Review

Laparoscopic skills training and assessment

R. Aggarwal, K. Moorthy and A. Darzi
Department of Surgical Oncology and Technology, Imperial College, London, UK
Correspondence to: Mr R. Aggarwal, Department of Surgical Oncology and Technology, Imperial College London, 10th Floor, Queen Elizabeth the Queen
Mother Building, St Mary’s Hospital, Praed Street, London W2 1NY, UK (e-mail: rajesh.aggarwal@imperial.ac.uk)

Background: The introduction of laparoscopic techniques to general surgery was associated with
many unnecessary complications, which led to the development of skills laboratories to train novice
laparoscopic surgeons. This article reviews the tools currently available for training and assessment in
laparoscopic surgery.
Methods: Medline searches were performed to identify articles with combinations of the following key
words: laparoscopy, training, curriculum, virtual reality and assessment. Further articles were obtained
by manually searching the reference lists of identified papers.
Results: Current training involves the use of box trainers with either innate models or animal tissues;
it lacks objective assessment of skill acquisition. Virtual reality simulators have the ability to teach
laparoscopic psychomotor skills, and objective assessment is now possible using dexterity-based and
video analysis systems.
Conclusion: The tools are now available for the development of a structured, competency-based,
laparoscopic surgical training programme.

Paper accepted 23 July 2004

Published online in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.4816

Introduction to teach basic psychomotor skills. As the number of

The first reported laparoscopic cholecystectomy was
performed by Phillipe Mouret in France in 19871 and
within 5 years the laparoscopic approach was established
as a feasible alternative to open cholecystectomy2 – 8 .
Patients experienced the benefits of smaller incisions, a
shorter hospital stay and decreased postoperative pain, and
could resume normal activities within a week2,9 – 13 . Initial
reports of success, the enthusiasm of many surgeons and
an increasingly competitive healthcare market led to a
large number of operators attempting the new technique.
However, doubts soon surfaced regarding its safety and
the qualifications of those performing the procedures14 – 19 .
This prompted the surgical community to reconsider the
training strategy in laparoscopic surgery.
Societies and regulatory bodies such as the Society
of American Gastrointestinal and Endoscopic Surgeons
(SAGES) and the European Association of Endoscopic
Surgeons (EAES) stipulated minimum requirements
for those performing laparoscopic surgery, with an
emphasis on training both in and outside the operating
theatre20 – 24 . Skills courses and drills were introduced
surgeons performing the procedure increased, more
opportunities were available for novice surgeons to assist.
Laparoscopic cholecystectomy gradually became a safe and
effective alternative to the open procedure for a diseased
gallbladder2,25 – 27 .
The advent of laparoscopic general surgery
The skills required to perform laparoscopic surgery are
different to those of open surgery, being more allied to
endoscopy than to traditional laparotomy. The surgeon
has to enter the peritoneal cavity using a smaller incision,
use long instruments with only their tips visible and
become accustomed to the fulcrum effect28 . Procedures are
performed by viewing a two-dimensional video image on a
screen up to 2 m away, with limited tactile feedback29 – 31 .
Traditional methods of acquiring surgical skill, using
the apprenticeship model, could not accommodate the
new skills required for laparoscopic surgery. This was the
first time a completely new technique had been introduced
and few surgeons had seen a laparoscopic cholecystectomy,
let alone performed one. Experienced biliary surgeons

Copyright  2004 British Journal of Surgery Society Ltd British Journal of Surgery 2004; 91: 1549–1558
Published by John Wiley & Sons Ltd
1550 R. Aggarwal, K. Moorthy and A. Darzi

assumed that their skills at open surgery would transfer to

the laparoscopic environment, but they too were novices
in the field32 . As Krummell33 has written, it was necessary
for the surgical curriculum to evolve away from the age-
old apprenticeship model and toward the teaching of skills
in a systematic and logical fashion by doing, rather than
through observation. The surgical community realized
that the early phase of the learning curve could be achieved
outside the operating theatre and that once proficiency
had been demonstrated the surgeon could proceed to real
operations.

