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The San Antonio kidney transplant model: validity evidence and proficiency benchmarks

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Simulation has become an increasingly important tool in training complex and high-stake surgical techniques, including kidney transplantation. While several kidney transplant models have been described, there remains a need for a low-cost model with established proficiency targets.


We developed a low-cost kidney transplant model to simulate a renal vein to iliac vein end-to-side anastomosis, and a proficiency-based curriculum to prepare and evaluate trainees. This low-fidelity model utilizes a constrained space and adjustable depth to simulate the iliac fossa, with replaceable Penrose drains as vascular conduits. 18 novices (PGY1), 19 junior intermediates (PGY 2–3), 7 senior intermediates (PGY 4–5) and 6 experts (faculty transplant surgeons) each performed anastomoses on the model. Three metrics were used to rate each performance—completion time, a scoring rubric, and a composite technical score (CTS) formula. Messick’s validity framework was used to evaluate the model and scoring rubric to provide evidence for content alignment, response process validity, internal structure validity, and construct validity.


Resident participants reported the model was easy to set up (8.6/10) and added value to their surgical education (9.8/10). Transplant surgery faculty reported the model realistically simulated an end-to-side renal vein anastomosis (8.3/10), supporting content alignment. One-way ANOVAs for each of the three metrics was statistically significant across all skill levels (p < 0.001), supporting construct validity. Response process validity was achieved using blinded raters to review the video performances. Finally, inter-rater reliability was obtained with an intraclass correlation coefficient of 0.896 (< 0.001), supporting internal structure validity.


We utilized Messick’s validity framework to provide validity evidence for a low-cost, low-fidelity kidney transplant model and a scoring rubric. Furthermore, we provided proficiency benchmarks for trainees to train towards. This model is well suited for preparing surgical trainees to perform in vivo kidney transplants.

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Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.


  1. Marzouk K, Lawen J, Alwayn I, Kiberd BA. The impact of vascular anastomosis time on early kidney transplant outcomes. Transplant Res. 2013;2(1):1–5.

    Article  CAS  Google Scholar 

  2. Hellegering J, Visser J, Kloke H, et al. Deleterious influence of prolonged warm ischemia in living donor kidney transplantation. Transplant Proc. 2012;44:1222–6.

    Article  CAS  Google Scholar 

  3. Weissenbacher A, Oberhuber R, Cardini B, et al. The faster the better: anastomosis time influences patient survival after deceased donor kidney transplantation. Transpl Int. 2015;28(5):535–43.

    Article  Google Scholar 

  4. Heylen L, Naesens M, Jochmans I, et al. The effect of anastomosis time on outcome in recipients of kidneys donated after brain death: a cohort study. Am J Transplant. 2015;15(11):2900–7.

    Article  CAS  Google Scholar 

  5. Heylen L, Pirenne J, Naesens M, Sprangers B, Jochmans I. “Time is tissue”—a mini review on the importance of donor nephrectomy, donor hepatectomy, and implantation times in kidney and liver transplantation. Am J Transplant. 2021;21(8):2653–61.

    Article  Google Scholar 

  6. Tennankore KK, Kim SJ, Alwayn IP, Kiberd BA. Prolonged warm ischemia time is associated with graft failure and mortality after kidney transplantation. Kidney Int. 2016;89(3):648–58.

    Article  Google Scholar 

  7. Fryer JP, Magee JC. Optimizing the surgical residents’ educational experience on transplant surgery. J Surg Educ. 2009;66(4):196–200.

    Article  Google Scholar 

  8. (ACGME) ACfGME. Surgery: national resident report; reporting period: total experience of residents completing programs in 2020–2021. 2021.

  9. Sturm LP, Windsor JA, Cosman PH, Cregan P, Hewett PJ, Maddern GJ. A systematic review of skills transfer after surgical simulation training. Ann Surg. 2008;248(2):166–79.

    Article  Google Scholar 

  10. Zendejas B, Cook DA, Bingener J, et al. Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair: a randomized controlled trial. Ann Surg. 2011;254(3):502–11.

    Article  Google Scholar 

  11. Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Use of simulation-based education to reduce catheter-related bloodstream infections. Arch Intern Med. 2009;169(15):1420–3.

    Article  Google Scholar 

  12. Andreatta P, Saxton E, Thompson M, Annich G. Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates. Pediatr Crit Care Med. 2011;12(1):33–8.

