a cost-effective approach to establishing a surgical skills laboratory

A cost-effective approach toestablishing a surgical skills laboratoryDavid A. Berg, MD, Richard E. Milner, BS, Carol A. Fisher, BA, Amy J. Goldberg, MD,Daniel T. Dempsey, MD, and Harsh Grewal, MD, Philadelphia, Penn

Background. Recent studies comparing inexpensive low-fidelity box trainers to expensive computer-based virtual reality systems demonstrate similar acquisition of surgical skills and transferability to theclinical setting. With new mandates emerging that all surgical residency programs have access to asurgical skills laboratory, we describe our cost-effective approach to teaching basic and advanced openand laparoscopic skills utilizing inexpensive bench models, box trainers, and animate models.Methods. Open models (basic skills, bowel anastomosis, vascular anastomosis, trauma skills) andlaparoscopic models (basic skills, cholecystectomy, Nissen fundoplication, suturing and knot tying,advanced in vivo skills) are constructed using a combination of materials found in our surgicalresearch laboratories, retail stores, or donated by industry. Expired surgical materials are obtained fromour hospital operating room and animal organs from food-processing plants. In vivo models areperformed in an approved research facility. Operation, maintenance, and administration of thesurgical skills laboratory are coordinated by a salaried manager, and instruction is the responsibility ofall surgical faculty from our institution.Results. Overall, the cost analyses of our initial startup costs and operational expenditures over a3-year period revealed a progressive decrease in yearly cost per resident (2002-2003, $1,151; 2003-2004, $1,049; and 2004-2005, $982).Conclusions. Our approach to surgical skills education can serve as a template for any surgeryprogram with limited financial resources. (Surgery 2007;142:712-21.)

From The Department of Surgery and the Institute for Clinical Simulation and Patient Safety, Temple University
School of Medicine, Philadelphia, Penn
The surgical training environment is currentlyexperiencing a marked evolution. The opportunityfor learning in the operating room is shrinking,mainly owing to pressure on time and costs.1 Thetraditional Halstedian apprenticeship model of“see one, do one, teach one” can no longer keeppace with these challenges that face surgical edu-cators. Recent changes to the limited number ofwork hours, along with the rapid advancement ofsurgical technology and development of innovativeminimally invasive techniques, have raised con-cerns regarding patient safety and underscore theneed to supplement training outside the traditional

Industry product donations accepted from Ethicon, UnitedStates Surgical, Karl Storz, and Stryker.

Accepted for publication May 17, 2007.

Reprint requests: Harsh Grewal, MD, Pediatric Surgery, 5 East,TUCMC, 3509 N Broad Street, Philadelphia, PA 19140. E-mail:[email protected]

0039-6060/$ - see front matter

© 2007 Mosby, Inc. All rights reserved.

doi:10.1016/j.surg.2007.05.011

712 SURGERY

clinical setting. Computer-based virtual reality sys-tems have recently been developed and incorpo-rated into some surgery residency trainingprograms2-10 for this purpose. These models havebeen shown to be valid and effective for both skillsacquisition and transferability to the operatingroom3,5,6,8,10,11; however, their high costs limittheir applicability to many programs faced withbudgetary constraints. In addition, recent studieshave shown that low-fidelity box trainers are just aseffective as virtual reality systems for improvingpsychomotor skills.5,12,13

The Residency Review Committee for Surgery ofthe Accreditation Council for Graduate MedicalEducation stated that, by July, 2008, all surgeryresidency programs will be required to have accessto a surgical skills laboratory. A recent survey14 ofsurgery residency program directors revealed that55% of surgery training programs have dedicatedlaparoscopic skills laboratories. These findings em-phasize that many surgery programs need to reas-sess their current curricula and make adjustmentsto be in compliance with these future changes in
surgical education. Program directors and chair-

Surgery Berg et al 713Volume 142, Number 5

persons of surgery residency programs currentlywithout access to skills laboratories need to evalu-ate their administrative and financial resources todetermine whether establishing a surgical skills lab-oratory is a practical option for their particulartraining program.

