Training Tools and Methods for Laparoscopic Surgery

Special Article – Laparoscopic Surgery

Austin J Surg. 2018; 5(8): 1152.

Training Tools and Methods for Laparoscopic Surgery

Ueda Y¹, Shiraishi N¹*, Hirashita T¹ and Inomata M²

¹Department of Comprehensive Surgery for Community Medicine, Oita University Faculty of Medicine, Japan

²Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Japan

*Corresponding author: Shiraishi N, Department of Comprehensive Surgery for Community Medicine, Oita University Faculty of Medicine, Oita, Japan

Received: October 02, 2018; Accepted: October 29, 2018; Published: November 01, 2018


Background: Laparoscopic surgery has been rapidly advancing and is being disseminated worldwide. Therefore, laparoscopic surgeons have to further their efforts to acquire basic and advanced technical skills in laparoscopic surgery through training. Presently, numerous training tools and methods of training in laparoscopic surgery, such as box trainers, virtual reality simulators, animal models and human cadavers, have been developed.

Methods: We reviewed the reports published in the English-language literature to evaluate the training tools and training methods available for laparoscopic surgery.

Results: Numerous studies have evaluated each of the various training tools and methods and have reported their positive impact on the teaching of laparoscopic technical skills. Among them, the most popular studies compared the educational effectiveness of training using the box trainer versus the VR simulator for laparoscopic surgical trainees. However, it might be difficult to determine which of these two training tools is superior for trainees. Recently, the usefulness of educational programs that combine various training methods to acquire basic laparoscopic surgical skills has been reported, and these combination methods may become a new trend.

Conclusion: In the future, the impacts of multimodal educational programs or those combining training methods should be evaluated by assessing patient outcomes after laparoscopic surgery performed by the laparoscopic surgical trainees.

Keywords: Laparoscopic surgery; Training tools; Training methods


Since the late 1990s, minimally invasive laparoscopic surgery has become the standard treatment for not only benign but also for malignant disease because of the quicker postoperative recovery compared with that of conventional open surgery. However, laparoscopic procedures sometimes require more advanced surgical techniques than do open abdominal procedures. As well, much time and work must be invested to acquire laparoscopic surgical skills that have a prolonged learning curve in the clinical setting. Furthermore, patient safety concerns have made it more difficult for trainees to learn laparoscopic technical skills on real patients. The 100-yearold Halstedian surgical mantra of “see one, do one, teach one” [1] is now unacceptable for the practice of laparoscopic skills by trainees in the operating room because it exposes patients to potential risks. Additionally, previous studies reported that many surgeons with little or no advanced laparoscopic skills might have higher rates of postoperative complications and procedure failure [2-4]. Therefore, an appropriate and safe training method is essential for trainees to learn basic to advanced laparoscopic procedures with shortened learning curves and to reduce postoperative complications. Therefore, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has recommended incorporating educational programs for laparoscopic surgery into the training of general surgical residents [5].

In this article, we review the reports published in the Englishlanguage literature that have evaluated individual training tools and educational programs for the acquisition of laparoscopic surgical skills.

Development of training tools for laparoscopic surgery

In the past, various training tools for laparoscopic surgery were developed outside of the operating room [6]. Simulator training using classical box trainers was first proven to be a useful teaching method in the field of anesthesiology [7,8]. These trainers are being used to acquire basic surgical skills in laparoscopic surgery because of their low cost, portability, and time efficiency. They provide tactile feedback and practice through repetition for multiple trainees [9]. However, trainees require more realistic simulations to learn complex skills as they progress to advanced laparoscopic procedures. Therefore, other training tools, such as virtual reality (VR) simulators, animal and human cadavers, and live animal models, have been used to improve the trainees’ skills. Recently, a number of studies have shown that well-designed training methods for trainees have a significant impact on the clinical setting in laparoscopic surgery [10].

Evaluation of individual training tools for laparoscopic surgery

Box Trainer: The box trainer has been used to learn basic laparoscopic skills for trainees around the world for well over a decade, and this training method has been applied in many firstyear surgical residency programs. The generically manufactured box trainer contains an opaque box that approximates the size of the human abdominal cavity, video monitor, camera, and laparoscope. Various targets are manipulated inside the box based on visual information. One of the important attributes of the box trainer is the sensory feedback, also called haptics, that it provides [9]. Haptics is physical sensory feedback conferred via the box trainer that is on par with that of real laparoscopic operations. An additional attribute of this trainer is its lower acquisition cost. These reasons make the box trainer the most widely expanding training method in the world. A recent systematic literature review on box trainers showed evidence that surgical training using a box trainer appears to improve the basic laparoscopic skills of trainees without previous laparoscopic experience compared with limited prior laparoscopic experience [11]. Therefore, training box of the fundamentals of laparoscopic surgery (FLS) that was developed by the SAGES is already accessible to surgical trainees to hone their laparoscopic skills [12]. However, the problems about FLS skills test are still remain. One of the problems is high cost [13]. And the other is the most appropriate time when do they should perform for trainees [14].

