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ORIGINAL REPORTS

Tablet Based Simulation Provides a NewSolution to Accessing Laparoscopic SkillsTraining

Ali Nehme Bahsoun, BSC,* Mohsan Munir Malik, BSC,* Kamran Ahmed, MRCS,*Oussama El-Hage, MRCS,* Peter Jaye, FRCP,† and Prokar Dasgupta, FRCS(Urol)*

Medical Research Council (MRC) Center for Transplantation, NIHR Biomedical Research Centre, Guy’sospital, King’s College London, King’s Health Partners, London, United Kingdom; †SAIL Center, St Thomas

Hospital, London, United Kingdom

AIM: Access to facilities that allow trainees to develop theiraparoscopic skills is very limited in the hospital environmentnd courses can be very expensive. We set out to build annexpensive yet effective trainer to allow laparoscopic skill ac-uisition in the home or classroom environment based on usingtablet as a replacement for the laparoscopic stack and camera.

METHODS: The cavity in which to train was made from acardboard box; we left the sides and back open to allow fornatural light to fill the cavity. An iPad 2 (Apple Inc.) was placedover the box to act as our camera and monitor. We provided 10experienced laparoscopic surgeons with the task of passing asuture needle through 3 hoops; then they filled in a question-naire to assess Face (training capacity) and Content (perfor-mance) validity.

RESULTS: On a 5-point Likert scale, the tablet-based laparo-copic trainer scored a mean 4.2 for training capacity (hand eyeoordination, development, and maintenance of lap skills) andor performance (graphics, video, and lighting quality) it scoredmean 4.1.

CONCLUSIONS: The iPad 2-based laparoscopic trainer wasuccessfully validated for training. It allows students and trainees toractice at their own pace and for inexpensive training on theo. Future “app-”based skills are planned. (J Surg 70:161-163.

2013 Association of Program Directors in Surgery. Pub-ished by Elsevier Inc. All rights reserved.)

KEY WORDS: simulation, iPad 2, laparoscopy, laparoscopic,ox trainer, validation, face, content, solution

COMPETENCIES: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Systems-Based Practice

Correspondence: Inquiries to Prokar Dasgupta, Medical Research Council (MRC) Center

for Transplantation, Guy’s Hospital, King’s College London, London, SE1 9RT, UK;e-mail: prokarurol@gmail.com

Journal of Surgical Education • © 2013 Association of Program DirecPublished by Elsevier Inc. All rights res

INTRODUCTION

Laparoscopy has become a well-established means of surgery butthe trainee faces several issues to overcome before confidence andcompetence are achieved. Many training modalities have been de-veloped for patient-safe skill acquisition and though these may begreat for procedural tasks, it would be unjustified to use such ex-pensive tools for the acquisition of basic laparoscopic skills.

The laparoscopic trainer has several key components, whichare the cavity in which to train, the camera, the display, and alight source. The concept of creating an inexpensive homemadelaparoscopic trainer is not a new concept but a successful tabletbased trainer can open new opportunities into the way wetrain.1

We aim to develop and validate a tablet-based trainer forhome use that is simple and cheap to reproduce.

MATERIALS AND METHODS

We will be using a basic iPad 2 by Apple Inc. as a replacementfor the laparoscopic stack and camera. The iPad 2 has a 9.7 in.wide screen, touch-screen display, and a resolution of 1024 �768. On the back of the iPad 2 there is a 720p video camera.The iPad can also be connected to a TV or projector for dem-onstration purposes.

To create the cavity, we used part of a cardboard box andsome polystyrene. We added a hole for the iPad camera and 2trocars were placed directly below to allow for instrument place-ment. The gaps on the sides and back of the box allowed fornatural light from the room to fill the cavity of the box; thus, noexternal light source was needed (Figure 1).

Participants

We sought experienced laparoscopic surgeons for the validation

of the iPad.

tors in Surgery 1931-7204/$30.00erved. http://dx.doi.org/10.1016/j.jsurg.2012.08.008

161

Task Performed

Participants were asked to pass a suture needle through threehoops standing on a cork board. The hoops were at differingheights and at differing distances from the camera. This taskrequired the user to use his or her depth perception and alsodemonstrated different textures and the look of graspers, a nee-dle, and thread (Figure 2).

Validation

For Face validation we asked our experts if the trainer can helpdevelop hand-eye coordination and whether or not the trainercan help develop and maintain laparoscopic skills. For Contentvalidation we looked at the quality of the feed and compared itwith the laparoscopic camera and stack. We felt that Constructvalidation was not necessary as it is a tool that assess the task andour trainer is designed for use with any task currently used instandard box trainers.

FIGURE 1. An overview of the home-made tablet trainer.

FIGURE 2. An overview of a cheaper version of hand-eye coordination/

suturing tool.

