Advertisement

Surgical Endoscopy

, Volume 31, Issue 1, pp 38–48 | Cite as

A systematic review of low-cost laparoscopic simulators

  • Mimi M. LiEmail author
  • Joseph George
Open Access
Review

Abstract

Background

Opportunities for surgical skills practice using high-fidelity simulation in the workplace are limited due to cost, time and geographical constraints, and accessibility to junior trainees. An alternative is needed to practise laparoscopic skills at home. Our objective was to undertake a systematic review of low-cost laparoscopic simulators.

Method

A systematic review was undertaken according to PRISMA guidelines. MEDLINE/EMBASE was searched for articles between 1990 and 2014. We included articles describing portable and low-cost laparoscopic simulators that were ready-made or suitable for assembly; articles not in English, with inadequate descriptions of the simulator, and costs >£1500 were excluded. Validation, equipment needed, cost, and ease of assembly were examined.

Results

Seventy-three unique simulators were identified (60 non-commercial, 13 commercial); 55 % (33) of non-commercial trainers were subject to at least one type of validation compared with 92 % (12) of commercial trainers. Commercial simulators had better face validation compared with non-commercial. The cost ranged from £3 to £216 for non-commercial and £60 to £1007 for commercial simulators. Key components of simulator construction were identified as abdominal cavity and wall, port site, light source, visualisation, and camera monitor. Laptop computers were prerequisite where direct vision was not used. Non-commercial models commonly utilised retail off-the-shelf components, which allowed reduction in costs and greater ease of construction.

Conclusion

The models described provide simple and affordable options for self-assembly, although a significant proportion have not been subject to any validation. Portable simulators may be the most equitable solution to allow regular basic skills practice (e.g. suturing, knot-tying) for junior surgical trainees.

Keywords

Laparoscopic Simulation Trainer Trainee Model Low-cost 

The use of laparoscopic surgery has become widely established in clinical practice, with the acquisition of laparoscopic skills now essential for surgical trainees. The technical skills required are, however, distinct from those needed for open surgery; depth perception is impaired due to visualisation on a two-dimensional screen, there is limited tactile feedback, and long laparoscopic instruments create a fulcrum effect and amplify tremor. There is a significant learning curve associated with laparoscopic surgery, and these skills cannot be easily learnt using the traditional apprentice model of surgical training [1].

Simulation is widely regarded as the way forward, and its use has been shown to improve laparoscopic surgical skills in trainees [2, 3]. Simulation offers the opportunity to improve technical skills in a structured, low-pressure environment outside of the operating theatre without risk to patient safety [4]. Different methods of simulation have been described, ranging from high-fidelity virtual reality systems and animal models to low-fidelity box trainers. Box trainers generally have a less realistic interface and are designed for the practice of generic skills required for laparoscopic surgery, such as instrument handling, cutting, and intracorporeal suturing. Virtual reality simulation uses computer-generated graphics and tactile feedback to recreate the operating environment, facilitating practice of procedural-specific skills as well as generic laparoscopic skills [5, 6]. Virtual reality systems are, however, very cost prohibitive and may be inaccessible to many trainees for regular personal use [7]. With the implementation of the European Working Time Directive, opportunities for surgical trainees to gain operative experience in the workplace have also become more limited [8]. A low-cost alternative is needed for trainees to be able to practise and develop their laparoscopic skills outside the workplace. Our objective was to undertake a systematic review of low-cost laparoscopic simulators suitable for home use.

Methods

A systematic review was undertaken according to PRISMA guidelines [9] to define the properties of low-cost laparoscopic simulators. MEDLINE and EMBASE databases were searched for articles on low-cost laparoscopic simulators published between January 1990 and August 2014. The search terms used were (laparoscopic or thoracoscopic or urological or gynaecological or gynaecological), (simulator or simulation or trainer or training), and (low-cost or home-made or inexpensive or DIY or cheap). Relevant articles from the search were identified by their titles and abstracts; the full paper was then assessed for inclusion. Reference lists for relevant articles were also examined to identify additional studies not identified by the original search.

Articles included were those describing low-cost laparoscopic simulators, which were ready-made or suitable for self-assembly. Articles not written in English, with inadequate descriptions of the simulator, and costs of >£1500 were excluded. The simulators described were categorised into commercial (commercially available or intended for commercial use) and non-commercial (intended for self-assembly). Validation, cost, equipment required, and ease of assembly were examined. For ease of comparison, simulator prices in other currencies were converted into British Pound Sterling using the exchange rate on 16 August 2014. We examined whether any form of validation had been described by the authors. The face validity of each simulator was also rated based on pre-defined criteria for the abdominal cavity and visualisation, giving a score between 0 and 6 (see Table 1).
Table 1

Face validity rating system for laparoscopic simulators

Abdominal cavity

Visualisation

 Enclosed cavity

 Use of camera

 Elastic/flexible wall

 Easily adjustable camera

 Trocar used at port site

 Dedicated light source

A0—does not fulfil any of the criteria

B0—does not fulfil any of the criteria

A1—fulfils 1 criterion

B1—fulfils 1 criterion

A2—fulfils 2 criteria

B2—fulfils 2 criteria

A3—fulfils all 3 criteria

B3—fulfils all 3 criteria

Total score: A + B (out of 6)

Results

The results of the search are summarised in Fig. 1. 73 unique simulators were identified from 71 articles: 60 were non-commercial (Table 2) and 13 were commercial (Table 3); 55 % (33) of non-commercial trainers were subject to at least one type of validation compared with 92 % (12) of commercial trainers (Table 4). Commercial simulators were already constructed and ready to use, whereas non-commercial simulators required sourcing and self-assembly of materials. The key components required for non-commercial simulator construction were identified as abdominal cavity and wall, laparoscopic port site, light source, visualisation, and camera monitor.
Fig. 1