Laparoscopic training outside the operating

theatre

The introduction of laparoscopic courses for general

surgeons was an attempt to teach basic laparoscopic skills
within a structured curriculum. Courses lasted for 2–3 days
and consisted of didactic lectures with some hands-on
simulator practice. Synthetic models enabled surgeons to
practise tasks in box trainers and varied from performing
simple tasks with different laparoscopic instruments to the
learning of entire procedures34 – 37 . Many courses involved
performing a laparoscopic cholecystectomy on a cadaveric
porcine model, and some on an anaesthetized pig38 – 40 .
Surgeons were able to acquire skills in a controlled
environment, free of the pressures of operating on real
patients. This enabled the acquisition of basic skills
for proficiency in laparoscopic surgery with emphasis
on the fact that attendance at such courses was not
to be interpreted as a licence to perform unsupervised
laparoscopic procedures41 . The success of this form
of training is now evident from the large number of
laparoscopic courses available worldwide. However, box
trainers have been criticized for being unrealistic and
lacking any form of objective assessment. Computer
simulators have been used to train airline pilots for a
number of years, providing realistic simulation with an
accurate assessment of performance. The possibility of an
analogous situation in surgery is becoming a reality.
Virtual reality systems in laparoscopic surgery
The term virtual reality refers to ‘a computer-generated
representation of an environment that allows sensory
interaction, thus giving the impression of actually
being present’42 . The MIST-VR laparoscopic simulator
(Mentice, Gothenburg, Sweden) comprises two standard
laparoscopic instruments held together on a frame with
position-sensing gimbals43 (Fig. 1). These are linked to
a Pentium personal computer (Intel, Santa Clara, CA,
USA) and movements of the instruments are relayed in real
Fig. 1
The Minimally Invasive Surgical Trainer – Virtual Reality
(MIST-VR )
time to a computer monitor. Targets appear randomly on
the screen and are ‘grasped’ or ‘manipulated’ (Fig. 2), with
performance measured by time, error rate and economy of
movement for each hand.
The LapSim (Surgical Science, Gothenburg, Swe-
den) laparoscopic trainer has tasks that are more realistic
than those of the MIST-VR , involving structures that
are deformable and may bleed44 (Fig. 3). The Xitact
LS500 (Xitact, Morges, Switzerland) laparoscopy sim-
ulator comprises tasks such as dissection, clip application
and tissue separation, the integration of which can pro-
duce a procedural trainer45 . It differs from the MIST-VR
and LapSim in that it incorporates a physical object,
the ‘virtual abdomen’, with force feedback. Other newer
simulators include the Reachin Laparoscopic Trainer
TM
(Reachin, Stockholm, Sweden), ProMIS Surgical Simu-
TM
lator (Haptica, Dublin, Ireland) and LapMentor (Sim-
bionix, Cleveland, Ohio, USA).
The MIST-VR simulator has tasks that are abstract in
nature, enabling the acquisition of psychomotor skill rather
than cognitive knowledge. This enables the simulator to

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Published by John Wiley & Sons Ltd
Laparoscopic skills training and assessment 1551

a b

c d
Fig. 2 Sample tasks on the MIST-VR laparoscopic trainer. a acquire place; b traversal; c manipulate diathermy; d stretch diathermy

be used in a multidisciplinary manner to teach the basic
skills required for all forms of minimally invasive surgery.
However, newer simulators have augmented their basic
skills programmes to incorporate parts of real procedures,
allowing trainees to learn techniques they would use in the
operating theatre. For example, the LapSim has a module
for dissection of Calot’s triangle, and the recently launched
TM
LapMentor simulator enables the trainee to perform a
complete laparoscopic cholecystectomy with the benefit
of force feedback. Although the task-based simulators are
more advanced in terms of software, they are bulkier and
more expensive.
Using these simulators, trainees can practise standard-
ized laparoscopic tasks repeatedly, with instant objective
feedback of performance. The simulators are portable, use
standard computer equipment and are available commer-
cially. With graded exercises at different skill levels, they
can be used as the basis for a structured training pro-
gramme. The feedback obtained also enables comparisons
to be made between training sessions and trainees.
Learning curves on laparoscopic trainers
Studies to assess the ability of box and virtual reality trainers
to teach laparoscopic skills have analysed the learning
curves of experts and novices. Smith et al.46 constructed a
box trainer containing posts of varying heights and ten non-
surgeons touched each post in a sequential order, a total of
ten times. The laparoscopic instruments were connected
to sensors recording their position in space, hence accuracy
of movement was a measure of performance in addition
to time. Subjects improved their time taken during the
first three repetitions, although accuracy of movement
continued to improve throughout the ten sessions. This

