Magdalena K. Chmarra, Sharon P. Rodrigues, Frank-Willem Jansen, Jenny Dankelman


Training and objective assessment of surgical competence receives more and more attention from society and medical communities, and is an ongoing research challenge. For obvious reasons of patient safety, ethics, and cost-effectiveness, there is a need to shift the training and assessment from the operating theatre to a simulated environment (e.g. skills lab). This paper presents the state of the art on training and assessment of surgical skills in minimally invasive surgery, and discusses remaining challenges.


  1. Acosta, E., Temkin, B., 2005. Haptic laparoscopic skills trainer with practical user evaluation metrics. Stud Health Techn Inform, MMVR 111: 8-11.
  2. Aggarwal, R., Moorthy, K., Darzi, A., 2004. Laparoscopic skills training and assessment. Br J Surg 91: 1549- 1558.
  3. Aggarwal, R., Ward, J., Balasundaram, et al., 2007. Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery. Ann Surg 246: 771-779.
  4. Allen, B., Nistor, V., Dutson, E., et al., 2009. Support vector machines improve the accuracy of evaluation for the performance of laparoscopic training tasks. Surg Endosc 24: 170-178.
  5. Babineau, T. J., Becker, J., Gibbons, G., Sentovich, S., Hess, D., Robertson, S., Stone, M., 2004. The “cost” of operative training for surgical residents. Arch Surg 139: 366-369.
  6. Bailey, R. W., Imbembo, A. L., Zucker, K. A., 1991. Establishment of a laparoscopic cholecystectomy training program. Am Surg 57: 231-236.
  7. Böhm, B., Milsom, J. W., 1994. Animal models as educational tools in laparoscopic colorectal surgery. Surg Endosc 8: 707-713.
  8. Borel-Rinkes, I. H. M., Gouma, D. J., Hamming, J.F., 2008. Surgical Training in the Netherlands. World J Surg 32:2172-2177.
  9. Breedveld, P., Stassen, H. G., Meijer, D. W., Jakimowicz, J.J., 2000. Observation in laparoscopic surgery: overview of impending effects and supporting aids. J Laparoendosc Adv A 10: 231-241.
  10. Bridges, M., Diamond, D. L., 1999. The financial impact of teaching surgical residents in the operating room. Am J Surg 177: 28-32.
  11. Cavallo, F., Megali, G., Sinigaglia, S., et al., 2005. A biomechanical analysis of surgeon's gesture in a laparoscopic virtual scenario. Stud Health Technol Inform, MMVR 14: 79-84.
  12. Cesanek, P., Uchal, M., Uranues, S., et al., 2008. Do hybrid simulator-generated metrics correlate with content-valid outcome measures? Surg Endosc 22: 2178-2183.
  13. Chang, L., Hogle, N. J., Moore, B. B., et al., 2007. Reliable assessment of laparoscopic performance in the operating room using videotape analysis. Surg Innov 14: 122-126.
  14. Chmarra, M. K., Grimbergen, C. A., Jansen, F. W., et al., 2010a. How to objectively classify residents based on their psychomotor laparoscopic skills? Minim Invasiv Ther 19: 2-11.
  15. Chmarra, M. K., Klein, S., De Winter, J. C. F., et al., 2010. Objective classification of residents based on their psychomotor laparoscopic skills. Surg Endosc 24:1031-1039.
  16. Cohen, R., Reznick, R. K., Taylor, B. R., et al., 1990. Reliability and validity of the objective structured clinical examination in assessing surgical residents. Am J Surg 160: 302-305.
  17. Cotin, S., Stylopoulos, N., Ottensmeyer, M., et al., 2002. Metrics for laparoscopic skill trainers: the weakest link! Lect Notes Comput Sci 2488: 35-43.
  18. Crist, D. W., Davoudi, M. M., Parrino, P. E., Gadacz, T. R., 1994. An experimental model for laparoscopic common bile duct exploration. Surg Laparosc Endosc 4: 336-339.