PRISMA flow diagram of study selection for the systematic review

Table 2

Non-commercial laparoscopic simulator model comparison: 55 papers describing 57 unique simulators

Paper

Cost

Undergone validation

Face validity Score

Abdominal cavity

Abdominal wall

Port sites

Light source

Visualisation

Camera monitor

1991

Sackier (USA) [32]/

Yes

6 (A3 B3)

Custom-made black perspex box; rubber sheet sides

Black perspex

Hole; rubber gasket; trochar

Laparoscope

Laparoscope

Unspecified

1998

Chung (USA) [56]

1992

Majeed (UK) [33]

No

5 (A2 B3)

Metal frame

Black perspex double sheet

Hole; rubber disc; trocar

External lighting

Laparoscope

Video monitor

1992

Mughal (UK) [10]

£75

No

4 (A1 B3)

Opaque plastic storage box

Clear perspex lid

Hole; plastic floor tile; trocar

20 W strip lamps

Laparoscope (or direct vision)

Video monitor

1995

Gue (Australia/NZ) [43]

No

3 (A1 B2)

Small coffee table/TV stand

Black plastic sheet; wire mesh

Hole; trocar

Table lamp

Video camera

TV screen

1996

Shapiro (USA) [57]

Yes

6 (A3 B3)

Custom-made plastic box

Flexible plastic covering

Hole; trocar

Laparoscope

Laparoscope

Video monitor

2001

Hasson (USA) [58]

Yes

6 (A3, B3)

Custom-made metal box

Rubber sheet

Hole; rubber sheet; trocar

Laparoscope

Laparoscope (or camcorder)

Video monitor

2003

Lee (UK) [44]

No

4 (A1 B3)

Computer game station (tiered table)

Table top

Anchored trocar

Lamp; external lighting

Camcorder

TV screen

2004

Pokorny (NZ) [11]

NZ $200 (£101.69)

No

4 (A2 B2)

Translucent plastic storage box

Rubber foam sheet over plastic lid

Hole; rubber foam sheet

External lighting

Spy cam; plastic pipe

TV screen

2005

Beatty (UK) [12]

£50

No

2 (A1 B1)

Clear plastic storage box

Clear plastic lid

Hole

External lighting (bright room/lamp)

Webcam

Unspecified

2005

Blacker (UK) [24]

No

3 (A1 B2)

Desk drawer

Cardboard

Hole

Desk lamp/strip lamps

Webcam

Desktop computer monitor

No

3 (A1 B2)

Brick-weighted cardboard box

Cardboard

Hole

Desk lamp

Digital camera

Desktop computer monitor

2005

Chung (USA) [25]

Yes

2 (A1 B1)

Cut-out cardboard box

Cardboard

Hole

External lighting

Webcam

Laptop

2005

2007

Ricchiuiti (USA) [13]/Bell (USA) [14]

US $360 (£215.70)

No

6 (A3 B3)

Plastic storage box

Plastic lid; plastic sheet

Reinforced hole; neoprene; trocar

Laparoscope/halogen lights

Laparoscope

TV screen

2005

Sharpe (USA) [48]

US $185 (£110.84)

Yes

0 (A0 B0)

Custom-made plastic box

Clear plastic lid

Hole

External lighting

Direct vision

N/A

2006

Chandrasekera (UK) [26]

Yes

1 (A1 B0)

Cut-out cardboard box

Cardboard

Hole; trocar

External lighting

Direct vision (unilaterally blinded)

N/A

2006

Do (USA) [59]

Yes

5 (A2 B3)

2 large plastic basins

Plastic basin base

Hole; trocar

Lamp

Video camera

Laptop

2006

Griffin (UK) [45]

Yes

2 (A0 B2)

Custom-made wooden frame

Thin wooden sheet

Hole

Desk lamp

Camcorder

TV screen

2006

2006

Nataraja (UK) [60]/Nataraja (UK) [61]

Yes

3 (A0 B3)

Perspex box

Darkened perspex lid

Hole

Laparoscope

Laparoscope

TV screen

2006

Robinson (USA) [36]

US $50 (£29.96)

Yes

0 (A0 B0)

Custom-made metal box

Metal lid

Hole; unspecified covering material

External lighting

Mirrors

Mirrors

2007

Dhariwal (India) [42]

Yes

5 (A2 B3)

Custom-made plastic box

Black plastic lid

Hole; rubber gasket; trocar

Fibre-optic light source

Laparoscope

Video monitor

2007

Haveran (USA) [46]

Yes

2 (A0 B2)

Adjustable height posts; wooden sheet

Neoprene; plexiglass frame

Hole

Xenon light source

Camera

TV screen

2007

Martinez (Mexico) [34]

No

5 (A2 B3)

Custom-made semi-cylindrical metal box

Metal

Hole; rubber covering

Fluorescent lamp

Video camera; mirror

TV screen

2008

Clevin (Denmark) [62]

Yes

5 (A2 B3)

White plastic wash tub

Plastic

Hole; trocar

Laparoscope

Laparoscope

Unspecified

2008

Dennis (UK) [35]

£150

No

4 (A2 B2)

Custom-made wooden box

Plaster of paris

Hole; rubber grommet

Bicycle light

Camcorder

Camcorder screen

2008

Mir (India) [27]

No

4 (A1 B3)

Cardboard box

Cardboard

Hole

Laparoscope

Laparoscope

TV screen

2008

Raptis (UK) [15]

£27

No

3 (A2 B1)

Opaque plastic box

Plastic

Hole; trocar

None

Night-vision camera

Computer monitor/TV screen

2008

Sparks (USA) [39]

