Simulation Models: Box Trainers
Box trainers have in common that tasks are performed using regular laparoscopic instruments in a box containing a camera, which projects onto a computer, mobile device, or TV screen. A number of box trainers are commercially available (Figure 1.1) and carry the advantages of being portable and highly versatile. Utilizing a variety of video‐capable devices, homemade trainers can be a very cost‐effective alternative [17, 18]. An example of a homemade trainer used in the author's Veterinary Applied Laparoscopic Training (VALT) laboratory is presented in Figures 1.2–1.4. Homemade versions are used solely for practice and not for skills assessments.
Figure 1.1 A number of laparoscopic skills training boxes are commercially available. Most are portable, and many have cameras that connect to a computer by USB connections. Some, including the official box for Veterinary Assessment of Laparoscopic Skills (VALS; small inlay), require a TV screen.
Source: Photo courtesy of Henry Moore, Jr., Washington State University, College of Veterinary Medicine.
Figure 1.2 Commonly used dimensions in laparoscopic training boxes.
Figure 1.3 An example of a homemade training box.
A number of practice drills have been developed and validated. In the 1990s, several structured training tasks were described, including the Dr. Rosser's station tasks developed at Yale University, which are part of the popular “Top‐Gun Laparoscopic Skills Shoot‐Out” resident competition. The physical task training system with the most solid validation to date is the McGill Inanimate Simulator for Training and Evaluation of Laparoscopic Skills (MISTELS) [8,19–21]. MISTELS was the foundation for the task training included in the Veterinary Assessment of Laparoscopic Skills (VALS) program (Figure 1.5), which launched in 2017 (www.valsprogram.org). VALS intends to provide veterinarians with a validated curriculum with tutorials for independent skills practice and certification available for specialty trained surgeons [22]. Our group has trained and assessed veterinarians in our simulation training and research facility, the VALT laboratory at Washington State University since 2008. This experience was instrumental in the development of VALS [7, 23].
Figure 1.4 High‐quality web cameras enable real‐time imaging to a relatively low cost.
Figure 1.5 Logotype for the Veterinary Assessment of Laparoscopic Skills (VALS) training and assessment program.
Source: Veterinary Assessment of Laparoscopic Skills.
Tasks included in VALS include peg transfer, pattern cutting, ligature loop placement, and intra‐ and extracorporeal suturing.
1 Pegboard transfer: Laparoscopic grasping forceps in the nondominant hand are used to lift each of six pegs from a pegboard, transfer them to a grasper in the dominant hand, place them on a second pegboard, and finally reverse the exercise (Figure 1.6).
2 Pattern cutting: This task involves cutting a 4‐cm diameter circular pattern out of a 10 × 15‐cm piece of a gauze suspended between clips (Figure 1.7).
3 Ligature loop placement: The task involves placing a ligature loop pretied with a laparoscopic slip knot over a mark placed on a foam model and cinching it down with a disposable‐type knot pusher (Figure 1.8).
4 Extracorporeal suturing: A simple interrupted suture using long (90‐cm) suture on a taper point needle is placed through marked needle entry and exit points in a slitted Penrose drain segment. The first throw in the knot is tied extracorporeally with a slip knot and cinched down by use of a knot pusher. Thereafter, three single square throws are placed by use of laparoscopic needle holders and the suture is cut (Figure 1.9).Figure 1.6 Peg transfer task. Six objects are lifted from the left‐sided pegs with the nondominant (usually left hand) grasper, transferred mid‐air to the dominant hand grasper, and then placed on a right‐sided peg. The exercise is then reversed.Figure 1.7 Pattern cut task. A 4‐cm circle is cut, with a penalty applied if the cut is outside the mark.Figure 1.8 Ligature loop application task.
5 Intracorporeal suturing: A simple interrupted suture is placed using short (12‐ to 15 cm long) suture on a taper point needle through marked needle entry and exit points in a slitted Penrose drain segment. Three throws are placed, the first being a surgeon's (double) throw, by use of laparoscopic needle holders. The exercise is completed when the suture is cut (Figure 1.10).
Figure 1.9 Extracorporeal suture task. (A). A suture is placed in a Penrose drain segment. (B). The suture is exteriorized and a slip knot tied outside the box. (C). A knot pusher is used to cinch the knot. (D). Three intracorporeally tied suture throws are placed on top of the slip knot.
Figure 1.10 Intracorporeal suture task.
The one major disadvantage with box training is the lack of instant feedback. Without automated feedback, an experienced surgeon needs to be available to critique the performance of the trainee, which becomes an important limitation because of the busy schedules of most surgeons. However,