  19. Cristancho, S. M., Hodgson, A. J., Panton, O. N. M., et al., 2009. Intraoperative monitoring of laparoscopic skill development based on quantitative measures. Surg Endosc 23: 2181-2190.
  20. Cundiff, G. W., Weidner, A. C., Visco, A.G., 2001. Effectiveness of laparoscopic cadaveric dissection in enhancing resident comprehension of pelvic anatomy. J Am Coll Surg 192:492-497.
  21. Cuschieri, A., Buess, G., Perissat, J., 1992. Operative Manual of Endoscopic Surgery. Springer-Verlag, Berlin Heidelberg.
  22. Cuschieri, A., Gleeson, F. A., Harden, R. M., et al., 1979. A new approach to a final examination in surgery. Use of the objective structured clinical examination. Ann R Coll Surg Engl 61: 400-405.
  23. Dankelman, J., Chmarra, M. K., Verdaasdonk, E. G. G., et al., 2005. Fundamental aspects of learning minimally invasive surgical skills. Minim Invasiv Ther 14: 247- 256.
  24. Dankelman, J., Chmarra, M. K., Verdaasdonk, E.G.G., Stassen, L.P.S., Grimbergen, C. A., 2005. Fundamental aspects of learning minimally invasive surgical skills. Minim Invasiv Ther 14: 247-256.
  25. Darzi, A., Smith, S., Taffinder, N., 1999. Assessing operative skill. Needs to become more objective. BMJ 318: 887-888.
  26. Den Boer, K. T., DeWit, L. T., Dankelman, J., Gouma, D.J., 1999. Peroperative time-motion analysis of diagnostic laparoscopy with laparoscopic ultrasonography. Br J Surg 86: 951-955.
  27. Dosis, A., Aggarwal, R., Bello, F., et al., 2005. Synchronized video and motion analysis for the assessment of procedures in the operating theater. Arch Surg 140: 293-299.
  28. Duffy, A. J., Hogle, N. J., McCarthy, H., et al., 2005. Construct validity for the LAPSIM laparoscopic surgical simulator. Surg Endosc 19: 401-405.
  29. Eriksen, J. R., Grantcharov, T., 2005. Objective assessment of laparoscopic skills using a virtual reality stimulator. Surg Endosc 19: 1216-1219.
  30. Feldman, L. S., Sherman, V., Fried, G.M., 2004. Using simulators to assess laparoscopic competence: ready for widespread use? Surgery 135: 28-42.
  31. Fraser, S. A., Klassen, D. R., Feldman, L.S., et al., 2003. Evaluating laparoscopic skills: setting the pass/fail score for the MISTELS system. Surg Endosc 17: 964- 967.
  32. Gallagher, A. G., Richie, K., McClure, N., et al., 2001. Objective psychomotor skills assessment of experienced, junior, and novice laparoscopists with virtual reality. World J Surg 25: 1478-1483.
  33. Giger, U., Frésard, I., Häfliger, A., Bergmann, M., Krähenbühl, L., 2008. Laparoscopic training on Thiel human cadavers: a model to teach advanced laparoscopic procedures. Surg Endosc 22: 901-906.
  34. Goff, B. A., Lentz, G. M., Lee, D., et al., 2000. Development of an objective structured assessment of technical skills for obstetrics and gynecology residents. Obstet Gynecol 96: 146-150.
  35. Grantcharov, T. P., Rosenberg, J., Pahle, E., et al., 2001. Virtual reality computer simulation. An objectivemethod for the evaluation of laparoscopic surgical skills. Surg Endosc 15: 242-244.
  36. Gumbs, A. A., Hogle, N. J., Fowler, D. L., 2007. Evaluation of resident laparoscopic performance using global operative assessment of laparoscopic skills. J Am Coll Surg 204: 308-313.
  37. Halvorsen, F. H., Elle, O. J., Fosse, E., 2005. Simulators in surgery. Minim Invasiv Ther 14: 214-223.
  38. Hanna, G. B., Cuschieri, A., 1999. Influence of the optical axis-to-target view angle on endoscopic task performance. Surg Endosc 13: 371-375.
  39. Hanna, G. B., Shimi, S. M., Cuschieri, A., 1998 Task performance in endoscopic surgery is influenced by location of the image display. Ann Surg 227: 481-484.
