The Egyptian Journal of Surgery

: 2017  |  Volume : 36  |  Issue : 4  |  Page : 336--339

A comparative study on the effect of laparoscopic simulation on skill training in laparoscopic surgery

Mohamed Lotfy, Mohamed I Abdelhamid, Hazem N Ashri 
 Department of General and Laparoscopic Surgery, Faculty of Medicine, Zagazig University, Zagzig, Egypt

Correspondence Address:
Mohamed Lotfy
Department of General and Laparoscopic Surgery, Zagazig University, Zagazig, 44629


Context This study examined the effect of using laparoscopic simulation on the enhancement of psychomotor capabilities linked to performing laparoscopic appendectomy. Participants and methods Thirty surgical trainees carried out a laparoscopic appendectomy in the operating room (OR). The participants were then randomized to have a training course of six sessions (1 h each) on our simple simulator (MED-SIMU) or no training. Subsequently, all participants performed a further laparoscopic appendectomy in the OR. Both operations of each participant were recorded on video tapes, and assessed by two blinded laparoscopic senior surgeons using the predefined objective criteria such as time to complete the operation and the error counting. Results No differences in baseline variables were found between the two groups. Surgeons who received simulator training carried out laparoscopic appendectomy significantly faster than those in the control group (P=0.0006) and showed a greater improvement in error (P=0.0001). Conclusion Surgeons who had simulator training showed a greater enhancement in performance in the OR than those in the control group. Our simple surgical simulator is, therefore, a suitable tool for the training of laparoscopic motor skills and could be included in surgical training programs.

How to cite this article:
Lotfy M, Abdelhamid MI, Ashri HN. A comparative study on the effect of laparoscopic simulation on skill training in laparoscopic surgery.Egypt J Surg 2017;36:336-339

How to cite this URL:
Lotfy M, Abdelhamid MI, Ashri HN. A comparative study on the effect of laparoscopic simulation on skill training in laparoscopic surgery. Egypt J Surg [serial online] 2017 [cited 2017 Nov 21 ];36:336-339
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Laparoscopy has grown to be the standard progress for many conditions in almost all surgical specialties [1],[2],[3]. It is obvious, however, that during the learning curve of the surgeons, laparoscopy is accompanied with a longer operation time and a superior rate of surgical complications. [4],[5],[6],[7],[8]. The possibility of beating these problems throughout the learning curve by appropriate training and ensuring that surgeons carry out enough number of cases are also been known [9]. The first obstacles in learning laparoscopy are psychomotor and perceptual. Focusing on patients’ safety and rights and concern over costs of operating theater time are factors that confront the conventional surgical approach and give an increasing need for new methods in the training of laparoscopic surgeons [10]. Although simulation comes with important advantages in the spot of training for novel capabilities and procedures, proof of the shift of skills from the fake environment to the operating room is still inadequate [11],[12].

 Participants and methods

This study was carried out in the Emergency Department in Zagazig University Hospitals during February 2017. Participants were employed between March 2014 and March 2016. Thirty surgeons with limited practice in laparoscopic surgery (two to five laparoscopic appendectomies) participated in the study. All participants did a laparoscopic appendectomy, supervised by an experienced laparoscopic surgeon. The participants were then randomized to either a group that received training on our simple simulator (MED-SIMU, lyd917, China) ([Figure 1]) or a control group that did not receive training. Randomization was done using closed envelopes. Training included six sessions (1 h each) in 3 weeks. Six tasks were of increasing difficulty and were designed to imitate the techniques used during the laparoscopic appendectomy. Task 1, the participant was asked to hold a sphere and place it in a small box. In task 2, the sphere was held, transferred between instruments, and then put in the box. Task 3 consisted of holding alternately the parts of a pipe. Task 4 required the participant to hold the sphere, touch it with the tip of the other instrument, remove and re-enter this instrument, and once more touch the sphere. Task 5 involved putting a thread through a sequence of holes. Task 6 involved making an intracorporeal knot. Within 3 weeks after the initial operation, all participants carried out another laparoscopic appendectomy, supervised by an expert laparoscopic surgeon who was blinded to the training status. The operations carried out by the participants were documented on video tapes and assessed by two senior surgeons highly skilled in laparoscopic surgery. We compared the time required to carry out the two operations for each surgeon and calculated the number of errors mentioned by the reviewers in the two operations for each surgeon. Errors were related to the psychomotor skills only and not related to the technical knowledge and anatomy. Cases presented with complications or discovered as complicated during surgery were excluded and the participant submitted to operate another case. The only assessed component of the operation was starting from the point at which dissection the mesoappendix took place and control of the base and removing the specimen outside the abdominal cavity. All cases were operated via three ports (supraumbilical, left iliac fossa, and suprapubic). The video tapes reviewers were blinded to the training category of the participants and performed the evaluation independently. The statistical analysis was done using data from the 30 surgeons.{Figure 1}