VR simulators: Training using VR simulators is currently the most evolutionally advanced simulation training method in the area of laparoscopic surgery. VR simulators can assess various laparoscopic skills, such as camera navigation, object manipulation, insular dissection, and extracorporeal suturing [15]. VR simulators make many kinds of surgical training more believable for trainees than those using traditional box trainers do because the situation is made to be as real as possible [16]. Using the latest computer software, these training systems can be set up to record and save data for teaching the advanced skills required for laparoscopic surgery. These data make it possible for the educators to evaluate the trainees’ performance of various laparoscopic tasks, to track the progress of individual trainees, and to compare the trainees’ results [17,18]. In addition, several VR simulators, such as hybrid simulators, can provide the tactile feedback that is lacking in most simulators. VR training with haptic feedback is at least as effective as box trainers are and resulted in shorter operating times, less distance travelled, and fewer unnecessary movements when compared to VR training without haptic feedback [19]. Although these VR simulators are largely used for learning and practicing skills, they are rarely used as an assessment tool [20]. These training systems are relatively more expensive than box trainers, but their incorporation into laparoscopic surgical training programs may be increasingly encouraged if the price of these systems can be lowered. In recent years, low-cost laparoscopic simulators is regarded as being the most equitable solution to allow basic skills practice for junior surgical trainees [21].

Animal model training: Animal models, such as the anesthetized porcine model, are used to learn surgical skills for laparoscopic surgery because they have been shown to be a substitute for human tissues. Especially, the abdomen of the porcine model is sufficiently similar to the adult human in size and in intraabdominal anatomy [22]. Animal models are the only models in a non-patient environment for laparoscopic training that can simulate intraoperative bleeding and complications that can occur in a live patient. Therefore, animal models are frequently used for training together as a team before an operation [23]. It was recently reported that porcine-based training is useful in pediatric minimally invasive surgery [24], and a new animal model of calculous cholecystitis was created [25]. However, these training methods are prohibitive because of the substantial costs involved in providing appropriate staff and facilities. In addition, there are still some problems related to moral, ethical, and infection concerns with this particular training method [26].

Cadaver training: Cadaver training models that include animal and human cadavers have been useful in learning surgical anatomy and in performing tissue dissection, surgical handling, and complex laparoscopic procedures. Many reports have stressed the importance of cadaver training in the acquisition of laparoscopic skills. Fresh frozen cadavers have been recommended for wider use in a realistic laparoscopic operative training experience because of the perfect anatomy, normal colors, and consistency of the tissues [27,28]. Some authors have also recommended a training method using human cadavers embalmed by the Thiel method because this method provides better tissue flexibility and colors [29,30]. However, this embalming process is very complex and expensive, and it results in shorter conservation times [31]. The disadvantages of these cadaver-training methods are the limited availability of specialized environments and the high cost of their maintenance [32]. The limited supply of cadavers also constricts the wide use of cadaver training methods around the world.

Evaluations to establish well-designed educational programs for laparoscopic surgery

Application of training methods to educational programs: Box trainer and/or VR simulator (Table 1): Many studies have compared the effectiveness of training methods for laparoscopic surgery using the box trainer and the VR simulator. Most of these studies were performed as prospective randomized controlled trials, and the participants in most were novices, such as medical students and surgical interns. The assessments of each training method were based on the performance of several laparoscopic tasks or exercises on the box trainer, VR simulator, or in animal models. These tasks or exercises were scored for several parameters, such as time, movements, accuracy, and others. In these studies, the trained groups performed significantly better on most of the parameters than the control (no training) groups in learning laparoscopic skills. Most of these previous studies reported that VR simulator training was a more efficient method for trainees than the box trainer [33-36]. Youngblood et al. [34] reported that the mean Global ratings scores (1-5) of the VR training group was significantly better than both Box training and no training group (3.31 vs. 2.27 and 2.31, p=0.005). However, some studies reported that both the box trainers and VR simulators were equally effective means of teaching laparoscopic skills [8,37]. Reported that VR training was the more efficient training modality, whereas box training was the more cost-effective option [36]. Thus, from these randomized controlled trials, it remains controversial whether VR training or box training is more useful for laparoscopic surgical training.