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Objective To assess the participation of European urology residents in urological laparoscopy, their training patterns and facilities available in European Urology Departments. Materials and Methods A survey, consisting of 23 questions concerning laparoscopic training, was published online as well as distributed on paper, during the Annual European Association of Urology Congress in 2012. Exposure to laparoscopic procedures, acquired laparoscopic experience, training patterns, training facilities and motivation were evaluated. Data was analysed with descriptive statistics. Results In all, 219 European urology residents answered the survey. Conventional laparoscopy was available in 74% of the respondents' departments, while robotic surgery was available in 17% of the departments. Of the respondents, 27% were first surgeons and 43% were assistants in conventional laparoscopic procedures. Only 23% of the residents rated their laparoscopic experience as at least ‘satisfactory’; 32% of the residents did not attend any course or fellowship on laparoscopy. Dry laboratory was the most frequent setting for training (33%), although 42% of the respondents did not have access to any type of laparoscopic laboratory. The motivation to perform laparoscopy was rated as ‘high’ or ‘very high’ by 77% of the respondents, and 81% considered a post-residency fellowship in laparoscopy. Conclusions Urological laparoscopy is available in most European training institutions, with residents playing an active role in the procedure. However, most of them consider their laparoscopic experience to be poor. Moreover, the availability of training facilities and participation in laparoscopy courses and fellowships are low and should be encouraged.

Within the project "Applied research trajectory hands in laparoscopic and endoscopic operations", ITMS Project code 26240220056, funded by the European Regional Development Fund and the state budget of the Slovak Republic, we created a technical background and algorithms for monitoring and evaluating the hand movements of the surgeon during laparoscopic and endoscopic operations. This is a unique idea and unique project transformed into clinical practice, which is promising to assist in laparoscopic training and inclusion of surgeon / endoscopist to "skilfulness" group on the evaluation of the effectiveness of movements of his hands (Tab. 2, Ref. 11).

BACKGROUND: Virtual reality (VR) simulators are widely used to familiarize surgical novices with laparoscopy, but VR training methods differ in efficacy. In the present trial, self-controlled basic VR training (SC-training) was tested against training based on peer-group-derived benchmarks (PGD-training). METHODS: First, novice laparoscopic residents were randomized into a SC group (n = 34), and a group using PGD-benchmarks (n = 34) for basic laparoscopic training. After completing basic training, both groups performed 60 VR laparoscopic cholecystectomies for performance analysis. Primary endpoints were simulator metrics; secondary endpoints were program adherence, trainee motivation, and training efficacy. RESULTS: Altogether, 66 residents completed basic training, and 3,837 of 3,960 (96.8 %) cholecystectomies were available for analysis. Course adherence was good, with only two dropouts, both in the SC-group. The PGD-group spent more time and repetitions in basic training until the benchmarks were reached and subsequently showed better performance in the readout cholecystectomies: Median time (gallbladder extraction) showed significant differences of 520 s (IQR 354-738 s) in SC-training versus 390 s (IQR 278-536 s) in the PGD-group (p < 0.001) and 215 s (IQR 175-276 s) in experts, respectively. Path length of the right instrument also showed significant differences, again with the PGD-training group being more efficient. CONCLUSIONS: Basic VR laparoscopic training based on PGD benchmarks with external assessment is superior to SC training, resulting in higher trainee motivation and better performance in simulated laparoscopic cholecystectomies. We recommend such a basic course based on PGD benchmarks before advancing to more elaborate VR training.

PURPOSE OF REVIEW To provide an overview of the available evidence on the role of the different methods in laparoscopic training, and to summarize the results obtained with standardized training programmes in advanced laparoscopic gynaecological surgery. RECENT FINDINGS Box trainers as well as virtual reality simulators ensure a benefit in terms of surgical skills development. No data are available showing superiority of one method compared to another. Global Operative Assessment of Laparoscopic Skills (GOALS) remains the most widely used and established scoring system to assess the acquired laparoscopic abilities, also in the field of advanced gynaecological surgery. Standardized training programmes have been recognized as reliable tools able to improve the development of surgical skills, particularly for innovative surgical techniques, such as laparoscopic endoscopic single-site surgery. SUMMARY The traditional approach based on observing and assisting needs to be updated incorporating box trainers and virtual reality simulators. The development of innovative training methods, integrating box trainers and virtual reality simulators, represents the future horizon. All tertiary centres involved in advanced laparoscopic gynaecological surgery should contribute to the development of an integrated network of standardized training programmes, in order to ensure a high-quality laparoscopic training to gynaecologists.