US $150 (£89.87)

No

3 (A1 B2)

Plywood box; foam board

Plywood hinged lid

Hole

Fluorescent light

Webcam

Laptop

2009

Al-Abed (UK) [16]

£40

No

6 (A3 B3)

Plastic storage box

Foam; latex gloves

Hole; trocar

Halogen light

Webcam; plastic pipe

Laptop

2009

Helmy (Egypt) [40]

Yes

4 (A2 B2)

White foam food storage box

Foam box lid

Hole; trocar

Webcam in-built

Webcam

Laptop

2009

Pawar (India) [47]

No

3 (A1 B2)

Plywood board box

Plywood

Hole

Tube light

Digital camera

TV screen

2009

Jain (India) [63]

Yes

6 (A3 B3)

Custom-made box (unspecified material)

Elastic rubber sheet

Hole; trocar

Laparoscope

Laparoscope

Video monitor

2009

Singh (UK) [28]

No

4 (A2 B2)

Shoebox

Cardboard

Hole; trocar

Desk lamp

Digital camera

TV monitor/computer monitor

2010

Jaber (Saudi Arabia) [64]

US $41 (£24.57)

No

2 (A1 B1)

Metallic wire basket; acrylic sheet

Rubber mouse pad

Hole

External lighting

Webcam

Laptop

2010

Rabie (Saudi Arabia) [29]

No

3 (A1 B2)

Half large plastic water container; plywood board

Plastic

Hole; trocar

Light bulb

Video camera

TV screen

2010

Rivas (Spain) [17]

Yes

4 (A2 B2)

Translucent plastic storage box

Plastic

Reinforced hole; trocar

External lighting

Micro-camera; tube

TV screen

2010

Oliver (UK) [65]

Yes

3 (A1 B2)

Cardboard box

Cardboard lid

Hole

Desk light

Webcam

Laptop

2010

Ramalingam (India) [66]

Yes

5 (A2 B3)

Custom-made white box (unspecified material)

Box lid

Hole; rubber sheet; trocar/tube

Laparoscope

Laparoscope

TV screen

2011

Alfa-Wali (UK) [30]

Yes

3 (A1 B2)

Shoe box

Cardboard

Hole

Torch

Mobile phone camera

Phone screen

2011

Khine (UK) [18]

£60

No

5 (A3 B2)

Translucent plastic storage box

Foldable plastic lid

Hole; neoprene; trocar

Fluorescent light

Webcam

Laptop/desktop computer

2011

Kobayashi (USA) [20]

US $100 (£59.92)

Yes

3 (A2 B1)

Translucent plastic storage box

Plastic lid

Hole; rubber strip

External lighting

Webcam

Laptop

2011

Kiely (Canada) [19] 5 simulators

C $100-160 (£54.98-£87.97)

Yes

3 (A2 B1)

Translucent plastic storage box

Plastic lid

Hole; trocar

External lighting

Webcam (various brands)

Laptop/desktop computer (various brands)

2012

Afuwape (Nigeria) [67]

US $34 (£20.37)

No

2 (A1 B1)

Recycled plastic liquid container; plywood board

Plastic

Hole

External lighting

Webcam

Laptop

2012

Bahsoun (UK) [31]

Yes

3 (A3 B1)

Cut-out cardboard box; polystyrene

Cardboard

Hole; trocar

External lighting

iPad camera

iPad screen

2013

Akdemir (Turkey) [68]

Yes

4 (A1 B3)

Custom-made plastic box

Plastic

Hole; trocar

Laparoscope

Laparoscope

Video monitor

2013

Hennessey (Australia) [69]

No

2 (A1 B1)

None

Laptop lid

Trocar; string; skirt hanger

External lighting

Webcam

Laptop

2013

Moreira-Pinto (Portugal) [21]

€33.67 (£26.99)

Yes

4 (A3 B1)

Translucent plastic storage box

Cut-out plastic lid; rubber sheet

Hole; trocar

External lighting

Webcam

Laptop

2013

Omokanye (Nigeria) [41]

No

4 (A2 B2)

Plywood box

Box lid

Hole; foam piece

Camera in-built; light bulb

IR CCTV Camera

TV screen

2013

Ruparel (USA) [37]

US $5 (£3.00)

Yes

1 (A0 B1)

Ring binder

Ring binder

Hole

External lighting

iPad camera

iPad screen

  

US $5 (£3.00)

Yes

2 (A1 B1)

Cut-out cardboard box

Cardboard

Hole

External lighting

iPad camera

iPad screen

2013

Smith (UK) [70]

US $100 (£59.92)

No

4 (A2 B2)

Plastic crate, plywood and cork sheet

Plastic

Hole; trocar; plastic rings

LED lamp

Webcam

Laptop

US $130 (£77.89)

No

5 (A3 B2)

Upgraded version: add plywood frame and foam pads to port site

2013

Wong (USA) [71]

US $309 (£185.14)

Yes

4 (A2 B2)

Custom-made hard plastic box

Vinyl membrane glued to plastic frame

Hole; trocar

LED strip

Miniature CCD camera

Video monitor

2014

Beard (USA) [22]

US $85 (£50.93)

Yes

3 (A2 B1)

Translucent plastic storage box

Plastic lid

Hole; flexible material cover

External lighting

Webcam

Laptop

2014

Escamirosa (Mexico) [38]

No

2 (A1 B1)

Clear plastic document case

Plastic

Hole

External lighting

Smartphone or tablet camera

Video monitor

2014

Walczak (Poland) [23]

US $51 (£30.56)

No

3 (A2 B1)

