Surgical Endoscopy

, Volume 26, Issue 11, pp 3207–3214 | Cite as

A randomized crossover trial examining low- versus high-fidelity simulation in basic laparoscopic skills training

  • Swee Chin Tan
  • Nicholas Marlow
  • John Field
  • Meryl Altree
  • Wendy Babidge
  • Peter Hewett
  • Guy J. Maddern



Previous randomized studies have compared high- versus low-fidelity laparoscopic simulators; however, no proficiency criteria were defined and results have been mixed. The purpose of this research was to determine whether there were any differences in the learning outcomes of participants who had trained to proficiency on low- or high-fidelity laparoscopic surgical simulators.


We conducted a randomized, prospective crossover trial with participants recruited from New South Wales, Western Australia, and South Australia. Participants were randomized to high-fidelity (LapSim, Surgical Science) or low-fidelity (FLS, SAGES) laparoscopic simulators and trained to proficiency in a defined number of tasks. They then crossed over to the other fidelity simulator and were tested. The outcomes of interest were the crossover mean scores, the proportion of tasks passed, and percentage passes for the crossover simulator tasks.


Of the 228 participants recruited, 100 were randomized to LapSim and 128 to FLS. Mean crossover score increased from baseline for both simulators, but there was no significant difference between them (11.0 % vs. 11.9 %). FLS-trained participants passed a significantly higher proportion of crossover tasks compared with LapSim-trained participants (0.26 vs. 0.20, p = 0.016). A significantly higher percentage of FLS-trained participants passed intracorporeal knot tying than LapSim-trained participants (35 % vs. 8 %, p < 0.001).


Similar increases in participant score from baseline illustrate that training on either simulator type is beneficial. However, FLS-trained participants demonstrated a greater ability to translate their skills to successfully complete LapSim tasks. The ability of FLS-trained participants to transfer their skills to new settings suggests the benefit of this simulator type compared with the LapSim.