Robotic surgical technology has been adopted by surgeons with and without previous standard laparoscopic experience. The necessity or benefit of prior training and experience in laparoscopic surgery is unknown. We hypothesized that laparoscopic training enhances performance in robotic surgery.Fourteen medical students with no surgical experience were instructed to incise a spiral using the da Vinci(®) surgical robot with time to completion and errors recorded. Each student was then trained for 1 month in standard laparoscopy, but with no further robotic exposure. Training included a validated laparoscopic training program, including timed and scored parameters. After completion of the month-long training, the students repeated the cutting exercise using the da Vinci robot as well as with standard laparoscopic instruments and were scored within the same parameters.The mean time to completely incise the spiral robotically before training was 16.72 min with a mean of 6.21 errors. After 1 month of validated laparoscopic training, the mean robotic time fell to 9:03 min (p=0.0002) with 3.57 errors (p=0.02). Laparoscopic performance after 1 month of validated laparoscopic training was 13.95 min with 6.14 errors, which was no better than pretraining robotic performance (p=0.20) and worse than post-training robotic performance (p=0.01).Formal laparoscopic training improved the performance of a complex robotic task. The initial robotic performance without any robotic or laparoscopic training was equivalent to standard laparoscopic performance after extensive training. Additionally, after laparoscopic training, the robot allowed significantly superior speed and precision of the task. Laparoscopic training may improve the proficiency in operation of the robot. This may explain the perceived ease with which robotics is adopted by laparoscopically trained surgeons and may be important in training future robotic surgeons.

Hysterectomy is the most common operative procedure for benign gynaecological disease. The choice of hysterectomy will highlight the surgeon's mental attitude and surgical dexterity in offering the patient the safest cost-effective and reliable procedure. At present, abdominal hysterectomy is the most common method of hysterectomy, but evidence shows that patients prefer vaginal hysterectomy. With the advent of laparoscopic hysterectomy and improved surgical equipment and laparoscopic training programmes, laparoscopic hysterectomy provides equally effective hysterectomy; the patient should, therefore, have the benefit of either vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy in preference to abdominal hysterectomy.

Laparoscopic cholecystectomy is treatment of choice for gall stone disease. Procedure is technically demanding and complication rate varies according to level of training and experience of surgeon in laparoscopy. Training modules and exercises play a definitive role in minimizing the complication rate and making the procedure safe. Here, we share our experience of initial 70 cases of laparoscopic cholecystectomy after a short course of laparoscopic training exercises.

SummaryBackground: The development of new resources, such as surgical techniques and approaches, results in continuous modification of surgery. To assess these modifications, it is necessary to use measures that quantify the impact of resources on surgical processes.Objectives: The objective of this work is to introduce and evaluate distance measurements that are able to represent differences in the courses of surgical interventions as processes.Methods: Hence, we present four different distance measures for surgical processes: the Jaccard distance, Levenshtein distance, Adjacency distance, and Graph matching distance. These measures are formally introduced and evaluated by applying them to clinical data sets from laparoscopic training in pediatric surgery.Results: We analyzed the distances of 450 surgical processes using these four measures with a focus on the difference in surgical processes performed by novices and by experienced surgeons. The Levenshtein and Adjacency distances were best suited to measure distances between surgical processes.Conclusion: The measurement of distances between surgical processes is necessary to estimate the benefit of new surgical techniques and strategies.

BackgroundThe aim of this study was to determine growth in trainee laparoscopic skill as recorded by the TrEndo laparoscopic simulator during a laparoscopic training course, compared to an expert level.MethodsA prospective observational cohort study was conducted between February 1 and November 31, 2010. Trainees in laparoscopic surgery completed a basic laparoscopic suturing task on a laparoscopic box trainer at three successive assessment points during a laparoscopic training course. Experts were assessed only once to define an expert level. The TrEndo recorded four motion analysis parameters (MAPs) individually for each hand and the amount of time taken to complete the suturing task.ResultsSeventy-two residents and 56 experts were included in this study. Overall, the amount of time taken on the suturing task and seven out of eight MAPs significantly increased toward an expert level during the course, representing an improvement in task efficiency. During the first training day, the amount of time spent on the suturing task and five out of eight MAPs improved significantly. After the retention period, five out of eight MAPS demonstrated a significant improvement compared to the end of the first training day.ConclusionsLaparoscopic skill of trainees as recorded by the TrEndo laparoscopic simulator grows toward an expert level during a laparoscopic training course in a large and heterogeneous study group. Construct validity of the TrEndo is established.

Purpose: We describe an extended training program using the pelvitrainer to improve the basic laparoscopic skills of the junior urologists.Ten junior residents were involved in our program that consisted of an hour of training every other day; every 3 hours represented one training session. This curriculum started with 4 inanimate tasks that included peg transfer, disc cutout, extracorporeal, and intracorporeal knot tying. Each task was practiced for one training session with an objective evaluation at the initial attempt and at the end of its session. Thereafter, the participants began to perform an anastomosis using a latex glove model of the laparoscopic urethrovesical anastmosis (L-UVA) (5 experiments). This was followed by 10 experiments of the sheep intestine model of the L-UVA. The performance in these models was evaluated by both the amount of leakage of the injected saline and the time required for completing it. Lastly, another sheep intestine model was performed 3 weeks after the end of the training program.The continuous evaluation of these trainees showed that there was a significant decrease in the time required to perform each of the first 4 tasks at the end of their corresponding sessions compared to the base line values (p=0.000). We also detected a significant decrease in the time and the amount of leakage in sheep intestine models in the 10th attempt compared to the first one (p=0.000). However, there was no significant difference between the results at the 10th model and those of the 3 weeks retest regarding both the time (p=0.198) and the amount of leakage (p=0.076).The use of the two described models of the L-UVA after the inanimate tasks in the pelvitrainer distributed course of training could help in the improvement and in the retention of the basic laparoscopic skills of the junior urologists.

