447focus of the LS500 was on laparoscopic cholecystectomy, and it has been validated
in a number of studies [ 33 – 35 ]. It was from the LS500 platform that LAP Mentor™
(Simbionix, Cleveland, OH) was launched in 2003. Now on its third edition, the
LAP Mentor is a validated VR laparoscopic simulator that has expanded from a
number of laparoscopic-specific tasks to include modules on a number of operations
[ 36 ]. The LAP Mentor helps develop many basic laparoscopic skills, such as trans-
location of objects, camera manipulation, clip applying, clipping and grasping, cut-
ting, and a variety of two handed maneuvers. Several skills necessary for suturing
can also be learned on LAP Mentor, including needle loading, knot tying, inter-
rupted suturing, continuous suturing, and more advanced techniques such as the
“backhand” technique and anastomosis suturing. Because FLS is considered the
“gold standard” for laparoscopic training, Simbionix set to mirror FLS with the
introduction of the “essential tasks module.” Included in this module are peg trans-
fer, pattern cutting, and placement of ligating loop, as are seen in the FLS program.
In a study by Pitzul et al., the LAP Mentor “essential tasks module” demonstrated
moderate concurrent validity with FLS, suggesting construct validity [ 15 ].
While both box trainers and VR simulators have their own merits, it is natural to
question if one modality is better than the other. Gurusamy et al. did a meta-analysis
of all studies that directly compared VR training versus box trainers and found two
studies that attempted to answer this question [ 37 ]. The first study found operative
time was significantly shorter for the VR group compared to the box-trainer group,
but there were no reported numerical values (p < 0.004). In the second study, the VR
group was found to have a 36% improvement in terms of operative performance
versus 17% for the box trainer group (p < 0.05) [ 38 ]. Given the low power in these
studies, as well as the few number of studies that compare between the two simula-
tion modalities, the question of superiority of training continues to go unanswered.
This question also becomes more complex when considering cost-effectiveness.
This will ultimately require further studies.
Adrenal and Kidney
Clayman and coworkers performed the first laparoscopic nephrectomy in 1990.
Since then, laparoscopy has found its way to nearly every indication for renal sur-
gery. In contrast to open surgery, laparoscopic renal surgery has been found to
decrease hospital stays and postoperative pain and improve cosmesis without sacri-
ficing surgical outcomes [ 39 – 42 ]. One could argue that the majority of renal proce-
dures done today, including radical nephrectomy, partial nephrectomy, and
pyeloplasty, should be performed with laparoscopy or robotics.
Radical/Partial Nephrectomy
There are many current simulation options specific to radical and partial nephrec-
tomy, many of which have been validated in a number of studies. The simplest is a
bench model out of the University of Western Ontario. Using a commercially avail-
able polyvinyl alcohol (PVA) powder (Air Products and Chemicals, Inc., Allentown,
24 Simulation in Surgery