Endoscopic sinus surgery (ESS) requires specialized technical skills involving complex spatial, perceptual and psychomotor performances [1]. Expertise in this minimally invasive surgery necessitates bimanual dexterity within a small 3-dimensional space [1], avoidance of key vital structures (i.e. orbits, brain and carotid artery), thorough applied knowledge of the intricate anatomy, and proficiency in maneuvering with the indirect visual aid of a 2-dimensional monitor [2]. Given the proximity of the paranasal sinuses to critical structures such as the orbits and skull base, it can be understood why ESS is the most frequent reason for otolaryngic surgical litigation in the United States [3], and why the rate of complications during ESS is higher in trainees when compared to attending physicians [4].

Those teaching ESS have found alternative modalities to the traditional apprenticeship training model such as cadaveric dissections and 3D silicone models [1]. However, the latter have substantial limitations with regards to the complex needs of ESS training, such as the lack of tissue mobility of rigid silicone models [5] and the inadequate representation of tissue strength in cadavers [6]. Virtual reality (VR) simulators solve these deficiencies, as well as offer a standardized environment for a trainee to repeat a procedure multiple times until proficiency is achieved [7]. Additional benefits of VR simulation documented in other surgical domains include the ability to objectively assess surgical skills without the need of a tutor [8], reduction of patient risk, and the standardization of residency training regardless of a particular institution¿s practice profile or access to a cadaver laboratory [9]. VR simulation has been demonstrated to be beneficial in many surgical disciplines [2],[10]-[12], including otolaryngology [13],[14].

In the field of ESS, the first VR sinus surgery simulator, the ES3, was developed between 1995 and 1998 [15]. To date, rigorous published validation studies supporting use of ESS simulators in resident training derive uniquely from the ES3 [1],[3]. However, it is no longer commercially available and there are only a few devices in existence [15]. Other simulators, such as the Dextroscope endoscopic sinus simulator [16] and the VOXEL-MAN [17], have yet to demonstrate evidence to support their use for training. Thus, there is an obvious need for a VR simulator with evidence of acceptability and validity to fill the void in ESS training.

The McGill Simulator for Endoscopic Sinus Surgery (MSESS) is a VR simulator that aims to address this issue. The objectives of this study were to assess the feasibility, usability, perceived value, and initial evidence supporting the validity of the simulator.

Attributes available on the MSESS include increasing task difficulties, blurring of the camera field with tissue contact, an endonasal wash function, a microdebrider, and mobility of the nasal tissues. Compared to previous sinus simulators, we believe that a combination of these attributes allow the user to experience a more realistic, higher fidelity physical and visual environment. Furthermore, measurement of performance metrics from both hands independently, including measures of bimanual dexterity, as well as the ability to identify contact with danger zones allow a more elaborate performance assessment.

Given the lack of available ESS simulators with enough data supporting validity as a training tool, the current initial validation study of the MSESS is the first step towards filling this void. In fact, we demonstrated that participants from all levels of training found the simulator to be realistic in terms of visual appearance and content. They also responded that the simulator allowed them to practice the technical skills required for ESS. Furthermore, through analysis of the performance metrics, not unexpectedly, novices fared significantly worse than senior surgeons in measures of operative efficiency, which echoes previous reports in studies of surgical simulators [22],[23]. Similarly, within the field of ESS simulation, Edmond showed that novice surgeons without ESS experience performed worse on simulation training [24].

The inability of the performance metrics to differentiate medical students from junior residents is likely related to the fact that residents do not routinely perform ESS until their senior years. Moreover, the lack of difference between senior residents and attending faculty on the performance metrics may be related to the small number of attending faculty (n = 3), as some metrics, namely those related to efficiency, demonstrated a tendency towards improved performance by the attending faculty compared to senior residents. Nevertheless, these findings may indicate that the learning curve for performing simple ESS tasks is relatively steep and that the MSESS may be most valuable for junior residents prior to direct patient contact.

Research has demonstrated that recognition of anatomy with an endoscopic view is one of the more challenging parts of ESS [25]. In fact, authors have reported that a strong familiarity with intranasal 3D relationships and spatial boundaries are more vital for operative success than the technical skills of sinus surgery [1],[24] Thus, one of the main focuses during the development of the MSESS was to develop a simulated nasal model that was as realistic as possible, reflected by the participants¿ high assessment scores on the questionnaire.