We describe our method of developing a cost-effective surgery skills laboratory curriculum totrain surgical residents in basic and advanced openand laparoscopic surgical skills utilizing inexpen-sive bench models, box trainers, and animate mod-els in the setting of limited financial resources.

MATERIALS AND METHODSThe Surgical Skills Laboratory of the Temple

University School of Medicine was established bythe Department of Surgery during the 2002-2003academic year. Each year, the Temple UniversityDepartment of Surgery employs approximately 50residents, both designated and nondesignated pre-liminary residents (PGY 1 and 2) and general sur-gery categorical residents (PGY 1-5). The totalnumber of residents participating in the surgicalskills laboratory during the 2002-2003, 2003-2004,and 2004-2005 academic years was 48, 49, and 49,respectively.

Training exercises utilized in our skills labora-tory are either based on variations of establishedmodels15,16 or have been designed in our labora-tory. Models are constructed using a combina-tion of materials found in our surgery researchlaboratories, items purchased at low-cost fromretail stores, or industry-sponsored equipmentdonations. Expired surgical materials are ac-quired from the hospital operating room and alocal food-processing plant serves as an inexpen-sive source of animal organs. Animate teachingexercises are conducted in an animal facility ap-proved by the Institutional Animal Care and UseCommittee of Temple University. A salaried labo-ratory manager is responsible for maintaining thelaboratory schedule, setting up and administeringall skill modules, and keeping records of laboratoryexpenditures. The manager, however, has otherresponsibilities within the Department of Surgery,including managing the animal care and research;he devotes approximately 0.5 full time equivalents(FTE) to the skills laboratory. This percentage ofFTE was used in our cost analysis.

When beginning the residency program, all resi-dents are provided with a syllabus that utilizes dia-grams, photographs, and text to outline the methodsand objectives of each training module. This infor-mation is also accessible via our online web-based
curriculum. The skills laboratory is scheduled for a
3-hour time block and begins after our weekly edu-cational conferences. The time during which resi-dents are either attending conferences or scheduledfor the skills laboratory is considered “protected time”(i.e., residents are free from clinical duties). Eachskills session is attended by up to 6 residents andone attending surgeon. The entire skills laboratoryprogram is directed by one of the authors (HG);the skills lab director spends approximately 0.1FTE in these activities for the time periods de-scribed in this report, and this time allocation wasused in our cost calculations. Before the start ofeach module, the attending surgeon leads a didac-tic session that covers the material relevant to theparticular skill session, and is present for the entireskills session to provide instruction and immedi-ate feedback (the attending staff spend approximately2.5 hours for each session they are instructing).The faculty participating are full-time academic fac-ulty and are not compensated separately for theirtime and effort; in addition, each section is respon-sible for staffing the modules, for example, thetrauma section staffs the trauma critical care mod-ules.

The skills laboratory curriculum is composed of4 open modules (basic skills, bowel anastomosis,vascular anastomosis, and trauma skills) and 5 lapa-roscopic modules (basic skills, cholecystectomy,Nissen fundoplication, suturing and knot tying,and advanced in vivo skills). During the first year ofthe skills laboratory (2002-2003), most trainingmodules were administered to residents of all PGYlevels. Before the second year (2003-2004) of theskills laboratory, the curriculum was evaluated andresidents were surveyed, resulting in the currentskills laboratory curriculum in which modules aregeared toward appropriate skills and tasks for theirPGY level (Table I).

Open skills. Basic open skills: All PGY 1 residentsparticipate in the basic open skills module when theylearn the identification of basic instruments, the clas-sification and uses of different types of sutures, meth-ods of knot tying and wound closure, and the use ofelectrocautery and ultrasonic dissector. No-cost mate-rials include pig bowel harvested from prior in vivoskills sessions. Purchased materials include pig feet,chicken thighs, and industry-manufactured skin padtrainers.

