Construct validation of a novel hybrid surgical simulator

Background Simulated minimal access surgery has improved recently as both a learning and assessment tool. The construct validation of a novel simulator, ProMis, is described for use by residents in training. Methods ProMis is a surgical simulator that can design tasks in both virtual and actual reality. A pilot group of surgical residents ranging from novice to expert completed three standardized tasks: orientation, dissection, and basic suturing. The tasks were tested for construct validity. Two experienced surgeons examined the recorded tasks in a blinded fashion using an objective structured assessment of technical skills format (OSATS: task-specific checklist and global rating score) as well as metrics delivered by the simulator. Results The findings showed excellent interrater reliability (Cronbach’s α of 0.88 for the checklist and 0.93 for the global rating). The median scores in the experience groups were statistically different in both the global rating and the task-specific checklists (p < 0.05). The scores for the orientation task alone did not reach significance (p = 0.1), suggesting that modification is required before ProMis could be used in isolation as an assessment tool. Conclusions The three simulated tasks in combination are construct valid for differentiating experience levels among surgeons in training. This hybrid simulator has potential added benefits of marrying the virtual with actual, and of combining simple box traits and advanced virtual reality simulation.     

Computer-based laparoscopic and robotic surgical simulators: performance characteristics and perceptions of new users

Background  This study aimed to define perceptions of the need and the value of new simulation devices for laparoscopic and robot-assisted surgery. The initial experience of surgeons using both robotic and nonrobotic laparoscopic simulators to perform an advanced laparoscopic skill was evaluated. Methods  At the 2006 Society of American Gastroesophageal Surgeons (SAGES) meeting, 63 Learning Center attendees used a new virtual reality robotic surgery simulator (SEP Robot) and either a computer-enhanced laparoscopic simulator (ProMIS) or a virtual reality simulator (SurgicalSIM). Demographic and training data were collected by an intake survey. Subjects then were assessed during one iteration of laparoscopic suturing and knot-tying on the SEP Robot and either the ProMIS or the SurgicalSIM. A posttask survey determined users’ impressions of task realism, interface quality, and educational value. Performance data were collected and comparisons made between user-defined groups, different simulation platforms, and posttask survey responses. Results  The task completion rate was significantly greater for experts than for nonexperts on the virtual reality platforms (SurgicalSIM: 100% vs 36%; SEP Robot: 93% vs 63%; p < 0.05). Prior robot use was predictive of task completion on the SEP Robot, and nonexperts were more likely to complete the virtual reality task on the SEP Robot than on the SurgicalSIM. Experts performed better than nonexperts for all performance measures on the ProMIS. All the survey scores pertaining to realism except image quality were higher for the ProMIS than for either virtual reality trainer. Conclusion  The task completion rate was the best discriminant of expert performance on both virtual reality platforms, whereas simulator metrics best discriminated expertise for the videoscopic platform. Similar comparisons for the virtual reality platforms were not feasible because of the low task completion rate for nonexperts. The added degrees of freedom associated with the robotic surgical simulator instruments facilitated completion of the task by nonexperts. All platforms were perceived as effective training tools.     

The contribution of simulation training in enhancing key components of laparoscopic competence

This study aims to investigate how basic training contributes to the performance of complex laparoscopic tasks performed in a virtual reality (VR) environment. An assessment methodology is proposed based on quantitative error analysis of key components of laparoscopic competence. Twenty-five inexperienced surgeons were trained on four basic tasks. The effect of training was assessed on three independent scenarios (two procedural: adhesiolysis and bowel suturing, and a laparoscopic cholecystectomy [LC]). Several error parameters were post hoc analyzed to yield a quantitative performance index for two fundamental skills: proficiency and safety. Time and instrument path length were also measured and compared. Correlation analysis was performed to study how these indices correlate one another. Significant learning curves were demonstrated during training. For adhesiolysis, all four indices improved significantly (P < 0.05). Time and path length presented plateaus for all basic tasks, whereas proficiency and safety only for two and one task(s), respectively. For bowel suturing, only time and safety errors showed a decrease (P < 0.05). Significant performance enhancement was observed for LC in which errors and path length reduced after training (P < 0.05). Our results revealed also an increased number of correlations after training, especially for proficiency. This study finds it possible to assess key competence skills based on the quantitative analysis of various parameters generated by a VR simulator. The improvement in basic training is transferred to more complex tasks. The proposed methodology is useful for structured evaluation of laparoscopic performance demonstrating fundamental elements of surgical competence.     