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Published by John Wiley & Sons Ltd
1552
a Before the incorporation of simulators into the general
b randomized to training on the MIST-VR simulator or
Fig. 3 Sample tasks on the LapSim laparoscopic trainer. a
cutting; b suturing
implies that the learning curve for operator speed is shorter
than that for operator accuracy.
Gallagher and Satava47 reported data on experienced,
inexperienced and novice laparoscopic surgeons who
completed ten trials of six tasks on the MIST-VR .
The first trial revealed significant differences between
the three groups, the experienced group being the
fastest and most consistent. Performance variables for
all groups had reached a plateau by trial 5, with most
improvement for novice and inexperienced groups. With
repeated practice on the simulator, the novices had
improved their performance to match that of experienced
surgeons.
A criticism of laparoscopic trainers is that they are
abstract, with tasks being too simple and not related to real
procedures. Rosser et al.48 described a structured training
method for enhancing laparoscopic surgical skills, with
150 trainee surgeons performing a series of three simple
standardized laparoscopic drills on a box simulator, ten
times each. At the end of each drill their skill at performing
Copyright  2004 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
R. Aggarwal, K. Moorthy and A. Darzi
an intracorporeal stitch was assessed by time taken. After
only one series of tasks, the time taken to complete an
intracorporeal stitch improved significantly, with further
significant improvement at the end of ten repetitions. An
equivalent programme with MIST-VR as the training
tool revealed significant improvements in knot-tying times
after a 5-day training period49 .
Transfer of skill from laparoscopic trainer to
human patient
surgical curriculum, it is necessary to show transfer of
laparoscopic skill to real operations. Scott et al.50 assessed
22 general surgical trainees performing a laparoscopic
cholecystectomy on a human patient. Nine were enrolled in
a 10-day training programme on a laparoscopic box trainer;
the remainder underwent no formal training. The trained
group improved to a significantly greater extent than the
control group on four of the eight assessment criteria, with
non-significant improvements on the remaining criteria.
The first study to assess the transfer of skills from a
virtual reality simulator recruited 16 surgical trainees of
varying experience (postgraduate years 1–4), who were
to a control group51 . The simulator group trained on
MIST-VR until they attained a previously specified expert
score. All subjects then completed a human laparoscopic
cholecystectomy, scored by two independent observers
using a checklist for gallbladder dissection. The trained
group dissected the gallbladder 29 per cent faster; they
were nine times more likely to make progress and
five times less likely to make errors. However, there
was no evaluation of baseline laparoscopic skill before
the study, merely a non-specific test of psychomotor
ability. A subsequent study of surgical skill on a real
laparoscopic cholecystectomy recruited 16 laparoscopic
novices (fewer than ten procedures performed previously)
and divided them into a MIST-VR -trained group
and a control group52 . The trained group performed
significantly faster than the control group and had
greater improvement in error and economy of movement
scores.
Although performed with small numbers of subjects,
these initial studies have shown transfer of laparoscopic
skills from virtual reality systems to real operations. This
may be a more cost-effective method of imparting surgical
skill, although it is necessary to make comparisons with
current methods of training, namely box trainers.
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Laparoscopic skills training and assessment
Comparison of standard and virtual laparoscopic
trainers
Hamilton et al.53 randomized surgical trainees to ten half-
hour sessions on a box trainer or to the MIST-VR ,
with baseline and post-training skill assessments on both
trainers. All achieved significant improvements regardless
of which simulator they had trained on, although the
magnitude of improvement for the MIST-VR -trained
group was significantly greater than that for the box-trained
group on both forms of assessment.
However, evidence for the role of virtual reality
simulators in the transfer of skills to the operating theatre
remains weak. There is a lack of standardization in the
operative techniques used and assessment is performed by
direct observation, enabling the observer to be influenced
by attitudes of the surgical team to the operating surgeon.
Time alone has been shown to be a poor indicator. The