Bowel anastomosis: The bowel anastomosis mod-ule is administered to all PGY 2 residents andteaches the skills of both hand-sewn (1 and 2 lay-ers) and stapled anastomoses. With the exceptionof a trial of an industry-manufactured bowel model(Limbs and Things, Inc., Bristol, United King-
dom), all supplies are either harvested from prior

714 Berg et al SurgeryNovember 2007

in vivo laboratories (pig bowel), fabricated in thelaboratory (latex bowel model), or donated (sta-plers and reloads).

Vascular anastomosis: PGY 2 residents are intro-duced to vascular instruments and instructed onthe anastomosis of a donated synthetic graft to aharvested pig aorta in an end-to-side fashion. Vas-cular instruments were purchased during the firstyear and have been reused for subsequent labora-tory sessions.

Trauma skills: The trauma skills module utilizes alive porcine model to teach PGY 1 residents variousskills essential to the treatment of the injured pa-tient (tracheostomy, peripheral venous cutdown,chest tube placement, diagnostic peritoneal lavage,and thoracotomy). Purchased materials include alive animal, central venous catheter kits, peritoneallavage kits, and ultrasound supplies (battery andcharger). Donated items include chest tubes andan ultrasound machine.

Laparoscopic skills. Basic laparoscopic skills: Inthe basic laparoscopic skills module, first-year resi-dents are instructed on abdominal access, propertrocar placement, and various fundamental skillssets including pegboard, cup drop, rope pass, pat-tern cutting, and endoscopic clip and loop appli-cation.15,16 Outcomes were measured using a timeand error system to obtain a composite score.

Laparoscopic cholecystectomy: PGY 2 residents par-ticipate in the ex vivo laparoscopic cholecystectomymodule using a laparoscopic box trainer. They areinstructed on the proper methods of exposure,

Table I. Surgical skills laboratory curriculum (Xdenotes postgraduate year in which moduleprovided)

Postgraduate Year

1 2 3 4 5

Open skillsBasic open skills XBowel anastomosis XVascular anastomosis XTrauma skills X

Laparoscopic skillsBasic laparoscopic skills XLaparoscopic

cholecystectomyX

Laparoscopic Nissenfundoplication

X X X

Laparoscopic suturing/knot tying

X X X

Advanced in vivolaparoscopic skills

X X X

dissection, identification of the cystic artery, cystic

duct, and common bile duct, application of lapa-roscopically placed clips, and removal of the gall-bladder from the liver bed using electrocautery orultrasonic dissector. Pig livers are purchased from alocal food-processing plant. Laparoscopic clips areeither purchased or donated. Outcomes were mea-sured using a checklist system.

Laparoscopic Nissen fundoplication: Using an exvivo porcine stomach model in a laparoscopic boxtrainer, PGY 3, 4, and 5 residents are instructed onperforming key steps of a laparoscopic Nissen fundo-plication, including esophageal dissection, fundopli-cation, and proper suture placement.17 Pig stomachsare purchased from a local food processing plant.

Laparoscopic suturing and knot tying: This moduleis offered to PGY 3, 4, and 5 residents and coversthe skills of extracorporeal and intracorporeal knottying and both interrupted and continuous sutur-ing. Cloth suspended from alligator clips serves as amedium on which to suture and is available in thelaboratory. Purchased items include chicken thighsand endoscopic suturing devices.

Advanced in vivo laparoscopic skills: Utilizing a liveporcine model, PGY 3, 4, and 5 residents performvarious laparoscopic procedures, such as cholecys-tectomy, Nissen fundoplication, splenectomy, andcolectomy. Costs are incurred for a live animal,endoscopic clips, and insufflation supplies. Endo-scopic staplers and reloads are donated.

Cost calculations. For every skills module admin-istered in the surgical skills laboratory, the labora-tory manager maintained a database of all materialspurchased with department funds, provided by ouroperating room, or donated by industry. Residentattendance was mandatory and recorded for eachlaboratory session. Therefore, total expenditureswere available on a per resident/per session basis.The laboratory manager’s salary was also factoredinto the costs for each module. The total time toschedule, set up, and administer each skills labora-tory module was estimated at 6 hours per moduleper session (3 hours scheduling and setup, 3 hoursadministration and clean up). The compensationto the laboratory manager was factored as $40/hour (we utilized the equivalent of 0.5 FTE in ourcalculations).

