentor improved rates of independent practice, Thoracic Surgery Directors Association assessment scores, and anastomosis time. Our next step is validating the coronary simulator curriculum by measuring improvement of resident performance in the operating room.