DOI: 10.1111/tog.

12619 2020;22:69–74
The Obstetrician & Gynaecologist
Education
http://onlinetog.org

‘Perfect practice makes perfect’: the role of laparoscopic

simulation training in modern gynaecological training
Alison Bryant-Smith MBBS/BA MPH MSurgEd MRCOG FRANZCOG,a,* Janice Rymer MD FRCOG FRANZCOG FHEA,
b

Tom Holland MBBS MRCOG MD (Res),b Maximilian Brincat BSc (Hons) MDc
a
Locum Consultant Obstetrician Gynaecologist, Northern Health, Melbourne, 3076, Vic, Australia
b
Consultant Gynaecologist, Guy’s and St Thomas’ NHS Foundation Trust, London, SE1 7EH, UK
c
Specialist Trainee, Mater Dei Hospital, Msida, MSD 2080, Malta
*Correspondence: Alison Bryant-Smith. Email: dr.alison.bryantsmith@gmail.com

Accepted on 1 April 2019. Published Online 1 November 2019.

Key content programme; this programme is likely to play an increasing role in

 Unique psychomotor and perceptual challenges of laparoscopy – trainees’ attainment and validation of laparoscopic skills.
such as marred depth perception, the requirement for advanced
Learning objectives
hand–eye coordination and the use of long instruments – mean
 To understand the role of laparoscopic simulation training in
that laparoscopic trainees face a steep learning curve.
 The difficulties that trainees encounter in meeting required
modern gynaecological training.
 To know about the European Academy of Gynaecological
laparoscopic competencies may, in part, be overcome through the
Surgery’s Gynaecological Endoscopic Surgical Education and
use of laparoscopic simulation training (LST), with benefits for
Assessment programme.
trainees, patients, consultant staff and hospital budgets.
 There is growing evidence that LST improves patient outcomes, Ethical issues
such as shorter operative duration, fewer intraoperative errors and  How does laparoscopic simulation training benefit patient safety?
cancellations, and reduced litigation.  How can trainees’ access to laparoscopic simulation training
 In 2017, the British Society for Gynaecological Endoscopy formally be standardised?
adopted the European Academy of Gynaecological Surgery’s
Keywords: box trainers / laparoscopic simulation training /
Gynaecological Endoscopic Surgical Education and Assessment
laparoscopy / simulation / virtual reality

Please cite this paper as: Bryant-Smith A, Rymer J, Holland T, Brincat M. ‘Perfect practice makes perfect’: the role of laparoscopic simulation training in modern
gynaecological training. The Obstetrician & Gynaecologist 2020;22:69–74. https://doi.org/10.1111/tog.12619

do one, teach one’ will be replaced with a new educational

Introduction
heuristic: ‘perfect practice makes perfect’.2
A 2010 national survey revealed that trainees of the Royal
College of Obstetricians and Gynaecologists (RCOG) struggle
A brief relevant history of gynaecological
to achieve required laparoscopic competencies.1 The gap
training
between trainees’ operative exposure and the experience
required for laparoscopic mastery can be partially bridged by Recently, several trends have led to the situation whereby
laparoscopic simulation training (LST). The use of LST to many RCOG trainees lack sufficient laparoscopic skills. These
climb the steep learning curve faced by laparoscopy trainees include the steep learning curve in laparoscopy, the
has many benefits, including improved patient safety. increasing complexity of laparoscopic cases and trainees’
The RCOG 2011–2014 Strategic Plan1 stated the need for reduced operative exposure.
national recommendations and standards for LST. In 2017,
the British Society for Gynaecological Endoscopy (BSGE) The steep learning curve in laparoscopy
adopted the European Academy of Gynaecological Surgery’s Since its advent in the 1970s, laparoscopy has become the
(EAGS’s) Gynaecological Endoscopic Surgical Education and gold-standard approach for many gynaecological
Assessment (GESEA) programme. Given that this operations.3–5 However, several unique psychomotor and
programme is likely to play an increasing role in trainees’ perceptual challenges mean that there is a steep learning
attainment of laparoscopic skills, a review of LST in trainees’ curve in the field of laparoscopy. Foremost among these
surgical education is timely. Seemingly, the adage of ‘see one, challenges is the unavoidable marring of surgeons’ depth

