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Scandinavian Journal of Surgery 101: 5–12, 2012
virtual reality simulator training of laparoscopic
cholecystectomies – a systematic review
t. s. ikonen
1
, t. antikainen
2
, m. silvennoinen
3
, J. isojärvi
1
, e. mäkinen
1
,
t. m. scheinin
4
1
Finnish Office for Health Technology Assessment, National Institute of Health and Welfare,
Helsinki, Finland
2
Department of Surgery, Central Hospital of Central Finland, Jyväskylä, Finland
3
Department of Computer Science and Information Systems, University of Jyväskylä,
Jyväskylä, Finlanland
4
Department of Gastrointestinal Surgery, Helsinki University Central Hospital, HUC, Helsinki, Finland
aBstract
Background and Aims: simulators are widely used in occupations where practice in au-
thentic environments would involve high human or economic risks. surgical procedures
can be simulated by increasingly complex and expensive techniques. this review gives
an update on computer-based virtual reality (vr) simulators in training for laparoscop-
ic cholecystectomies.
Materials and Methods: from leading databases (medline, cochrane, embase), ran-
domised or controlled trials and the latest systematic reviews were systematically
searched and reviewed. twelve randomised trials involving simulators were identified
and analysed, as well as four controlled studies. furthermore, seven studies comparing
black boxes and simulators were included.
Results: the results indicated any kind of simulator training (black box, vr) to be
beneficial at novice level. after vr training, novice surgeons seemed to be able to per-
form their first live cholecystectomies with fewer errors, and in one trial the positive
effect remained during the first ten cholecystectomies. no clinical follow-up data were
found. optimal learning requires skills training to be conducted as part of a systematic
training program. no data on the cost-benefit of simulators were found, the price of a
vr simulator begins at eur 60 000.
Conclusions: theoretical background to learning and limited research data support the
use of simulators in the early phases of surgical training. the cost of buying and using
simulators is justified if the risk of injuries and complications to patients can be reduced.
Developing surgical skills requires repeated training. in order to achieve optimal learn-
ing a validated training program is needed.
Key words: Virtual reality; computer simulation; computer-assisted instruction; user-computer interface;
cholecystectomy; laparoscopy; systematic review; surgery; training techniques
Correspondence:
Tuija S. Ikonen, M.D.
Finnish Office for Health Technology Assessment
National Institute of Health and Welfare
PO Box 30
FI - 00271 Helsinki, Finland
Email: tuija.ikonen@thl.fi
6 T. S. Ikonen, T. Antikainen, M. Silvennoinen, J. Isojärvi, E. Mäkinen, T. M. Scheinin
INTRODUCTION
Laparoscopic techniques are being considered as
standard methods in cholecystectomy, bariatric and
anti-reflux surgery, as well as in gynaecology, amongst
others. During 2008, altogether 7800 cholecystecto-
mies were performed in Finland, of which 85% were
laparoscopic (1). Bile duct injury is the most com-
monly reported severe complication during cholecys-
tectomy. Its incidence is higher (0.4–0.7% vs. 0.2%)
with laparoscopic technique than in open surgery
(2–6).
The specific problems of video assisted surgery are
mainly related to getting used to the instrumentation
and the ability to handle picture, space, and move-
ment in a two dimensional image (7). The instruments
are long and their paradoxical movements ergonom-
ically restricted. These challenges have recently been
reviewed in this journal (8).
Basic surgical training is insufficient for the learning
of laparoscopic surgery. Therefore, both training and
teaching environments are being improved (9, 10).
Aircraft pilots have been trained with simulators since
the beginning of the II World War and information
technology has been used in flight simulators since the
1980’s. In aviation, research results have shown that
simulator training significantly shortens the time to
reach the qualification (11). Simulation is also used in
other high-risk fields such as nuclear power plants
and military function (12). The use of surgical simula-
tors while practising different procedures aims at risk
reduction on an ethically sound basis.
Different training models (phantoms) have been
used in basic medical training outside clinical work;
e.g. in anaesthesiology. In surgery, procedure training
was started with animal models and black box train-
ing. The newest available methods are computerised
virtual reality (VR) simulators.
Simulation in surgery can be defined as learning
methods or strategies, in which a learning device or
exercises are created to reproduce or represent condi-
tions that are similar to or likely to occur in actual
performance (13). The most elementary first genera-
tion simulator is a surgical black box. It is a closed
box with an inside camera which transmits to a mon-
itor the image of three dimensional tasks being per-
formed with laparoscopic instruments. New-genera-
tion computer-based simulators use VR technology
with three dimensional graphics. Surgical tasks and
exercises are presented on a computer screen and the
instrument tips are represented on a screen as virtual
images. In the latest software versions of VR simula-
tion (e.g. LapSim and LapMentor), anatomical struc-
tures can be simulated in addition to graphical games.