At the beginning of each academic year, certainitems not considered a specific aspect of any par-ticular skills module but deemed necessary to ad-minister the skills laboratory were factored into thetotal annual expenditures. For the 2002-2003 skillslaboratory, television monitors, VCRs, portablevideo carts, a camera lens, and printed laboratorymanuals were purchased. For the 2003-2004 aca-
demic year, in addition to laboratory manual re-


prints for new residents, 2 computer systems werepurchased at the start of the academic year foradministrative purposes. For the 2004-2005 aca-demic year, the only items that were purchased inaddition to items needed for each skills modulewere laboratory manual reprints for incoming resi-dents. In addition, because donated equipment andsupplies may not be readily available, we have esti-mated the costs if these supplies needed to be pur-chased using manufacturers list prices whereavailable; however, most health systems in bulk pur-chasing arrangements pay less than list price.

RESULTSAn itemized list of all necessary materials and

costs to administer each open and laparoscopic

Table II. Itemized costs of open skills

Module Items

Basic open skills Pig bowelSutureSilk tiesPig feetChicken thighsSkin pad trainer

Bowel anastomosis Pig bowelLatex bowel modelStaplerStapler reloadSutureCommercial latex bowel

Vascular anastomosis Vascular surgery needle hoPotts scissorsPig aortaGore-tex graftSuture

Trauma skills Pig, delivery, room/boardTrauma central line kitDPL catheter kitUltrasound batteryUltrasound chargerOperating room light bulbUltrasound machineChest tubesSuture

DPL, diagnostic peritoneal lavage.*Ten sutures per resident.†One pack of 12 ties per resident.‡Based on $50.00 for 1 gallon of latex mold (makes approximately 20 b§One per resident.¶Two per resident.�Four per resident.**Based on $1,200 for 8 mm � 80 cm graft, cut to 5-cm length per resi††Two polypropylene sutures per resident.‡‡List price for refurbished Site-rite IV.§§One chest tube per resident.

skills module is shown in Tables II (open) and III

(laparoscopic). Table IV gives a breakdown of ac-tual costs and estimated costs for donations for allopen and laparoscopic skills modules, the aca-demic years each module was administered, thetotal number of sessions, and the total number ofresidents participating in each module per year.Table IV also depicts the total annual cost for eachskills module and the annual cost per module perresident (based on the number of residents em-ployed by the department each year). The totalannual cost per resident for administering andmaintaining the entire skills laboratory, consider-ing total initial expenditures each year, total num-ber of sessions administered for all modules, andthe total number of residents in our residency pro-gram each year decreased progressively ($1,151 for

Cost per item ($)Estimated list price

(each) of donated items ($)

0 (harvested)0 (donated) 4.00*0 (donated) 1.50†

0.51

14.880 (harvested)0 (made in lab) 3.00‡0 (donated) 343.80§0 (donated) 180.35¶0 (donated) 4.00�

45.5040.8089.29

0 (harvested)0 (donated) 15.00/cm**0 (donated) 5.83††

4002029

215200141

0 (donated) 8,000‡‡0 (donated) 8.76§§0 (donated) 4.00§

ments); 2 bowel segments per resident.

lders

s

owel seg

dent.

2002-2003 [total cost for 48 residents � $55,234],


$1,049 for 2003-2004 [total cost for 49 residents �$51,377], and $982 for 2004-2005 [total cost for 49residents � $48,120]). We also calculated esti-mated costs per resident including donated ser-vices: $3,702 for 2002-2003, 1,462 for 2003-2004,and $1,066 for 2004-2005 (Table V).