Our purpose is to develop a system based on image processing methods that can inform users of the angular relationship between the needle and the forceps. The user thereby adjusts their needle grasping posture according to the angle information, which leads to an improvement in suturing accuracy. The system prototype consists of a camera and an image processing computer. The image captured by the camera is input to the computer, and then, the angular relationship between the forceps and needle is calculated via image processing. Then, the system informs the user of the calculated angular relationship between the needle and forceps in real time. To evaluate whether the system improves suturing accuracy, we invited 12 participants to enroll in an experiment based on a suturing task. The experimental results illustrate that the system allows participants to easily adjust the positional relationship between the needle and the forceps and that this adjusted angular relationship leads to higher suturing accuracy. Adjustment to holding the needle at a right angle before insertion has a critical effect on suturing quality. Therefore, we developed a system that informs the user of the angular relationship between the needle and the forceps. The results of the evaluation show that the system significantly improves the suturing accuracy of participants via informing them of the angle.

Laparoscopic surgery has been shown to have many favorable effects on surgical outcomes and postoperative recovery times. However, the cost of currently available training programs, such as the Fundamentals of Laparoscopic Surgery (FLS), limits their adoption in developing countries. To address this cost constraint, educators at the Justinian University Hospital (JUH) in Northern Haiti used local materials to build their own laparoscopic skills box trainer. This trainer is used to teach all surgical and OB/GYN residents in their laparoscopic skills program. The progressive curriculum consists of seven modules, three of which are for all trainees and four of which are specifically for surgery and OB/GYN (2). The seven modules are arranged in the order of difficulty; they start with basic maneuvers and progress to complex skills. This report describes both the preparation of the seven models and evaluation of the skills that are learned. This approach may facilitate global access to feasible, progressive, and sustainable laparoscopic training.

Laparoscopic hepatectomy remains one of the most difficult procedures for young surgeons to perform. We recently developed a new training method and standardization procedure for teaching young surgeons to perform laparoscopic left hepatectomy (Lap-LHx). The aim of this study was to assess the effectiveness of our method. In 2004, we standardized a laparoscopic procedure for Lap-LHx, using a laparoscopy-assisted method as a stepping stone. The laparoscopic training method comprised the following three steps: (1) training in fundamental procedures using a dry box and checking by mentors; (2) detailed preoperative simulation using Vincent three-dimensional software for each patient; and (3) self-assessment including understanding of relevant anatomy and completion grade for each procedure using a check sheet and feedback by both mentors and a professor. Twenty-three Lap-LHx procedures performed during the study period were divided into two groups: those performed by young non-board-certified surgeons (n = 9) and those performed by senior board-certified surgeons (n = 14). The blood loss and operative time were similar in the young surgeon (194 g and 336 min, respectively) and senior surgeon groups (208 g and 322 min, respectively). Our standardized Lap-LHx procedure and stepwise training to perform it enable young surgeons to perform Lap-LHx as confidently and safely as more experienced surgeons.

Laparoscopy has been widely used to perform abdominal surgeries, as it is advantageous in that the patients experience lower post-surgical trauma, shorter convalescence, and less pain as compared to traditional surgery. Laparoscopic surgeries require precision; therefore, it is imperative to train surgeons to reduce the risk of operation. Laparoscopic simulators offer a highly realistic surgical environment by using virtual reality technology, and it can improve the training efficiency of laparoscopic surgery. This paper presents a virtual Laparoscopic surgery system. The proposed system utilizes the Visible Chinese Human (VCH) to construct the virtual models and simulates real-time deformation with both improved special mass-spring model and morph target animation. Meanwhile, an external device that integrates two five-degrees-of-freedom (5-DOF) manipulators was designed and made to interact with the virtual system. In addition, the proposed system provides a modular tool based on Unity3D to define the functions and features of instruments and organs, which could help users to build surgical training scenarios quickly. The proposed virtual laparoscopic training system offers two kinds of training mode, skills training and surgery training. In the skills training mode, the surgeons are mainly trained for basic operations, such as laparoscopic camera, needle, grasp, electric coagulation, and suturing. In the surgery-training mode, the surgeons can practice cholecystectomy and removal of hepatic cysts by guided or non-guided teaching.

To be successful, a surgeon must master a variety of skills. To meet the high demand for surgical expertise, an extracurricular undergraduate project was launched. The extracurricular project consists of hands-on laparoscopic training and a mentorship programme. The project aims to find the best surgical talents among fourth-year medical students. The aim of the present paper is threefold: 1) to present the structure, i.e., the selection and training methods, of the Dream Team project; 2) to investigate the gender and grade distribution among the Dream Team students compared with their peers in medical school; and 3) to investigate the Dream Team students’ evaluation of the project. Students (n=168) were satisfied with the 1-week course. This post-programme evaluation revealed a variation in satisfaction (n=68). The gender distribution on the Dream Team did not correlate with the gender distribution at the medical school. Dream Team students’ grades showed variation, but generally matched the average grades obtained by medical school graduates. The 1-week extracurricular course increased students’ interest in the surgical specialty. The role of the mentor was pivotal. Dream Team participants performed at an average level in medical school. Male students seemed to perform better in the laparoscopic tests.

