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Background: Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical paradigm, where peritoneal access is achieved through one of the natural orifices of the body. It is being reported as a safe and feasible surgical technique with significantly reduced external scarring. Virtual Translumenal Endoscopic Surgical Trainer (VTEST™) is the first virtual reality simulator for the NOTES. The VTEST™ simulator was developed to train surgeons in the hybrid transvaginal NOTES cholecystectomy procedure. The initial version of the VTEST™ simulator underwent face validation at the 2013 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) summit. Several areas of improvement were identified as a result, and the corresponding modifications were implemented in the simulator. This manuscript outlines the results of the subsequent evaluation study, performed in order to assess the face and content validity of the latest VTEST™ simulator., Methods: Twelve subjects participated in an institutional review board-approved study that took place at the 2014 NOSCAR summit. Six of the 12 subjects, who are experts with NOTES experience, were used for face and content validation. The subjects performed the hybrid transvaginal NOTES cholecystectomy procedure on VTEST™ that included identifying the Calot's triangle, clipping and cutting the cystic duct/artery, and detaching the gallbladder. The subjects then answered five-point Likert scale feedback questionnaires for face and content validity., Results: Overall, subjects rated 12/15 questions as 3.0 or greater (60 %), for face validity questions regarding the realism of the anatomical features, interface, and the tasks. Subjects also highly rated the usefulness of the simulator in learning the fundamental NOTES technical skills (3.50 ± 0.84). Content validity results indicate a high level of usefulness of the VTEST™ for training prior to operating room experience (4.17 ± 0.75)., Competing Interests: Dr. Kurt Roberts: NovaTract Surgical (ownership, intellectual property). Drs. Denis Dorozhkin, Arun Nemani, Woojin Ahn, Tansel Halic, Saurabh Dargar, Jinling Wang, Caroline Cao, Ganesh Sankaranarayanan, and Suvranu De have no conflicts of interest or financial ties to disclose.

Background: There is no evidence demonstrating the feasibility of colorectal natural orifice transluminal endoscopic surgery (NOTES) resection with currently available endoscopic instrumentation., Objective: This study aimed to evaluate the responsiveness of surgical endoscopists to simulated transanal NOTES sigmoidectomy training., Design: Participants were trained in simulated NOTES sigmoidectomy by using disposable abdominal trays with tattooed sigmoid cancer in a hybrid simulator., Setting: Endoscopy simulation laboratory in a university hospital., Interventions: NOTES sigmoidectomy included 8 steps performed transanally with 2 colonoscopes, endoscopic scissors, and clip applier: (1) colonoscopic viscerotomy with a balloon; (2) retroperitoneal dissection; (3) left ureter identification, inferior mesenteric vessels division; (4) colonoscopy; (5) splenic flexure mobilization; (6) left side of the colon/rectal mobilization; (7) transanal specimen transection; (8) extracorporeal colorectal anastomosis., Main Outcome Measurements: Responsiveness was defined as a change in performance over time and assessed comparing baseline testing with unmentored final testing. Content-valid measures included the length of the specimen, the distance of the anastomosis from the anal verge, and the proximal and distal resection margins and operating time (minutes)., Results: Four participants performed 21 resections. Tumor distance from the anal verge was 29.2 cm (range 26-2.5 cm). Operating time overall (127.5 vs 74 minutes, P = .068), viscerotomy (17.5 vs 9 minutes, P = .197), colonoscopy (4.5 vs 3.5 minutes, P = .655), flexure mobilization (19.5 vs 10 minutes, P = .144), colon mobilization (20 vs 14.5 minutes, P = .461), specimen extraction (9.5 vs 8.5 minutes, P = .465), and anastomosis (14 vs 11 minutes, P = .715) times improved., Limitations: Ceiling effects because of fixed anatomy., Conclusions: Simulated NOTES sigmoidectomy training affected responsiveness of surgical endoscopists with a 42% reduction in operating time., (Copyright © 2014 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Importance: Simulation-based standardized training is important for the clinical training of physicians practicing robotic surgery., Objective: To train robotic surgery-naïve student volunteers using the da Vinci Skills Simulator (dVSS) for transoral robotic surgery (TORS)., Design: Prospective inception cohort in 2012., Setting: Academic referral center., Participants: Sixteen medical student volunteers lacking experience in robotic surgery., Interventions: Participants trained with the dVSS in 12 exercises until competent, defined as an overall score of at least 91%. After a 1-, 3-, 5-, or 7-week postinitial training hiatus (n = 4 per group), participants reachieved competence on follow-up., Main Outcomes and Measures: Total training time (TTT) to achieve competency, total follow-up time (TFT) to reachieve competency, and performance metrics., Results: All participants became competent. The TTT distribution was normal based on the Anderson-Darling normality test (P > .50), but our sample was divided into a short training time (STT) group (n = 10 [63%]) and long training time (LTT) group (n = 6 [37%]). The mean (SD) TTT was 2.4 (0.6) hours for the STT group and 4.7 (0.5) hours for the LTT group. All participants reachieved competence with a mean TFT that was significantly shorter than TTT. There was no significant difference between STT and LTT in mean TFT at 1 and 3 weeks (P = .79), but the LTT group had a longer TFT at 5 and 7 weeks (P = .04) but with no difference in final follow-up scores (P = .12)., Conclusions and Relevance: Physicians in training can acquire robotic surgery competency. Participants who acquire skills faster regain robotic skills faster after a training hiatus, but, on retraining, all participants can regain equivalent competence. This information provides a benchmark for a simulator training program.