Translucent plastic storage box

Opaque plastic lid

Hole; rubber sheet; metal washer; trocar

LED light bulb

Mirrors

Mirrors

  

US $99 (£59.32)

No

5 (A3 B2)

Translucent plastic storage box

Opaque plastic lid

Hole; rubber sheet; metal washer; trocar

LED light bulb

Webcam

Home computer

Table 3

Commercial laparoscopic simulator model comparison: 16 papers describing 14 unique simulators

Paper

Simulator

Price

Validation

Face validity

1998

Derossis [72]/Keyser [73]

USSC Laptrainer

Yes

6 (A3 B3)

2000

2000

Scott [74] /Nakamura [55]

Karl-Storz

Yes

6 (A3 B3)

2011

2003

Adrales [75]/Adrales [76]

US Surgical Trainer

Yes

5 (A2 B3)

2004

2005

Waseda [77]

Tuebinger MIC Trainer (Richard Wolf GmbH)

No

6 (A3 B3)

2007

Hruby [49]

EZ Trainer

$600 (£359.50)

Yes

1 (A0 B1)

2008

Dayan [78]/Boon [79]

Simulab Laptrainer

Yes

3 (A0 B3)

2008

2008

Singh [80]

iSim

Yes

3 (A1 B2)

2010

Hull [81]

Body Torso Trainer BTS300D (Pharmabotics)

£390 ($585) + £975 for Box trainer

No

6 (A3 B3)

2011

Nakamura [55]

Ethicon TASKit

Yes

6 (A3 B3)

2013

Xiao [51]/Xiao [52]

Ergo-Lap

$500 (£299.58)

Yes

5 (A2 B3)

2014

2014

Yoon [53]

iTrainer

$100 (£59.92)

Yes

1 (A0 B1)

2013

Hennessey [50]

eoSim

$750 (£449.37)

Yes

3 (A1 B2)

  

FLS simulator

$1680 (£1006.58)

Yes

5 (A3 B2)

Table 4

Comparison between commercial and non-commercial simulators

 

Non-commercial simulators

Commercial simulators

Unique simulators

60

13

Price range

£3.00–£215.70

£59.92–£1006.58

Subject to validation (%)

33 (55 %)

12 (92 %)

Average Face Validity Score

3 (A2 B2)

5 (A3 B2)

Abdominal cavity and wall

Materials used to simulate the abdominal cavity aimed to prevent direct vision of the laparoscopic instruments; 68 % (41) of non-commercial simulators utilised off-the-shelf components for the abdomen, whilst 32 % (19) required a custom-made box. The commonest off-the-shelf component was a plastic storage box for the abdominal cavity, with the box lid serving as the abdominal wall [10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23]. Cardboard boxes were also commonly utilised [24, 25, 26, 27, 28, 29, 30, 31].

Laparoscopic port site

The majority of non-commercial simulators (97 %, 58) required creating a hole in the abdominal wall material (by cutting, drilling or piercing) for the laparoscopic port site. Instruments could then be inserted directly into the cavity or through a trocar. Use of a flexible covering material, such as neoprene [13, 18], and ring reinforcement around the port site [13, 32, 33, 34, 35] were also described as methods to increase simulator authenticity.

Primary light source

An adequate light source was required to visualise the interior of the abdominal cavity. External lighting was used for 38 % (23) of non-commercial simulators, particularly where boxes were made from a translucent material [11, 12, 17, 21] or had open sides [36, 37, 38]. This was useful in cost reduction, as no additional equipment was required to provide lighting in these cases. The built-in light source from the laparoscope itself provided lighting for 17 % (10) of simulators, desk lamps for 13 % (8), and light-emitting diodes (LED) for 8 % (5). Other lighting methods described included fluorescent lights [18, 34, 39], webcam in-built [40, 41], fibre optics [42], and torchlight [30].

Visualisation and camera monitor

Visualisation for non-commercial simulators was most commonly achieved using a webcam (37 %, 22) or laparoscope (22 %, 13). Other cameras types described included video cameras [29, 34, 43, 44, 45], digital cameras [24, 28, 46, 47], and tablet/smartphone cameras [30, 31, 37, 38]. Direct vision (full [10, 48] or unilaterally blinded [26]) and mirrors [23, 36] were non-electronic methods of visualisation described. Where electronic visualisation was used, a laptop computer, video monitor, tablet, or smartphone were prerequisite and not included in any cost estimates; this was true of both commercial and non-commercial simulators; 40 % (24) of models described use of a laptop/desktop computer screen and 38 % (23) described using a television or video monitor.

Cost

Forty-six percentage (26) of non-commercial and 54 % (6) of commercial simulators provided a figure for cost. For non-commercial, this was the cost of materials and assembly (e.g. custom-made parts); for commercial simulators, the cost represented the current or intended retail price. The cost ranged from £3 to £216 for non-commercial simulators and £60 to £1007 for commercial simulators. The cost of laparoscopic equipment (instruments and laparoscope) was not included in cost estimates for non-commercial simulators. However, a number of articles suggested that used or expired disposable instruments could be obtained from the operating department at no cost to the trainee [16, 23, 24, 25, 26, 39, 40, 44]. Alternatively, they could also be obtained by donation from laparoscopic equipment manufacturers [15, 20, 26]. Electronic devices for visualisation (video monitor, laptop computer, tablet/smartphone) were not included in cost estimates for non-commercial simulators. Laparoscopic equipment and visualisation monitors were also not consistently included for commercial simulator model packages [49, 50, 51, 52].

Face validity

Commercial simulators had better face validity than non-commercial simulators, with a median score of 5 compared to 3 (maximum 6). Commercial simulators tended to utilise higher-fidelity visualisation equipment, with a median visualisation score of B3 compared with B2 for non-commercial simulators. For the abdominal cavity, there was comparable face validity, with both groups having a median score of A2.