Prosthetic mesh rolled up and fixed with stitches like a slim cigarette ("slim-mesh") for laparoscopic ventral hernia (VH) repair is an new technique which allows an easy intraperitoneally introduction, distension and circumferential fixation of a prosthetic mesh without transabdominal fixation sutures even for meshes larger than 16 cm up to 30 cm for the "slim-mesh" repair of wide ventral hernias. We report the technique of laparoscopic repair of VH with "slim-mesh". This technique enables an easy intra-peritoneally introduction of the mesh through the trocar because it reduces consistently its size, it allows a rapid intra-abdominal handling of the mesh and a fast and easy fixation for VH repair. The average time of surgery with "slim-mesh" for treatment of all 28 VH was 97 min ranging from 57 to 160 min. The average time for the repair of the 24 VH smaller than 10 cm was 91 and 135 min for the four VH larger than 10-22 cm. This new surgical technique leads to a reduction of surgical risks avoiding the use of transfascial sutures with the associated complications. This new surgical procedure in our experience is fast, safe, simple and also easily reproducible by surgeons in laparoscopic training. This technique may be used in wide VH (larger than 10-22 cm) that generally require open surgery.

Laparoscopic surgery requires surgeons to view rotated visual feedback of the surgical field. However, systematic assessments of the effects of visuomotor rotations on performance have been controversial. Forty novice undergraduates performed a pointing task in a laparoscopic trainer box while experiencing one of five different visuomotor rotations: 0°, 45°, 90°, 135°, and 180°. Performance was measured using root mean squared error (RMSE). When initially exposed to the visuomotor rotations, participants’ performance was superior in the 0° condition when compared to the 45°, 90°, and 135° conditions. The pattern of results observed in the present study were consistent with basic research by Cunningham (1989) that showed the most severe performance decrements for rotations between 90° and 135°. With prolonged exposure to the visuomotor rotations, participants adapted to the distortions. The results of the present study are relevant to the design of laparoscopic training currilicula.

To evaluate the feasibility of intensive laparoscopic training shortening the learning curve of laparoscopic suturing in surgical postgraduate students.Eighty-seven surgical postgraduate students participated in this study, including novice (N), junior (JR), and senior (SR) trainees. The N trainees were divided into novice control (NC) and novice experimental (NE) groups. The training curricula contain three stages: Fundamentals of laparoscopic surgery tasks, intensive laparoscopic suturing task, and laparoscopic enucleation model training. The NE, JR, and SR groups completed all three stages. The NC group just performed the first and third stages. The performances of each group were recorded and analyzed.For the first stage, the SR group performed better than the N and JR groups. There was no significant difference in the post-test total scores between the N and JR groups, although the N group had lower pretest total scores. For the second stage, no significant difference was found in the post-test scores among the NE, JR, and SR groups, although the SR group had better pretest scores. For the third stage, the NE, JR, and SR groups had better performance than the NC group at the five exercises. There was no significant difference at the fifth exercise among the NE, JR, and SR groups, although the SR group performed better at the former four exercises.This study documented the feasibility of intensive laparoscopic training curricula shortening the learning curve of laparoscopic suturing in surgical postgraduate students, regardless of baseline experience.

Simulation may provide a solution to acquire advanced laparoscopic skills, thereby completing the curriculum of residency programs in general surgery. This study was designed to present an advanced simulation-training program and to assess the transfer of skills to a live porcine model.First-year residents were assessed in a 14-session advanced laparoscopic training program followed by performing a jejunojejunostomy in a live porcine model. Previous and after training assessments at the bench model were compared to a single performance of six expert laparoscopic surgeons. Results obtained by trainees at the porcine model assessment were compared to those of 11 general surgeons without any laparoscopic lab-simulation training and 6 expert laparoscopic surgeons. In all assessments, global and specific OSATS scores, operative time, and covered path length of hands were registered.Twenty-five residents improved significantly their global and specific OSATS score median at the bench model [7 (range, 6-11) vs. 23 (range, 21-24); p 0.05 and 7 (range, 4-8) vs. 18 (range, 18-19); p 0.05, respectively] and obtained significantly better scores on the porcine model compared with general surgeons with no lab-simulation training [21 (range, 20.5-21) vs. 8 (range, 12-14); p 0.05]. The results were comparable to those achieved by expert certificated bariatric surgeons. Total path lengths registered for trainees were more efficient post-training and significantly lower compared with general surgeons on the porcine model [7 (range, 6-11) vs. 23 (range, 21-24); p 0.05] with no statistical difference compared with experts.Trainees significantly improved their advanced laparoscopic skills to a level compared with expert surgeons. More importantly, these acquired skills were transferred to a more complex live model.

