Discussion
hernia, tiredness
The present study assessed the potential transferability of surgical skills between the laparoscopic hernia modules on TS and on the VR trainer LapMentor™ III. Furthermore, some validity evidence for the laparoscopic hernia repair module on TS was collected. This study showed that TS provided additional benefit for students to improve their skills regarding anatomical knowledge about the procedure of laparoscopic inguinal hernia repair on the VR trainer for task 1. However, results showed no skill transfer from TS to the VR trainer for task 2, nor from the VR trainer to TS for either phase. There were no differences between groups in operating time needed to perform task 2 on the VR trainer proficiently. Content evidence could be collected for the module “Laparoscopic Inguinal Hernia Repair” on the serious game TS as the module was rated positively regarding usefulness by the participants. As a further aspect of construct validity, some evidence regarding relations to other variables was collected. In fact, as there were no score differences between students, residents, and senior physicians, the interpretation of this result shows that experience level had no influence on performance on the laparoscopic inguinal hernia repair module on TS.Students from the TS group started with the module on TS and performed afterward on the VR trainer, and students from the VR group performed on the VR trainer first and then on TS. Students from the TS group needed significantly less attempts to reach the predefined goal for task 1 (Anatomy Identification) on the VR trainer than students from VR group. One cannot strictly speak of skill transfer between TS and VR as the two modalities test different competencies. TS puts focus on theoretical knowledge of procedures, and the Lap Mentor tests practical skills. Nevertheless, prior performance of the module on TS led to an additional benefit as it helped students increase their performances on the VR simulator regarding anatomical skills. For task 2 on the VR trainer, no significant differences were observed between the groups and so, no skill transfer from TS to the VR trainer took place for task 2. There were also no differences in the time needed to complete task 2 proficiently between the TS and VR groups. Indeed, TS provides purely theoretical training which could help students perform better during task 1, as this task requires anatomical knowledge. Task 2 on the other hand requires practical skills, as students had to perform the incision and peritoneal dissection steps of the TAPP. TS therefore provided theoretical knowledge about anatomy which helped to improve student’s skills on the VR trainer. So, TS can be considered a useful tool to supplement and improve surgical laparoscopic training. This has also been shown in previous educational research in this field [For both phases on TS, students in both groups showed similar numbers of attempts needed to reach a score of 100%. Therefore, no significant skill transfer from the VR trainer to TS was observed. This is to be expected as the laparoscopic hernia module on the VR trainer teaches purely practical knowledge about the procedure, and the MC questions used in test mode on TS are based on theoretical aspects of the procedure. Furthermore, phase 1 on TS tests knowledge about patient preparation, which is not taught in the VR trainer module. Additionally, the mesh placement component of task 2 on the VR trainer was still under development while conducting this study, so students were trained only for the peritoneal preparation. Phase 2 on TS tested knowledge about the whole procedure, including mesh placement. Previous research has shown similar results; one study showed no additional benefit from the VR trainer in a multimodal training setting [This study collected some evidence for construct validity based on the assessment of content evidence and relations to other variables evidence. Content evidence was gathered for the module “Laparoscopic Inguinal Hernia Repair” on the serious game TS as it was positively rated by all three groups. The possibility of mobile use was considered by students to be an advantage of the program and it may allow take-home training as users can freely access the application anytime. Take-home training has been shown to be an effective training method even if unsupervised and can enable higher training frequency, as session duration can be chosen freely. Even self-rating by the user has been considered as reliable [An additional factor which could explain why surgeons and especially senior physicians did not score significantly higher than students was that most of them participated after long working hours in the operating room and showed more signs of tiredness and drops of concentration and motivation than students. Furthermore, students are more accustomed to the MC format of the TS test mode as they still use it on a regular basis and read through the training mode more slowly and carefully as the surgeons before taking test mode as they were usually less pressed for time. Finally, some senior physicians criticized the fact that the module is only available in English and showed some linguistic barriers.