Discussion

Cost will undeniably be a key factor in the accessibility of a simulator model. Many articles omitted cost estimates, so there is difficulty in making a true cost comparison between commercial and non-commercial simulators available. Although there is an overlap in the price range, non-commercial models appear to be able to achieve a lower cost than commercial ones, with the lowest reported figure being $5 (£3) compared to $100 (£60) for a commercial model [37, 53]. This difference could be due to commercial models factoring in a profit margin and assembly fee in addition to the value of the raw materials. Moreover, commercial models will usually include expensive laparoscopic instruments in the cost, which could potentially be obtained cost-free when self-assembling [16, 23, 24, 25, 26, 44].

Non-commercial models commonly utilised off-the-shelf components—a potentially a cost-reductive strategy, as custom-made parts could incur a greater expense. In particular, the use of a translucent plastic box provided a sturdy frame and utilised external lighting, negating the need for an additional light source inside the box [11, 12, 17, 21]. Visualisation using a webcam and computer offered an inexpensive solution, as they can be obtained cheaply. With computer ownership being widespread [54], it can be assumed that most trainees have access to a computer at home. Many trainees may also own a tablet computer. Tablet-based simulation could provide a video feed more comparable in quality to a laparoscope than a budget webcam [31]. Using a tablet or smartphone, where the screen and camera are on the same device, may also be easier to assemble. However, adjustment of camera position would be more difficult.

Commercial simulators, although seemingly costlier in comparison, do have the advantage that they come assembled and ready to use, with more models having undergone some form of validation. However, the appropriateness of the validation methods undertaken are not easily assessed, and only models from established industry suppliers appear to have undergone more extensive validation [50, 55]. In terms of face validity, commercial simulators largely seem to have better face validity, particularly as laparoscopes are more frequently used for visualisation, allowing realistic image quality and camera motion. A laparoscope may be difficult to obtain at a reasonable cost; an alternative may be to use a small camera mounted on a plastic pipe, which also allows adjustment of the operative field view [11, 16, 17]. The ideal simulator would have a highly realistic user interface and allow development of both the technical and non-technical skills required for laparoscopic surgery. The simulators examined in this review chiefly aim to develop basic laparoscopic skills such as instrument handling and cutting; therefore, a highly realistic user interface, as in virtual reality simulators, may be superfluous to requirements. However, use of lower-fidelity simulators does not preclude the development of non-technical skills. For example, the simulator could be incorporated into an operating theatre environment with other team members present, where trainees could be observed and assessed on emergency or elective scenarios.

Of course, simply having access to a simulator does not equate to improvement in surgical skill. Regular use of the trainer with feedback from a supervisor would be ideal. Simulator training could take place during the normal working day with allocated practice time, or this could be done at leisure at home.

Conclusion

The models described provide simple and affordable options for self-assembly, although a significant proportion has not been subject to any validation. Whilst simulation cannot replace operating theatre experience, portable simulators may be the most equitable solution to allow regular basic skills practice (e.g. intra-corporeal suturing, knot-tying) for junior surgical trainees.

