Journal of Nature and Science of Medicine

: 2019  |  Volume : 2  |  Issue : 1  |  Page : 5--9

Fundamentals of laparoscopic surgery: Principles, implementation, and comparison to other modalities

Abdulaziz Alkanhal 
 Department of Surgery, King Saud University, Riyadh, Saudi Arabia

Correspondence Address:
Abdulaziz Alkanhal
P.O. Box 99971, 11625 Riyadh
Saudi Arabia


The minimally invasive laparoscopic surgery has gained popularity among various surgical specialties. However, unique skills are required to perform it. These skills are not transferable from open approach and are associated with a steep learning curve. Therefore, they need to be obtained in a safe-simulated environment. Fundamental laparoscopic surgery program is currently considered the gold standard for assessing laparoscopic skills and a mandatory requirement for board certification in the United States and for promotional advancement of residents in different surgical residency programs. Despite its proven benefits and its superiority when compared to other training models, challenges exist related to its implementation outside North America. The lack of sufficient eligible examiners is the major obstacle. Once overcome, one can aspire to achieve the remaining standards required for full implementation.

How to cite this article:
Alkanhal A. Fundamentals of laparoscopic surgery: Principles, implementation, and comparison to other modalities.J Nat Sci Med 2019;2:5-9

How to cite this URL:
Alkanhal A. Fundamentals of laparoscopic surgery: Principles, implementation, and comparison to other modalities. J Nat Sci Med [serial online] 2019 [cited 2022 May 21 ];2:5-9
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For the last two decades, laparoscopic surgery has been the most abundant approach by various surgical specialties. That is because minimally invasive surgery intended to minimize the postoperative pain and speed up the recovery of patients. However, skills acquired to perform laparoscopic surgery are unique and are impossible to be transferred from the open surgical approach.[1] The Halstedian apprenticeship model of “see one, do one, teach one” is not efficient to train surgeons on such skills. Restricted vision by the lack of depth and spatial relationships judgment, need for adaptation to two-dimensional display of monitors, video-eye-hand coordination, limited working area, and minimal haptic are the factors contributing to challenges and complexity of this approach.[2] The learning curves for new laparoscopic procedures are as steep for experienced surgeons as novice surgical residents,[1] and the complications are increased during the early stages of the learning curve.[2] For these reasons, psychomotor skills of this approach need to be obtained in a safe environment outside the operating room. A survey has been done for program directors of various surgical specialties; 92% responded with agreement on the need for training of laparoscopic skills outside the operating room.[3]

 Historical Background

Simulation gives the opportunity to learn surgical skills with standardized experience. These facts were realized from the beginning of the laparoscopy era. Hands-on training has been offered in the earliest 1970s as was Kurt Semm from University of Kiel, Germany, introducing thefirst laparoscopic training box (PelviTrainer) in the early 1980s, an invention that facilitated teaching the hand-eye coordination and suturing techniques for operative laparoscopy and helped accelerating learning curve even more.[4]

Various simulated models have been developed to teach and assess laparoscopic skills as a structured course during conference workshops and academic institutions. Simulators in laparoscopy can be under two major categories:[5] physical simulators that use the same instruments in laparoscopic procedures and computer-based simulators that rely on a virtual environment. Currently, only one model with certain tasks and measurable metrics has been extensively validated and used within a program called “fundamentals of laparoscopic surgery (FLS).” FLS program was introduced in 2004 by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) as a comprehensive educational program to teach and assess fundamental cognitive knowledge and technical skills of laparoscopic surgery.[6]

In this article, I will focus on the characteristics of manual skill testing component in the FLS program, comparing it with other teaching and assessing methods of laparoscopic skills.

