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State of the Evidence on Simulation-Based Training for Laparoscopic Surgery: A Systematic Review

Zendejas, Benjamin MD, MSc*; Brydges, Ryan PhD†,‡; Hamstra, Stanley J. PhD§; Cook, David A. MD, MHPE¶,‖

doi: 10.1097/SLA.0b013e318288c40b

Objective: Summarize the outcomes and best practices of simulation training for laparoscopic surgery.

Background: Simulation-based training for laparoscopic surgery has become a mainstay of surgical training. Much new evidence has accrued since previous reviews were published.

Methods: We systematically searched the literature through May 2011 for studies evaluating simulation, in comparison with no intervention or an alternate training activity, for training health professionals in laparoscopic surgery. Outcomes were classified as satisfaction, skills (in a test setting) of time (to perform the task), process (eg, performance rating), product (eg, knot strength), and behaviors when caring for patients. We used random effects to pool effect sizes.

Results: From 10,903 articles screened, we identified 219 eligible studies enrolling 7138 trainees, including 91 (42%) randomized trials. For comparisons with no intervention (n = 151 studies), pooled effect size (ES) favored simulation for outcomes of knowledge (1.18; N = 9 studies), skills time (1.13; N = 89), skills process (1.23; N = 114), skills product (1.09; N = 7), behavior time (1.15; N = 7), behavior process (1.22; N = 15), and patient effects (1.28; N = 1), all P < 0.05. When compared with nonsimulation instruction (n = 3 studies), results significantly favored simulation for outcomes of skills time (ES, 0.75) and skills process (ES, 0.54). Comparisons between different simulation interventions (n = 79 studies) clarified best practices. For example, in comparison with virtual reality, box trainers have similar effects for process skills outcomes and seem to be superior for outcomes of satisfaction and skills time.

Conclusions: Simulation-based laparoscopic surgery training of health professionals has large benefits when compared with no intervention and is moderately more effective than nonsimulation instruction.

Supplemental Digital Content is Available in the Text.We appraised the literature to summarize the outcomes and describe best practices of simulation training for laparoscopic surgery. Results show that simulation-based training in laparoscopic surgery provides large benefits when compared with no intervention and moderate benefits in comparison with nonsimulation instruction. Box trainers appear comparable with virtual reality simulators.

*Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN

Department of Medicine, University of Toronto, Toronto, Ontario, Canada

The Wilson Centre, University Health Network, Toronto, Ontario, Canada

§Academy for Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN

Office of Education Research, Mayo Medical School, Rochester, MN.

Reprints: Benjamin Zendejas, MD, MSc, Department of Surgery, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905. E-mail:

This work was supported by intramural funds, including an award from the Division of General Internal Medicine, Mayo Clinic.

The funding sources for this study played no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation of the manuscript. The funding sources did not review the manuscript.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Disclosure: The authors declare no conflicts of interest.

© 2013 Lippincott Williams & Wilkins, Inc.