  40. Inspectie voor de gezondheidszorg, 2007, Risico's minimaal invasieve chirurgie onderschat, kwaliteitssysteem voor laparoscopische operaties ontbreekt.
  41. Katz, R., Hoznek, A., Salomon, L., Antiphon, P., de la Taille, A., Abbou, C. C., 2005. Skill assessment of urological laparoscopic surgeons: can criterion levels of surgical performance be determined using the pelvic box trainer? Eur Urol 47: 482-487.
  42. Kolkman, W., van de Put, M. A. J., van den Hout, W. B., Trimbos, J. B. M. Z., Jansen, F.W., 2007. Implementation of the laparoscopic simulator in a gynecological residency curriculum. Surg Endosc 21: 1363-1368.
  43. Kundhal, P. S., Grantcharov, T. P., 2009. Psychomotor performance measured in a virtual environment correlates with technical skills in the operating room. Surg Endosc 23: 645-649.
  44. Mackay, S., Morgan, P., Datta, V., et al., 2002. Practice distribution in procedural skills training: a randomized controlled trial. Surg Endosc 16: 957-961.
  45. Martin, J. A., Regehr, G., Reznick, R., et al., 1997. Objective structured assessment of technical skills (OSATS) for surgical residents. Brit J Surg 84: 273- 278.
  46. McKinley, R. K., Strand, J., Ward, L., et al., 2008. Checklists for assessment and certification of clinical procedural skills omit essential competencies: a systematic review. Med Educ 42: 338-349.
  47. Mehrabi, A., Yetimoglu, C. L., Nickkholgh, A., et al., 2006. Development and evaluation of a training module for the clinical introduction of the da Vinci robotic system in visceral and vascular surgery. Surg Endosc 20: 1376-1382.
  48. Moorthy, K., Munz, Y., Sarker, S. K., et al., 2003 Objective assessment of technical skills in surgery. BMJ 327:1032-1037.
  49. Nebot-Cegarra, J., Macarulla-Sanz, E., 2004. Improving laparoscopy in embalmed cadavers: a new method with a lateral abdominal wall muscle section. Surg Endosc 18: 1058-1062.
  50. Olinger, A., Pistorius, G., Lindemann, W., Vollmar, B., Hildebrandt, U., Menger, M. D., 1999. Effectiveness of a hands-on training course for laparoscopic spine surgery in a porcine model. Surg Endosc 13: 118-122.
  51. Park, A. E., Witzke, D., 2002. The surgical competence conundrum. Surg Endosc 16: 555-557.
  52. Passerotti, C. C., Nguyen, H. T., Retik, A. B., et al., 2008. Patterns and Predictors of Laparoscopic Complications in Pediatric Urology: The Role of Ongoing Surgical Volume and Access Techniques. J Urology 180: 681- 685.
  53. Pellen, M., Horgan, L., Barton, J. R., et al., 2009. Laparoscopic surgical skills assessment: can simulators replace experts? World J Surg 33: 440-447.
  54. Rasmussen, J., 1983. Skills, rules and knowledge; signals, signs and symbols, and other distinctions in human performance models. IEEE Trans Syst Man Cybern B Cybern 13:257-266.
  55. Reznick, R., Regehr, G., MacRae, H., et al., 1997. Testing technical skill via an innovative “bench station” examination. Am J Surg 173: 226-230.
  56. Ritchie, W. P., 2004. Basic certification in surgery by the American Board of Surgery (ABS). What does it mean? Does it have value? Is it relevant? A personal opinion. Ann Surg 239:133-139.
  57. Roberts, K. E., Bell, R. L., Duffy, A. J., 2006. Evolution of surgical skills training. World J Gastroenterol 12: 3219-3224.
  58. Rosen, J., Solazzo, M., Hannaford, B., et al., 2001. Objective Laparoscopic Skills Assessments of Surgical Residents Using Hidden Markov Models Based on Haptic Information and Tool/Tissue Interactions. Stud Health Tech Inform, MMVR 81:417-423.
