61have commonly been used. A variety of box trainers have been developed over the
years, running a wide spectrum of technological complexity. The simplest can be
constructed with a smartphone, a box, a video display screen, and some non-sterile
or expired laparoscopic instruments (YouTube provides numerous demonstrations
and instructions for building these), while the more advanced have sophisticated
integrated cameras and realistic mimetic tissue models for procedural practice.
Virtual reality (VR) simulators have integrated metrics that grade each perfor-
mance, whereas “dry lab” rehearsal relies on either self-evaluation or that of a proc-
tor. Herein lies the problem – what is the basis of this assessment? Time to complete
a task, as well as many overt errors such as instrument collisions, suture breakage,
and drops, can be immediately and easily identified and quantified; however, detec-
tion and analysis of more subtle errors and techniques is increasingly difficult. With
the addition of a trained observer, further skills such as keeping instruments in view
of the camera, dissection and suturing patterns, and proper handoff techniques can
be gauged. However, without extra hardware and software, box trainers lack the
ability to track and analyze motion-based metrics such as path length and economy
of motion, among other metrics important for successful surgery.
For laparoscopic surgery there are a multitude of VR trainers available, but not
all record metrics of assessment in the same way. As one of the first medical simula-
tors that recorded objective measures, the Minimally Invasive Surgical Trainer,
Virtual Reality by Mentice Medical Simulation, MIST-VR emerged in the late
1990s as the forerunner of what would soon be a highly competitive and technologi-
cally advanced market. MIST-VR functioned with handles mimicking laparoscopic
instruments attached to gimbals with motion information transferred to an adjacent
computer and the monitor displaying relative VR instrument tips. Foot pedals could
also be operated for simulated energy application.
Unlike the advanced modules seen on simulators today, MIST-VR made no
attempt to create simulated tissues or surgical materials, like suture. Instead,
MIST-VR required trainees to perform hand to hand transitions and object manipu-
lation with a virtual ball. This could include instrument exchanges, diathermy appli-
cation, and highly specific object placement tasks. The computer would log time
duration of the exercise, any designated errors that occurred, and overall accuracy
of the performance [ 11 ]. MIST-VR was intentionally not representative of a surgical
environment as it was intended to be used for assessment rather than training [ 11 ].
Since MIST-VR, the medical industry has seen a surge in VR technology, pro-
ducers of simulators, and growth in laparoscopic procedures. As a result, there are
numerous laparoscopic VR simulators on the market with the ability to focus on
both training and assessment. Only two will be discussed here; however a variety of
other reputable options exist.
The LAP Mentor, by 3D systems (formerly Simbionix) is one such example. The
latest iteration includes an adjustable height tower housing a 24′′ touch screen moni-
tor, PC with processor, and foot pedals. Operative tools include exchangeable
instrument handles with haptic feedback and five degrees of freedom and a multi-
angle endoscope. The LAP Mentor can be connected to other devices for team train-
ing, such as the LAP Express, a portable laparoscopic simulator, or the RobotiX
Mentor, discussed below.
5 Performance Assessment in Minimally Invasive Surgery