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 Laparoscopic simulation training

perception. Laparoscopy also demands advanced hand–eye because surgeons received inadequate laparoscopic training.2
coordination, because surgeons are not able to operate under Hence, a strong ethical case can be made for supporting
direct vision. The long instruments used in laparoscopy cause trainees to acquire basic skills in a safe, simulated environment.
amplification of surgeons’ movements and are subject to the The days of a slow ascendance to competence, through trial and
‘fulcrum effect’, in which laparoscopic ports act as a fulcrum, error on real patients, are over.
causing the tips of instruments to move in the opposite LST can improve trainees’ operative exposure, the lack of
direction to the surgeon’s hands. which is both widely recognised and problematic. Abbott8
Trainees’ learning of basic laparoscopic skills in vivo has been approximates that trainees perform only ten salpingectomies
challenged by both medicolegal concerns regarding patient safety, during their entire training. Encouragingly, Larsen9 estimates
and fiscal constraints demanding improved theatre efficiency. that it would take only 3 hours of LST for junior trainees
Thankfully for patients, trainees can approach laparoscopic (with no advanced laparoscopic skills) to emulate this,
mastery within the safe environment of LST. thereby mitigating trainees’ limited operative exposure.
Given their reduced operative exposure, trainees must
Trainees’ reduced operative exposure capitalise on every potential learning opportunity in theatre.
Modern trainees are receiving less operative exposure for Having mastered basic skills using LST, their “first few
several reasons, including duty hour limitations. Historically, laparoscopic cases will no longer be nerve-wracking
gynaecological training followed the apprenticeship model of experiences in which a staff surgeon painfully tries to teach
graded responsibility, decreasing direct supervision and the resident basic video–eye–hand coordination, resulting in
voluminous caseload: paraphrased by the adage ‘see one, frustration for all those involved.”9 On the contrary, theatre
do one, teach one.’ However, when the European Working time should be used to explore anatomical nuances, develop
Time Directive (EWTD) was adopted in 2004, the effect on sophisticated intraoperative decision-making and manage
junior doctors’ rotas led to the widespread breakdown of complications. Thereafter, a virtuous learning cycle exists in
firm-based structures within many hospitals. With this which preoperative LST enhances trainees’ intraoperative
devolution, the potential to perform operations with the learning, allowing consultants to entrust them with more
same consultant week-in, week-out, was lost – to the difficult cases. Trainees can then build on these experiences
detriment of trainees’ surgical education. Moreover, when using simulation.
gaps in rotas appear, trainees are increasingly called upon to
cover service provision roles (such as labour ward cover),
Different types of laparoscopic simulators
rather than being able to attend theatre, thus missing
potential operative learning opportunities. First developed in the 1970s, laparoscopic simulators include
As well as the effect of the EWTD on trainees’ operative box trainers, virtual reality (VR) simulators, animal models
exposure and supervisory continuity, trainees are now expected and cadavers.
to perform a greater variety of surgical techniques. Increasing
utilisation of non-surgical management (e.g. expectant Box trainers
management, physical therapy, medical management and Box trainers are the most basic and most widely available
interventional radiology) reduces trainees’ operative laparoscopic simulators (see Figure 1). Their strengths
exposure further still. Hence, there has been a demonstrated include the use of real surgical instruments and low cost
reduction in major gynaecological procedures6 and, as a result, (the acquisition cost can be as low as £200, and maintenance
there is now international concern ‘that surgical training of costs are negligible). It is even possible to build your own box
obstetrics and gynaecology trainees is inadequate and that new trainer using cheap, accessible items (e.g. a cardboard box, a
specialists lack the confidence and surgical skills to perform the mobile phone and a headlight), following van Duren and van
same breadth of procedures that previous generations did’.7 Boxel’s instructions.10
The challenges of laparoscopy, combined with the reduced Compared with VR systems, box trainers are more robust,
opportunities available for trainees to receive hands-on less prone to equipment failures and cheaper to maintain.
training, demands a paradigm shift in laparoscopic skills Box trainers are highly versatile and relatively portable; they
training. also provide haptic feedback and depth perception akin to a
real operation. The acquisition of basic skills using box
trainers is equivalent to that with VR simulators and may
The growing importance of laparoscopic
even produce superior skill retention.11
simulation training
Surgical complications are decreased when LST is used to Virtual reality systems
master basic laparoscopic skills. In the early days of A key advantage of VR systems is their versatility: VR
laparoscopy, complication rates increased five-fold, largely software encompasses a variety of laparoscopic skills – and

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 Bryant-Smith et al.

The main disadvantage of cadaveric training is its cost:

cadavers can be sourced for £1850 each, but this does not
include transport from the USA (personal communication, B
O’Connell, March 2019). In addition, there is a limited
supply of cadavers, unlike box trainers or VR simulators.
Anecdotally, the duration of training with each cadaver is
limited because of malodour.
Training using cadavers can best be employed by advanced
trainees; e.g. having mastered basic skills using box trainers
and VR systems, trainees can then attempt advanced
laparoscopic operations, such as total laparoscopic
hysterectomy or prolapse surgery (e.g. hysteropexy), in the
cadaveric setting.