    Article  Google Scholar 

  13. Claflin J, Waits SA. Three dimensionally printed interactive training model for kidney transplantation. J Surg Educ. 2020;77(5):1013–7.

    Article  Google Scholar 

  14. Melkonian V, Huy T, Varma CR, Nazzal M, Randall HB, Nguyen M-TJ. The creation of a novel low-cost bench-top kidney transplant surgery simulator and a survey on its fidelity and educational utility. Cureus. 2020;12(11).

  15. Kusaka M, Sugimoto M, Fukami N, et al. Initial experience with a tailor-made simulation and navigation program using a 3-D printer model of kidney transplantation surgery. Transplant Proc. 2015;47:596–9.

    Article  CAS  Google Scholar 

  16. Coloma L, Cabello R, González C, et al. Cadaveric models for renal transplant surgery education: a comprehensive review. Curr Urol Rep. 2020;21(2):1–7.

    Article  Google Scholar 

  17. Sáenz Medina J, Asuero de Lis M, Cuevas B, et al. Experimental models for research and training in renal transplant. Actas Urol Esp. 2008;32(1):83–90.

    Article  Google Scholar 

  18. Golriz M, Fonouni H, Nickkholgh A, Hafezi M, Garoussi C, Mehrabi A. Pig kidney transplantation: an up-to-date guideline. Eur Surg Res. 2012;49(3–4):121–9.

    Article  CAS  Google Scholar 

  19. Alessi S. Simulation design for training and assessment. 1st ed. Aircrew Train Assess. 2000:197–222.

  20. Alessi SM. Fidelity in the design of instructional simulations. J Comput Based Instr. 1988;15(2): 40–47

    Google Scholar 

  21. Messick S. Test validity: a matter of consequence. Soc Indic Res. 1998;45(1):35–44.

    Article  Google Scholar 

  22. Patnaik R, Khan MT, Yamaguchi S, Fritze DM. Building a low-cost and low-fidelity kidney transplant model: a technical report on the San Antonio kidney transplant model. Cureus. 2022.

    Article  Google Scholar 

  23. Patnaik R, Anton NE, Stefanidis D. A video anchored rating scale leads to high inter-rater reliability of inexperienced and expert raters in the absence of rater training. Am J Surg. 2020;219(2):221–6.

    Article  Google Scholar 

  24. Ritter EM, Scott DJ. Design of a proficiency-based skills training curriculum for the fundamentals of laparoscopic surgery. Surg Innov. 2007;14(2):107–12.

    Article  Google Scholar 

  25. Fraser S, Klassen D, Feldman L, Ghitulescu G, Stanbridge D, Fried G. Evaluating laparoscopic skills. Surg Endosc. 2003;17(6):964–7.

    Article  CAS  Google Scholar 

  26. Martin J, Regehr G, Reznick R, et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg. 1997;84(2):273–8.

    Article  CAS  Google Scholar 

  27. Reznick RK. Teaching and testing technical skills. Am J Surg. 1993;165(3):358–61.

    Article  CAS  Google Scholar 

  28. Stogowski P, Fliciński F, Białek J, Dąbrowski F, Piotrowski M, Mazurek T. Microsurgical Anastomosis Rating Scale (MARS10): a final product scoring system for initial microsurgical training. Plast Surg. 2020.

    Article  Google Scholar 

  29. Temple CL, Ross DC. A new, validated instrument to evaluate competency in microsurgery: the University of Western Ontario Microsurgical Skills Acquisition/Assessment instrument [outcomes article]. Plast Reconstr Surg. 2011;127(1):215–22.

    Article  CAS  Google Scholar 

  30. Anton NE, Sawyer JM, Korndorffer JR Jr, et al. Developing a robust suturing assessment: validity evidence for the intracorporeal suturing assessment tool. Surgery. 2018;163(3):560–4.

    Article  Google Scholar 

  31. Willis RE, Wiersch J, Adams AJ, Al Fayyadh MJ, Weber RA, Wang HT. Development and evaluation of a simulation model for microvascular anastomosis training. J Reconstr Microsurg. 2017;33(07):493–501.

    Article  Google Scholar 

  32. Datta V, Mandalia M, Mackay S, Chang A, Cheshire N, Darzi A. Relationship between skill and outcome in the laboratory-based model. Surgery. 2002;131(3):318–23.

    Article  Google Scholar 

  33. Malas T, Al-Atassi T, Brandys T, Naik V, Lapierre H, Lam B-K. Impact of visualization on simulation training for vascular anastomosis. J Thorac Cardiovasc Surg. 2018;155(4):1686.e5-1693.e5.

