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Year : 2021  |  Volume : 54  |  Issue : 1  |  Page : 11-18

Virtual reality laparoscopic simulator: Training tool for surgical trainee in Malaysia

Department of Surgery, Faculty of Medicine, The National University of Malaysia, Kuala Lumpur, Malaysia

Date of Submission02-May-2020
Date of Decision02-Jul-2020
Date of Acceptance18-Aug-2020
Date of Web Publication22-Jan-2021

Correspondence Address:
Ian Chik
Department of Surgery, Faculty of Medicine, The National University of Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_59_20

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Background: Virtual reality laparoscopic simulators were introduced to provide an optimal and safe learning environment for surgical trainees. The simulators had been validated and proven to be beneficial.
Materials and Methods: The aim of this study is to assess the performance of the local surgical trainees using a validated simulator and help in the development of a training program using the simulator. Prospective repeated measures study in a single center using a validated virtual reality simulator was performed. Years 1 and 2 local postgraduate surgical trainees with limited laparoscopic cholecystectomy experience were included in the study. The trainees underwent a proposed training module, and the simulator evaluated each performance. Comparison was made between the performance before and after the training module.
Results: Nine surgical trainees (eight males, median age: 33 years old) with a median of 5 years of surgical experience after graduation were included in the study. The time to complete each basic laparoscopic skill improved between 26.5% and 64.3% (P < 0.05) while the time taken to complete each of the cholecystectomy procedural task improved between 43.2% and 73.8% (P < 0.05). The time taken to complete a full cholecystectomy procedure improved from 873s to 512s (P = 0.008), and the efficiency of cauterization improved by 15.3% (P = 0.008). Analysis of the various learning curve showed the improvement plateaued between the third and tenth sessions.
Conclusion: Virtual reality laparoscopic training should be implemented as part of training as it improves certain skill sets.

Keywords: Cholecystectomy, computer simulation, education, laparoscopic, laparoscopy, training support

How to cite this article:
Khoo HC, Chik I, Azman A, Zuhdi Z, Harunarashid H, Jarmin R. Virtual reality laparoscopic simulator: Training tool for surgical trainee in Malaysia. Formos J Surg 2021;54:11-8

How to cite this URL:
Khoo HC, Chik I, Azman A, Zuhdi Z, Harunarashid H, Jarmin R. Virtual reality laparoscopic simulator: Training tool for surgical trainee in Malaysia. Formos J Surg [serial online] 2021 [cited 2021 Mar 6];54:11-8. Available from: https://www.e-fjs.org/text.asp?2021/54/1/11/307622

  Introduction Top

Since the first laparoscopic cholecystectomy (LC) by Mühe in 1985,[1] laparoscopic surgery had since expanded its field.[2] With this, there was a significant increase in laparoscopic complications due to the steep learning curve to overcome psychomotor hurdles.[3],[4],[5]

Previous learning via apprenticeship could not be optimally applied as patients' safety may be jeopardized during the initial training stages.[6] Simulation training was then introduced with the use of box trainers, cadaveric animal models, and anesthetized animal models, each with its own advantages and disadvantages.[6] The use of simulators was to improve the motor skills during surgery, as laparoscopic surgery loses tactile sensation and certain movements in comparison to open surgery. Simulators provided a safe environment for practice before transferring the skills onto a real patient.

Virtual reality simulators (VRSs) were then introduced and have progressed to include haptic feedback and scenarios.[6] Various studies showed that VRS training improves operative performance in comparison to more traditional simulators.[7],[8],[9],[10],[11] Despite the advantages, there is a lack of dedicated simulation training programs and laparoscopic simulators.[12] A VRS with specific scenarios such as LC and its skill subsets may be helpful in reducing the learning curve.

In our local setting, laparoscopic training is provided through short courses or under the direct supervision of experienced surgeons. The aim of this study is to use a validated VRS to determine the performance level of our local surgical trainees through a training module and help in the development of a structured training program for the local surgical trainees in laparoscopic surgery.

  Materials and Methods Top


This prospective repeated-measure study was conducted in a single center at the Advanced Surgical Skills Centre, Universiti Kebangsaan Malaysia, where the virtual reality laparoscopic simulator (VRLS) was located in. The local institution research and ethics committee approved the study. UKMREC approval number: UKM FF-2015-333.

The study recruited a total of 17 participants, but only nine participants completed the entire training program to be included in the final analysis of the study. All participants were 1st and 2nd year postgraduate surgical trainees in the local specialist-training program with prior experience in assisting LC. Participants with more than five LC performed as primary surgeons, prior experience of training with VRLS and any physical disability that compromise on the usage of the simulator were excluded from the study. Consent for usage of participants information for the study was taken prior to commencement of the study.