These latest equipment can be used to exercise com-
plete operations or partial tasks from procedures. The
tissues are simulated as realistic as possible to enable
e.g. bleeding and perforations. Additionally, the hap-
tic sensation is available in the instrument ports as a
robotic force feedback element. The performance data
are also captured in user logs as various parameters,
which can be used to monitor training progress, as
well as to set standards and goals to skills training
and learning.
The hindrances of implementing simulators to sur-
gical training are high purchasing cost and challenges
related to integration of simulator training to clinical
practice and surgical curriculums. (14). Specific crite-
ria have been set up for effective simulation training.
Simulator training programs should be validated, ob-
jectively assessed, and mandatory for residents. The
training should be realised, distributed, and based on
proficiency, and further learning should be continued
in the real authentic situations as soon as possible
after simulator training period (15).
There are several technically advanced and expen-
sive simulators on the market, which are thought to
make possible versatile surgical training. Laparo-
scopic cholecystectomy is the most advanced simula-
tor procedure. The cost of VR simulators varies be-
tween 60 000 and 100 000 Euros. Program modules
for additional exercises or operations (such as intes-
tinal resection, gastric by-pass, hernioplasties or ad-
nex surgery) each will add the cost by 17 000 Euros.
This systematic review aims to provide an update
on computer-based virtual reality (VR) simulators in
training for laparoscopic cholecystectomies. Further-
more, skills learning with VR simulators is compared
to learning on black box trainers.
MATERIAL AND METHODS
Together with the National Institute for Health and Wel-
fare, the Finnish hospital districts have established a sys-
tematic appraisal of new technology, Managed Uptake of
Medical Methods program (MUMM, HALO-ohjelma), to
identify and evaluate new technologies in the specialised
health care. The aim of the program is to assess evidence of
safety and efficacy/effectiveness of new technologies to
support the decision making among hospital districts con-
cerning the uptake of these technologies. The council of
MUMM program gives recommendations about the ap-
plication of technologies among hospital districts by using
traffic light signals. In 2009, laparoscopic simulator training
was approved by hospital districts for a systematic litera-
ture review and assessment within the MUMM program.
The initial review was published in Finnish (16). The re-
view was focussed on the transferability of simulator
trained skills to live laparoscopic cholecystectomies.
Studies reporting the use of the newest generation of
cholecystectomy simulators in laparoscopic training were
systematically reviewed by using the following PICO set-
ting: P population of interest, I intervention, C comparator
(or control intervention), O outcome.
P: a surgical trainee learning laparoscopic cholecystec-
tomy
I: learning by a virtual reality simulator
C: patient-based training in the operation theatre, or other
forms of technical training outside the operating
theatre
(e.g. black box training)
O1: clinical outcomes in surgical patients: mortality, com-
plications, conversion to laparotomy
O2: technical measures: scores of technical skills, use of
materials, operation time, etc.
O3: learning indicators: rating of learning results, error
rates, autonomy, decision making, etc.
7Virtual reality simulator training of laparoscopic cholecystectomies – a systematic review
SYSTEMATIC REVIEW
The initial literature search was performed from Medline-,
Cochrane-, Embase- and HTA-databases in October 2009
and updated in February 2011. The search terms included
virtual reality and laparoscopic cholecystectomy among
others, and searches were conducted without language re-
strictions. Time limitation for the literature search was five
years. The ongoing trials were searched from the following
registries: Clinical Trials.gov and metaRegister of Con-
trolled Trials. The search strategies will be provided by the
authors upon request. Based on pre-set PICO criteria, alto-
gether three reviews / HTA-reports and 17 original studies
were identified, of which full text articles were ordered. The
inclusion criteria were as follows: randomised or compara-
tive studies about (virtual reality) simulation with at least
five (in randomised) or ten (non-randomised comparative)
study objects per group. Fourteen original studies met the
inclusion criteria. These studies were completed by two
older studies (three articles) recognised by one of the sys-
tematic reviews (17). Three registered ongoing trials were
found. A completion search concerning comparison of back
boxes and simulators was performed in January 2010. Al-
together 13 original studies were identified, of which seven
full text articles were included.
VALIDITY OF ORIGINAL STUDIES
For the assessment of methodological validity of original
articles, the quality criteria from the Australian Safety &
Efficacy Register of New Interventional Procedures – Surgi-
cal (ASERNIP-S) report were used (17). Only randomised
studies were assessed. Requirement for adequate quality
was fulfilled with five yes -answers including blinded as-
sessment (question 2). Not reported or unclear information
were considered as negative. The questions were as fol-
lows:
1. Was the method of randomisation adequate?
2. Was the outcome assessor blinded to the intervention?
3. Was the analysis by intention-to-treat?
4. Was the power calculation done?
5. Was the drop-out rate described and acceptable?
6. Was the timing of the outcome assessment in all groups
similar?