development of objective measures of operative skill is
important to confirm the role of simulators in laparoscopic
surgery, and if successful may lead to further advances in
the credentialing and revalidation of all surgeons.
Assessment of technical skills in laparoscopic
surgery
In 1991, SAGES required surgeons to demonstrate compe-
tency before performing a laparoscopic procedure21,23,24 .
Competency was based on the number of procedures per-
formed and time taken, or on evaluation of the trainee
by senior surgeons30,54 – 56 . These criteria are known to
be crude and indirect measures of technical skill, or to
suffer from the influence of subjectivity and bias. Profes-
sional organizations have recently recognized the need to
assess surgical performance objectively57 . Currently, this
consists of dexterity analysis and video-based assessment,
which also enables structured progression during train-
ing, together with identification of trainees who require
remedial action.
For any method of skill assessment to be used with
confidence, it must be reliable, valid and feasible. Reliability
is a measure of the precision of a test and supposes that
results for a test repeated on two separate occasions, with
no learning between the two tests, will be identical. It is
measured as a ratio from 0 to 1·0, a test with reliability
of 0–0·5 being of little use, 0·5–0·8 being moderately
reliable, and over 0·8 being the most useful. Validity refers
to the concept of whether a test measures what it purports
to measure. Face validity refers to whether the model
resembles the task it is based upon, and content validity
considers the extent to which the model measures surgical
skill and not simply anatomical knowledge. Construct
Copyright  2004 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
1553
validity is a test of whether the model can differentiate
between different levels of experience. Concurrent validity
compares the test to the current ‘gold standard’, and
predictive validity determines whether the test corresponds
to actual performance in the operating theatre.
Dexterity analysis in laparoscopic surgery
Laparoscopic surgery lends itself particularly well to
motion analysis, as hand movements are confined
to the limited movements of the instruments. Smith
et al.46 connected laparoscopic forceps to sensors to
map their position in space, and relayed movements of
the instruments to a personal computer. This enabled
calculation of the instrument’s total path length, which
was compared to the minimum path length required to
complete the task.
The Imperial College Surgical Assessment Device
(ICSAD) has sensors placed on the back of a surgeon’s
TM
hands58,59 . A commercially available device (Isotrack II ;
Polhemus, Vermont, USA) emits electromagnetic waves
to track the position of the sensors in x, y and z
axes 20 times per second (Fig. 4). This device is able
to run from a standard laptop computer and data are
analysed in terms of time taken, distance travelled and
total number of movements for each hand. Previous
studies have confirmed the construct validity of the
ICSAD as a surgical assessment device for laparoscopic
procedures, both for simple tasks60 and for real procedures
such as a laparoscopic cholecystectomy61 . Experienced
laparoscopic surgeons made significantly fewer movements
than occasional laparoscopists, who in turn were better than
novices in the field. The ICSAD device has also been shown
objectively to assess the acquisition of psychomotor skill of
trainees attending laparoscopic training courses62,63 .
The Advanced Dundee Endoscopic Psychomotor Tester
(ADEPT) is another computer-controlled device, consist-
ing of a static dome enclosing a defined workspace, with
two standard laparoscopic graspers mounted on a gimble
mechanism64 . Within the dome is a target plate containing
innate tasks, overlaid by a spring-mounted perspex sheet
with apertures of varying shapes and sizes. A standard
laparoscope relays the image to a video monitor. Each task
involves manipulation of the top plate with one instrument
enabling the other instrument to negotiate the task on the
back plate through the access hole. The system registers
time taken, successful task completion, angular path length
and instrument error score (a measure of instrument con-
tact with the sides of the front plate holes). Experienced
surgeons exhibit significantly lower instrument error rates
than trainees on the ADEPT system65 . Comparison of per-
formance on ADEPT also correlated well with a blinded
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1554
a b
Fig. 4The Imperial College Surgical Assessment Device (ICSAD). a standard laptop and motion tracking hardware; b sensors placed
on surgeon’s hands for assessment of laparoscopic skill on a box trainer