Virtual reality laparoscopic skill assessment in microgravity

BACKGROUND: The objective of the study was to assess if performance of basic laparoscopic skills on a virtual reality (VR) simulator is impaired in microgravity relative to normal gravitational influences. MATERIALS AND METHODS: Fourteen subjects with various educational backgrounds underwent basic laparoscopy skill training for five consecutive days on the ground before flying aboard NASA's KC-135 zero-gravity laboratory. The participants performed basic laparoscopic exercises (clip applying, grasping, cutting, and suturing) on a VR laparoscopy simulator, both on the ground and during 25-s microgravity windows in parabolic flight. Skill levels after ground training were compared with skill levels in performing the same tasks in microgravity. Blinded reviewers measured the number of tasks successfully completed, tissue damage number, left and right hand path lengths during task execution, and percentage of task attempts that resulted in successful completion. RESULTS: A significant increase in tissue injury (t test, P < 0.05) and task erosion were seen in clip applying, cutting, and grasping in microgravity (45%, 20% and 57% decrease in task attempts that resulted in a successful completion, respectively). However, there was no significant difference in the left and right hand path lengths, and the total number of tasks successfully completed on the ground versus in microgravity, for any of the four laparoscopic exercises (t test, P > 0.05). CONCLUSION: This study demonstrates decreased efficiency and increased injury to the simulated tissues in performing laparoscopic skills during microgravity as compared to performing these skills in standard gravitational influence. Additional experiments are indicated to further develop and validate VR microgravity surgical simulation.     

A Pilot Study of Surgical Training Using a Virtual Robotic Surgery Simulator

Background and Objectives:

Our objectives were to compare the utility of learning a suturing task on the virtual reality da Vinci Skills Simulator versus the da Vinci Surgical System dry laboratory platform and to assess user satisfaction among novice robotic surgeons.

Methods:

Medical trainees were enrolled prospectively; one group trained on the virtual reality simulator, and the other group trained on the da Vinci dry laboratory platform. Trainees received pretesting and post-testing on the dry laboratory platform. Participants then completed an anonymous online user experience and satisfaction survey.

Results:

We enrolled 20 participants. Mean pretest completion times did not significantly differ between the 2 groups. Training with either platform was associated with a similar decrease in mean time to completion (simulator platform group, 64.9 seconds [P = .04]; dry laboratory platform group, 63.9 seconds [P < .01]). Most participants (58%) preferred the virtual reality platform. The majority found the training “definitely useful” in improving robotic surgical skills (mean, 4.6) and would attend future training sessions (mean, 4.5).

Conclusion:

Training on the virtual reality robotic simulator or the dry laboratory robotic surgery platform resulted in significant improvements in time to completion and economy of motion for novice robotic surgeons. Although there was a perception that both simulators improved performance, there was a preference for the virtual reality simulator. Benefits unique to the simulator platform include autonomy of use, computerized performance feedback, and ease of setup. These features may facilitate more efficient and sophisticated simulation training above that of the conventional dry laboratory platform, without loss of efficacy.     

A surgical virtual reality simulator distinguishes between expert gynecologic laparoscopic surgeons and perinatologists

Background:Concern regarding the quality of surgical training in obstetrics and gynecology residency programs is focusing attention on competency based education. Because open surgical skills cannot necessarily be translated into laparoscopic skills and with minimally invasive surgery becoming standard in operative gynecology, the discrepancy in training between obstetrics and gynecology will widen. Training on surgical simulators with virtual reality may improve surgical skills. However, before incorporation into training programs for gynecology residents the validity of such instruments needs to first be established. We sought to prove the construct validity of a virtual reality laparoscopic simulator, the SurgicalSim^TM, by showing its ability to distinguish between surgeons with different laparoscopic experience.Methods:Eleven gynecologic surgeons (experts) and 11 perinatologists (controls) completed 3 tasks on the simulator, and 10 performance parameters were compared.Results:The experts performed faster, more efficiently, and with fewer errors, proving the construct validity of the SurgicalSim.Conclusions:Laparoscopic virtual reality simulators can measure relevant surgical skills and so distinguish between subjects having different skill levels. Hence, these simulators could be integrated into gynecology resident endoscopic training and utilized for objective assessment. Second, the skills required for competency in obstetrics cannot necessarily be utilized for better performance in laparoscopic gynecology.     

Construct validity of the LapSim: Can the LapSim virtual reality simulator distinguish between novices and experts?