7. Were the assessment tools validated?
8. Were the inclusion criteria clearly described?
9. Were the groups similar at baseline regarding the most
important prognostic indicators?

RESULTS
SIMULATOR TRAINING
The health technology assessment (HTA) report of
the ASERNIP-S from 2007 was accepted as a back-
ground document and its results dealing with laparo-
scopic cholecystectomies were incorporated into our
review (17). In the ASERNIP-S report, study ques-
tions were formulated to describe how the skills
transfer to the operating room, i.e. how different
forms of simulation training influence operative out-
come in the operation room. As conclusion of the
review for laparoscopic cholecystectomy, participants
who received simulation-based training prior to con-
ducting patient-based assessment generally per-
formed better than their counterparts who did not
have this training. This improvement was not univer-
sal for all the parameters measured, but the untrained
group never outperformed the trained group. Trained
groups generally made fewer errors, and had less
instances of supervising surgeon takeover than par-
ticipants who did not have the training (17).
Nine randomised trials of VR simulators and one
of a video assisted simulator were identified to fill the
inclusion criteria (Table 1) (18–27). In addition, two
earlier studies from the ASERNIP-S review were in-
cluded to the analysis (28, 29). Apart from the basic
skills (cutting, clip placement, grasping and orienta-
tion with the camera), simulation training included
cholecystectomies at least by stages (deliberation of
the cystic duct, clip placement and cutting of vessels
and other anatomical structures, removal of the gall
bladder). One recent study tested haptics feature (27).
All reported materials were small. The study objects
comprised surgical residents with varying postgrad-
uate years, one study included medical students. In
some studies (Table 1) the effects of simulator train-
ing were described mainly with outcome measures
registered by the simulator device. Seven studies
evaluated live cholecystectomies.
The results from all studies were rather consistent:
the use of a simulator improved motor skills of the
surgical trainees when assessed by various technical
or quality measures (Table 1). The duration of the
procedure became shorter along with the training,
but this result was not considered to be of high im-
portance. The use of haptics was problematic and did
not improve the performance in one study (27). In all,
those who had trained with simulators usually per-
formed better than those who had not, at least when
measured by some of the indicators used in each
study. In one study no difference for the benefit of
training was observed (18). Six of seven studies that
evaluated live cholecystectomies resulted in signifi-
cantly better overall performance and/or fewer er-
rors in the trained group when compared to the un-
trained participants. In the study of Ahlberg et al. this
difference persisted during the first ten laparoscopic
cholecystectomies in the operation room. (22).
Four comparative studies were evaluated (30–33).
In three of them the goal was to develop a simulation
training curriculum, and in one study the effects of a
four day simulation course in addition to a basic
skills course was evaluated. As a conclusion, in order
to achieve the best benefit from simulation training,
it needs to be incorporated into a training curriculum
with pre-set goals of learning.
BLACK BOX TRAINING
From the separate literature search concerning black
boxes and VR simulators, seven randomised studies
were assessed (Table 2) (10, 34–39). The study subjects
consisted mainly of medical students – there were no
surgical trainees in the groups. The training included
basic laparoscopic skills rather than the complete per-
formance of cholecystectomy. The methods and re-
sults varied so much that it was not possible to make
definite conclusions. More or less, the technical skills
were improved with both tested training methods.
8 T. S. Ikonen, T. Antikainen, M. Silvennoinen, J. Isojärvi, E. Mäkinen, T. M. Scheinin
TABLE 1
Randomised trials of simulator training of laparoscopic cholecystectomy
Authors, Year
Country
Study ArrangementsNumber of
Participants (IG/
CG)
InterventionMethods of MeasurementResults of Technical, Time and
Quality Measures, IG vs CG
(p-value)
Authors’ ConclusionsComments
Maschuw et al.
2011, Germany
Baseline tests. Randomisation. IG:
structured simulator training for 3
months. Evaluation on VR simulator.
50 (25/25) 1
st year
surgical residents,
limited MIS
experience
IG: LapSim basic
procedure modules.
CG: no training.
Performance on LapSim
diathermy cutting.
Standardized tests for
self-efficacy, stress-coping
and motivation.
Technical: ES 2.28 vs 8.12
(0.010), EM 7.20 vs 22.16 (0.004).
Time: 141 min vs 214 min
(0.008). Quality: NA.
IG: Motivation correlated
with skills development.
CG: Stress coping and
self-efficacy correlated with
skills development.
