Over the last two decades, minimally invasive surgery has been widely adopted and has become the standard procedure for gynecologic diseases. Considerable evidence indicates that, owing to the nonrequirement of a large abdominal incision, laparoscopic surgery offers substantial advantages over open surgery, including less postoperative pain, shorter hospital stays, faster postoperative recovery, improved cosmetic outcomes, fewer wound-related complications, and lower costs. Recent data suggest that up to 80% of gynecologic surgeries can be accomplished laparoscopically [4].
Over the last decade, simulation-based surgical education has received significant attention, and several laparoscopic simulators have been employed. Box trainers (BTs) and virtual reality (VR) simulators are the two main training modalities employed in hospitals and clinical training centers for laparoscopic skills acquisition and development. However, VR simulators and BTs have some fundamental inadequacies; for example, VR simulators provide worse depth perception compared to BTs, whereas in some tasks the properties of the graphical models are not so realistic. On the other hand, BTs provide no automated means for performance assessment, whereas training models require replacement after task performance, and maintenance [5].
Virtual reality applications in healthcare are driven by several objectives, which include reducing the rate of error in patient care; increasing virtual training opportunities to supplement reductions in clinical practice time, specifically limited access to training inside operating rooms (ORs), and providing safer, controlled environments to facilitate training without compromising patient safety. In surgery, the use of VR facilitates the practice of basic and complex procedures both in the field and through simulated training in lab environments [6].
It has been demonstrated that delicate training on simulators by surgical residents, results in improved technical performance in the operating room with fewer errors and injuries, an enhanced ability to attend to cognitive components of surgical expertise, the efficiency of movements during the operation, and a significant decrease in operative time [7].
In our study, we evaluated the proper sequence of pelvic trainers and VR simulator training to improve gynecological laparoscopic skills. We found no difference in the training whether started on a pelvic trainer or the VR simulator.
Many other studies have been conducted to assess the use of box trainers and laparoscopic VR simulators for proper laparoscopic training. Tanoue et al. (2008) compared the effectiveness of students training on the MIST virtual reality (VR) simulator and laparoscopic box trainer for teaching the fundamental skills of endoscopic surgery and found that both laparoscopic VR and box trainers had better performance than controls and different outcomes for training different skills [8]. Diesen et al. (2011) found that both laparoscopic box trainers and laparoscopic VR simulators were equally effective in teaching laparoscopic skills [9]. In contrast, Hennessey, and Hewett (2014) concluded that testing with the low-fidelity FLS box trainer appears to demonstrate greater validity than the high-fidelity Lapsim virtual reality laparoscopic simulator [10].
Torricelli et al. suggested that the best way to disseminate laparoscopic surgery to obstetrics-gynecology residents is the induction of laparoscopic simulators for a short training period [11].
A randomized controlled trial comparing trainee-directed virtual reality simulation training and box training on the acquisition of laparoscopic suturing skills was conducted in a university-affiliated teaching hospital, recruiting participants who had no laparoscopic suturing experience to undergo suturing skill training in the virtual reality simulator, box training, or no training as a control. Thirty-six participants were recruited. Twenty-seven participants (75%) had no laparoscopic experience. Participants with no laparoscopic experience took longer to complete training than those with laparoscopic experience (median 90 minutes [interquartile range (IQR) 80–115] vs. 55 minutes [IQR 40–65], respectively; P = 0.044). There were no differences in successful completion of the task (7/12 [58.3%], 10/12 [83.3%], 7/12 [58.3%]; P = 0.325), median suturing time in seconds (628 [IQR 460–835], 611 [IQR 434–691], 609 [IQR 540–837]; P = 0.702), mean subjective (mean ± SD 9.8 ± 1.8, 10.4 ± 2.8, 9.3 ± 2.4; P = 0.710), and objective (7.2 ± 1.8, 8.2 ± 2.1, 7.6 ± 1.7; P = 0.426) modified Global Operative Assessment of Laparoscopic Skills score in the simulator, pelvic trainer, and control groups, respectively. They concluded that neither the box trainer nor the virtual reality simulator had a beneficial effect on the time taken or performance score when compared to participants with no training. These findings are contrary to multiple prior reports that showed substantial evidence that focused and repeated laparoscopic training on both low- and high-fidelity trainers improves laparoscopic skills, both in simulation and surgery [12].
Papanikolaou et al. suggested that teaching hospitals should introduce training programs using laparoscopic simulators with standardized and reproducible tasks to achieve better patient care with safety, efficiency, and lower cost [13].
In conclusion, there was no difference in training, whether started on a pelvic trainer or the VR simulator, so both could be used in laparoscopic training with no preferred order.