Background Virtual reality simulators may be invaluable in training and assessing future endoscopic surgeons. The purpose of this study was to investigate if the results of a training session reflect the actual skill of the trainee who is being assessed and thereby establish construct validity for the LapSim virtual reality simulator (Surgical Science Ltd., Gothenburg, Sweden). Methods Forty-eight subjects were assigned to one of three groups: 16 novices (0 endoscopic procedures), 16 surgical residents in training (>10 but <100 endoscopic procedures), and 16 experienced endoscopic surgeons (>100 endoscopic procedures). Performance was measured by a relative scoring system that combines single parameters measured by the computer. Results The higher the level of endoscopic experience of a participant, the higher the score. Experienced surgeons and surgical residents in training showed statistically significant higher scores than novices for both overall score and efficiency, speed, and precision parameters. Conclusions Our results show that performance of the various tasks on the simulator corresponds to the respective level of endoscopic experience in our research population. This study demonstrates construct validity for the LapSim virtual reality simulator. It thus measures relevant skills and can be integrated in an endoscopic training and assessment program.     

Virtual reality simulator training equals mechanical robotic training in improving robot-assisted basic suturing skills

Background This study aimed to investigate the effect of a virtual reality simulator on the learning of basic robotic suturing skills. Methods Two randomized groups of students underwent a controlled training program. Both groups completed an identical test before and after training. The increase in the number of stitches placed during the pretest and posttest was used as an objective measure of the training effect. To evaluate the subjective feeling of understanding and mastering, the students indicated this on a visual analog scale. Results Both groups showed a significant increase in the number of stitches placed during the posttest, and an increase in subjective feeling of understanding and mastering. The increase did not differ between the groups, indicating that the virtual reality simulator equaled the mechanical trainer in training of robotic suturing technique. Conclusions Training in basic robot-assisted suturing skills using a virtual reality simulator without additional training equaled training using a mechanical simulator.     

A prospective randomized study to test the transfer of basic psychomotor skills from virtual reality to physical reality in a comparable training setting

OBJECTIVE: To test whether basic skills acquired on a virtual endoscopic surgery simulator are transferable from virtual reality to physical reality in a comparable training setting. SUMMARY BACKGROUND DATA: For surgical training in laparoscopic surgery, new training methods have to be developed that allow surgeons to first practice in a simulated setting before operating on real patients. A virtual endoscopic surgery trainer (VEST) has been developed within the framework of a joint project. Because of principal limitations of simulation techniques, it is essential to know whether training with this simulator is comparable to conventional training. METHODS: Devices used were the VEST system and a conventional video trainer (CVT). Two basic training tasks were constructed identically (a) as virtual tasks and (b) as mechanical models for the CVT. Test persons were divided into 2 groups each consisting of 12 novices and 4 experts. Each group carried out a defined training program over the course of 4 consecutive days on the VEST or the CVT, respectively. To test the transfer of skills, the groups switched devices on the 5th day. The main parameter was task completion time. RESULTS: The novices in both groups showed similar learning curves. The mean task completion times decreased significantly over the 4 training days of the study. The task completion times for the control task on Day 5 were significantly lower than on Days 1 and 2. The experts' task completion times were much lower than those of the novices. CONCLUSIONS: This study showed that training with a computer simulator, just as with the CVT, resulted in a reproducible training effect. The control task showed that skills learned in virtual reality are transferable to the physical reality of a CVT. The fact that the experts showed little improvement demonstrates that the simulation trains surgeons in basic laparoscopic skills learned in years of practice.     

Assessing suturing techniques using a virtual reality surgical simulator

Advantages of virtual‐reality simulators surgical skill assessment and training include more training time, no risk to patient, repeatable difficulty level, reliable feedback, without the resource demands, and ethical issues of animal‐based training. We tested this for a key subtask and showed a strong link between skill in the simulator and in reality. Suturing performance was assessed for four groups of participants, including experienced surgeons and naive subjects, on a custom‐made virtual‐reality simulator. Each subject tried the experiment 30 times using five different types of needles to perform a standardized suture placement task. Traditional metrics of performance as well as new metrics enabled by our system were proposed, and the data indicate difference between trained and untrained performance. In all traditional parameters such as time, number of attempts, and motion quantity, the medical surgeons outperformed the other three groups, though differences were not significant. However, motion smoothness, penetration and exit angles, tear size areas, and orientation change were statistically significant in the trained group when compared with untrained group. This suggests that these parameters can be used in virtual microsurgery training. © 2010 Wiley‐Liss, Inc. Microsurgery 30:479–486, 2010.     