Simulation tool

The LAP Mentor™ VRLS (Simbionix Corporation, Cleveland, Ohio, USA) was used as the simulator for this study. The simulator consisted of a touch-sensitive monitor, body which provides haptic feedback and two generic laparoscopic instruments, in which the instrument types are chosen through the on-screen menu [Figure 1]. For this study, the simulations were divided into basic laparoscopic skills, cholecystectomy procedural tasks, and full cholecystectomy procedure. The details of each skill and task are described in detail in [Table 1].
Figure 1: The LAP Mentor™ virtual reality laparoscopic simulator

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Table 1: Description of the simulation modules in the LAP Mentor™ virtual reality simulator

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Training program

All participants were given a handout on the instructions of use for the skills and tasks required 2 weeks before the study. Briefing was then given by an experienced operator to familiarize themself with the simulator before the start of the hands-on session. Participants who were not present during the briefing, were given a video recording. Before the start of the training program, participants were given their own username and password to ensure the privacy of the outcome of the study. A questionnaire consisting of demographic data, previous surgical experience, previous laparoscopic experience, and a scale to assess their confidence level was also distributed.

At the start on the training program, participants were required to watch the tutorial videos for each skill and tasks before proceeding in performing the skills and tasks for the first time. Participants then completed the full list of skills (nine basic laparoscopic skills, five cholecystectomy procedural tasks, and one complete cholecystectomy procedure) as the baseline of their performance before commencement of the training program. No assistance was provided during the hands-on sessions.

Participants then proceeded to the start of the training program consisting of three phases. Phase one consisted of ten sessions of all nine basic laparoscopic skills [Figure 2], [Figure 3], [Figure 4], phase two consisted of ten sessions of all five cholecystectomy procedural tasks [Figure 5] and [Figure 6] and phase three consisted of five sessions of full cholecystectomy procedure [Figure 7]. Each subject was required to complete each phase of training first before progressing to the next phase. The confidence level was assessed at the end of each phase of training.
Figure 2: Laparoscopic basic skills page on Simbionix LAP Mentor™ - curriculum description

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Figure 3: Laparoscopic basic skills task 1-6 on Simbionix LAP Mentor™

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Figure 4: Laparoscopic basic skills task 5-9 on Simbionix LAP Mentor™

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Figure 5: Laparoscopic cholecystectomy procedural page on Simbionix LAP Mentor™ - curriculum description

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Figure 6: Laparoscopic cholecystectomy procedural page on Simbionix LAP Mentor™

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Figure 7: Complete laparoscopic cholecystectomy procedure module on Simbionix LAP Mentor™

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Performance evaluations

The performance evaluations were done by the simulator itself after the completion of each skill. Data evaluated included time taken to complete the tasks, the accuracy rate of the skills, the efficiency of cautery, the completion of dissection, and the percentage of safe cautery. Feedback was immediately given by the simulator at the end of each session to enable to the participants to assess their own performance status. The data were then extracted for data analysis on the completion of the study.

The confidence level of the trainees to perform a LC as a primary surgeon was evaluated in the questionnaire. The level was evaluated using a simple ordinal scale of 1–10, with one being not confident and ten being very confident.

Statistical analysis

A total of eight subjects were required for this study based on paired t-test with a Type one error probability of 0.05 and power of 90% based on the time taken to complete the tasks from the previous study.[13] A total of 17 subjects were subsequently recruited due to high drop-out rate, and only nine were included in the final analysis.

As the data were not normally distributed, nonparametric tests were used to analyze the data. Wilcoxon signed-ranked tests were used to analyze the difference between the baseline and final results of each skill. Friedman's test was used to analyze the learning curve of each skill to identify the sessions in which the results had reached a plateau. Value of P < 0.05 was considered statistically significant. All data were analyzed using SPSS® version 22.0 (SPSS, Chicago, IL, USA).

  Results Top

There were a total of 8 males and 1 female postgraduate surgical trainees who completed the entire training program. The median age of the trainees was 33 years old with 5 years (interquartile range [IQR]: 4.5–6.0) of surgical training experience after graduation. All the participants had no prior experience of performing an LC as a primary surgeon but had assisted about 30 (IQR: 27.5–37.5) LC before the study was conducted.

The confidence level to perform a LC as a primary surgeon scored 1 initially, but improved to seven (Z = −2.724, P = 0.06) after the completion of the program.

Basic laparoscopic skills

The time required to complete each set of basic laparoscopic skills showed statistically significant improvement between the first session and the last session. The most notable differences are the time used to complete cutting and electrocautery skills (skill 7 and 8), with an improvement of 64.3% (P = 0.011) and 61.4% (P = 0.008), respectively. The accuracy rate also showed improvement across the first eight basic laparoscopic skills but only skills one, four, and five showed statistically significant differences with P ≤ 0.05. The efficiency of translocations in basic skills nine also showed a statistically significant improvement of 50.3% (P = 0.012). The details of the results are summarized in [Table 2].
Table 2: Summary of results for basic laparoscopic skills assessment

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The learning curve required by the participants was analyzed by repeated measures of the time required to complete each skill and to determine the session in which their performance plateau off. Only skill two (camera manipulation 30°) showed continuous significant improvement until the last session. The rest of the skills showed performance plateau off at earlier sessions.