    Article  Google Scholar 

  34. Goldenberg M, Lee JY. Surgical education, simulation, and simulators—updating the concept of validity. Curr Urol Rep. 2018;19(7):1–5.

    Article  Google Scholar 

  35. Carmines EG, Zeller RA. Reliability and validity assessment. Thousand Oaks: Sage Publications; 1979.

    Book  Google Scholar 

  36. Cook DA, Beckman TJ. Current concepts in validity and reliability for psychometric instruments: theory and application. Am J Med. 2006;119(2):166.e7-166.e16.

    Article  Google Scholar 

  37. Cronbach LJ, Meehl PE. Construct validity in psychological tests. Psychol Bull. 1955;52(4):281.

    Article  CAS  Google Scholar 

  38. Willis RE, Richa J, Oppeltz R, et al. Comparing three pedagogical approaches to psychomotor skills acquisition. Am J Surg. 2012;203(1):8–13.

    Article  Google Scholar 

  39. Patnaik R, Stefanidis D. Outcome-based training and the role of simulation. In:Stefanidis D, Korndorffer JR, Sweet R, editors. Comprehensive healthcare simulation: surgery and surgical subspecialties. Springer; 2019. p. 69–78.

  40. Hughes MA, Garrett DE. Intercoder reliability estimation approaches in marketing: a generalizability theory framework for quantitative data. J Mark Res. 1990;27(2):185–95.

    Article  Google Scholar 

  41. Zevin B, Aggarwal R, Grantcharov TP. Surgical simulation in 2013: why is it still not the standard in surgical training? J Am Coll Surg. 2014;218(2):294–301.

    Article  Google Scholar 

  42. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002;236(4):458.

    Article  Google Scholar 

  43. Stefanidis D, Acker C, Heniford BT. Proficiency-based laparoscopic simulator training leads to improved operating room skill that is resistant to decay. Surg Innov. 2008;15(1):69–73.

    Article  Google Scholar 

  44. Schwab B, Hungness E, Barsness KA, McGaghie WC. The role of simulation in surgical education. J Laparoendosc Adv Surg Tech. 2017;27(5):450–4.

    Article  Google Scholar 

  45. Schwab B, Teitelbaum EN, Barsuk JH, Soper NJ, Hungness ES. Single-stage laparoscopic management of choledocholithiasis: an analysis after implementation of a mastery learning resident curriculum. Surgery. 2017.

    Article  Google Scholar 

  46. Korndorffer JR, Dunne JB, Sierra R, Stefanidis D, Touchard CL, Scott DJ. Simulator training for laparoscopic suturing using performance goals translates to the operating room. J Am Coll Surg. 2005;201(1):23–9.

    Article  Google Scholar 

  47. Lee CS, Khan MT, Patnaik R, Stull MC, Krell RW, Laverty RB. Model development of a novel robotic surgery training exercise with electrocautery. Cureus. 2022.

    Article  Google Scholar 

  48. Gilbody J, Prasthofer A, Ho K, Costa M. The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review. Ann R Coll Surg Engl. 2011;93(5):347–52.

    Article  CAS  Google Scholar 

  49. Hildebrandt S. Capital punishment and anatomy: history and ethics of an ongoing association. Clin Anat. 2008;21(1):5–14.

    Article  CAS  Google Scholar 

  50. Hasan T. Is dissection humane? J Med Ethics Hist Med. 2011;4.

  51. Gallagher AG, Ritter EM, Champion H, et al. Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Ann Surg. 2005;241(2):364.

    Article  Google Scholar 

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We would like to thank the Surgical Education Research Fellowship (SERF) for supporting this project and Dr. Daniel Scott for being my SERF mentor. We would like to thank the Ruth L Kirschstein NRSA Institutional Research Training Grant (T32CA148724 awarded to Dr. Mustafa Khan). We would like to acknowledge the transplant surgery faculty at UT Health San Antonio for their support in making this project a reality. Finally, we would like to thank Sushmitha Ramesh, MD, for her arterial anastomosis illustrations for the next iteration.

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Correspondence to Ronit Patnaik.

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Supplementary file1 Appendix: A) Video of performance (DOCX 15 KB)

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Patnaik, R., Khan, M.T.A., Willis, R.E. et al. The San Antonio kidney transplant model: validity evidence and proficiency benchmarks. Global Surg Educ 1, 39 (2022).

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