 Fundamentals of Laparoscopic Surgery Manual Skills Component

Validation and implementation process

As mentioned, several inanimate and virtual reality systems were designed to teach and assess the basic laparoscopic skills.[7] Since FLS committee formed in 1990 by SAGES to develop educational materials for the basic laparoscopic skills, they chose McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) as its manual skills component.[8] MISTLES wasfirst introduced in 1998, started by developing standardized tasks by a group of experienced laparoscopic surgeons.[9] These tasks were noted after reviewing video-recorded laparoscopic procedures, including cholecystectomy, appendectomy, inguinal hernia repair, and Nissen fundoplication. They identified the particular domains for training and evaluation that form the seven MISTELS tasks in the physical simulator training box: pegboard patterns, pattern cutting, clip application, placement of ligating loop, mesh placement over a defect, and intra- and extra-corporeal knot tying. Two exercises (placement mesh over a defect and clipping of tubular structure) were dropped for MISTELS. They failed to contribute discriminatory value to the training or assessment, feasibility, and cost although they proved to be of educational value.[8] These exercises are designed to improve the technical skills of basic laparoscopic surgery, are not procedure specific, and can be used by different surgical specialties with laparoscopic procedures.[10] A scoring system for each task measures the time (efficiency) and number of errors (precision), with different penalties' scores used for each task. It takes 45–60 min to complete the tasks, depending on the surgeon's skills. This manual skill's component has been extensively evaluated and proved to be valid and reliable [Table 1].{Table 1}

Fraser et al.[18] determined the pass/fail score for the MISTELS system, with known sensitivity and specificity (both >0.80) to discriminate between competent and noncompetent laparoscopic surgeons. This extensive validation of MISTELS system (as a component of the FLS program) allows it to be used as a high-stake examination for certification and to be used in residency programs, through SAGES and the American College of Surgeons, for advancement purposes. The SAGES FLS Committee has endorsed an additional edge of the FLS program after Scott et al.[19] determined the feasibility of implementing a proficiency-based technical skills curriculum using the validated FLS program. The curriculum was efficient and cost-effective, and 100% of the candidates achieved the passing score of the FLS certification program. The proficiency-based training curriculum uses a slightly modified scoring system, with the same format of FLS manual skills tasks, except for the pattern cut task, where the gauze template contains two concentric circles (5-mm gap in-between) and requires cutting between the lines for achievement of proficiency.

This highly validated comprehensive manual skill's component is complemented by a cognitive content and forms the FLS program. The program is widely accepted by many surgical residency programs, especially in North America. Currently, the American Board of Surgery requires FLS certification for graduating residents.[20] Certification for practicing surgeons and proficiency verification of operating room personnel have been shown to be feasible,[21] as well as it may be necessary to ensure surgeon competency.

Comparison to other laparoscopic simulators

As mentioned, the laparoscopic simulators are either physical using real instruments in operating room or virtual reality using special hardware connected to a computer. This review will include skill-based simulators rather than procedure specific, with emphasis on their validity and metrics.

Laparoscopic trainer developed by Rosser et al.

Rosser et al.[22] from Yale University developed four tasks that can be performed in a videoscopic trainer box. This system measures the efficiency (time) to perform the task, with no assessment of the precision.

The tasks were three transfer drills (rope, cup drop, and triangle transfer) in addition to one suturing task (intracorporeal suturing) by approximating of a harvested pig intestine. No correlation was found between different levels of experience and “Rosser” tasks' measured time, except for suturing and rope pass.[23]

Inability to determine a significant correlation between performance scores in this system and level of experience in laparoscopic skills (failing to have good evidence of construct validity), as well as missing the tool to measure the quality of doing the tasks are sufficient factors to reject Rosser's tasks as an assessment tool of laparoscopic skills.

Guided endoscopic module

This system was developed by Southwestern Center for Minimally Invasive Surgery from University of Texas.[24] It consist of five tasks; three transferring tasks of Rosser's model with some modifications, one more transferring exercise (checkerboard), and suturing task performed on two foam organs approximated by intracorporeal suture.