Objective: The aim of this study was to identify the critical decisions surgeons need to make regarding laparoscopic surgery, the information these decisions are based on, the strategies employed by surgeons to reach their objectives, and the difficulties experienced by novices. Background: Laparoscopic training focuses on the development of technical skills. However, successful surgical outcomes are also dependent on appropriate decisions made during surgery, which are influenced by critical cues and the use of appropriate strategies. Novices might not be as adept at cue detection and strategy use. Method: Participants were eight attending surgeons. The authors employed task-analytic techniques to identify critical decisions inherent in laparoscopy and the cues, strategies, and novice traps associated with these decisions. Results: The authors used decision requirements tables to organize the data into the key decisions made during the preoperative, operative, and postoperative phases as well as the cues, strategies, and novice traps associated with these decisions. Key decisions identified for the preoperative phase included but were not limited to the decision of performing a laparoscopic versus open surgery, necessity to review the literature, practicing the procedure, and trocar placement. Some key decisions identified for the operative phase included converting to open surgery, performing angiograms, cutting tissue or organs, and reevaluation of the approach. Only one key decision was identified for the postoperative phrase: whether the surgeon’s technique needs to be evaluated and revised. Conclusion: The laparoscopic environment requires complex decision making, and novices are prone to errors in their decisions. Application: The information elicited in this study is applicable to laparoscopic training.

This study aimed (1) to evaluate the impact of clinical factors, particularly operation by trainees, on the short-term outcomes of laparoscopic resection for sigmoid and rectosigmoid cancer, and (2) to determine patients suitable for operation by trainees.From a prospectively maintained single-institution database, we identified 133 patients who underwent laparoscopic resection for sigmoid or rectosigmoid cancer between 2007 and 2010. Gender, age, body mass index (BMI), previous abdominal surgery, tumor location, tumor size, tumor stage, extent of lymph node dissection, and primary surgeon were evaluated using univariate and multivariate analyses to determine the predictive significance of these variables on surgical outcomes including operative time, blood loss, complication, postoperative stay, and retrieved lymph nodes.Multivariate analysis showed that location of the tumor in the rectosigmoid (p0.001), higher BMI (p0.001), operation by trainees (p0.001), male gender (p = 0.002), and greater tumor depth (p = 0.011) were independently predictive of longer operative time. Larger tumor size (p = 0.025) and higher BMI (p = 0.040) were independently predictive of greater blood loss. Larger tumor size was also related to longer postoperative stay (p = 0.001) and a greater number of retrieved lymph nodes (p = 0.001).This study identified operation by trainees as an independent risk factor for longer operative time but with no negative impact on any of the other outcomes. Female patients with a low BMI, sigmoid cancer, shallow tumor depth, and/or small tumor are suitable for operation by trainees.

To assess the educational value of an ongoing interval practice laparoscopy training program among obstetrics and gynecology residents.Prospective cohort, multi-institutional recruitment study. We conducted structured laparoscopic training sessions for residents, using both inanimate and porcine models. The 6-day course was separated into two 3-day long modules conducted 2 months apart. A prospective evaluation of standardized tasks was performed using validated scales. Resident's performance was compared using the Student t test and Wilcoxon signed-rank test when appropriate.International Center of Endoscopic Surgery (CICE), Clermont-Ferrand, France.191 PGY2 or PGY3 residents from different institutions.Significant improvement in time and technical scores for both laparoscopic suturing and porcine nephrectomy was noted (p0.0001). After 2 months, we found no improvement in suturing time (p = 0.59) or technical scores (p = 0.62), and significant technical deterioration was observed for the right hand (p = 0.02). Porcine nephrectomy improvement remained significant after 2 months (p0.0001).Despite significant short-term educational value of interval practice in laparoscopic performance, some acquired skills seem to deteriorate faster than anticipated.

Introduction: In the era of flowering minimally invasive surgical techniques there is a need for new methods of teaching surgery and supervision of progress in skills and expertise. Virtual and physical box-trainers seem especially fit for this purpose, and allow for improvement of proficiency required in laparoscopic surgery. Material and methods: The study included 34 students who completed the authors‘ laparoscopic training on physical train-boxes. Progress was monitored by accomplishment of 3 exercises: moving pellets from one place to another, excising and clipping. Analysed parameters included time needed to complete the exercise and right and left hand movement tracks. Students were asked to do assigned tasks prior to, in the middle and after the training. Results: The duration of the course was 28 h in total. Significant shortening of the time to perform each exercise and reduction of the left hand track were achieved. The right hand track was shortened only in exercise number 1. Conclusions: Exercises in the laboratory setting should be regarded as an important element of the process of skills acquisition by a young surgeon. Virtual reality laparoscopic training seems to be a new, interesting educational tool, and at the same time allows for reliable control and assessment of progress.