Notes

Compliance with ethical standards

Disclosures

Miss. Mimi M Li and Mr. Joseph George have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Aggarwal R, Moorthy K, Darzi A (2004) Laparoscopic skills training and assessment. Br J Surg 91:1549–1558CrossRefPubMedGoogle Scholar
  2. 2.
    Nagendran M, Gurusamy KS, Aggarwal R, Loizidou M, Davidson BR (2013) Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database Syst Rev (8):CD006575. doi: 10.1002/14651858.CD006575.pub3
  3. 3.
    Zendejas B, Brydges R, Hamstra SJ, Cook DA (2013) State of the evidence on simulation-based training for laparoscopic surgery: a systematic review. Ann Surg 257:586–593. doi: 10.1097/SLA.0b013e318288c40b CrossRefPubMedGoogle Scholar
  4. 4.
    Gaba DM (2004) The future vision of simulation in health care. Qual Saf Health Care 13(Suppl 1):i2–i10CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Undre S, Darzi A (2007) Laparoscopy simulators. J Endourol 21:274–279CrossRefPubMedGoogle Scholar
  6. 6.
    Dunkin B, Adrales G, Apelgren K, Mellinger J (2007) Surgical simulation: a current review. Surg Endosc 21:357–366CrossRefPubMedGoogle Scholar
  7. 7.
    Schijven M, Jakimowicz J (2003) Virtual reality surgical laparoscopic simulators. Surg Endosc Other Interv Tech 17:1943–1950CrossRefGoogle Scholar
  8. 8.
    Fitzgerald J, Caesar B (2012) The European working time directive: a practical review for surgical trainees. Int J Surg 10:399–403CrossRefPubMedGoogle Scholar
  9. 9.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535. doi: 10.1136/bmj.b2535 CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Mughal M (1992) A cheap laparoscopic surgery trainer. Ann R Coll Surg Engl 74:256–257PubMedPubMedCentralGoogle Scholar
  11. 11.
    Pokorny MR, McLaren SL (2004) Inexpensive home-made laparoscopic trainer and camera. ANZ J Surg 74:691–693CrossRefPubMedGoogle Scholar
  12. 12.
    Beatty JD (2005) How to build an inexpensive laparoscopic webcam-based trainer. BJU Int 96:679–682CrossRefPubMedGoogle Scholar
  13. 13.
    Ricchiuti D, Ralat DA, Evancho-Chapman M, Wyneski H, Cerone J, Wegryn JD (2005) A simple cost-effective design for construction of a laparoscopic trainer. J Endourol 19:1000–1005CrossRefPubMedGoogle Scholar
  14. 14.
    Bell R, Maseelall P, Fanning J, Fenton B, Flora R (2007) A laparoscopic simulator tool for objective measurement of residents’ laparoscopic ability. JSLS 11:470–473PubMedPubMedCentralGoogle Scholar
  15. 15.
    Raptis D, Mouzaki K, Gore D (2008) Technical notes and tips: DIY laparoscopic kit. Ann R Coll Surg Engl 90:167CrossRefPubMedCentralGoogle Scholar
  16. 16.
    Al-Abed Y, Cooper DG (2009) A novel home laparoscopic simulator. J Surg Educ 66:1–2CrossRefPubMedGoogle Scholar
  17. 17.
    Rivas AM, Vilanova AC, Pereferrer FS, González MH, del Castillo Déjardin D (2010) Low cost simulator for acquiring basic laparoscopic skills. Cirugía Española (English Edition) 87:26–32CrossRefGoogle Scholar
  18. 18.
    Khine M, Leung E, Morran C, Muthukumarasamy G (2011) Homemade laparoscopic simulators for surgical trainees. Clin Teach 8:118–121CrossRefPubMedGoogle Scholar
  19. 19.
    Kiely DJ, Stephanson K, Ross S (2011) Assessing image quality of low-cost laparoscopic box trainers: options for residents training at home. Simul Healthc 6:292–298. doi: 10.1097/SIH.0b013e31821cdb68 CrossRefPubMedGoogle Scholar
  20. 20.
    Kobayashi SA, Jamshidi R, O’Sullivan P, Palmer B, Hirose S, Stewart L, Kim EH (2011) Bringing the skills laboratory home: an affordable webcam-based personal trainer for developing laparoscopic skills. J Surg Educ 68:105–109CrossRefPubMedGoogle Scholar
  21. 21.
    Moreira-Pinto J, Silva JG, Ribeiro de Castro JL, Correia-Pinto J (2013) Five really easy steps to build a homemade low-cost simulator. Surg Innov 20:95–99. doi: 10.1177/1553350612440508 CrossRefPubMedGoogle Scholar
  22. 22.
    Beard JH, Akoko L, Mwanga A, Mkony C, O’Sullivan P (2014) Manual laparoscopic skills development using a low-cost trainer box in Tanzania. J Surg Educ 71:85–90CrossRefPubMedGoogle Scholar
  23. 23.
    Walczak DA, Piotrowski P, Jędrzejczyk A, Pawełczak D, Pasieka Z (2014) A laparoscopic simulator—maybe it is worth making it yourself. Wideochir Inne Tech Maloinwazyjne 9(3):380–386. doi: 10.5114/wiitm.2014.44139 CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Blacker AJ (2005) How to build your own laparoscopic trainer. J Endourol 19:748–752CrossRefPubMedGoogle Scholar
  25. 25.
    Chung SY, Landsittel D, Chon CH, Ng CS, Fuchs GJ (2005) Laparoscopic skills training using a webcam trainer. J Urol 173:180–183CrossRefPubMedGoogle Scholar
  26. 26.
    Chandrasekera SK, Donohue JF, Orley D, Barber NJ, Shah N, Bishai PM, Muir GH (2006) Basic laparoscopic surgical training: examination of a low-cost alternative. Eur Urol 50:1285–1291CrossRefPubMedGoogle Scholar
  27. 27.
    Mir IS, Mohsin M, Malik A, Shah AQ, Majid T (2008) A structured training module using an inexpensive endotrainer for improving the performance of trainee surgeons. Trop Doct 38:217–218. doi: 10.1258/td.2008.070359 CrossRefPubMedGoogle Scholar
  28. 28.
    Singh I, Panesar N, Haq A (2009) Blue Peter: on a shoe string budget for laparoscopic training. J Postgrad Med 55:233–234. doi: 10.4103/0022-3859.57396 CrossRefPubMedGoogle Scholar
  29. 29.
