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A Comparison of 2 Ex Vivo Training Curricula for Advanced Laparoscopic Skills: A Randomized Controlled Trial

Orzech, Neil MD, MEd*; Palter, Vanessa N. MD*; Reznick, Richard K. MD, MEd, FACS; Aggarwal, Rajesh MA, PhD, MRCS; Grantcharov, Teodor P. MD, PhD, FACS§

doi: 10.1097/SLA.0b013e31824aca09
Randomized Clinical Trials

Objective: To compare the effectiveness and cost of 2 ex vivo training curricula for laparoscopic suturing.

Background: Although simulators have been developed to teach laparoscopic suturing, a barrier to their wide implementation in training programs is a lack of knowledge regarding their relative training benefit and their associated cost.

Method: This prospective single-blinded randomized trial allocated 24 surgical residents to train to proficiency using either a virtual reality (VR) simulator or box trainer. All residents then placed intracorporeal laparoscopic stitches during a Nissen fundoplication on a patient. The operating room (OR) cases were video-recorded and technical proficiency was assessed using 2 validated tools. OR performance of both groups was compared to that of conventionally trained residents and to fellowship-trained surgeons. A cost analysis of box training, VR training, and conventional residency training across Canadian surgical programs was performed.

Results: After ex vivo training, no significant differences in laparoscopic suturing in the OR were found between the 2 groups with respect to time (P = 0.74)—global rating score (P = 0.65) or checklist score (P = 0.97). It took conventionally trained residents 6 practice attempts in the OR to achieve the technical proficiency of the ex vivo trained groups (P = 0.83). VR training was more efficient than box training (transfer effectiveness ratio of 2.31 vs 1.13). The annual cost of training 5 residents on the FLS trainer box was $11,975.00, on the VR simulator was $77,500.00, and conventional residency training was $17,380.00. Over 5 years, box training was the most cost-effective option for all programs, and VR training was more cost-effective for programs with more 10 residents.

Conclusions: Training on either a VR simulator or on a box trainer significantly decreased the learning curve necessary to learn laparoscopic suturing. VR training, however, is the more efficient training modality, whereas box training the more cost-effective option.

Laparoscopic suturing is one of the most technically demanding minimally invasive skills to acquire. Although ex vivo training curricula have been developed for this procedure, their relative efficiency and cost have yet to be compared. This study demonstrates that although virtual reality and laparoscopic box training equivalently reduce the learning curve necessary to learn laparoscopic suturing, virtual reality training does so in a more time-efficient manner, whereas laparoscopic box training is the more cost-effective option.

*Department of Surgery, University of Toronto, Ontario, Canada

Department of Surgery, Queen's University, Ontario, Canada

Department of Surgery and Cancer, Imperial College, London, United Kingdom

§Department of Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada.

Reprints: Vanessa N. Palter, MD, University of Toronto, 600 University Avenue, Room No. 440, Toronto, ON M5G 1×5. E-mail:

Disclosure: N.O. is supported by a Royal College of Physicians and Surgeons of Canada Medical Education Research Grant. R.A. is funded by a Clinician Scientist Award from the National Institute for Health Research.

Presented at the 2010 American College of Surgeons (ACS) meeting in Washington, DC.

© 2012 Lippincott Williams & Wilkins, Inc.