  59. Salgado, J., Grantcharov, T. P., Papasavas, P. K., et al., 2009. Technical skills assessment as part of the selection process for a fellowship in minimally invasive surgery. Surg Endosc 23: 641-644.
  60. Satava, R. M., 2006. Assessing surgery skills through simulation. Clin Teacher 3: 107-111.
  61. Satava, R. M., Cuschieri, A., Hamdorf, J., 2003. Metrics for objective assessment. Surg Endosc 17: 220-226 Schijven, M., Jakimowicz, J., 2003. Virtual reality surgical laparoscopic simulators. How to choose. Surg Endosc 17: 1943-1950.
  62. Scott, D. J., Bergen, P. C., Rege, R. V., et al., 2000. Laparoscopic training on bench models: better and more cost effective than operating room experience? J Am Coll Surg 191: 272-283.
  63. Stefanidis, D., Hope, W.W., Korndorffer, J.R., et al., 2010. Initial laparoscopic basic skills training shortens the learning curve of laparoscopic suturing and is costeffective. J Am Coll Surg 210:436-40.
  64. Tang, B., Hanna, G. B., Cuschieri, A., 2005. Analysis of errors enacted by surgical trainees during skills training courses. Surgery 138: 14-20.
  65. Van Sickle, K. R., McClusky, D. A., Gallagher, A. G., et al., 2005. Construct validation of the ProMIS simulator using a novel laparoscopic suturing task. Surg Endosc 19: 1227-1231.
  66. Vassiliou, M. C., Ghitulescu, G.A., Feldman, L. S., et al., 2006. The MISTELS program to measure technical skill in laparoscopic surgery. Evidence for reliability. Surg Endosc 20: 744-747.
  67. Verdaasdonk, E. G. G., Stassen, L.P.S., van Wijk, R. P. J., et al. 2007. The influence of different training schedules on the learning of psychomotor skills for endoscopic surgery. Surg Endosc 21: 214-219.
  68. Villegas, L., Schneider, B. E., Callery, M. P., Jones, D. B., 2003. Laparoscopic skills training. Surg Endosc 17: 1879-1888.
  69. Waseda, M., Inaki, N., Mailaender, L., Buess, G. F., 2005. An innovative trainer for surgical procedures using animal organs. Minim Invasive Ther Allied Technol 14: 262-266.
  70. Wentink, M., 2003. Hand-eye coordination in minimally invasive surgery. Theory, surgical practice & training. PhD thesis. Delft University of Technology, Faculty of Mechanical Engineering and Maritine Technology.
  71. Wincckel, C.P., Reznick, R. K., Cohen, R., et al., 1994. Reliability and construct validity of a structured technical skills assessment form. Am J Surg 167: 423- 427.
  72. Wolfe, B. M., Szabo, Z., Moran, M. E., Chan, P., Hunter, J.G., 1993. Training for minimally invasive surgery. Need for surgical skills. Surg Endosc 7: 93-95.
  73. Youngblood, P. L., Srivastava, S., Curet, M., Heinrichs, W. L., Dev, P., Wren, S. M. 2005. Comparison of training on two laparoscopic simulators and assessment of skills transfer to surgical performance. J Am Coll Surg 4: 546-551.

Paper Citation

in Harvard Style

K. Chmarra M., P. Rodrigues S., Jansen F. and Dankelman J. (2011). CHALLENGES IN TRAINING AND ASSESSMENT OF MINIMALLY INVASIVE SURGICAL SKILLS . In Proceedings of the 3rd International Conference on Computer Supported Education - Volume 2: CSEDU, ISBN 978-989-8425-50-8, pages 261-268. DOI: 10.5220/0003289502610268

in Bibtex Style

author={Magdalena K. Chmarra and Sharon P. Rodrigues and Frank-Willem Jansen and Jenny Dankelman},
booktitle={Proceedings of the 3rd International Conference on Computer Supported Education - Volume 2: CSEDU,},

in EndNote Style

JO - Proceedings of the 3rd International Conference on Computer Supported Education - Volume 2: CSEDU,
SN - 978-989-8425-50-8
AU - K. Chmarra M.
AU - P. Rodrigues S.
AU - Jansen F.
AU - Dankelman J.
PY - 2011
SP - 261
EP - 268
DO - 10.5220/0003289502610268