The total cost for our skills laboratory over a 3-yearperiod ($154,732 for academic years 2002-2005;$146,884 is the estimated costs of donated equipmentand supplies) are not comparable to the purchaseprice of various commercially available computer-based simulators. To contrast the cost of a singlevirtual reality laparoscopic simulator, estimates wereobtained from vendors in February, 2005, and do notinclude service contracts, which can approach $3,000per year. Company A’s laparoscopic virtual realitysystem was quoted at $49,475. Company B’s laparo-scopic virtual reality system was quoted at $61,155.Company B’s endoscopic virtual reality system wasquoted at $86,985. These estimates are the up-frontpurchase costs, do not include service contracts ordown time, and have not been depreciated.

DISCUSSIONThe traditional system of educating surgery res-

Table III. Itemized costs of laparoscopic skills

Module Items

Basic laparoscopic skills Video trainersPegboardCupdropRope passEndoscopic clipEndoscopic loo

Laparoscopic cholecystectomy ElectrocauteryHarmonic scalpPig liverEndoscopic clip

Laparoscopic suturing/knot tying ClothSutureEndoscopic stitcEndoscopic stitc

Laparoscopic Nissen fundoplication Pig stomachSuture

Advanced laparoscopic in vivo skills Pig (delivery, hEndoscopic clipEndoscopic stapEndoscopic stapInsufflator supp

*List price for 1 trainer (quoted February 2007; includes trainer cart, tr†Ten per resident.‡Six per resident.§One per session.¶Six per session.

idents is facing many challenges of time efficiency,

costs, and patient safety.11 These issues have led tothe emergence of surgical skills laboratories as im-portant components of curricula for surgery resi-dents in many training programs. Surgical skillslaboratories provide residents with the opportunityto acquire technical skills in a low-stress, simulatedenvironment, while focusing on learning and re-peating key steps of procedures in a setting wherethey are able to reduce their learning curve withthe goal of decreasing potential harm to patients.

Currently, various media, both organic and in-organic, exist for surgical simulation outside of theoperating room.5 Organic models include humancadavers, live animals, or animate cadavers. Humancadavers provide the benefit of high fidelity andanatomy identical to the simulated procedure;however, they are costly, not readily available, andowing to individual variability, cannot provide stan-dardized assessments.5 Live animate models arehigh fidelity with bleeding tissue, but their use islimited by cost, variations from human anatomy, orlaws banning their use in some countries.5 We de-veloped in vivo animate models for trauma skills,18

cholecystectomy, Nissen fundoplication, splenec-tomy, and colectomy. Animal cadaver models are

Cost per item ($)Estimated list price

(each) of donated items ($)

0 (donated) 28,680*0 (made in lab)0 (made in lab)0 (made in lab)

ers 108iers 15.58

0 (donated) 1,7000 (donated) 20,902

3er 108

0 (made in lab)0 (donated) 4.00†

ice 186.38ads 35.89

40 (donated) 4.00‡

) 400er 108

0 (donated) 700§loads 0 (donated) 217.64¶

217

odule, skin pads, flat panel display).

applip appl

el

appli

h devh relo

ousingapplilerler relies

aining m

inexpensive, readily available, and provide good

osts. Th

scribed


tissue handling when fresh; however, anatomy dif-fers from that of humans.5 In our skills laboratory,utilizing animate organs, we have employed ex vivomodels of bowel anastomosis, vascular anastomosis,cholecystectomy, and Nissen fundoplication.17

Inorganic media are either based on syntheticmodels or virtual reality systems.5 Synthetic modelsare reproducible, standardized, and useful for as-sessing isolated skills. We have adopted various in-

