Validation of an anorectal malformation trainer - Can a high-fidelity model simulate real life?

The exposure problem

American pediatric surgery fellows perform an average of 15 posterior sagittal anorectoplasties during training 0:09. Once in practice, recertifying surgeons average 2 PSARPs per year, and nearly 30% perform none [c2, c3]. This matters because technical precision in PSARP directly impacts continence outcomes 0:23.

The simulator

A multi-institutional team from Boston Children's, Cincinnati Children's, and Nationwide Children's Hospitals developed a 3D-printed PSARP simulator for recto-vestibular and cloacal malformations 0:30. The model replicates the fistula, sphincter complex, vagina, and rectum with realistic haptics 0:42.

Validation study

Twenty-seven surgeons — 11 experts and 16 novices — performed a complete PSARP on the model at an international meeting 0:51. Three blinded colorectal surgeons independently scored each session 0:51.

The simulator demonstrated face, content, and construct validity 1:03. Participants rated the anatomy and haptics as highly realistic 1:07. Experienced colorectal surgeons confirmed its value as a teaching tool 1:11. Most importantly, the simulator reliably differentiated experts from novices on every step of the procedure 1:11.

Current use and development

Boston Children's Hospital has integrated the simulator into their fellowship curriculum 1:27. A male rectal-urethral fistula version is in development 1:31.

What this means for trainees

This is a validated tool for deliberate practice in a procedure you will not see often enough to maintain proficiency through clinical volume alone. The simulator's ability to discriminate expert from novice performance means it can provide meaningful feedback on technical execution. For a procedure where millimeter-level precision affects long-term continence, structured simulation training may be the only way to build and maintain the required skill.

The Volume Problem

American pediatric surgery fellows perform an average of 15 posterior sagittal anorectoplasties during training 0:09. Once in practice, recertifying surgeons average 2 PSARPs per year, and nearly 30% perform none 0:16 0:16. For a procedure where technical precision directly impacts continence outcomes, this creates a skills-maintenance challenge for both trainees and practicing surgeons 0:23.

The Simulator

A multi-institutional team from Boston Children's, Cincinnati Children's, and Nationwide Children's Hospitals developed and validated a 3D-printed PSARP simulator, publishing their results in the Journal of Pediatric Surgery 0:30 0:30. The model replicates the complete anatomy of a rectovesibular fistula malformation — including the fistula, sphincter complex, vagina, and rectum — with realistic tissue handling throughout 0:42.

Validation Study

Twenty-seven surgeons (11 experts, 16 novices) performed a complete PSARP on the simulator at an international meeting 0:51. Three blinded colorectal surgeons independently scored each session 0:51. The model demonstrated face, content, and construct validity 1:03. Participants rated the anatomy and haptics as highly realistic 1:07. Experienced colorectal surgeons confirmed the simulator's teaching value 1:11. Most critically, the simulator reliably differentiated expert from novice performance on every procedural step 1:11.

Implementation

Boston Children's Hospital has integrated the simulator into their fellowship curriculum 1:27. A male version modeling a rectourethral fistula is in development 1:31.

What This Means

For a low-volume, high-stakes procedure, validated simulation offers a path to deliberate practice outside the operating room. The model's ability to discriminate skill levels suggests it could support both initial training and skills maintenance for practicing surgeons who rarely perform the operation. Whether simulation translates to improved patient outcomes remains to be demonstrated, but the training gap it addresses is real.