FLS LapSim Proficiency-based training Simulation Surgical education Laparoscopy 


  1. 1.
    Semm K (1983) Die endoskopische Appendektomie. Gynakolog Prax 7:131–140Google Scholar
  2. 2.
    Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ (2006) Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst 4:CD006231Google Scholar
  3. 3.
    Jones DB, Brewer JD, Soper NJ (1996) The influence of three dimensional video systems on laparoscopic task performance. Surg Laparosc Endosc 6:191–192PubMedCrossRefGoogle Scholar
  4. 4.
    Gallagher AG, McClure N, McGuigan J, Ritchie K, Sheehy NP (1998) An ergonomic analysis of the fulcrum effect in the acquisition of endoscopic skills. Endoscopy 30:617–622PubMedCrossRefGoogle Scholar
  5. 5.
    Bridges M, Diamond DL (1997) The financial impact of teaching surgical residents in the operating room. Am J Surg 177:28–32CrossRefGoogle Scholar
  6. 6.
    Scott DJ, Valentine RJ, Bergen PC, Rege RV, Laycock R, Tesfay ST, Jones DB (2000) Evaluating surgical competency with the American Board of Surgery In-Training Examination, skill testing and intraoperative assessment. Surgery 128:613–622PubMedCrossRefGoogle Scholar
  7. 7.
    Fried GM, Feldman LS, Vassiliou MC, Fraser SA, Stanbridge D, Ghitulescu G, Andrew CG (2004) Proving the value of simulation in laparoscopic surgery. Ann Surg 240:518–528PubMedCrossRefGoogle Scholar
  8. 8.
    Zheng B, Hur HC, Johnson S, Swanstrom LL (2010) Validity of using Fundamentals of Laparoscopic Surgery (FLS) program to assess laparoscopic competence for gynaecologists. Surg Endosc 24:152–160PubMedCrossRefGoogle Scholar
  9. 9.
    Duffy AJ, Hogle NJ, McCarthy H, Lew JI, Egan A, Christos P, Fowler DL (2005) Construct validity for the LAPSIM laparoscopic surgical simulator. Surg Endosc 19:401–405PubMedCrossRefGoogle Scholar
  10. 10.
    van Dongen KW, Tournoij E, van der Zee DC, Schijven MP, Broeders IA (2007) Construct validity of the LapSim: can the LapSim virtual reality simulator distinguish between novices and experts? Surg Endosc 21:1413–1417PubMedCrossRefGoogle Scholar
  11. 11.
    Iwata N, Fujiwara M, Kodera Y, Tanaka C, Ohashi N, Nakayama G, Koike M, Nakao A (2011) Construct validity of the LapVR virtual-reality surgical simulator. Surg Endosc 25:423–428PubMedCrossRefGoogle Scholar
  12. 12.
    Hamilton EC, Scott DJ, Fleming JB, Rege RV, Laycock R, Bergen PC, Tesfay ST, Jones DB (2002) Comparison of video trainer and virtual reality training systems on acquisition of laparoscopic skills. Surg Endosc 16:406–411PubMedCrossRefGoogle Scholar
  13. 13.
    Lehmann KS, Ritz JP, Maass H, Cakmak HK, Kuehnapfel UG, Germer CT, Bretthauer G, Buhr HJ (2005) A prospective randomised study to test the transfer of basic psychomotor skills from virtual reality to physical reality in a comparable training setting. Ann Surg 241:442–449PubMedCrossRefGoogle Scholar
  14. 14.
    Munz Y, Kumar BD, Moorthy K, Bann S, Darzi A (2004) Laparoscopic virtual reality and box trainers: is one superior to the other? Surg Endosc 18:485–494PubMedCrossRefGoogle Scholar
  15. 15.
    Pearson AM, Gallagher AG, Rosser JC, Satava RM (2002) Evaluation of structured and quantitative training methods for teaching intracorporeal knot tying. Surg Endosc 16:130–137PubMedCrossRefGoogle Scholar
  16. 16.
    Jordan JA, Gallagher AG, McGuigan J, McClure N (2001) Virtual reality training leads to faster adaptation to the novel psychomotor restrictions encountered by laparoscopic surgeons. Surg Endosc 15:1080–1084PubMedCrossRefGoogle Scholar
  17. 17.
    Kothari SN, Kaplan BJ, DeMAria EJ, Broderick TJ, Merrell RC (2002) Training in laparoscopic suturing skills using a new computer-based virtual reality simulator (MIST–VR) provides results comparable to those with an established pelvic trainer system. J Laparoendosc Adv Surg Tech 12:167–173CrossRefGoogle Scholar
  18. 18.
    Sharpe BA, MacHaidze Z, Ogan K (2005) Randomized comparison of standard laparoscopic trainer to novel, at-home, low-cost, camera-less laparoscopic trainer. Urology 66:50–54PubMedCrossRefGoogle Scholar
  19. 19.
    Korndorffer JR Jr, Hayes DJ, Dunne JB, Sierra R, Touchard CL, Markert RJ, Scott DJ (2005) Development and transferability of a cost-effective laparoscopic camera navigation simulator. Surg Endosc 19:161–167PubMedCrossRefGoogle Scholar
  20. 20.
    Buzink SN, Botden SM, Heemskerk J, Goossens RH, de Ridder H, Jakimowicz JJ (2009) Camera navigation and tissue manipulation; are these laparoscopic skills related? Surg Endosc 23:750–757PubMedCrossRefGoogle Scholar
  21. 21.
    Kim HK, Rattner DW, Srinivasan MA (2004) Virtual-reality-based laparoscopic surgical training: the role of simulation fidelity in haptic feedback. Comput Aided Surg 9:227–234PubMedGoogle Scholar
  22. 22.
    Hiemstra E, Terveer EM, Chmarra MK, Dankelman J, Jansen FW (2011) Virtual reality in laparoscopic skills training: is haptic feedback replaceable? Minim Invasive Ther Allied Technol 20:179–184PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Swee Chin Tan
    • 1
  • Nicholas Marlow
    • 2
  • John Field
    • 3
  • Meryl Altree
    • 2
  • Wendy Babidge
    • 2
    • 4
  • Peter Hewett
    • 4
  • Guy J. Maddern
    • 2
    • 4
  1. 1.Department of SurgeryThe Royal Adelaide HospitalAdelaideAustralia
  2. 2.Research Audit and Academic Surgery DivisionRoyal Australasian College of SurgeonsAdelaideAustralia
  3. 3.John Field Consulting Pty. LtdAdelaideAustralia
  4. 4.Department of SurgeryUniversity of Adelaide and The Queen Elizabeth HospitalAdelaideAustralia

Personalised recommendations