In both groups and all
measures, marked
differences between
individuals.
Gauger et al.
2010, Michigan
USA
Randomisation. IG: proficiency
targets. IG and CG: equal access to
simulators for 4 months. Evaluation
of live LC:s.
14 (7/7) 1
st year
surgical residents,
limited MIS
experience
IG and CG: LapSim
and VR trainer box ad
libitum. IG: task-
specific proficiency
criteria.
Blinded evaluators analysed
videotapes of at least 2 LC:s
per resident by GOALS.
Technical: ES 6.20 vs 13.64
(0.004), SA 4.57 vs 3.71 (0.228).
Time: NA. Quality: Autonomy
5.00 vs 3.86 (0.147), TH 5.29
vs 4.14 (0.091).
Simulator training with
proficiency targets
improves early LC
performance.
IG trained more and
met proficiency
targets. CG failed in
most targets.
Sroka et al. 2010,
Quebec Canada
Baseline tests. Randomisation. IG:
training with FLS programme at
least 6 weeks. Evaluation on
simulator and of dissection in a live
LC.
17 (9/8) junior
residents, no MIS
experience
IG: MISTELS training
with proficiency
targets. 5 basic tasks.
CG: surgical residency.
Blinded observers evaluated
performance on simulator
and LC:s by GOALS.
Technical: FLS 95.1 vs 60.5
(0.004), SA 6.1 vs 1.8 (0.0003).
Time: NA. Quality: Autonomy
0.6 vs 0.3 (0.58), TH 1.13 vs 0.3
(0.04). FLS proficiency 8 vs 3.
Proficiency oriented
training with a physical
simulator improved the
competence of novice
surgeons better than
residency only.
MISTELS is an
inexpensive, portable,
and flexible physical
system.
Thompson et al.
2010, Ohio USA
Baseline questionnaire. Randomisa-
tion. IG1: training with haptics. IG2:
training haptics off. IG:s trained to
verified proficiency. Evaluation of 10
VR LC:s.
33 (11/11/11)
medical students,
no MIS experience
LapMentor2 (with
haptics). IG1 and IG2:
9 basic tasks. CG: all
tasks once. All: 4 LC
procedural tasks once.
Automatic data collection
and blinded observers
evaluated 10 consecutive
VR-simulator LC:s with
haptics engaged and off.
IG1 vs IG2 vs CG. Technical:
Path (right) 649 vs 570 vs 736
(0.604), (left) 179 vs 177 vs 353
(0.045). Time: 440 vs 376 vs 553
(0.036). Quality: NA.
Training with defined skills
levels was better than no
training. Haptics did not
improve the efficiency of
training.
Simulator-related
technical problems
with haptics. Only 4
students in IG:s
completed assess-
ment.
Hogle et al. 2009,
New York USA
(study 1 / 3)
Baseline tests. Randomisation. IG:
training to verified task level.
Evaluation of two live LC:s.
12 (6/6) 1
st year
surgical residents
IG: LapSim 7 basic
tasks. Level 3 to be
passed for each task.
CG: no training.
The first 2 LC:s were
videotaped and evaluated by
seniors blinded to the group
by GOALS.
Technical: SA 2.89 vs 2.82 (0.93).
Time: NA. Quality: Autonomy
3.23 vs 3.11 (0.85), TH 2.96
vs 3.10 (0.56).
No difference between
trained and untrained
residents.
One of evaluators
participated as an
assistant in LC:s.
Hogle et al. 2008,
New York USA
Evaluation of 1
st LC in pig.
Randomisation. IG: training for 5
weeks to proficiency. Evaluation of
2nd LC in pig.
21 (10/11) 1
st year
residents, no MIS
experience
IG: LapSim 7 basic
tasks. CG: hospital
residency.
LC in pig. Senior surgeons
evaluated LC videotapes
by GOALS scoring.
Technical: SA 2.7 vs 2.36. Time:
NA. Quality: Autonomy 2.90
vs 2.58, TH 2.8 vs 2.55.
Basic LapSim training to
competence lacks
predictive validity in most
GOALS domains.
Videogame players
learned faster, but
benefit not transferred
to clinical LC.
Lucas et al. 2008,
Texas USA
Baseline tests. Introduction to
simulator. Randomisation. IG:
training ad libitum for several
weeks. Evaluation of pig MIS
nephrectomy.
32 (16/16) medical
students, no MIS
experience
IG: LapMentor
multitask curriculum,
in the end virtual LC
dissections. CG: no
training.
Blinded senior surgeons
evaluated a MIS nephrec-
tomy in pig by OSATS
scoring system.