162 Journal of Surgi

Assessment of the Laparoscopic Trainer

The questionnaire had 5 yes/no questions and 7 questionsmarked with a Likert scale (where 1 represented poor, 3 was fair,and 5 was very good).

The questionnaire was based on 3 main aspects of the trainer;training capacity was looked at to asses Face validation, perfor-mance of the tablet was used to asses Content and Usage of thetablet to help us see if the trainer was accepted by the trainees.The questions are shown in Table 1 below.

RESULTS

Ten participants were recruited for the study. We assessed thetrainer under the 3 parameters: performance, training capacity,and utility of the trainer.

For performance, participants rated the trainer at a mean of4.1. Participants found that the trainer was simple to set up(4.5), and had good quality Video 4.3, and lighting (4.2). Com-pared with the laparoscopic stack and camera, the trainer onlyscored 3.5; this is because the iPad 2 runs on 720p while alaparoscopic camera runs on full HD. This may change as newand better tablets come out.

For training capacity, the trainer scored 4.4 for developinghand-eye coordination, 4.3 for developing laparoscopic skill,and 4 for maintenance of laparoscopic skills.

For utility of the tablet, it rated a mean 90% positive rating;with ease of tablet use, scoring only 70% agreement and thuscrying out for a better interface (Figures 3, 4, and 5).

DISCUSSION

Our study researched the components of a laparoscopictraining setup and recreated a simplified, less expensive

TABLE 1. Evaluation Form for the Feedback (Acceptability andFeasibility)

Tablet PerformanceHow satisfied were you with the video quality?How satisfied were you with the lighting in the box?How satisfied were you with the simplicity of the set up?Compared to a laparoscopic stack, how would you rate

these graphics?Training capacity

Developing hand-eye coordinationDeveloping laparoscopic skillMaintenance of laparoscopic skills

Use of tabletIs this box trainer easier to use than a standard box

trainer?Would you use this set-up for training if it were provided

for you?Would the record function of the camera be useful to a

trainee?If you had a tablet, would you use the box trainer if it

were made available?

model based on the use of a tablet to overcome the greatest

cal Education • Volume 70/Number 1 • January/February 2013

iv

obstacle to home training, the cost of the laparoscopic stackand camera (Video 1).

Past inexpensive alternatives to the laparoscopic box trainer havebeen developed and they vary in several different ways. The leaseexpensive solutions are based around creating a window into acavity, thus requiring no electronic equipment.2 Another electron-c-less solution includes mirror-based trainers, such as the Simu-iew.3 The webcam-based solution creates the most realism of all

solutions as the user is looking away from the working cavity andallows the user to develop his or her depth perception on a two-dimensional plane. The tablet-based trainer also stops the traineefrom working on the tasks under direct vision.

The limitations of our study are the number of participants (atotal of 10), all of whom were of one surgical field (Urology)and it was conducted at a single center (Guy’s Hospital).

Our study adds a training modality that has great potential.This form of training allows the trainees’ performance to berecorded and uploaded online or carried on the tablet for dem-onstrations or review for feedback.

FIGURE 3. Participants feedback for feasibility.

FIGURE 4. Participants feedback on acquisition of type of skills learnt

through this tablet trainer.

Journal of Surgical Education • Volume 70/Number 1 • January/Febr

We can now also introduce “apps” to the training process. Theapps can help improve the interface, provide feedback, such as tasktime, and allow users to upload their performance. With app de-velopment we can also start exporting virtual reality simulation tothe IOS, Windows, or Android operating systems.

CONCLUSIONS

The tablet has been shown to have face and content validity. Fortrainees looking to develop their laparoscopic skills at home orfor hospitals looking to invest in inexpensive simulation, a tab-let-based simulator may prove to be cost-effective and will allowthe trainees to develop in their own time.

CONFLICT OF INTEREST

Ali Nehme Bahsoun, BSC, has recently worked with 3-DMEDto develop a commercial Tablet based trainer.

REFERENCES

1. Gavazzi A, Bahsoun AN, Van Haute W, et al. Face, content,and construct validity of a virtual reality simulator for robotic sur-gery (SEP robot). Ann R Coll Surg Engl. 2011;93:152-156.

2. Chandrasekera SK, Donohue JF, Orley D, et al. Basic lapa-roscopic surgical training: examination of a low-cost alter-native. Eur Urol. 2006;50:1285-1290; 1290-1291.

3. Chung SY, Landsittel D, Chon CH, Ng CS, Fuchs GJ.Laparoscopic skills training using a webcam trainer. J Urol.2005;173:180-183.

Supplementary dataSupplementary data associated with this article can be found, inthe online version, at http://dx.doi.org/10.1016/j.jsurg.2012.

FIGURE 5. Participants feedback for acceptability and utility.

08.008.

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