A simplified simulator for the training and evaluation of
laparoscopic skills
E. J. Keyser, A. M. Derossis, M. Antoniuk, H. H. Sigman, G. M. Fried
Section of Video-endoscopic Surgery, Division of General Surgery, McGill University, Montreal, Quebec, Canada
Received: 26 April 1999/Accepted: 2 July 1999
Abstract
Background: Laparoscopic skills can be measured objec-
tively in a video-laparoscopic cart simulator system. These
scores have been shown to be sufficiently sensitive to dis-
tinguish differences in performance between residents at
different levels of training. The purpose of this study was to
compare a simplified mirrored-box simulator to the video-
laparoscopic cart system.
Methods: A total of 22 surgical residents performed seven
structured tasks in both simulators in random order. Scores
reflected precision and speed. The tasks were transferring,
cutting, clip + divide, looping, mesh placement + fixation,
and suturing with intracorporeal and extracorporeal knots.
Results: There were no significant differences in mean raw
scores between the simulators for six of the seven tasks.
Resident total scores correlated well between simulators (r
ס 0.68, p ס 0.001). Resident ranking also correlated well
(r ס 0.69, p < 0.001).
Conclusions: A mirrored-box simulator was shown to pro-
vide a reasonable reflection of relative performance of lap-
aroscopic skills. Practical, effective laparoscopic skills
training and evaluation can be accomplished without the
need for cumbersome equipment.
Key words: Laparoscopy — Laparoscopic training —
Simulation — Education
Laparoscopic surgery requires the mastery of several basic
technical skills using indirect two-dimensional optical sys-
tems. There is growing interest in using inanimate training
systems to accelerate the learning curve of laparoscopic
trainees [3, 5]. Our center as well as others [1, 6] has de-
veloped basic skills training curricula. The ultimate goal is
the more efficient and precise performance of laparoscopic
operations.
Most curricula for in vitro training utilize the video-
laparoscopic cart and endoscopic trainer-box setup (video-
cart). The advantage of this setup is that it closely mimics
the actual operating room. Using the MISTELS program
(McGill Inanimate System for Training and Evaluation of
Laparoscopic Skills), we previously demonstrated that basic
laparoscopic skills can be objectively assessed and scored in
a video-cart using a series of structured tasks [3]. These
scores have been shown to be sufficiently sensitive to dis-
criminate between different levels of resident training and
between laparoscopic and nonlaparoscopic surgeons.
There are disadvantages to using the video-cart for in
vitro skills development. It is expensive and its use must be
scheduled in advance. Access is therefore usually restricted
and not conducive to frequent, convenient practice. Several
companies are currently marketing a variety of simple simu-
lators as “laparoscopic trainers.” However, these devices
have not been studied to establish their validity as training
devices. We therefore evaluated one such device, a simpli-
fied mirrored-box simulator (Simuview Suture Trainer;
Simulab Corporation, Seattle, WA, USA), and objectively
compared the performance of surgical residents measured
using this device and the traditional laparoscopic system.
Materials and methods
Study design
Twenty-two surgical residents (PGY-1 to PGY-5) were enrolled in the
study. Each watched a 20-min introductory video describing the seven
structured tasks to be performed. Each resident was then randomized to
perform the tasks initially with either the video-cart or the mirrored box.
The residents were then crossed over to the other simulator. The goal of the
study was to compare the ranking of the 22 surgical residents when evalu-
ated in the mirrored box system as opposed to the traditional laparoscopic
system.
Presented at the annual meeting of the Society for American Gastrointes-
tinal Endoscopic Surgeons (SAGES), San Antonio, Texas, USA, 24–27
March 1999
Correspondence to: G. M. Fried, Department of Surgery, The Montreal
General Hospital, 1650 Cedar Avenue, Suite L9-412, Montreal, Quebec,
Canada H3G 1A4
Surg Endosc (2000) 14: 149–153
DOI: 10.1007/s004649900088
© Springer-Verlag New York Inc. 2000