Technical: SA 2.4 vs 1.9 (0.2). IH
2.9 vs 1.7 (0.002). Time: 2.5
vs 1.9 (0.2). Quality: Flow 2.7
vs 2.1 (0.08), TH 3.1 vs 2.6 (0.3).
Simulator training and VR
LC helped to gain skills for
a different kind of
operation (MIS nephrec-
tomy).
Total score 21 vs 15.7
(0.03).
Aggarwal et al.
2007, UK
Baseline tests. Randomisation. IG:
training until a defined skills level.
Evaluation of 3 (IG) or 5 (CG) LC:s
in cadaver pig.
20 (10/10) novice
surgeons, no MIS
experience
IG: LapSim 7 tasks
curriculum and partial
LC module training.
CG: no training.
Two blinded senior surgeons
evaluated LC dissections by
OSATS. Motions of
instruments registered by
detectors.
3rd LC:s Technical: Path 49
vs 145 (0.005), EM 647 vs 1631
(0.005). Time: 1365s vs 2740s
(0.016). Quality: GRS 31 vs 24
(0.001).
A proficiency based VR
curriculum shortens
learning of MIS procedures
compared with traditional
training.
No more time or
movement differences
in IG 3
rd vs CG 5
th
LC:s.
Ahlberg et al.
2007, Sweden
Baseline tests. Randomisation. IG:
training until defined skills level.
Evaluation of ten consecutive live
LC:s.
13 (7/6) 1
st to 2
nd
year surgical
residents, no MIS
experience
IG: LapSim 7 tasks
training and simplified
gall bladder dissec-
tions. CG: hospital
residency.
Evaluation of LC:s 1, 5 and
10 by assistant and from
videotapes (blinded
assessors) with an error
scoring matrix.
Technical: ES 28.4 vs 86.2
(0.0037). Time: IG 58% faster
than CG (0.06). Quality: CG: All
3 conversions in CG.
LapSim curriculum trained
novice surgeons performed
LC:s with less hazards. The
difference persisted to the
10th LC.
More attending
takeovers in CG.
Grantcharov et
al. 2004,
Denmark
A live LC operation. Randomisation.
IG: training within 14 days.
Evaluation of 2
nd live LC.
16 (8/8) surgeons,
limited MIS
experience
IG: MIST-VR simulator
6 basic skills tasks at
least 10 times. CG: no
training.
Blinded senior surgeons
evaluated videotaped LC:s
with predefined criteria.
2nd LC vs 1
st LC Technical: ES
and EM improved in IG (0.003,
both).
Time: faster in IG (0.021).
Quality: NA.
VR training improved the
performance of surgeons
with some former
laparoscopic experience.
Difference between IG
and CG was not
tested.
*Seymour et al.
2002, Connecti-
cut USA
Baseline testing. Randomisation. IG:
training to specified expertise level
(3 to 8 sessions). Evaluation of a live
LC.
16 (8/8) 1
st to 4
th
year surgical
residents
IG: MIST-VR training
of manipulation and
electrocautery. CG:
no training.
Two surgeons evaluated
videotapes of dissection of
gall bladder with standard-
ized scores.
Technical: ES 1.19 vs 7.38
(0.006). Time: 29% faster in IG.
Quality: NA.
Simulator training with
specific target criteria
improved operative
performance.
*Scott et al. 2000,
Texas USA
Randomisation. Assessment of a live
LC. IG: training ad libitum during
allocated hours for 10 days.
Evaluation of simulator drills and
2nd live LC.
27 (13/14) 2
nd and
3rd year surgical
residents
IG: 5 video-trainer
drills. CG: no training.
1 week after training
evaluation of simulator drills
in practice. Evaluation of
LC:s using GRSOP scoring
system.
2nd LC vs 1
st LC Technical: SA
0.7 vs 0.2 (0.007). EM 1.0 vs 0.4
(0.09). Time: IG faster in all
drills. Quality: TH 0.6 vs 0.3
(0.005).
Intense training improves
video-eye-hand skills and
translates into improved
operative performance
for junior residents.
22 (9/13) were
analyzed. Difference
between IG and CG
was not tested.
IG, intervention group; CG, control group; VR, virtual reality; MIS, minimally invasive surgery; ES, error score / tissue damage; EM, economy of movement; TH, tissue handling; NA,
not assessed; LC, laparoscopic cholecystectomy; GOALS, global operative assessment of laparoscopic operative skills: depth perception, bimanual dexterity, efficiency, tissue handling,
and overall competence; SA, skills assessment / overall competence; FLS, Fundamentals of Laparoscopic Surgery; IH, instrument handling; GRS, global rating score.
* Identified from the ASERNIP-S report 2007
9Virtual reality simulator training of laparoscopic cholecystectomies – a systematic review
TABLE 2
Virtual reality (VR) simulators compared to black box trainers in learning laparoscopic skills, randomised controlled trials.