Table IV. Three-year breakdown of costs incurred

Skill moduleAcademic

yearNo. of

sessions

Total costwith

donations ($

Open skillsBasic skills 2002-2003 None —

2003-2004 8 428.562004-2005 3 137.88

Bowelanastomosis

2002-2003 None —2003-2004 5 02004-2005 3 91.00

Vascularanastomosis

2002-2003 9 423.382003-2004 8 02004-2005 4 0

Trauma skills 2002-2003 None —2003-2004 3 2,352.002004-2005 4 1,796.00

Laparoscopic skillsBasic skills 2002-2003 9 4,087.68

2003-2004 3 1,333.522004-2005 8 1,333.52

Cholecystectomy 2002-2003 8 1,440.002003-2004 None —2004-2005 3 482.00

Suturing andknot tying

2002-2003 13 2,281.862003-2004 None —2004-2005 3 800.58

Nissenfundoplication

2002-2003 8 192.002003-2004 None —2004-2005 1 40.00

Advanced invivo skills

2002-2003 2 1,233.002003-2004 2 1,016.002004-2005 None —

*Does not include skills laboratory manager and faculty director salary c

Table V. Total annual costs for administration of

Academic yearCost with

donations ($)Cost/resident

donations (

2002-2003 55,234.32 1,150.722003-2004 51,377.19 1,048.512004-2005 48,120.14 982.04

*Costs include skills laboratory manager and faculty director salary as de

expensive synthetic simulation models, including

pegboard, cup drop, rope pass, pattern cutting,and endoscopic application of clips and loops,15,16

and have developed our own models for basic opensurgical skills and laparoscopic suturing. Virtualreality systems allow one to perform an operationor individual tasks in real time with instant objec-tive feedback.5 Computer-based technology alsomay be more effective in training residents in en-doscopic and laparoscopic procedures because

dministration of a surgical skills laboratory*

Total costwithout

nations ($)

No. ofresidents

participating

Cost perresident withdonations ($)

Cost perresidentwithout

donations ($)

— — — —1,341.56 22 19.48 60.981,050.88 22 6.27 47.77

— — — —6,046.30 16 0 377.891,585.30 10 9.10 158.537,983.38 48 8.82 166.321,733.00 20 0 86.65

867.00 10 0 86.70— — — —

0,633.00 22 106.91 483.322,077.00 22 81.64 94.41

0,127.68 48 85.16 1,877.661,333.52 22 60.61 60.611,333.52 22 60.61 60.614,042.00 48 30.00 500.88

— — — —482.20 10 48.20 48.20

4,101.86 48 47.54 85.46— — — —

1,240.58 11 72.78 112.781,344.00 48 4.00 28.00

— — — —160.00 5 8.00 32.00

4,544.00 8 154.13 568.004,327.00 8 127.00 540.88

— — — —

ese costs are reflected in total annual costs (see Table V).

ical skills laboratory*

Estimated costwithout donations ($)

Estimated cost/residentwithout donations ($)

177,719.32 3,702.4971,661.49 1,462.4852,235.34 1,066.03

in text.

for a

) do

1

9

2

a surg

with$)

this technology ensures accurate accomplishment


of tasks and evaluates trainees using several param-eters in addition to speed.12 Currently, however,the cost and absence of virtual reality open surgicalprocedures limit their widespread use in most sur-gery residency training programs.

As the adoption of surgical skills laboratoriesinto residency training programs becomes morewidespread, it is imperative that well-designed, ran-domized, controlled studies comparing differentmedia and their effects on the acquisition, mainte-nance, and transferability to the clinical venue ofskills attained in the laboratory continue to be con-ducted. Recently, such studies have investigatedbench models, traditional box trainers, and virtualreality systems. These studies are summarized inTable VI.

Simple, low-cost bench models are more effectivethan didactics alone for acquisition of surgical skills,as measured in the laboratory.19,20 Four studies21-24

have gone on to test the transferability of skillslearned in the laboratory on laparoscopic box train-ers or bench models to performance in an operatingroom setting. These studies have demonstrated thattechnical skills and operative performance are im-proved by formal training on laparoscopic box train-ers or bench models when compared with either notraining or didactics alone.