Comparing laparoscopic simulation systems

Figure 1. A box trainer in use (reproduced with permission from the Most comparative studies have evaluated box trainers and
Australasian Gynaecological Endoscopy & Surgery Society). VR simulators, since these are the two most widely used
systems. Several studies have concluded that box trainers and
VR systems are equally effective at teaching basic skills to
even entire operations – from start to finish, thereby enabling novice laparoscopists.15,16 Table 1 presents the advantages
trainees to refine their procedural knowledge. Another and disadvantages of different LST systems (based on
notable advantage is the quantitative objective feedback Reznick et al.14).
provided regarding efficiency of movement, instrument–path
length, ‘tissue damage’ and ‘blood loss’.
The validity of laparoscopic simulation
One disadvantage of VR simulators is their cost: many
training
systems cost in excess of £70,000, with maintenance costs
adding thousands more over time.2 While costs may decrease LST can be used to overcome the psychomotor and
as VR technology evolves, such price tags remain prohibitive perceptual challenges discussed previously: in only 5 hours,
for many units. Another disadvantage is that some VR trainees can become competent at many of the skills
simulators lack haptic feedback: this functionality is available, necessary to perform basic laparoscopic procedures.17 The
but comes at a cost. fundamental assumption underlying LST is that these skills
are directly transferable to real operations. However,
Animal models important questions that must be answered include: does
The most realistic, non-human environment for LST is in LST train appropriate surgical skills? Does it improve skills
anaesthetised animals (e.g. pigs or sheep). Benefits of using performance in vivo? What impact does this have on patient
live animals include bleeding tissue (that is therefore more outcomes? The relevant types of validity are summarised in
realistic than cadaveric training) and that complications can Table 2 and are discussed briefly below.
be created and managed. However, animal models are not
widely used because of their prohibitive cost, ethical concerns Face validity
and the need for purpose-built facilities. The first step in objective validation is establishing face
validity: does the simulator represent what it is supposed to?
Cadaveric training Over 92% of trainees report that skills learned during LST are
Intuitively, cadavers are the best models for LST. Cadaveric transferable to real operations.18
training is best used to improve spatial perception of surgical
anatomy, to practise developing tissue planes and to perform Construct and discriminative validity
a variety of laparoscopic operations (e.g. salpingectomy, ‘Construct validity’ is the degree to which a trainee’s
oophorectomy, hysterectomy and hysteropexy). The main performance in the laparoscopic simulator reflects their
advantages of cadaveric training are its high fidelity and face actual laparoscopic proficiency. ‘Discriminative validity’
validity. Sharma et al.12 compared perceptions of cadaveric describes whether or not the tool can discriminate between
training with those of VR training and concluded that different proficiency levels (e.g. novice through to expert
cadaveric training is significantly better in almost all surgeons). Several studies have demonstrated the construct
domains, including tactile feedback and demonstration of and/or discriminative validity of the LapSim VR
anatomy and tissue planes. simulator.19,20 There is a relative paucity of studies

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 Laparoscopic simulation training

Table 1. Advantages and disadvantages of different LST models. Based on Reznick et al.14

Advantages Disadvantages Comments

Box trainers Cheap Facilitators required to provide Most widely available LST system
Portable detailed feedback Most validated LST system
Reusable Limited fidelity Best used for basic and/or
Minimal risks Basic tasks only discrete skills, by novice
Real surgical instruments used laparoscopists
Present realistic perceptual and
psychomotor challenges
Versatile

Virtual reality systems Reusable Cost Best used for basic laparoscopic
Objective feedback, with data capture Maintenance skills, completing
Minimal set-up time Not easily portable whole-operation modules
Sophisticated surgical models (e.g. whole Often lack haptic feedback (e.g. total laparoscopic
operations from start to finish) Three dimensions not well represented hysterectomy module)

Animal models High fidelity Cost Helpful to teach advanced

Can practise entire operations Requires special facilities and personnel procedural knowledge
Complications can be created and managed Single-use Best used to teach dissection
Ethical concerns skills and procedures for which
Anatomical differences active blood flow is important

Cadavers High fidelity: currently the only ‘true’ Cost Best used to teach dissection
anatomy simulator Availability skills and advanced procedural
Can practise entire operations Single-use knowledge
Limited duration of training on
each cadaver

LST = laparoscopic simulation training.