Authors, Year,
Country
Study ArrangementsNumber of
Participants (IG/
CG)
InterventionMethods of
Measurement
Results of Technical, Time and
Quality Measures, IG vs CG (p-value)
Authors’ ConclusionsComments
Ikehara et al.
2009,
Hawaii, USA
Baseline tests. Randomi-
sation. IG:s time-equiva-
lent training. Skills
assessment.
57 participants, 3
groups. No:s and
experience not
specified
IG1: VRMSS training.
IG2: Box trainer. CG: Two
chapters of telemedicine.
LapSim simulator 3
tasks
Technical: Passed 3 tasks IG1 75%,
IG2 70%, CG 40%. Time: IG1 = IG2 >
CG (0.044).
VRMSS and box trainer
similar on performance.
VRMSS provides scoring
without need of instuctor.
Poor methodological
quality. Numeric
data missing.
Chmarra et al.
2008,
The Nether-
lands
Randomisation. Tasks
presented by a movie and
verbal explanation. Tasks
with both simulators in
opposed orders.
19 (9/10)
gynaecologic
residents, some
or no MIS
experience
VR SIMENDO, Box
trainer. IG: box - VR. CG:
VR - box.
Three basic
laparoscopic tasks
with different levels
of force application
in box and VR
trainer, once on each.
Technical: Elastic band IG > CG. Tasks
of coordination IG = CG. Time: Elastic
band IG 50% faster than CG. Other
tasks IG = CG
Force application should be
trained with natural force
feedback. Eye-hand
coordination can be trained
without force feedback.
Madan et al.
2007 (SurgEn-
dosc), USA
Randomisation. Baseline
tests. IG:s video-instruc-
tion, training 10 x 20 min.
Evaluation of LC tasks in
pig.
65 (17/14/18/16)
preclinical
medical students,
no MIS experi-
ence
Training of 5 box skills or
6 VR tasks. IG1: MIST-VR.
IG2: Box (LTS 2000). IG3:
MIST-VR + box. CG: No
training.
Four predefined LC
tasks in porcine
laboratory. A blinded
examiner evaluated
the tasks by scoring
(0-100).
Technical: Total ES 1.5 vs 1.2 vs 1.3 vs
2.7 (ns). Time: IG1 = IG2. IG3 > CG in
2/4 tasks. Quality: TH 79.1 vs 82.5 vs
84.2* vs 62.8* (*< 0.005).
Combination of VR and box
trainers leads to better LC
skills than either method
alone or no training.
Optimal LC training should
incorporate both methods.
Madan et al.
2007
(JSLS), USA
Randomisation.
Video-instruction,
training 10 x 20 min.
Assessment of 1
st and 10
th
session on box trainer.
32 (18/14)
preclinical
medical students,
no MIS experi-
ence
IG: Training of 5 skills on
box (LTS 2000) 10 min
and 6 tasks on MIST-VR
10 min, CG: Box training
20 min.
Box trainer scores for
5 exercises. 1
st and
10th sessions
compared.
Technical: No differences in ES. Time:
No differences in time. In both groups
10th session better than 1
st session.
No difference in LC skills
acquisition. Training
laboratories should include
both methods.
Hypothesis:
substitution of box
trainers (with tactile
feedback) by a VR
trainer makes no
difference.
Madan et al.
2005,
USA
Introduction to LC in pig
lab. Randomisation.
Training 10 x 20 min.
Opinion survey of LC
tasks in pig.
50 (18/14/18)
preclinical
medical students,
no MIS experi-
ence
IG1: MIST-VR. IG2: Box
(LTS 2000). IG3: MIST-VR
+ box. Training fixed
tasks for 10 x 20 min.
Structured question-
naires for each group
concerning task
performance and
opinion of the device.
Quality: IG3: box trainer better for
skills development, more realistic,
more help of it (89%), more interest-
ing (56%). 83% chose box trainer
when asked to pick one.
Students perceived box
trainer better, but authors
concluded that an appropri-
ate basic skills laboratory
should have both trainers.
Apparently same
students as in other
studies of Madan et
al.
Youngblood et
al. 2005,
USA
Screening questionnaire.
Randomisation. Training
in 12 days. Evaluation in
porcine lab.
43 (17/16/13)
preclinical
medical students,
no MIS experi-
ence
Four 45 min sessions of 3
tasks x 10. IG1: LapSim.
IG2: Tower Trainer. CG:
No training.
Post-test assessment
in pig within 2
weeks. Videotapes of
3 tasks were
blindedly evaluated.
Technical: Accuracy: Tasks 1 & 3 ns.
Task 2 0.81 vs 0.68 vs 0.75 (0.039).
