445Basic Laparoscopic Skills
General Training
A number of unique skills are required to be proficient in laparoscopic surgery. One
example is the requirement of good hand-eye coordination to achieve accurate
movements while watching a monitor that is producing a two-dimensional image of
a three-dimensional space. Given the amplification of small movements by the
length of the instruments, manual dexterity is also very important. At the same time,
there is the fulcrum effect of the body causing movements of the hands to mirror
that of the instrument. These are just a few of the basic skills that must be mastered
to be proficient in laparoscopy. Because of this, several simple bench models have
been created that aim to help trainees master the basic skills of laparoscopy. In addi-
tion to acquiring skills, there is also evidence to suggest that practicing on a simula-
tor prior to real surgery improves surgical performance [ 13 ].
The field of bench trainers (also termed “box trainers” or “video trainers”) for
laparoscopy is vast. There are many variations of trainers, with the basic premise of
having a box through which instruments can be passed to perform a variety of tasks
while using a camera to project the images onto a monitor. In their 2014 Cochrane
review on the topic of laparoscopic surgical box trainers (limited to those with no
prior laparoscopic experience), Nagendran et al. found an astounding 770 publica-
tions requiring screening, of which 32 were ultimately included on the topic [ 14 ].
Within the confines of a standard box trainer, a number of tasks can be performed
depending on the desired skill to be practiced. The Fundamentals of Laparoscopic
Surgery (FLS) simulator is one such box trainer that is considered by many to be the
“gold standard” for the development of laparoscopic skills [ 15 ]. Based on the
McGill Inanimate System for Training and Evaluation of Laparoscopic Skills
(MISTELS), the FLS consists of five tasks: peg transfer, pattern cutting, ligating
loop, extracorporeal suturing, and intracorporeal suturing. The complete program
also has an online didactic portion. The FLS has been extensively studied, with all
five tasks being validated, and proficiency on FLS has been shown to improve oper-
ative performance [ 16 – 19 ]. In fact, in 2009, FLS was added by the American Board
of Surgery as a requirement before being able to sit for board examinations in gen-
eral surgery [ 20 ].
Munz et al. have put forth a number of suggested tasks to be performed on box
trainers that can easily be done at any institution [ 21 ]. To practice instrument navi-
gation, Munz et al. had trainees conduct preset calculations on a calculator inside
the box by using a pair of graspers. Coordination was practiced by placing a 30 cm
piece of twine marked at 1 cm intervals with blue lines inside the box. Users then
“walked” their way down the twine by only grasping at the lines. To practice grasp-
ing, a simple setup of two dishes can be placed inside the box, and objects can be
transferred back and forth between dishes (chickpeas or small bolts are common
objects to grasp). Cutting can be accomplished with a number of setups including
grasping twine as above and cutting every centimeter on a marked line or cutting out
along the lines of a circle drawn on a piece of cloth or examination glove. An added
24 Simulation in Surgery