The development of skills and abilities in laparoscopy is directly related to the use of trainers. The trainer should model the patient with all its natural complexities as closely as possible. In this article we propose a system for training the establishment of pneumoperitoneum executing the basic tasks to create the workspace in the trainer, the insertion of primary umbilical trocar and simulate some of the everyday problems in surgery. Materials and Methods. A group of electrical with biomedical engineers and laparoscopic surgeons developed a physical trainer that allows implementing the pneumoperitoneum. The system uses pneumatic electro valves that are controlled with a dedicated microprocessor. The user can program the system to set the parameters of the pneumoperitoneum. Results. This new trainer facilitated the programming of right values of parameters to distend the abdominal cavity according a specific clinical case. The model developed enables the trainee to consolidate his knowledge on establishing the parameters required within clinical practice, as well as the entry techniques. Conclusions. A new physical model for laparoscopic training was designed. The system enables the laparoscopic surgeon to set the parameters for establishing the workspace according to the clinical case. The trainer allows the surgeon to train in the Hasson technique for the introduction of the first trocar, as well as the placement of the rest of surgical instruments with video assistance. We think this new trainer system will help minimize entry-related injuries.

Study Objective To validate the Virtual Basic Laparoscopic Skill Trainer (VBLaST-PT; the peg transfer task) for concurrent validity based on its ability to differentiate between novice, intermediate, and expert groups of gynecologists, and the gynecologists' subjective preference between the physical Fundamentals of Laparoscopic Surgery (FLS) system and the virtual reality system. Design Prospective study (Canadian Task Force II-2). Setting Academic medical center. Participants Obstetrics and gynecology residents (n = 18) and attending gynecologists (n = 9). Interventions Twenty-seven subjects were divided into 3 groups: novices (n = 9), intermediates (n = 9), and experts (n = 9). All subjects performed 10 trials of the peg transfer on each simulator. Assessment of laparoscopic performance was based on FLS scoring, whereas a questionnaire was used for subjective evaluation. Measurements and Main Results The performance scores in the 2 simulators were nearly identical. Experts performed better than intermediates and novices in both the FLS trainer and the VBLAST, and intermediates performed better than novices in both simulators. The results also show a significant learning effect on both trainers for all subgroups; however, the greatest learning effect was in the novice group for both trainers. Subjectively, 74% participants preferred the FLS over the VBLaST for training laparoscopic surgical skills. Conclusion This study demonstrates that the peg transfer task was reproduced well in the VBLaST in gynecologic surgeons and trainees. The VBLaST has the potential to be a valuable tool in laparoscopic training for gynecologic surgeons.

Laparoscopic surgery requires a unique set of technical skills. There is emphasis on increasing patient safety, and therefore, a growing need to improve laparoscopic training. The aim of this study is to determine if the use of a ‘take-home’ box trainer would improve gynaecological surgeon performance. Thirteen obstetricians and gynaecologists (consultants and registrars) were enrolled to receive 6 months formal laparoscopic training using a ‘take-home’ box trainer. Laparoscopic skills were objectively assessed using a virtual reality haptic-enhanced simulator prior to commencement and at the completion of the course utilising three defined exercises (locating and coordinating, tissue manipulation and object positioning) where task duration, path length, economy of movement, hand dominance and overall score were assessed. Data is presented as mean ± SEM and differences between groups evaluated with ANOVA. All 13 gynaecologists completed the programme. For tissue manipulation, laparoscopic training using the box trainer reduced the task duration (214.8 ± 16.5 s vs. 147.7 ± 12.6 s, P = 0.04) and increased economy of movement (22 ± 7.1% vs. 78.9 ± 2.3%, P < 0.001) and overall score (11.7 ± 3.1% vs. 33.7 ± 1.8%, P < 0.001). For object positioning, laparoscopic training with the box trainer reduced task duration (280.1 ± 40.3 s vs. 106.6 ± 5.1 s, P < 0.001) and path length (825.3 ± 48.3 cm vs. 463.4 ± 16.8 cm, P < 0.001) and increased overall score (4.15 ± 1.7% vs. 15.2 ± 2%, P < 0.001). The box trainer did not significantly affect laparoscopic locating and coordinating or change hand dominance. Formal training and continuous practice using the box trainer model improves surgical skills required for laparoscopic surgery. The box trainer could be a more accessible and preferred tool for those training to become laparoscopic surgeons.

General surgery trainees’ perceptions regarding their own laparoscopic training remain poorly defined. The objective of this survey was to identify and evaluate learner experiences with laparoscopic procedures in general surgery programs on a national level. Two hundred eighty-four residents were identified and contacted at English-speaking general surgery programs across Canada. Each was asked to complete a web- or paper-based survey regarding their demographics, experiences with basic and advanced minimally invasive surgery (MIS) procedures, and perceived barriers to training. Two hundred fifty-two of 284 (89%) surveyed residents responded. Eighty-seven percent of the residents had access to a skills lab that taught MIS techniques; however, standardized MIS curricula were implemented 53% of the time. Eighty percent of residents felt that skills lab training translated to improved performance in the OR. Although 90% of residents felt that they would be comfortable performing basic laparoscopic procedures, only 8% stated they would be comfortable performing advanced procedures at the end of their training. Moreover, 90% of general surgery residents felt that it was the academic surgical department’s responsibility to teach both basic and advanced procedures, and 35% of respondents felt their surgical program was meeting this requirement. Half of the residents felt they had limited opportunity to be a primary surgeon because an MIS fellow was present. There exists a wide disparity between the expectations of residents and their actual experience. The majority of residents are concerned that they will not acquire sufficient laparoscopic skills during their training to perform advanced cases in practice. Additionally, the balance between resident and fellow-level cases needs to be more clearly defined as the majority of respondents identified the presence of a MIS fellow as a negative learning influence. Finally, although most centers had a surgical skills lab, 47% of respondents felt that the curriculum was not standardized and this also needs to be addressed.