Cholecystectomy procedural tasks

Similar results were obtained in the procedural tasks module with statistically significant improvement seen in the time required for the completion of each task. In procedural task one, involving clipping and cutting the cystic artery and cystic duct, there was an improvement of 73.8% (P = 0.008) in the time of completion. In task two, the time required improved 60.8% (P = 0.008), while in task three, 64.3% (P = 0.008) improvement was seen between the first and last session of the module. Less significant improvement was seen in task four and five, but both were still statistically significant at 52% (P = 0.008) and 43.2% (P = 0.008), respectively. The assessment of accuracy rate, completion of dissection, efficiency, and safety of cauterization are summarized in [Table 3].
Table 3: Summary of results for cholecystectomy procedural tasks assessment

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Assessment of the learning curve required by the subjects showed the performance plateau off earlier, although at a later stage compare to the basic laparoscopic skills. Task two showed no statistically significant improvement after the sixth session, while task four showed similar achievement after the seventh session. The results of task one and three achieve plateau at the eighth session, and task five only achieve plateau at the ninth session.

Full cholecystectomy procedures

The time required to complete a full-LC procedure showed an improvement on average of 361s, which was a 41.4% (P = 0.008) difference. The efficiency of cauterization also improved from 55.3% (52.85–64.35) to 70.6% (66.55–76.25) (P = 0.008). Some improvement was seen with the percentage of safe cauterization from although the result was not statistically significant. The time taken to extract gallbladder had a 42.4% (P = 0.008) improvement on the completion of all the sessions. There was no plateau of the learning curve for the full procedure before the last session [Figure 8] and [Figure 9].
Figure 8: Learning curve for time taken to complete full cholecystectomy procedure and time taken to extract gallbladder

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Figure 9: Learning curve for efficiency of cauterization and safe cauterization for full cholecystectomy procedure

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  Discussion Top

VRLSs had been developed as an alternative to the training of laparoscopic surgery out of the typical training in the operating theater. It provides a safe and controlled environment for repeated practice of tasks without compromising on the safety of patients.[6] There was, however, an initial doubt regarding the transfer of skills from the simulators to actual operating theaters.

A randomized control trial by Grantcharov et al. in Denmark involving 20 surgeons with limited laparoscopic experience, showed significant improvement in operating time, the economy of movement, and less error in comparison with those without training.[8] A randomized controlled trial by Aggarwal et al. in the United Kingdom showed that the virtual reality trained novice surgeons were able to achieve similar movement dexterity and video rating scores as the experienced surgeons' group.[9] However, the overall time in the novice group was still significantly longer.[9] A systemic review by Nagendran et al. further concluded that surgical trainees trained with VRSs achieved better operative performance and less operating time in comparison to those using box trainer training or had no training.[7] While any kind of laparoscopic simulators would improve skill, box trainers may be limited as it cannot provide particular skill sets like electrocautery, without a comprehensive set up. VRLS has a higher cost than box trainers, but it presents itself as a complete training tool. Other than a near realistic scenario visually, the haptic feedback provides some lifelike movements in comparison with a regular box trainer. While VRLS may be a more costly option, it may have a better choice in the long run in helping trainees customize to laparoscopy, and should be integrated as part of the training program for surgical trainees.[14]

In the presence of many different types of VRLS in the market, the choice of simulator must be validated before used for training. LAP Mentor™ (Simbionix, Cleveland, Ohio, USA) is one of 'he newer VRLS that enables a trainee to perform basic psychomotor skills, procedural tasks, and complete clinical procedures, with the benefit of haptic feedback and realistic imaging. Various studies had been done to validate the simulator with a positive correlation in basic laparoscopic skills,[15],[16] cholecystectomy procedural tasks, and complete cholecystectomy procedure.[17] There were studies for the creation of gastric pouch and gastro-jejunal anastomosis in bariatric surgery as well.[18] The performance evaluation of the simulator was validated in a study conducted by Matsuda et al., which showed a positive correlation between the performance evaluation systems by the simulator with actual laparoscopic performance as assessed by videotape assessment.[19] This is important as it makes it a valuable tool to track ones' progress of learning laparoscopic surgery. As it correlates to real-life performance, one can detect deficiencies and improve specific skill sets on the simulator, before transferring their skills onto a live patient. The availability of VRLS may actually improve the speed of training, as it is not limited to the availability of patients.