Time: Task 1 ns. Task 2
IG1 < IG2 = CG. Task 3 IG1 = IG2 < CG.
Quality GS: 3.31 vs 2.31 vs 2.27
(p = 0.005).
VR training overcame box
trainer. Systems to be used
for simulator training are
highly dependent on the
nature of surgical tasks to
be practised.
Munz et al.
2004,
Great Britain
Baseline tests. Randomi-
sation. IG:s training 3
weeks. Evaluation in box
trainer.
24 (8/8/8)
medical students,
no MIS experi-
ence
Weekly 30 min sessions.
IG1: LapSim. IG2:
Simulations Trainer. CG:
No training.
3 tasks on a
water-filled surgical
glove. Analysis of
motion (ICSAD) and
error scores.
Technical: Improvement in movement
IG2 > IG1 > CG. ES improved in all
groups, no difference between
groups. Time: ns.
Both trainers are equally
effective in teaching
psychomotor skills to
novices.
Five videogame
players in IG2.
Assessment on the
trainer, which IG2
practised with.
IG, intervention group; CG, control group; VRMSS, virtual reality motor skills simulator; VR, virtual reality; MIS, minimally invasive surgery; ES, error score / tissue damage; TH, tissue;
handling; LC, laparoscopic cholecystectomy; ns, not significant; GS, Global score; ICSAD, the Imperial College Surgical Assessment Device comprised of a motion-tracking system and
software.
10 T. S. Ikonen, T. Antikainen, M. Silvennoinen, J. Isojärvi, E. Mäkinen, T. M. Scheinin
METHODOLOGICAL VALIDITY OF ORIGINAL STUDIES
The quality of studies varied considerably. Nine of
twelve studies concerning simulators were estimated
to be of adequate quality (18, 20–26, 29), as well as
three of seven black box studies (36, 38, 39). Various
studies did not have comparable simulation methods
or outcome measures, which hampered drawing firm
conclusions. Furthermore, all but two studies (26, 29)
lacked the power calculation, and in most studies the
number of participants was so small, that it might
have affected the statistical analysis.
DISCUSSION
Our systematic review focussed on assessment of VR
simulators with outcome measures applicable to live
laparoscopic cholecystectomies. Disappointingly,
only few studies provided measures transferable to
clinical settings, and no long-term results could be
found of the impact of simulator training on patient
outcome. Thus, the evidence is scarce concerning the
clinical benefits. In order to clarify the relationship
between VR simulators and less expensive primitive
trainers, a completion search was performed. The box
trainers were typically tested among medical stu-
dents, whereas the studies of VR training were un-
dertaken among surgical residents.
Inexpensive simple black box or video trainers
seem to work well in teaching the basic skills of lap-
aroscopic surgery (26, 36, 39), and VR simulation did
not unambiguously seem to bring further advantage.
These box trainers are simple, durable and cheap and
suit for teaching technical details in the early stages
of surgical training. Typically their use requires pres-
ence of a tutor to achieve faultless performance. Full
procedures may be trained in black box models, but
the technical implementation is often demanding, re-
quiring animal specimens and continuous supervi-
sion. Therefore, these more complex box models are
best suited for, e.g. different training courses. Using
cadavers and animal models is expensive and usually
subject to license.
Computer based laparoscopic VR simulators
seemed to be of benefit when applied with profi-
ciency goals and as part of structured training pro-
gram with expert tuition combined with systematic
and structured evaluation (14, 40, 41). Simulator
training diminishes the number of technical mistakes,
thus enabling the surgeon to concentrate more on the
other aspects of surgery, such as decision making and
fluent performance. There is a theoretical foundation
for the use of simulators in order to improve patient
safety and skills learning. The supposition is, based
on the experience from aviation, that both motivation
and learning benefit from the simulation being as
realistic as possible. More studies are needed about
the usefulness of haptic features in VR simulators.
So far there are only preliminary data on the trans-
ference of skills learned with laparoscopic simulators
to live operations (14, 17, 22, 40). Regarding laparo-
scopic cholecystectomies, there were only seven small
randomised studies on how and to which extent the
motor skills learned with simulators were transferred
to live surgery (18, 22, 23, 25, 26, 28, 29). It is not
known what is the minimum of technical properties
needed in a simulator to achieve the training goals.
In order to measure improvement in skills, an auto-
matic recording and feed-back system is required.
Further research to assess the characteristics of opti-
mal simulator training and its timing in the curricu-
lum is required.
It is difficult to evaluate the clinical benefit of sim-
ulators as many different aspects influence the learn-
ing of surgical techniques over a long training period.