The concept of virtual reality for surgical skillssimulation was introduced in the early 1990s.25

Since then, various commercial virtual reality sim-ulators have been developed for surgical skillstraining and have been incorporated into residencytraining programs. Only in the last 5 years, how-ever, have randomized, controlled trials examiningtheir efficacy been completed.3,5,8,10,12,13,26,27

As with box trainers and bench models, the ma-jority of randomized, controlled studies have dem-onstrated that training on a virtual reality simulatoris more effective for transfer of skills to the operat-ing room than no training at all. Of 4 studiescomparing virtual reality to no training, 3 studiesdemonstrated transferability to the operatingroom8,10,27; one suggested no difference in opera-tive performance.26

With the emergence of virtual reality systems,residency program directors and surgery educatorsare now faced not only with the task of developingsurgical skills laboratories, but must also decidewith what to equip the laboratory and how much tospend. To date, 4 randomized, controlled trialshave compared traditional box trainers with virtualreality simulators.3,5,12,13 Three of these studiesdemonstrated that both models were equally effec-
tive at improving psychomotor skills,5,12,13 whereas
2 studies3,12 demonstrated better performance bysubjects trained on the virtual reality simulators.

Although only 2 studies have suggested benefitof virtual reality over box trainers,3,12 it is essentialthat more studies comparing the 2 modal-ities are conducted before one can conclude thatthe potential benefits to resident education gainedfrom costly, virtual reality computer-based surgicalsimulation are superior to those provided by inex-pensive, easily constructed box trainers. Until thattime comes, and while programs are currentlyfaced with important decisions regarding manda-tory access to technical skills and simulation facili-ties, our model of a surgical skills laboratory thatutilizes animate models, inexpensive bench mod-els, and laparoscopic box trainers represents a cost-effective means to provide an adjunct to surgicaltraining outside of the operating room. In ourlaboratory, we are now able to provide surgicalskills training for about $1,000 per resident peryear, and for the last 3 years we have successfullyprovided our surgical residents PGY level-appropri-ate modules for basic and advanced open and lapa-roscopic skills.

In addition to lower costs, our skills laboratorymodel provides other benefits over a surgical skillslaboratory based entirely on virtual reality. First,current virtual reality technologies preclude simu-lation of open surgical procedures. Our model pro-vides a means to instruct residents on the basicopen surgical skills that will form the foundation oftheir surgical skill sets. Second, assuming a pro-gram has the financial resources to purchase avirtual reality simulator, a single simulator can onlytrain one resident at a time, on a single task orprocedure, whereas our model, equipped with mul-tiple stations, affords the opportunity to train sev-eral residents simultaneously. Third, the haptics ofthe box trainers utilized by our skills laboratory aremore realistic than those provided by a virtual re-ality simulator. In fact, in one study, when asked tocompare virtual reality to video (box) trainers, res-idents preferred training on the video trainer, feltit was a more effective training tool, more realistic,and provided better tactile feedback and depthperception.12

Despite the proposed benefits of a skills labora-tory model such as we have described, we acknowl-edge limitations of our cost analysis. As mentioned,we have estimated the cost of donated services,equipment, and supplies. In addition, our instruc-tors were attending surgeons from our departmentand arranged their clinical schedules graciously tovolunteer to lead skills laboratory sessions. They
received no compensation in addition to their reg-


Table VI. Summary of randomized, controlled trials for surgical simulation

Reference Media tested Skill tested Comparison Significant findings

Bench modelMatsumoto et al

(2002)20Bench model Ureteroscopy and

stone extractionPerformance on high-

or low-fidelity modelversus didactic only

Hands-on better thandidactic; low betterthan high fidelity;low-fidelity more costeffective

Grober et al (2004)19 Bench model Microsurgicaltechnique

Performance on high-or low-fidelity modelversus didactic only

Hands-on better thandidactics; low andhigh fidelity equallyeffective

Bench model/box trainertransferability to OR

Fried et al (1999)22 Lap video boxtrainer

Technical skills invivo (animal)