Furthermore, the MSESS was tailored to help train users on complex technical skills, such as bimanual dexterity and hand-eye coordination, which are prerequisite skills for ESS [2]. The fact that there was decreasing fluctuation in the distance between the two tool tips with increasing degree of experience suggests that there is a notable learning curve for bimanual dexterity, which has previously been shown to vary with level of expertise [26]. In fact, Narazaki et al. demonstrated that experts outperformed novices in terms of bimanual dexterity skills significantly on a laparoscopic surgery simulator and advocated for its¿ testing as a means to objectively assess the proficiency of a surgeon [27].

In order to demonstrate validity as an educational tool, many studies on simulators have aimed to show a difference between users of different degrees of experience [28]. The latter shows that the simulator actually measures the technical skills that are intended to be measured [2]. Previous simulators have demonstrated this metric in support of ¿construct validity¿, including simulators for surgical skills in laparoscopic surgery [29], bone sawing skills [30], neurosurgery [20] and ESS [9],[31], as well as diagnostic skills such as coronary angiography [32], obstetrical ultrasonography [33] and colonoscopy [34].

The performance metrics recorded by the MSESS ¿ divided into measures of quality, efficiency and safety ¿ allowed us to test this form of validity. With regards to quality, users across all groups removed similar percentages of the anterior and posterior ethmoids. This is not surprising as removing tissue is not a difficult task in and of itself, but doing so efficiently and safely differentiates a novice from an experienced surgeon. Furthermore, a notable tendency was observed towards increasing extent of the sphenoidotomy with advancing level of expertise, most likely explained by the fact that more experienced surgeons had a heightened awareness of what is safe to remove in the sphenoid sinus and what are danger zones for injury to critical structures such as the optic nerve and carotid artery. In contrast, junior surgeons are more apprehensive in this region and thus elect to be more conservative.

Moreover, despite this suspected apprehensiveness demonstrated by juniors, users in the medical students and junior residents groups made contact with ¿no-go¿ zones such as the lamina papyracea and optico-carotid recess more commonly. Edmond demonstrated that the most discriminating performance factor during the novice mode on a previous ESS simulator was the ability to avoid hazards [24], which is a skill that senior surgeons learn with experience and thorough anatomy knowledge. Through recognition of these errors, novice surgeons may learn to avoid trauma to collateral tissue. In fact, decreased tissue injury during technical skills assessments after training on VR simulators has previously been demonstrated [7].

Endoscopic sinus surgeons are cognizant of the fact that the lamina papyracea and skull base are sensitive areas due to their fragility as well as the structures that they protect, thus it is important to be able to measure the amount of force that is applied upon them by our tools. Our study demonstrated that there was a significant difference in the maximal force applied between novice surgeons and more senior surgeons. The importance of force measurements also highlights a pitfall of training on cadaveric tissues, which do not adequately estimate the force necessary to perform endoscopic sinus procedures [6] and thus, do not show trainees the acceptable force allowed during ESS. Although novice surgeons applied more force in our study, the next step would be to determine the critical amount of force that would be needed to cause damage and assess whether the increased force applied by junior surgeons is truly clinically dangerous.

The benefits of simulation training are highlighted by the difference in efficiency between junior and senior surgeons. Simulation training allows residents to be more efficient, thus saving time in the operating room, where time is limited and expensive [35]. The premise of training on the MSESS is that if a junior can practice ESS on the simulator, he begins hands-on training at an earlier stage, prior to direct patient contact [24] and thus is better prepared when in the operating room. Furthermore, with decreased resident working hours [36], it is even more essential to have alternative methods for junior surgeons to practice their technical skills.

The MSESS demonstrated initial evidence supporting its use for residency education with regards to being a realistic and useful training tool. The performance metrics relating to quality, efficiency and safety also demonstrated a dichotomy between novice and senior surgeons. The next step in this validation process will be to compare the MSESS to other teaching modalities, including cadaveric dissection which is currently the gold standard of ESS training; to assess the predictive validity of the MSESS; and to demonstrate translation of technical skills in the setting of live patient interactions.

RV: Study design, creation and development of the MSESS, data collection, data analysis, manuscript preparation. SF: Study design, creation and development of the MSESS, manuscript preparation. LHPN: Study design, data analysis and interpretation, manuscript preparation. RDM: Study design, creation and development of the performance metrics, study coordination. AZ: Creation and development of the MSESS, data analysis, manuscript preparation. ES: Data analysis, creation of software to analyze the raw data into meaningful data, analysis of performance metrics. WRJF: Data analysis, creation of software to analyze the raw data into meaningful data, analysis of performance metrics. NRC: Creation and development of the MSESS, creation of performance metrics. MAT: Study design, creation and development of the MSESS, data collection, data analysis and interpretation, manuscript preparation. All authors read and approved the final manuscript.