    Rabie M (2010) Acquiring laparoscopic suturing skills using a homemade trainer. Eur Surg 42:149–151CrossRefGoogle Scholar
  30. 30.
    Alfa-Wali M, Antoniou A (2011) Eco-friendly laparoscopic home trainer. Simul Healthc 6:176–179. doi: 10.1097/SIH.0b013e318208549b CrossRefPubMedGoogle Scholar
  31. 31.
    Bahsoun AN, Malik MM, Ahmed K, El-Hage O, Jaye P, Dasgupta P (2013) Tablet based simulation provides a new solution to accessing laparoscopic skills training. J Surg Educ 70:161–163CrossRefPubMedGoogle Scholar
  32. 32.
    Sackier JM, Berci G, Paz-Partlow M (1991) A new training device for laparoscopic cholecystectomy. Surg Endosc 5:158–159CrossRefPubMedGoogle Scholar
  33. 33.
    Majeed AW, Reed MW, Johnson AG (1992) Simulated laparoscopic cholecystectomy. Ann R Coll Surg Engl 74:70–71PubMedPubMedCentralGoogle Scholar
  34. 34.
    Martinez AM, Espinoza DL (2007) Novel laparoscopic home trainer. Surg Laparosc Endosc Percutan Tech 17:300–302. doi: 10.1097/SLE.0b013e31805d091d CrossRefPubMedGoogle Scholar
  35. 35.
    Dennis R (2008) A simple and cheap home built laparoscopic trainer. J Minim Access Surg 4:88CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Robinson JK, Kushner DM (2006) Development and validation of a home-based, mirrored, gynecologic laparoscopy trainer. J Minim Invasive Gynecol 13:102–107CrossRefPubMedGoogle Scholar
  37. 37.
    Ruparel RK, Brahmbhatt RD, Dove JC, Hutchinson RC, Stauffer JA, Bowers SP, Richie E, Lannen AM, Thiel DD (2014) “iTrainers”–novel and inexpensive alternatives to traditional laparoscopic box trainers. Urology 83:116–120CrossRefPubMedGoogle Scholar
  38. 38.
    Escamirosa Fernando P, Flores Ricardo O, Martínez Arturo M (2014) How to build a portable laparoscopic trainer for smartphones and tablets. J Laparoendosc Adv Surg Tech B. doi: 10.1089/vor.2014.0200
  39. 39.
    Sparks D, Chase D, Lee W (2008) An inexpensive solution for laparoscopic simulation. OPUS 12:1–3Google Scholar
  40. 40.
    Helmy S, El-Shenoufy A (2009) Development of laparoscopic skills using a new inexpensive webcam trainer. J Biol Sci 9:766–771CrossRefGoogle Scholar
  41. 41.
    Omokanye L, Olatinwo A, Salaudeen A, Balogun O, Saidu R (2013) An improvised endotrainer for low resource settings. Res J Health Sci 1:2360–7793Google Scholar
  42. 42.
    Dhariwal AK, Prabhu RY, Dalvi AN, Supe AN (2007) Effectiveness of box trainers in laparoscopic training. J Minim Access Surg 3:57–63. doi: 10.4103/0972-9941.33274 CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Gue S (1995) Home-made videoscopic trainer for operative laparoscopic surgery. Aust N Z J Surg 65:820–821CrossRefPubMedGoogle Scholar
  44. 44.
    Lee AC (2003) A homemade minimal access surgical skills station. Pediatric Endosurg Innov Tech 7:273–277CrossRefGoogle Scholar
  45. 45.
    Griffin S, Kumar A, Burgess N, Donaldson P (2006) Development of laparoscopic suturing skills: a prospective trial. J Endourol 20:144–148CrossRefPubMedGoogle Scholar
  46. 46.
    Haveran LA, Novitsky YW, Czerniach DR, Kaban GK, Taylor M, Gallagher-Dorval K, Schmidt R, Kelly JJ, Litwin DE (2007) Optimizing laparoscopic task efficiency: the role of camera and monitor positions. Surg Endosc 21:980–984CrossRefPubMedGoogle Scholar
  47. 47.
    Pawar DS, Singh SK, Benjwal S, Kumari I (2010) A novel idea of using digital camera for laparoscopy training in urology. Urol J 7:56–58PubMedGoogle Scholar
  48. 48.
    Sharpe BA, MacHaidze Z, Ogan K (2005) Randomized comparison of standard laparoscopic trainer to novel, at-home, low-cost, camera-less laparoscopic trainer. Urology 66:50–54CrossRefPubMedGoogle Scholar
  49. 49.
    Hruby GW, Sprenkle PC, Abdelshehid C, Clayman RV, McDougall EM, Landman J (2008) The EZ Trainer: validation of a portable and inexpensive simulator for training basic laparoscopic skills. J Urol 179:662–666CrossRefPubMedGoogle Scholar
  50. 50.
    Hennessey IA, Hewett P (2013) Construct, concurrent, and content validity of the eoSim laparoscopic simulator. J Laparoendosc Adv Surg Tech 23:855–860CrossRefGoogle Scholar
  51. 51.
    Xiao DJ, Albayrak A, Buzink SN, Jakimowicz J, Goossens RHM (2013) A newly designed portable laparoscopic trainer based on ergonomic guidelines. Surg Endosc Other Interv Tech 27:S5Google Scholar
  52. 52.
    Xiao D, Jakimowicz JJ, Albayrak A, Buzink SN, Botden SM, Goossens RH (2014) Face, content, and construct validity of a novel portable ergonomic simulator for basic laparoscopic skills. J Surg Educ 71:65–72CrossRefPubMedGoogle Scholar
  53. 53.
    Yoon R, del Junco M, Kaplan A, Okhunov Z, Bucur P, Hofmann M, Alipanah R, McDougall EM, Landman J (2015) Development of a novel iPad-based laparoscopic trainer and comparison with a standard laparoscopic trainer for basic laparoscopic skills testing. J Surg Educ 72:41–46CrossRefPubMedGoogle Scholar
  54. 54.
  55. 55.
    Nakamura LY, Martin GL, Fox JC, Andrews PE, Humphreys M, Castle EP (2012) Comparing the portable laparoscopic trainer with a standardized trainer in surgically naive subjects. J Endourol 26:67–72CrossRefPubMedGoogle Scholar
  56. 56.
    Chung J, Sackier J (1998) A method of objectively evaluating improvements in laparoscopic skills. Surg Endosc 12:1111–1116CrossRefPubMedGoogle Scholar
  57. 57.
    Shapiro S, Paz-Partlow M, Daykhovsky L, Gordon L (1996) The use of a modular skills center for the maintenance of laparoscopic skills. Surg Endosc 10:816–819CrossRefPubMedGoogle Scholar
