Transferability of Simulation-Based Training in Laparoscopic Surgeries: A Systematic Review

Table 1

Included randomized clinical trials which have evaluated the transferability of simulation-based training in a real operating room.

Study	Simulation method	Number of participants	Groups	Assessment	Results
Zendejas et al. [21]	Guildford MATTU TEP hernia task trainer (Limbs and Things, Ltd. Bristol, UK)	50 surgical surgeons	(i) Simulation-based mastery learning (ML) curriculum; (ii) Standard practice (self-learning and intraoperative learning)	Totally extraperitoneal (TEP) inguinal hernia repair	Operative time was shorter, and operative performance (GOALS scale) was better in the simulation group (). Intraoperative and postoperative complications were statistically decreased for simulation-trained residents ().
Nilsson et al. [22]	LapSim virtual reality simulator (software version 2015, Surgical Science, Gothenburg, Sweden)	36 surgical novices without prior laparoscopic experience	(i) Camera group; (ii) Simulation-based cholecystectomy (procedure group); (iii) Control group	Camera assessment during a laparoscopic cholecystectomy	No statistically significant differences in camera navigation skills were found during a laparoscopic cholecystectomy between the groups. On the simulation-based test (LASTT model), technical skills were significantly better for the camera and the procedure group compared with the control group.
Franzeck et al. [23]	LAP Mentor^TM (Simbionix USA, Cleveland, OH). ProMISTM surgical hybrid simulator (Haptica Ltd., Dublin, Ireland)	24 pregraduation medical students	(i) Simulation group; (ii) Training in the operating room	Camera assessment test in the operating room	Both groups improved their navigation skills significantly. The simulation group showed a trend towards better performance.
Seymour et al.[24]	Minimally invasive surgical trainer-virtual reality (MIST-VR) system (Mentice AB, Gothenburg, Sweden)	16 surgical residents	(i) Virtual reality; (ii) Control group	Laparoscopic cholecystectomy	Simulation group performed the procedure 29% faster. Intraoperative complications (gallbladder injury or burn of nontarget tissue) occurred more commonly in the control group ().
Grantcharov et al. [25]	MIST-VR system (Mentice AB, Gothenburg, Sweden)	16 surgical trainees	(i) Virtual reality; (ii) Control group	Laparoscopic cholecystectomy	Participants in the simulation group conducted the surgery statistically faster (). Percentage of errors and economy of movements were significantly improved after virtual reality training ().
Palter et al. [26]	LapSim virtual reality simulator	20 general surgery residents(PGY 1-2)	(i) Structured training and assessment curriculum (STAC) group; (ii) Conventional residency training	Laparoscopic cholecystectomy	Residents performed five sequential laparoscopic cholecystectomies in the operating room. The STAC group conducted the first four operations statistically better than the control group (OSAT global rating scale). In the fifth procedure, there was no significant difference. Participants in the STAC group showed improved nontechnical skills compared with the control group ().
Palter and Grantcharov [27]	LapSim VR simulator (Gothenburg, Sweden, 2008 version)	16 surgery residents(PGY 1-2)	(i) Virtual reality group; (ii) Conventional residency training group	Laparoscopic cholecystectomy	Individualized deliberate practice on simulator results in a statistically superior performance in the operating theater for the simulation group compared with the control group ().
Ahlberg et al. [28]	LapSim	13 surgical residents	(i) Training group; (ii) Control group	Laparoscopic cholecystectomy	Virtual reality group outperformed the control group in terms of operative time and number of errors intraoperatively.
Bansal et al. [29]	Box trainer, the Tubingen MIC-Trainer (Richard Wolf GmbH, Germany)	17 surgery residents	(i) Laparoscopic training group; (ii) Standard training group	Laparoscopic cholecystectomy	The laparoscopic training group showed statistically better results in the operative time (), plane of dissection (), and GOALS criteria. The rate of gallbladder perforation was higher for untrained surgeons, but a statistically significant difference was not found.
Banks et al. [30]	Laparoscopy simulator (Limbs and Things, Bristol, UK) and an operative laparoscopy tower	20 residents(PGY 1)	(i) Simulation-based training and surgical training in the operating room; (ii) Surgical training in the operating room	Laparoscopic bilateral tubal ligation	Simulation group performed the intervention statistically better than the control group. Surgical skills in simulation-trained residents were improved compared with the control group ().
Gala et al. [31]	Psychomotor board testing with a peg board test	44 lower-level residents (PGY 1-2) and 66 upper-level (PGY 3-4)	(i) Traditional training	Laparoscopic Pomeroy bilateral tubal ligation	Simulation-trained surgeons showed significantly higher normalized simulation scores () and higher levels of competence on the simulated tasks (). Simulation group had improved surgical skills (Likert scale) in the operating theater compared with the control group ().
Larsen et al. [32]	LapSim Gyn v 3.0.1 (Surgical Science, Gothenburg, Sweden)	32 trainees in gynecological specialty(PGY 1 and 2)	(i) Intervention group; (ii) Control group	Laparoscopic salpingectomy	Intervention group performed the surgery with statistically significant superiority compared with the control group (). Operative time was significantly shorter in the simulation group ().
Patel et al. [33]	Porcine cadaver	22 residents	(i) Simulation group; (ii) Control group	Laparoscopic salpingectomy	Simulation can improve significantly surgical skills (OSAT scores) in laparoscopic salpingectomy. Combination of simulation and traditional training is recommended.
Ahlborg et al. [34]	LapSim Gyn VR simulator (Surgical Science, Gothenburg, Sweden)	28 trainees	(i) Simulator training; (ii) Simulator training with mentorship; (iii) Control group	Laparoscopic tubal occlusion	Visuospatial ability, flow score, and self-efficacy were significantly higher for both the simulator-training groups compared with the control group. Duration of surgery was significantly shorter in the training groups. Differences in surgical performance between the two simulation groups were not detected.
Palter et al. [35]	LapSim (Surgical Science, Gothenburg, Sweden)	25 surgical residents(PGY 2-4)	(i) Curriculum training group; (ii) Conventional residency training	Laparoscopic right colectomy	Curriculum group showed statistically significant superiority in technical proficiency compared with the conventional group (OSATS score, ). Curriculum-trained participants performed more operative steps than residents in the conventional group.
Orzech et al. [36]	LapSim	24 surgical residents(PGY 2 or above)	(i) Virtual reality; (ii) Box trainer; (iii) Conventional training; (iv) Experienced surgeons	Laparoscopic suturing	No statistically significant differences were found between virtual reality and box trainer in time and technical proficiency. Box training is thought as a cost-effective training program, whereas virtual reality provides a time-efficient education. Simulation-trained surgeons conducted the procedure better compared to conventionally trained surgeons.
Van Sickle et al. [37]	Virtual reality and box trainer	22 surgery residents (PGY level 3, 5, or 6)	(i) Curriculum training group; (ii) Standard training group	Laparoscopic intracorporeal suturing and knot tying during a laparoscopic Nissen fundoplication	Laparoscopic suturing training group performed the suturing task statistically faster with a reduced rate of errors and fewer needle manipulations than the control group ( and , respectively).