Laparoscopic surgery is different from open surgery because of:

How to teach laparoscopic surgery to residents in a safe and efficient way is the topic of many debates, conventions, and research projects. Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. Different procedures have different learning curves. Surgeons experienced in one procedure may not be experienced in another, and results improve with experience in an individual procedure. An increasing number of surgical procedures are being done laparoscopically. This includes laparoscopic cholecystectomy, laparoscopic anti-reflux procedures, laparoscopic hysterectomy, and laparoscopic nephrectomy. Learning should be gradual. For example, laparoscopic intracorporeal suturing and knot tying are considered some of the most technically demanding minimally invasive skill to acquire. Proficiency in these skills is a requirement for surgeons to perform advanced laparoscopy. Studies have demonstrated that technical aptitude in open suturing and knot tying is not transferable to the laparoscopic technique. Compounding the difficulty inherent in learning this advanced laparoscopic skill are the diminished operative opportunities for surgical residents resulting from work-hour restrictions and the ethical concerns related to trainees learning novel skills on patients. As a consequence of these pressures and the technical demands of minimally invasive surgery, alternative ex vivo training methods have been developed [1] (LoE1b). The different methods of laparoscopic surgical training include live animal training, human and animal cadaver training, training using box trainer (video trainer), and virtual reality training (training using computer simulation). Video trainer is currently being used for laparoscopic training in various courses run by the Royal College of Surgeons of England and has been shown to be better than standard training. Virtual reality training has been reported to improve the learning outcomes in different surgical procedures [2–6] (LoE4). It also offers an ethical way of assessing the competency of a surgeon in performing a procedure without a risk to the patient. There are other reports that suggest that virtual reality training alone is inferior to traditional training for certain procedures [7] (LoE3b). Virtual reality training has been mainly used for development of component skills (such as diathermy, clipping, suturing) and not training in the entire procedure (such as laparoscopic cholecystectomy). As opposed to the limited variability of data available during a flight on which a pilot requires to be trained using a custom-designed simulator, anatomical variations are common throughout the human body, and skills acquired on a single computer simulation program may not be applicable in patients. Although the price of the simulators can vary depending upon the learning outcome, traditional training is not without costs. The operating time increases significantly for junior surgeons compared to senior surgeons, and the average costs of this increased operating time is about 12,000 US dollars per year per resident during the period 1993–1997 [8] (LoE1a). The complication rate is also higher for junior surgeons compared to senior surgeons [9] (LoE2a), [10] (LoE3a). Thus, the cost of the virtual reality training system has to be balanced against the cost of increased operating time and complication rates during traditional surgical training. The Cochrane Review [11] (LoE1) included 23 trials with 612 participants, comparing virtual reality training versus other forms of training including video trainer training, no training, or standard laparoscopic training in surgical trainees with little or no prior laparoscopic experience. Also include trials comparing different methods of virtual reality training. Four trials compared virtual reality versus video trainer training. Twelve trials compared virtual reality versus no training or standard laparoscopic training. Four trials compared virtual reality, video trainer training and no training, or standard laparoscopic training. Three trials compared different methods of virtual reality training. Most of the trials were of high risk of bias. In trainees without prior surgical experience, virtual reality training decreased the time taken to complete a task, increased accuracy, and decreased errors compared with no training; virtual reality group was more accurate than video trainer training group. In the participants with limited laparoscopic experience, virtual reality training reduces operating time and error better than standard in the laparoscopic training group; composite operative performance score was better in the virtual reality group than in the video trainer group. The conclusion is that the virtual reality training can supplement standard laparoscopic surgical training of apprenticeship and is at least as effective as video trainer training in supplementing standard laparoscopic training. Newer studies [12] (LoE3) have evaluated the benefits of haptics in VR laparoscopic surgery training. Randomly, 33 laparoscopic novice students were placed in one of three groups: control, haptics trained, and nonhaptics trained. The number of attempts required to reach proficiency did not differ between the haptics- and nonhaptics-trained groups. The haptics and nonhaptics groups exhibited no difference in performance. Both training groups outperformed the control group in number of movements as well as path length of the left instrument. In addition, the nonhaptics group outperformed the control group in total time. The conclusion in that haptics does not improve the efficiency or effectiveness of LapMentor II VR laparoscopic surgery training; the limited benefit and the significant cost suggest that haptics should not be included routinely in VR laparoscopic surgery training. Van Det et al. [13] (LoE1) have proposed a new training method called INtraoperative Video-Enhanced Surgical Training (INVEST) and have compared it with the traditional master-apprentice model (MAM). The conclusions are that INVEST significantly enhanced skill development during the early learning curve for laparoscopic cholecystectomy, but a balanced training program commences with essential basic skills training on VR and/or AR simulators. Elements of procedures should be practiced in box trainers with cadaveric models. Ideally, but is difficult in Europe, trainees should attend courses that use live animal model or human cadavers to perform specific procedures on healthy organs before they go to the operating theater to perform their first procedures on real patients with INVEST. A number of governing bodies and surgical societies have published guidelines that outline standards for training for postgraduate surgeons for skill acquisition in minimal access surgery, but these recommendations are based more on common sense and clinical experience than rigorous evidence.