In our study, significant improvement was seen in the time taken to complete all the skills and tasks allocated to the surgical trainees. In basic laparoscopic skills, the time taken to complete the skills improved between 26.6% and 64.3% while the accuracy rate improved between 0% and 50.3%. These results were similar in comparison to the study conducted by Kim et al., which showed an improvement of up to 62% in completion time and up to 32% improvement in accuracy rate.[15] Fu et al. had also shown that with laparoscopic simulator training, an inexperienced group of doctors had significant improvements in performing a simulated LC after simulator training.[20] Our study showed that despite the expectations of postgraduate surgical trainees in the mastery of basic laparoscopy, the simulator was still able to help improve basic laparoscopic skills before embarking on more complicated laparoscopic procedures. Similar findings of improvement were also seen in the procedural tasks and hence improving in overall operating time.

In our local setting, surgical trainees still learn laparoscopic procedures under direct apprenticeship. Most only attend a short course or workshop before being allowed to perform procedures under the supervision of experienced surgeons. With enough cases, trainees are eventually able to perform independently. This, however, may compromise on patients' health and safety in the early stages of training, not to mention the adequacy of cases for all trainees. With the use of a validated VRLS, our local surgical trainees can hone their skills and be accurately assessed before progressing in training and thus, reducing compromise on patients' care. More importantly, as there is a breakdown of a full-LC procedure performed, the trainee may go back to the basic components he/she is lacking, to improve with further practice.

Based on the learning curve analysis of various laparoscopic skills and tasks that the trainees went through, a training module utilizing the VRLS can be proposed to be part of the surgical training program before the trainees can operate on patients under supervision. An example of a proposed training module is described in[Figure 10]. With this, the trainees would have achieved a certain proficiency in laparoscopic surgery as assessed by the simulator.
Figure 10: Proposed basic laparoscopy and laparoscopic cholecystectomy training module

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There were, however, limitations associated with this study as well as the proposed implementation of the training module. The study recruited a total of 17 participants, but only nine completed the study. This high dropout rate was due to the long period required to complete all three phases of the training process. As all the recruited participants were postgraduate surgical trainees who were involved in clinical work, research and examinations, time is a big limitation for the trainees to complete the study within the allocated time frame. A longer time frame of the study, with scheduled timetables for each trainee to use the laparoscopic simulator, would improve the sample size study. With this, the analysis of the learning curve is essential for the future planning of the training module.

Another problem associated with this is the limited availability of the VRLS in our local setting. A similar problem was also seen in a developed country[12] and this had also affected the use of the simulators for training. For the training module using the simulator to be successfully implemented as part of the surgical training in the postgraduate program, the simulator should be easily available and accessible for the trainees. Hence, every effort should be made to increase the availability and improve the accessibility of these simulators.

Finally, the simulator only trains in dexterity and economy of movement. To perform safe surgery, proper identification of structures is also vital in any surgery. The VRLS is unable to give a more realistic picture, and hence limits the identification of real-life anatomy. While this is a good tool to improve motor skills, students will also need to learn to outline important structures in a patient. The use of a laparoscopic simulator aids with training, but it may not transfer skills to a clinical setting. Våpenstad et al. in their study, showed that practice in a simulator before use in a clinical setting in medical students did not transfer skills acquired.[14] However, this needs to be studied further, particularly in surgical trainees, to determine if the laparoscopic simulator does improve surgery in a real patient.

  Conclusion Top

The various time and scores evaluated showed significant improvement after training with the VRLS, including basic laparoscopic skills, cholecystectomy procedural tasks, and full cholecystectomy procedure. VRLS could be implemented as part of the training tool for surgical trainees in the local setting. Learning and training can be achieved in a controlled and safe environment before progressing to the next step of training in the operating theater.


We would like to thank the Advanced Surgical Skills Centre of the National University of Malaysia Medical Centre for allowing the study to be conducted on the premises and the use of the laparoscopic trainer.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Richardson MC, Bell G, Fullarton GM. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: An audit of 5913 cases. West of Scotland Laparoscopic Cholecystectomy Audit Group. Br J Surg 1996;83:1356-60.  Back to cited text no. 4
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Giannotti D, Patrizi G, Casella G, Di Rocco G, Marchetti M, Frezzotti F, et al. Can virtual reality simulators be a certification tool for bariatric surgeons? Surg Endosc 2014;28:242-8.  Back to cited text no. 18
Matsuda T, McDougall EM, Ono Y, Hattori R, Baba S, Iwamura M, et al. Positive correlation between motion analysis data on the LapMentor virtual reality laparoscopic surgical simulator and the results from videotape assessment of real laparoscopic surgeries. J Endourol 2012;26:1506-11.  Back to cited text no. 19
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]

  [Table 1], [Table 2], [Table 3]


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