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, proficiency goals have been defined for MISTELS and VALS such that the trainee can monitor his or her progress by simple metrics such as time and errors [22, 24] With these goals in mind, the trainee can practice independently for the basic tasks of peg transfer, pattern cutting, and ligature loop placement. Laparoscopic suturing may require instructive sessions with an experienced surgeon. When suturing techniques have been learned, the trainee can continue to practice independently to reach an expert level of performance, as defined by the proficiency goals [22].
Another disadvantage of box training is the current lack of veterinary higher fidelity synthetic models for practicing surgical procedures. Physical models for cholecystectomy, appendectomy, and so on are commercially available, but they are all fairly expensive and most are based on human anatomy and physiology. A physical model, which can often be used only once, may not be feasible for most residency training programs if the cost is more than $100/each. Hopefully, cost‐effective medium and high fidelity synthetic models for veterinary MIS training will become more available in the future.
Virtual Reality Simulation
Highly realistic VR simulation (Figure 1.11) is commercially available for both basic skills as well as entire simulated surgical procedures. In fact, one of the main advantages with VR training is realistic simulation of surgical procedures, which is hard to achieve to a reasonable cost in box training. For veterinarians, this advantage is somewhat limited, though, because anatomy and surgical procedures are all based on human anatomy.
Basic task simulations give the trainee opportunity to experience a variety of surgical complications, such as bleeding, dropping clips, and repercussion from rough tissue handling while benefiting from instant and more objective motion metrics feedback and suggestions on how to proceed. Other advantages of VR simulation are that modules contain detailed instruction for performance of all tasks and summative feedback comparing the overall performance with an expert level. The summative performance is also broken down into a number of performance metrics, such as time, instrument path length for the dominant and nondominant hands, and errors, giving objective information about the performance. Therefore, the provided feedback of VR gives the trainee opportunity to practice without the need for an instructor. We have found that this instant feedback also serves as motivation because most surgeons and residents have competitive personalities and enjoy the comparison with expert level.
At present, a number of VR simulators are commercially available, but they all carry the disadvantage of being expensive. Costs range from $28 000 (LapSim Essence) to over $90 000 for units with haptic feedback (LapSim haptic, Surgical Science, Minneapolis, MN) (personal communication, Martin Jansson, GM, Surgical Science, Inc., June 2020), and software updates are also expensive. Another disadvantage is that, as mentioned, all VR simulation is based on human anatomy, and developing software for veterinary simulation is expensive; such models may not become available, at least not in the near future.
Figure 1.11 The LapSimHaptic system virtual reality trainer is combining high‐technological virtual reality exercises with haptic feedback.
Source: © Surgical Science Inc. Reproduced with permission from Surgical Science Inc.
Because of the high cost of VR training, investigations have tried to determine if VR training can be justified by being more effective than box training. A systematic review through the Cochrane Institute found that VR procedural training shows some advantage over box training in operating time and performance [25]. Similar results were reported in another recent meta‐analysis, showing that VR was associated with higher performance score during MIS, and faster completion of peg transfer task [26]. No differences were, however, demonstrated in any of 6 other outcomes parameters [26]. Some controversy seems to exist: a similar review concluded that VR and box training both are valid teaching models and that both methods are recommended in surgical curricula but with no definitive superiority of VR [27]. Important for veterinary conditions, VR procedural training may not be superior unless it is procedure specific [28], and thus it likely needs to be species specific.
In veterinary medicine, there is limited accessibility to the VR trainer. A recent study conducted by the VALT laboratory failed to demonstrate the construct validation on VR trainer [29]. Based on our experience, using VR simulator does not provide superior results compared to traditional box trainers.
Hybrid Training Models: Augmented Reality
VR simulation has been criticized for the lack of realistic haptic feedback [30]; therefore, hybrid, or AR, simulators were developed that combine a live and a virtual environment. A number of AR simulators are commercially available [31]. To date, the most validated system is the ProMIS simulator (CAE Healthcare, Montreal, Quebec; Figure 1.12), which has been used in the VALT laboratory since 2010. Tasks are performed in a box trainer using real instruments, but a virtual interface can be placed over the image of the camera. Three cameras are used for motion tracking of the physical instruments in three planes. Therefore, objective metrics such as instrument path and economy of movement (i.e., velocity and directional changes over time, also expressed as motion smoothness) are provided. The metrics used have showed construct validity in suturing tasks and in the ability to separate expert colorectal surgeons from experienced laparoscopic, but novice colorectal, surgeons [32, 33].
Figure 1.12 The ProMis augmented reality trainer is a combination of a physical box trainer and a virtual reality overlay used in many surgical exercises.
Source: Photo courtesy of CAE Healthcare, © 2014 CAE Healthcare.
In our experience, the use of surgical instruments adds realism to the simulation, which is in agreement with studies comparing AR with VR simulation [29, 33, 34]. However, an even bigger advantage for veterinary surgery is the ability to use novel physical models for simulation. Species‐specific