  58. 58.
    Hasson HM, Aruna Kumari NV, Eekhout J (2001) Training simulator for developing laparoscopic skills. JSLS 5:255–265PubMedPubMedCentralGoogle Scholar
  59. 59.
    Do AT, Cabbad MF, Kerr A, Serur E, Robertazzi RR, Stankovic MR (2006) A warm-up laparoscopic exercise improves the subsequent laparoscopic performance of Ob-Gyn residents: a low-cost laparoscopic trainer. JSLS 10:297–301PubMedPubMedCentralGoogle Scholar
  60. 60.
    Nataraja R, Ade-Ajayi N, Holak K, Arbell D, Curry J (2006) Pilot study of new training model for laparoscopic surgery. Pediatr Surg Int 22:546–550CrossRefPubMedGoogle Scholar
  61. 61.
    Nataraja R, Ade-Ajayi N, Curry J (2006) Surgical skills training in the laparoscopic era: the use of a helping hand. Pediatr Surg Int 22:1015–1020CrossRefPubMedGoogle Scholar
  62. 62.
    Clevin L, Grantcharov TP (2008) Does box model training improve surgical dexterity and economy of movement during virtual reality laparoscopy? A randomised trial. Acta Obstet Gynecol Scand 87:99–103CrossRefPubMedGoogle Scholar
  63. 63.
    Jain M, Tantia O, Khanna S, Sen B, Kumar Sasmal P (2009) Hernia endotrainer: results of training on self-designed hernia trainer box. J Laparoendosc Adv Surg Tech 19:535–540CrossRefGoogle Scholar
  64. 64.
    Jaber N (2010) The basket trainer: a homemade laparoscopic trainer attainable to every resident. J Minim Access Surg 6:3–5. doi: 10.4103/0972-9941.62525 CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Oliver J, Carty N, Wakefield C (2010) Low-cost model for laparoscopic appendicectomy in a webcam simulator. Bull R Coll Surg Engl 92:122–125CrossRefGoogle Scholar
  66. 66.
    Ramalingam M, Senthil K, Murugesan A, Pai MG (2010) Cost reductive laparoendoscopic single site surgery endotrainer and animal lab training-our methodology. Diagn Ther Endosc 2010:598165. doi: 10.1155/2010/598165 CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Afuwape O (2012) An affordable laparoscopic surgery trainer for trainees in poor resource settings. West Afr J Med 31(1):63–65PubMedGoogle Scholar
  68. 68.
    Akdemir A, Şendağ F, Öztekin MK (2014) Laparoscopic virtual reality simulator and box trainer in gynecology. Int J Gynecol Obstet 125:181–185CrossRefGoogle Scholar
  69. 69.
    Hennessey IA (2012) How to make a portable laparoscopic simulator. J Laparoendosc Adv Surg Tech 22Google Scholar
  70. 70.
    Smith MD, Norris JM, Kishikova L, Smith DP (2013) Laparoscopic simulation for all: two affordable, upgradable, and easy-to-build laparoscopic trainers. J Surg Educ 70:217–223CrossRefPubMedGoogle Scholar
  71. 71.
    Wong J, Bhattacharya G, Vance SJ, Bistolarides P, Merchant AM (2013) Construction and validation of a low-cost laparoscopic simulator for surgical education. J Surg Educ 70:443–450CrossRefPubMedGoogle Scholar
  72. 72.
    Derossis AM, Fried GM, Abrahamowicz M, Sigman HH, Barkun JS, Meakins JL (1998) Development of a model for training and evaluation of laparoscopic skills. Am J Surg 175:482–487CrossRefPubMedGoogle Scholar
  73. 73.
    Keyser EJ, Derossis AM, Antoniuk M, Sigman HH, Fried GM (2000) A simplified simulator for the training and evaluation of laparoscopic skills. Surg Endosc 14:149–153CrossRefPubMedGoogle Scholar
  74. 74.
    Scott DJ, Bergen PC, Rege RV, Laycock R, Tesfay ST, Valentine RJ, Euhus DM, Jeyarajah DR, Thompson WM, Jones DB (2000) Laparoscopic training on bench models: better and more cost effective than operating room experience? J Am Coll Surg 191:272–283CrossRefPubMedGoogle Scholar
  75. 75.
    Adrales G, Chu U, Witzke D, Donnelly M, Hoskins D, Mastrangelo M, Gandsas A, Park A (2003) Evaluating minimally invasive surgery training using low-cost mechanical simulations. Surg Endosc Other Interv Tech 17:580–585CrossRefGoogle Scholar
  76. 76.
    Adrales G, Chu U, Hoskins J, Witzke D, Park A (2004) Development of a valid, cost-effective laparoscopic training program. Am J Surg 187:157–163CrossRefPubMedGoogle Scholar
  77. 77.
    Waseda M, Inaki N, Mailaender L, Buess G (2005) An innovative trainer for surgical procedures using animal organs. Minim Invasive Ther Allied Technol 14:262–266CrossRefPubMedGoogle Scholar
  78. 78.
    Dayan AB, Ziv A, Berkenstadt H, Munz Y (2008) A simple, low-cost platform for basic laparoscopic skills training. Surg Innov 15:136–142CrossRefPubMedGoogle Scholar
  79. 79.
    Boon JR, Salas N, Avila D, Boone TB, Lipshultz LI, Link RE (2008) Construct validity of the pig intestine model in the simulation of laparoscopic urethrovesical anastomosis: tools for objective evaluation. J Endourol 22:2713–2716CrossRefPubMedGoogle Scholar
  80. 80.
    Singh PB, Saw NK, Mokete M, Martin FL, Matanhelia SS (2008) An integrated laparoscopic simulator (i-Sim™) to develop surgical skills outside the operating theatre: a novel means to improve training facilities in the UK. Int J Surg 6:64–70CrossRefPubMedGoogle Scholar
  81. 81.
    Hull L, Kassab E, Arora S, Kneebone R (2010) Increasing the realism of a laparoscopic box trainer: a simple, inexpensive method. J Laparoendosc Adv Surg Tech Part A 20:559–562CrossRefGoogle Scholar

Copyright information

© The Author(s) 2016

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  1. 1.Faculty of MedicineImperial College LondonLondonUK
  2. 2.Department of Cardiothoracic SurgeryMorriston HospitalSwanseaUK

Personalised recommendations