Aim: To provide an evidence-based analysis on the status and perspectives of laparoscopic training in urologic surgery. Methods: A thorough review of the current literature was performed as of January 31, 2009, using the Medline database through a PubMed search. The search protocol included a free-text query using the following terms: "training,'' "urologic laparoscopy,'' "urology,'' and "laparoscopy.'' Suitable articles were selected on the basis of the study content. The following issues were addressed: prediction of laparoscopic skills and transfer of training in clinical practice; homemade and commercially available laparoscopic trainers and simulators; training models for specific laparoscopic procedures; mentored training programs; formal training programs; and the impact of robotics in laparoscopic training. Results: Currently available tools predicting laparoscopic skills lack adequate validation to justify their widespread adoption. There still is not enough evidence to show definite transfer of skills from currently available simulators to the operating theater. Learning opportunities continue to evolve. Specific models have been developed for complex procedures. Various informal training programs exist, yet most urologists will not be able to complete a formal fellowship. Postgraduate urologists may possibly be more rapidly and efficiently trained using a structured mentoring program. Robotics is likely to have an increasing role in teaching urological laparoscopy. Conclusions: Despite progress in recent years and an extensive amount of data from the urological literature, the ideal training program in urological laparoscopy remains a goal to be determined objectively

Background: Virtual reality (VR) simulation for laparoscopic surgical training is now a reality. There is increasing evidence that the use of VR simulation is a powerful adjunct to traditional surgical apprenticeship in the current climate of reduced time spent in training.Aim: This article reviews the early evidence supporting the case for VR simulation training in laparoscopic surgery.Methods: A standard literature search was conducted using the following phrases – ‘virtual reality in surgical training’, ‘surgical training’, ‘laparoscopic training’ and ‘simulation in surgical training’.Results and conclusion: This article outlines the early evidence which supports the use of VR simulation in laparoscopic training and the need for further research into this new training technique.

Reverse alignment (mirror image) visualization is a disconcerting situation occasionally faced during laparoscopic operations. This occurs when the camera faces back at the surgeon in the opposite direction from which the surgeon’s body and instruments are facing. Most surgeons will attempt to optimize trocar and camera placement to avoid this situation. The authors’ objective was to determine whether the intentional use of reverse alignment visualization during laparoscopic training would improve performance. A standard box trainer was configured for reverse alignment, and 34 medical students and junior surgical residents were randomized to train with either forward alignment (DIRECT) or reverse alignment (MIRROR) visualization. Enrollees were tested on both modalities before and after a 4-week structured training program specific to their modality. Student’s t test was used to determine differences in task performance between the 2 groups. Twenty-one participants completed the study (10 DIRECT, 11 MIRROR). There were no significant differences in performance time between DIRECT or MIRROR participants during forward or reverse alignment initial testing. At final testing, DIRECT participants had improved times only in forward alignment performance; they demonstrated no significant improvement in reverse alignment performance. MIRROR participants had significant time improvement in both forward and reverse alignment performance at final testing. Reverse alignment imaging for laparoscopic training improves task performance for both reverse alignment and forward alignment tasks. This may be translated into improved performance in the operating room when faced with reverse alignment situations. Minimal lab training can account for drastic adaptation to this environment.

Surgeons performing laparoscopic surgery have strong biases regarding the quality and nature of the laparoscopic video monitor display. In a comparative study, we used a unique computerized sensing and analysis system to evaluate the various types of monitors employed in laparoscopic surgery. We compared the impact of different types of monitor displays on an individual’s performance of a laparoscopic training task which required the subject to move the instrument to a set of targets. Participants (varying from no laparoscopic experience to board-certified surgeons) were asked to perform the assigned task while using all three display systems, which were randomly assigned: a conventional laparoscopic monitor system (2D), a high-definition monitor system (HD), and a stereoscopic display (3D). The effects of monitor system on various performance parameters (total time consumed to finish the task, average speed, and movement economy) were analyzed by computer. Each of the subjects filled out a subjective questionnaire at the end of their training session. A total of 27 participants completed our study. Performance with the HD monitor was significantly slower than with either the 3D or 2D monitor (p

Laparoendoscopic single site surgery (LESS) is a new avenue in laparoscopic urology. The main advantage is the enhanced cosmetic benefits of single hidden scar. Lately many papers are being published on various procedures done by LESS. Like conventional laparoscopy, this approach is likely to be used more widely and hence exposure to this field is essential. However, formal training in this technique is not widely available. Expensive ports and nonavailability of endotrainer may be the factors deterring the training. We have modified the standard laparoscopic endotrainer with improvised ports, to make it suitable for single port laparoscopic training. For the animal lab training improvised ports and low cost instruments were used. Thus the overall cost of the training in LESS was reduced, and better confidence levels were achieved prior to human applications.

