• Peyman Sardari Nia, Jean H T Daemen, and Jos G Maessen.
• Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands; Faculty of Health, Medicine and Life Sciences (FHML), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands. Electronic address: peyman.sardarinia@mumc.nl.
• J. Thorac. Cardiovasc. Surg. 2019 Apr 1; 157 (4): 1567-1574.

ObjectivesThe aim of this study was to develop a high-fidelity minimally invasive mitral valve surgery (MIMVS) simulator.MethodsThe process of industrial serial design was applied based on pre-set requirements, acquired by interviewing experienced mitral surgeons. A thoracic torso with endoscopic and robotic access and disposable silicone mitral valve apparatus with a feedback system was developed. The feedback system was based on 4 cameras around the silicone valve and an edge detection algorithm to calculate suture depth and width. Validity of simulator measurements was assessed by comparing simulator-generated values with measurements done manually on 3-dimensional reconstructed micro-computed tomography scan of the same sutures. Independent surgeons tested the simulator between 2014 and 2018, whereupon an evaluation was done through a questionnaire.ResultsThe feedback system was able to provide width and depth measurements, which were subsequently scored by comparison to pre-set target values. Depth did not significantly differ between simulator and micro-computed tomography scan measurements (P = .139). Width differed significantly (P = .001), whereupon a significant regression equation was found (P < .0001) to calibrate the simulator. After calibration, no significant difference was found (P = .865). In total, 99 surgeons tested the simulator and more than agreed with the statements that the simulator is a good method for training MIMVS, and that the mitral valve and suture placement looked and felt realistic.ConclusionsWe successfully developed a high-fidelity MIMVS simulator for endoscopic and robotic approaches. The simulator provides a platform to train skills in an objective and reproducible manner. Future studies are needed to provide evidence for its application in training surgeons.Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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