assessment of clinical competence, a measure of concurrent
validity66 . Test–retest reliability of the system produced
positive correlations for all variables when performance on
two consecutive test sessions was compared67 .
These three methods of assessing dexterity enable
objective assessment of surgical technical skill, but only
the ICSAD device can be used to assess real operations.
However, in this case it is important to know whether
the movements made are purposeful. For example, the
common bile duct may be injured during a laparoscopic
cholecystectomy, and dexterity analysis alone cannot
record this potentially disastrous error. To confirm surgical
proficiency it is necessary to analyse the context in which
these movements are made.
Video-based assessment in laparoscopic surgery
During the introduction of laparoscopic cholecystectomy,
SAGES and EAES advocated proctoring of beginners by
senior surgeons before awarding privileges in laparoscopic
surgery22,23 . A single assessment is open to subjectivity and
bias, although additional criteria can improve reliability
and validity. An example of this is the Objective Structured
Clinical Examination (OSCE), a method of assessing the
clinical skills of history taking, physical examination and
patient–doctor communication68 .
Copyright  2004 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
R. Aggarwal, K. Moorthy and A. Darzi
Martin et al.69 developed a similar approach to the
assessment of operative skill, the Objective Structured
Assessment of Technical Skill (OSATS). This involves
six tasks on a bench format, with direct observation and
assessment on a task-specific checklist, a seven-item global
rating score and a pass/fail judgement. Twenty surgeons
in training of varying experience performed equivalent
open surgical tasks on the bench format and on live
anaesthetized animals. There was excellent correlation
between assessment on the bench and live models, although
test–retest and inter-rater reliabilities were higher for
global scores, making them a more reliable and valid
measurement tool70,71 . However, a global rating scale is
generic and may ignore important steps of a particular
operation. Eubanks et al.72 developed a procedure-
specific scale for laparoscopic cholecystectomy with scores
weighted for completion of tasks and occurrence of errors.
For example, liver injury with bleeding scored 5, whereas
common bile duct injury scored 100. Three observers rated
30 laparoscopic cholecystectomies performed by trainees
and consultant surgeons. Correlation between observers
for final scores was good, although correlation between
final score and years of experience was only moderate.
A similar approach identified errors made by eight
surgical registrars undertaking a total of 20 laparoscopic
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Laparoscopic skills training and assessment
cholecystectomies73 . The procedure was broken down into
ten steps such as ‘dissect and expose cystic structures’ and
‘detach gallbladder from liver bed’. Errors were scored
in two categories: interstep (procedural) errors involved
omission or rearrangement of correctly undertaken steps,
and intrastep (execution) errors involved failure to execute
an individual step correctly. There was a total of 189
separate errors, of which 73 (38·6 per cent) were interstep
and 116 (61·4 per cent) intrastep. However, only 9 per cent
of the interstep errors required corrective action, compared
with 28 per cent of intrastep errors.
All of the above rating scales are complex and time
consuming; for example, the assessment of 20 surgical
trainers on the OSATS required 48 examiners for 3 h
each69 . Furthermore, the scales are open to human error
and not entirely without subjectivity. To achieve instant
objective feedback of a surgeon’s technical skills, virtual
reality simulation may be more useful.
Virtual reality simulators as assessment devices
Studies to confirm the role of virtual reality simulators
as assessment devices have concentrated on the demon-
stration of construct validity, with experienced surgeons
completing the tasks on the MIST-VR significantly faster,
with lower error rates and greater economy of movement
scores74 . A direct comparison of performance is possible
as all surgeons complete exactly the same task, without the
effects of patient variability or disease severity. The tasks
can be carried out at any time and further processing is
not required to produce a test score. This can lead to the
development of criterion scores that have to be achieved
before operating on real patients.
At the American College of Surgeons’ meeting in
2001, Gallagher et al.75 described the performance of 210
experienced laparoscopic surgeons on two trials of the