INTRODUCTION: Laparoscopy is rapidly emerging as the preferred surgical approach to a number of different diseases because it permits a correct diagnosis and accurate treatment; however, it is not yet being applied in a widespread manner in the management of benign or malignant colorectal disease. The aim of this work is to illustrate retrospectively the results of our experience of laparoscopic colorectal surgery carried out in a community hospital over the last 5 years to document its feasibility, safety, and benefits when carried out by general surgeons in this setting. MATERIALS AND METHODS: Between January 2003 and December 2007 a total of 628 patients underwent a colorectal procedure. Among them, 328 (52.2%) were operated on with a laparoscopic approach. RESULTS: In 12 cases, we had to convert to the open approach. Major complications occurred in 3.6% whereas minor occurrences occurred in up to 10%. CONCLUSIONS: Even if limited by its retrospective design, our experience exhibits that the laparoscopic may well be a safe and effective approach to colon pathology in a community hospital setting. Such features make laparoscopy a challenging alternative to open surgery in the approach to colon disease and it can be proven to be cost-effective without undue risk, as long adequate laparoscopic training is undertaken by the surgeon and proper preparation observed.

Laparoscopic surgery has become the standard of care for many surgical diseases. Haptic (tactile) feedback (HFB) is considered an important component of laparoscopic surgery. Virtual reality simulation (VRS) is an alternative method to teach surgical skills to surgeons in training. Newer VRS trainers such as the Simbionix Lap Mentor II provide significantly improved tactile feedback. However, VRSs are expensive and adding HFB software adds an estimated cost of $30,000 to the commercial price. The HFB provided by the Lap Mentor II has not been validated by an independent party. We used the Simbionix Lap Mentor II in this study to demonstrate the effect of adding an HFB mechanism in the VRS trainer.The study was approved by the University of Cincinnati Institutional Review Board. Twenty laparoscopically novice medical students were enrolled. Each student was asked to perform three different tasks on the Lap Mentor II and repeat each one five times. The chosen tasks demanded significant amount of traction and counter traction. The first task was to pull leaking tubes enough and clip them. The second task was stretching a jelly plate enough to see its attachments to the floor and cut these attachments. In the third task, the trainee had to separate the gallbladder from its bed on the liver. The students were randomized into two groups to perform the tasks with and without HFB. We used accuracy, speed, and economy of movement as scales to compare the performance between the two groups. The participants also completed a simple questionnaire that highlighted age, sex, and experiences in videogame usage.The two groups were comparable in age, sex, and videogame playing. No differences in the accuracy, the economy, and the speed of hand movement were noticed. In fact, adding HFB to the Lap Mentor II simulator did not contribute to any improvement in the performance of the trainees. Interestingly, we found that videogame expert players tend to have faster and more economic motion in their dominant hands. However, the performance accuracy was not significantly affected.The presence of HFB has less effect than it thought to be on the performance of the novice trainees. This may suggest that better HFB is still needed. However, there may be visual compensation for the lack of haptics. Playing videogames has a positive impact on economy, and the speed of the dominant had motion without affecting its accuracy. Further research is needed to clarify the value of haptics to the expert surgeon and compare it to the new trainees.

Background The complexity of laparoscopic surgery makes specific training out of the operating rooms necessary to shorten learning curves and to minimise morbidity rates. Our aim was to analyse the increase in laparoscopic skills after completion of a laboratory training program. Material and methods Prospective study of surgical resident training based on anastomosis performance on an “endotrainer.” The program consisted of 4 weeks per year (20 h per week) between 2004 and 2007. The outcome measures were the time and number of anastomosis necessary to perform a proper anastomosis. Upon completion, the anastomosis was checked by both trainee and evaluator and quality was assessed. Time and technical failures (loose suture, edge eversion, leakage) were recorded. Results Twelve surgical residents were trained. They performed 189 jejuno-jejunal anastomoses (JJA), mean 15.8 per resident and 197 gastro-jejunal anastomoses (GJA), mean 16.4 per resident. The performance mean time was 72.7 min for JJA and 87.2 for GJA. There was a marked reduction in time from the beginning to completion of training. The percentage of flawed anastomosis decreased with training: 26.6%, 21.8%, 17.1%, 17%, 16.1%, and 10.5% after 20, 40, 60, 80, 100, and 120 h, respectively. Bearing in mind reduction in both performance time and flawed anastomosis rate, it appears that after 70 h of training the learning curve reaches a plateau zone. Conclusions Intestinal anastomosis (either JJA or GJA) performed in “endotrainer” is a suitable model for laparoscopic training, without the need of live animals. After a training period of 70 hours, the improvement seems of little benefit.

Although time production is frequently used as a secondary task, research has not thoroughly investigated whether the length of the to-be-produced interval or the metric used to summarize productions affects sensitivity to mental workload. Fourteen participants produced four target intervals (6, 11, 16, or 21 s) while performing a surgical training task that required putting small beads into a cup (easy) or onto a peg (difficult). Intervals were summarized into two metrics of central tendency and four metrics of dispersion previously used in the literature. Results indicate that metrics of central tendency and shorter target intervals are more sensitive to mental workload.