demonstrating the construct validity of box trainers.21,22 integrated into a comprehensive curriculum, including:
Some studies have used artificial intelligence-based metrics to teaching of the relevant anatomy and pathology, and
discriminate between novice and expert surgeons.23 testing trainees on these materials; baseline skills-testing;
exercises at an appropriate level of difficulty and instruction
Predictive validity regarding the specific steps involved in the exercise; technical
‘Predictive validity’ is the extent to which a measure (e.g. a skills training using simulators, with immediate expert
trainee’s performance during LST) is related to an outcome feedback; and repeated trials of each exercise, with
assessed at a later stage (e.g. a trainee’s performance during reference to a proficiency-based performance goal.
operations in future). There is growing evidence that LST
improves patient outcomes, such as shorter operative Deliberate and distributed practice
duration,9 fewer intraoperative errors24 and cancellations25, It is vital that the technical skills training mentioned above
and reduced litigation.25 Such trials support that LST, when encourages ‘deliberate practice’. Deliberate practice
used as part of a structured curriculum, results in skills that encompasses: well-defined exercises, at an appropriate level
are transferable to theatre.2 of difficulty; focused repetitive practice of a very specific skill;
informative feedback from educational sources; and
evaluation to reach mastery standard, followed by
Educational theories underlying
advancement to a more difficult task.
laparoscopic simulation training
LST should also allow for distributed practice, in which
The importance of a structured laparoscopic sessions are relatively short (e.g. 1 hour or less), but spread
curriculum over a sustained period (e.g. one session per week for
The effectiveness of LST programmes depends on the quality 3 months).2 Practising skills in a distributed manner
of their curricula, which will determine what, how many and improves acquisition and retention of skills, compared with
how quickly skills can be acquired by trainees. LST must be mass practice.

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 Bryant-Smith et al.

Table 2. Types of validity relevant to educational assessment

Type of validity Definition (in relation to educational assessment) Relevance to laparoscopic simulation training

Face validity The extent to which an assessment is subjectively Does the simulator represent what it is supposed to represent?
thought to assess what it purports to assess.

Construct validity The degree to which an assessment measures Does the trainee's performance in the laparoscopic simulator
what it purports to measure. reflect their actual laparoscopic proficiency?

Discriminative validity The degree to which an assessment tool can Can laparoscopic simulation assessments accurately
discriminate between different proficiency levels. discriminate between novice and expert surgeons?

Predictive validity The extent to which the outcome of an assessment is Does the trainee's performance during laparoscopic
related to a different outcome, assessed at a later stage. simulation training predict their performance during
actual operations in future?

Unfortunately for trainees and the quantity of operative same multiple choice questions, and then a practical
exposure they receive, in-theatre learning opportunities examination of various exercises using a box trainer and a
depend on the operating schedule and rarely follow a plastic ‘uterus’ (to assess hysteroscopic skills).
logical path. Hence, the capacity of LST for distributed The founders of the programme have undertaken various
practice is particularly helpful, especially if trainees are not studies to validate the tools.21,22 Given that the BSGE
rostered to another operating list for some time. encourages trainees to undertake the GESEA programme,
further evaluation of its impact on the development of
The importance of expert feedback trainees’ laparoscopic skills, transferability of these skills to
Providing feedback is the single most important feature of theatre and patient outcomes is warranted.
simulation-based medical education. Facilitators can help
trainees to identify areas of weakness, provide structured
Should LST be made mandatory?
feedback and suggest techniques to help trainees
to progressively refine their skills. Facilitators can also On the basis of the importance of LST and the fact that
demonstrate specific techniques and explain why that trainees do not practise enough voluntarily, numerous
technique is superior. Such feedback improves trainees’ authors conclude that LST must be made mandatory.1,2,6
cognitive understanding of the skill and results in Inequitable operative exposure is a key rationale for LST:
better performance. only mandatory participation in LST can provide more
As well as encouraging good habits, corrective feedback uniform training experiences. Hence, LST should be a
from facilitators helps to prevent the development of bad mandatory component of the curriculum for
ones. Without feedback, behaviours will become ingrained: gynaecological trainees.
such practice makes ‘permanent’ but does not necessarily Some have argued that completion of an LST programme
make it ‘perfect’. Only when a facilitator provides timely and should be prerequisite before trainees can become the
specific feedback can trainees’ practice be perfected. primary operator on real patients.9,24 Being in the
operating theatre would then be a privilege that is learned
and earned, rather than a rite of passage.
The Gynaecological Endoscopic Surgical
Education and Assessment programme
Conclusion
In 2017, the BSGE formally adopted GESEA, the structured
LST programme developed by the EAGS. This stepwise The converging historical trends of the rapid rise of
certification programme comprises three certificated levels: laparoscopy, and a decrease in the opportunities for
Bachelor of Endoscopy, Minimally Invasive Gynaecological trainees to gain operative exposure, mean that it has
Surgeon (MIGS) certificate and the MIGS diploma. Each become increasingly important for trainees to utilise LST to
level comprises online lectures and online multiple choice master basic laparoscopic skills. Overcoming the
questions based on these lectures, an in-person test of the psychomotor and perceptual challenges inherent to

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 Laparoscopic simulation training

laparoscopy in a safe, simulated setting has several advantages 7 Koch J, Clements S, Abbott J. Basic surgical skills training: does it work? Aust
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Ottosen C, et al. Effect of virtual reality training on laparoscopic surgery:
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