We statistically analyzed 30 participants (15 in each group) whose operative procedures were documented on video tapes; their flow is demonstrated in [Figure 2]. The demographic data of the participants are shown in [Table 1]. There was a fair agreement in the assessment scores provided by the two reviewers related to changes in the time taken to complete the operation, and error counted between the first and the second laparoscopic appendectomies, as shown in [Table 2]. Participants who received simulator training performed laparoscopic appendectomy significantly faster than did individuals in the control group (P=0.0006, t-test). Furthermore, the simulator-trained group showed considerably greater progress in their error (P=0.0001, t-test).{Figure 2}{Table 1}{Table 2}


Enormous types of simulators exist for laparoscopic training in general surgery with different degrees of validity and dependability. They differ widely in their platforms (physical or virtual reality) [13]. Physical simulators contain a box trainer and real instruments (as used in the laparoscopic theater). The equipment used in those simulators can offer texture and behavior like real tissues. The measurement method can be scored by a trained viewer [14],[15],[16],[17]. Mammal’s models have also been used to advance laparoscopic skills [18],[19],[20],[21]. The conversion from the ‘dry lab’ to the ‘wet lab’ should be a necessary part of the exercise procedure of a laparoscopic surgeon. Animal training models offer an extensive variety of training applications, but although this is important, it is also costly and we do not have an animal lab in our hospital.

Most training devices such as pelvic trainers or VR simulators provide training abilities with a spotlight on eye-hand harmonization, targeting the skill of suturing and knotting techniques. The low cost of pelvic trainers has paved the way for their widespread use [22]. We have adopted the use of a simple simulator (MED-SIMU) consisting of a box with four lateral ports for a needle holder and forceps, while a camera and PC monitor are used to simulate a two-dimensional laparoscopic field. Similar equipment for laparoscopic training had been described by Beatty [22].

In our study, training schedule was for 6 h for each trainee (2 h weekly) and this was double the training hours in a similar study conducted by Ahlberg et al. [23], who denoted no improvement in skills after training with a VR simulator. However, the participants in that study were trained for 3 h, and may not have reached the area of stability in their learning curves. A previous study established that the learning curve for junior surgeons reached an area of stability after eight repetitions of the whole six tasks, a course that may need more than 3 h of training [23]. This study discovered that there was a significant reduction in the time of the second operation in the trained group, more than that in the nontrained group; this was in agreement with Grantcharov et al. [24] in a similar study.Our study revealed that there was a significant reduction in the number of psychomotor errors in the trained group, more than that in the nontrained group; this was in agreement with Grantcharov et al. [24]. In our study, we used a MED-SIMU simulator that costs around 500 US dollars including the shipping, which is much cheaper than the virtual simulator fees, and provided a thorough training of our junior staff.


Laparoscopic surgery has a significant component in the field of surgical therapy and includes procedures with variant levels of complexity. Therefore, laparoscopy should be an important component of the training for junior surgical staff. In this study, surgeons who had simulator training showed a considerably greater advance in performance in the operating room than did those in the control group. MED-SIMU laparoscopy trainer represents a promising economic tool for training in laparoscopic surgery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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