In spite of attempts to standardise evaluation criteria,
the meaning and importance of different variables
remains unclear. Research data support the assump-
tion that any kind of simulator training improves mo-
tor skills especially in the early stages of surgical
training. This could help adapt to more complicated
tasks, enhance cognitive capabilities, and eventually
reduce operative risks. Simulator training programs
with proficiency targets improved the consistency of
training and resulted in better performance (25).
According to skills learning theories, the learner is
actively involved in learning process and he/she con-
structs new knowledge on top of his/her own prior
knowledge and conceptions (42). The learner’s own
responsibility and reflection on learning and perfor-
mance are essential in the learning process. The tasks
and exercises have to be suitable to each learner’s
level of skill, and the role for instructor is to facilitate
and support the learner. Competence from the novice
level to medical (surgical) expertise is reached
through several stages (8), (43). Especially in the be-
ginning, concrete experiences and ‘learning by doing’
are fundamental (44). With simulation, the learner
encounters realistic problems and exercises, which
allow training in a controlled environment outside
the real-life situation but not without a connection to
authenticity (42, 45). Simulation allows opportunities
to explore, succeed and even fail without the risk of
harming patients.
Learners should be enabled to follow their own
progress and receive adequate feedback and evalua-
tion (46). A simulator can be connected to an interac-
tive social context in which facilitation and peer sup-
port promotes learning. Training results and expert
feedback should be available, especially in the begin-
ning, in order to avoid misapprehension (47). The
exercises should include partial tasks, supportive
feedback and several goals to strive for (46). Expertise
in complex visuo-motor skills can not be reached
without repetition and deliberate practice (48, 49).
Authentic operating situations are likely to cause ex-
tra stress for beginners and slow down the learning
process (50). The consequences of stress diminish
with experience (50). In controlled simulator training
the learner may fully concentrate on learning. In ad-
dition, the new generation simulators enable the
learning of decision making, the flow.
Besides training, simulators may be used for other
purposes. For surgeons infrequently doing laparo-
scopic procedures, simulators may provide a means
of keeping their skills up-to-date. Surgeon’s technical
skills could also be regularly assessed. Thus, a valid
11Virtual reality simulator training of laparoscopic cholecystectomies – a systematic review
license could be required from all surgeons doing
laparoscopic surgery. It has also been suggested, that
simulators could be used for choosing persons more
suitable for laparoscopic surgery. Any of these con-
cepts are not very familiar to the surgical profession,
at least in the Nordic countries. Validity for all these
issues needs further investigation.
Very little is known about the cost benefit of VR
simulators. The cost of a black box or video simulator
is only a small proportion of that of high technology
simulators. Besides the initial cost of buying a simula-
tor and appropriate software, there are continuous
expenses from its use and maintenance. E.g. simula-
tor training during working hours with tuition causes
expenses of the salaries of both trainees and trainers.
However, if simulator training leads to faster and
safer operations, this could result in savings as well.
One severe bile duct injury may necessitate even a
liver transplantation giving extra costs up to 100 000
euro (51). The value of the ethical considerations can’t
be evaluated.
Several questions remain unanswered. In the re-
port of ASERNIP-S, research recommendations were
given that remain valid. It recommends further re-
search into the transfer of skills acquired via simula-
tion-based training to the patient setting. Future stud-
ies could explore the nature and duration of training
required to deliver the greatest transfer effect, the
stage of training at which trainees receive maximum
skill transfer benefits from different forms of simula-
tion, the effect of different levels of mentoring during
the training on transfer rates, and changes in staff
productivity as a result of simulation-based training
(17). All these issues need further high quality studies
before we can conclude, whether the possible benefit
gained by a more complex simulator justifies the
higher price. Neither it is still not known, whether
training results get better with increasing complexity
of the simulator, although new providers and more
advanced simulators turn up on the market and the
use of them in surgical training is increasing.
All meaningful practise leads to the learning of
new skills. The lack of research data and the use of
simulators in different training settings made it dif-
ficult to evaluate the effect of simulators on surgical
training. To synthesise the data, current simulators
and learning programs might be of best value in set-
tings where basic surgical training is given, i.e. dur-
ing the first years of residency (in central hospitals in
the Finnish training system). So far the availability of
regular simulator training is not equally distributed,
but several courses utilising simulators are being ar-
ranged in Finland and abroad. The council of Man-
aged Uptake of Medical Methods (MUMM) consist-
ing of representatives from all hospital districts has
recently recommended that simulation training
within appropriate education programs should be
available for surgical residents. For saving invest-
ment cost, collaboration between hospital districts is
encouraged (52).
ACKNOWLEDGEMENTS
We wish to thank Tiina Lehmussaari, National Insti-
tute for Health and Welfare, for technical help.
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Received: May 30, 2011
Accepted: January 18, 2012