Formal training versusno training of lap skilldrills

Improved in vivoperformance informal training group

Scott et al (2000)24 Lap video boxtrainer

Technical skillsLC in OR


Improved technicalskills and operativeperformance informal training group

Naik et al (2001)23 Bench model Orotrachealintubation in OR

Fiberoptic intubationmodel versus didacticonly

Bench model moreeffective in clinicalsetting than didacticonly

Coleman et al (2002)21 Laparoscopicvideo boxtrainer

Technical skills Lapsalpingectomy inOR


Improved technical skilland operativeperformance informal training group

VR transferability to ORHyltander et al

(2002)27VR simulator Basic lap skills in

vivo (animal)VR training versus no

trainingVR performed basic lap

skills better thanuntrained

Seymour et al (2002)10 VR simulator LC in OR VR training versus notraining

VR performed LCbetter than untrained

Ahlberg et al (2002)26 VR simulator Simulated lapappendectomy(animal)

VR training versus notraining

No difference inperformance

Hamilton et al (2002)12 See VR versusbox trainer

Grantcharov et al(2004)8

VR simulator LC in OR VR training versus notraining

VR performed LCbetter than untrainedVR had betterimprovement in errorand economy ofmovement

Youngblood et al(2005)3

See VR versusbox trainer

Virtual reality versus boxtrainer

Torkington et al(2001)13

VR simulatorand boxtrainer

Standardized lapskill tests

VR simulator versusbox trainer versus notraining

Both equally effective atimproving skills overcontrol

Hamilton et al (2002)12 VR simulatorand boxtrainer

Psychomotor skilldevelopment LCin OR

VR simulator versus boxtrainer

Both effective atimprovingpsychomotor skills

VR simulatorperformed better in
OR

; VR, vi


ular salary. We did not provide an estimate of thecost of attending physician instructor time, whichlikely would have incurred substantive charges hadinstructors required compensation, a realistic situ-ation for a smaller department whose limited fac-ulty resources might require such arrangements.Last, our data did not include cost estimates forphysical space and facilities, because this infrastruc-ture already existed as part of the department atthe time we began our skills laboratory. Our surgi-cal skills laboratory utilized a portion of the SurgeryResearch laboratory; approximately 2,000 squarefeet were available for this activity (once a weekduring the academic year).

In addition, we have not addressed componentsof training that are an essential part of surgeryeducation, such as team training, interdisciplinarytraining, and communication skills. We have de-scribed the costs associated with specific task train-ing and procedural training that are essential tostart a successful surgical skills laboratory. We haveexpanded our laboratory and offer the above skillscurrently to our residents, but an analysis of thecosts associated with training in these skills was notthe intent of this paper.

REFERENCES1. Gawande AA. Creating the educated surgeon in the 21st

century. Am J Surg 2001;181:551-6.2. Lehmann KS, Ritz JP, Maass H, et al. A prospective random-

ized study to test the transfer of basic psychomotor skillsfrom virtual reality to physical reality in a comparable train-ing setting. Ann Surg 2005;241:442-9.

3. Youngblood PL, Srivastava S, Curet M, Heinrichs WL, Dev P,Wren SM. Comparison of training on two laparoscopic sim-ulators and assessment of skills transfer to surgical perfor-mance. J Am Coll Surg 2005;200:546-51.

4. Villegas L, Schneider BE, Callery MP, Jones DB. Laparo-scopic skills training. Surg Endosc 2003;17:1879-88.

5. Munz Y, Kumar BD, Moorthy K, Bann S, Darzi A. Laparo-scopic virtual reality and box trainers: is one superior to theother? Surg Endosc 2004;18:485-94.

6. Conn J. The games doctors play. Physicians are turning tohigh-tech simulators to practice their clinical techniques.Even video-game skills prove valuable in the OR. ModHealthc 2004;34:32-3.

Table VI. (Continued)

Reference Media tested Skill t

Munz et al (2004)5 VR simulatorand boxtrainer

Basic lappsychomo

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lap, laparoscopic; LC, laparoscopic cholecystectomy; OR, operating room

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Comparison Significant findings

illsVR simulator versus box

trainer versus notraining

Both equally effectiveat improving skillsover control

ivoVR simulator versus box

trainer versus notraining

VR simulatorperformed better

rtual reality.

ested

tor sk

lobalt in v

son of laparoscopic performance in vivo with performance


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a cost-effective approach to establishing a surgical skills laboratory

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