Although Scott et al.[25] determined fair evidence of construct validity and concurrent validity of this system by comparing the tasks scores of participants to their intraoperative global assessment results, a subsequent study has opposite results.[26]

This discrepancy in evidence with no further studies regarding the validity and reliability of Southwestern Center for Minimally Invasive Surgery simulator results in underestimation of the ability of this system to assess laparoscopic skills.

Virtual reality simulators

These computer-based simulators rely on sophisticated software to generate graphical images of wide varieties of normal anatomy, pathologies, and traumatic conditions according to what was programmed into them. They utilize surgical handles resembling the handles of real laparoscopic instruments and attached directly to virtual instrument tips.

It can allow practicing a single task or a full procedure. Metrics were used to assess performance range from simple (time to accomplish a task) to complex (motion analysis). This real-time tracking of the user's actions enables objective measurement, e.g., accuracy and pressure amount used.[27]

Face and construct validity has been demonstrated for most of the commercially available VR simulators.[28] Although the evidence of these systems shows similar effectiveness to box trainer simulators in developing proficiency at laparoscopic skills both in simulation and intraoperative,[2] several factors interfere with their use as a standardized tool in laparoscopic surgical programs. High start-up, maintenance, and upgrades costs in addition to lacking a structured curriculum and insufficient evidence of the validity and reliability limit their spread.

Computerized physical reality simulators

Using a traditional box trainer, embedded sensors in the physical model (that are used to perform the tasks) will sense touches by the inserted laparoscopic instruments and monitor the performance to transmit the data to the incorporated computer to give a report and can serve as display of the laparoscopic camera.

Sansregret et al.[29] have studied LTS 2000-ISM60 simulator in comparison to MISTELS. It has a comparable discrimination capability for level of performance with that of the MISTELS. No studies related to predefined proficiency criteria and no information on the intensity or duration of training needed to achieve technical competency. These systems have the same limitations of VR that holds back their use. There is a great need of evidence to make it efficient for surgical programs willing to use the physical reality simulators.

Besides the substantial existing evidence demonstrating the reliability and validity of the manual FLS skills component, being inexpensive, portable, and reproducible and using of similar instruments to those in the operating room put this system on top of other kinds of physical and computer-based simulators.

 Implementing Fundamentals of Laparoscopic Surgery Program Internationally

FLS certification testing and curriculum are widely used in North America. The certification testing is available through accredited test centers or certain surgical conferences' workshops. Currently, limited designated number of international testing centers exist.[20] A recent pilot study[30] assessed scoring and application of FLS examination remotely in comparison to onsite testing. Although remote administration did not interfere with the test validity, critical errors in scoring have been encountered which reflects that onsite testing through accredited centers has no alternatives. There is an increased demand for FLS centers and certification since FLS program is considered the gold standard for assessing laparoscopic skills and a mandatory requirement for board certification in the United States and for promotional advancement of residents in different surgical residency programs. To accommodate the high demands, SAGES set an accreditation process for qualifying international programs to be FLS testing centers through the International FLS Test Center Standard and Criteria. This accreditation process is to ensure standardization of the examination procedure.

There are not enough testing centers outside North America to fill the needs for certification, and in some countries, no centers were accredited. Institutions pursuing to be FLS examination centers must meet several standards and corresponding criteria at the time of application. It is evident that the most important and difficult requirement is qualified staff. The human element is a key part and plays a critical role in the success of maintaining the examination standards.

To implement this highly standardized program and accelerate the regional spread, concentrating on qualified staff familiar with laparoscopy, willing to do the 2-day training session, and identify the possible candidates who can be FLS proctors and champions according to SAGES protocols and criteria will facilitate meeting the rest of the criteria of accreditation process. It is better to choose staff from academic institutions based on the geographical area and test center capacity. With a special arrangement with SAGES, an FLS proctor training workshop can be held once for those candidates. After having the eligible examiners in each area, a timeline can be planned to meet the rest of the standards to submit the application to be accredited as an FLS certification center.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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