MIST-VR . The aim was to benchmark performance of
these surgeons to confirm future use as an assessment
tool. The results revealed marked variability in the
scores obtained, together with a significant learning
effect between trials. To use such data for high-stakes
assessments, perhaps a pool of expert scores from all centres
currently using virtual reality simulation might lead to the
development of an international benchmark for trainee
surgeons. Furthermore, as some trainees take longer to
achieve predefined levels of proficiency than others51 , this
may enable particularly gifted trainees to be fast-tracked
into an advanced laparoscopic programme, and the true
development of a competency rather than a time-based
curriculum.
Copyright  2004 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
1555
Comparison of assessment tools
Currently there is no consensus regarding the optimal
assessment tool for laparoscopic procedures, and perhaps
video-based and dexterity systems should be used in
conjunction. The authors’ department has recently
developed new software to enable the ICSAD trace to
be viewed together with a video of the procedure, leading
to a dexterity-based video analysis system76 . This still
requires an investment of time to assess the procedure on a
rating scale, but it may be possible to identify areas of poor
dexterity and to concentrate on video-based assessment
of these areas alone. Other tools, such as eye-tracking
devices, may also be used to highlight important areas of
the operation.
Conclusion
In the American Journal of Surgery in 1991 it was stated:
‘No surgical technique in recent memory has generated as
much excitement and enthusiasm among general surgeons
as has interventional laparoscopy . . . the access may be
minimal, but the operations and potential for complications
are major’19 . The introduction of laparoscopic techniques
in the past 15 years has had a phenomenal impact on
modern surgery. Laparoscopy is now the ‘gold standard’ for
cholecystectomy and is making major inroads elsewhere.
However, regulatory bodies have emphasized that the
expanding scope of this technology should be coupled
with validated training programmes incorporating inbuilt
measures of performance before progressing to real
procedures.
To ensure that virtual simulation can be incorporated
into current training programmes there is a need to
develop validated curricula for basic, intermediate and
advanced level laparoscopic training. Current simulators
should enable basic and some forms of intermediate
level training, although the methods for achieving this
remain unclear. The correct frequency of training and
whether tutors need to be present at all times should be
determined. Competency levels should be defined using
at least a national approach, enabling standardization of
training programmes. It is also important to ensure that
virtual reality simulation is seen as an adjunct to traditional
methods of training, and not as an alternative. Simulators
currently have the ability to teach basic laparoscopic skills,
enabling novice surgeons to progress along the early
part of the learning curve before entering the operating
theatre. With further developments in technology it may
be possible to practise complete procedures, such as Nissen
fundoplication and colectomy. However, surgeons will still
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1556
need to reach expert levels of skill in the operating theatre;
further training to achieve this is essential.
The organization of training programmes must also
be addressed. It is not necessary for every hospital to
have a virtual reality simulation laboratory; training can
be provided at regional skills centres. Currently, training
occurs in the form of isolated 2- or 3-day courses but,
with the establishment of regional centres, it should prove
possible to develop training programmes over periods of
months and years. Junior surgeons might initially attend
an intensive basic laparoscopic skills programme, followed
perhaps by one session per week to learn intermediate
and advanced skills. This could be aligned with their
operating theatre experience, and their performance might
be charted using the previously mentioned assessment
tools.
A recent BJS leading article commented on surgical
simulation as a ‘good idea whose time has come’77 and
there is a growing confidence in its ability to revolutionize
surgical education. The widespread introduction of
laparoscopic procedures should be handled in a controlled
and audited manner. Training programmes should exist
and proctoring should remain an important part of the
learning process. Only with this structured and defined
approach can the complications of the last decade be
avoided.
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