Construct validity for eye–hand coordination skill on a virtual reality laparoscopic surgical simulator

Background This study was carried out to investigate whether eye-hand coordination skill on a virtual reality laparoscopic surgical simulator (the LAP Mentor) was able to differentiate among subjects with different laparoscopic experience and thus confirm its construct validity. Methods A total of 31 surgeons, who were all right-handed, were divided into the following two groups according to their experience as an operator in laparoscopic surgery: experienced surgeons (more than 50 laparoscopic procedures) and novice surgeons (fewer than 10 laparoscopic procedures). The subjects were tested using the eye-hand coordination task of the LAP Mentor, and performance was compared between the two groups. Assessment of the laparoscopic skills was based on parameters measured by the simulator. Results The experienced surgeons completed the task significantly faster than the novice surgeons. The experienced surgeons also achieved a lower number of movements (NOM), better economy of movement (EOM) and faster average speed of the left instrument than the novice surgeons, whereas there were no significant differences between the two groups for the NOM, EOM and average speed of the right instrument. Conclusions Eye-hand coordination skill of the nondominant hand, but not the dominant hand, measured using the LAP Mentor was able to differentiate between subjects with different laparoscopic experience. This study also provides evidence of construct validity for eye-hand coordination skill on the LAP Mentor.     

Learning rate for laparoscopic surgical skills on MIST VR, a virtual reality simulator: quality of human-computer interface

Acquiring laparoscopic surgical skills involves initial learning of cognitive and motor skills followed by refinement of those skills. The successful use of a virtual reality simulator depends on the quality of the interface for the human-computer interaction and this can be determined by the initial learning rate. MIST VR, a part-task virtual reality laparoscopic simulator, provides objective assessment of psychomotor skills and can generate an overall score for performance, based upon errors made and time taken for six different tasks. This study analysed the rate of early task/instrument/computer familiarization on consecutive scores achieved by surgically experienced and naive individuals. Eleven surgeons, 18 medical students and seven non-medical personnel were tested on the simulator up to ten consecutive times, within a 2-week period. Performance data from every task and repetition were analysed to obtain individual scores of task performance. The calculation of overall score penalized errors far more heavily than total time taken, with high scores indicating poor performance. The surgeon-computer interface generated a rapid and significant early familiarization curve up to the third session on the simulator, with significant reductions in both time taken and total contact errors made. These results suggest that MIST VR represents a high quality interface. Surgeons scored consistently and significantly better than other subjects on all tasks. For surgically naive individuals, it was possible to predict the level of laparoscopic skills performance that would be attained after overcoming initial simulator learning curve, by studying their initial score. Overall scores reflected surgical experience and suggest that the simulator is measuring surgically relevant parameters. MIST VR provides a validated and much needed method for objective assessment of laparoscopic skills, for a variety of surgical disciplines.     

Does training in a virtual reality simulator improve surgical performance?

Background: The development of computerized surgical simulators in a virtual reality environment demands models for proper validation. Recent investigations have shown that a virtual reality simulator (MIST-VR) is a reliable tool for the assessment of laparoscopic psychomotor skills and that it improves the automation of the so-called fulcrum effect. Therefore, we set out to determine whether training with the MIST-VR would improve the surgical performance of surgically inexperienced medical students and to see if results obtained in the simulator would correlate with surgical performance. Methods: A total of 29 medical students were randomized into two groups. One group received preoperative MIST-VR training. Both groups then performed a simulated laparoscopic appendectomy in a pig. The operations were videotaped and examined by three independent observers. Results: There was no significant difference in performance between the two groups. The performance with the MIST-VR correlated with the results in surgery. Conclusion: A method that can measure surgical skill, based on the scoring of independent observers who view videotaped performances, seems to be reliable. MIST-VR did not improve the surgical skills of the subjects, but the results with MIST-VR did predict surgical outcome.     

Telementoring versus on-site mentoring in virtual reality-based surgical training

BACKGROUND: Telementoring can be an adjunct to surgical training using virtual reality surgical simulation. Telementoring is hypothesized to be as effective as a local mentor for surgical skills training. METHODS: In this study, 20 Romanian medical students trained using a virtual reality surgical simulator (LapSim) with a telementor or local mentor. All the students watched an instructional module at the beginning of the exercise. The telementor, in the United States, interacted by videoconferencing. Before and after training sessions, tool path length and time for task completion were measured. RESULTS: Instructional media and training with mentoring resulted in similar levels of performance between locally mentored and telementored groups. Right- and left-hand path length and time decreased significantly within each group from the initial to the final evaluation (p < 0.05) for most tasks (grasping, cutting, suturing). No significant difference was achieved for clip-applying. CONCLUSIONS: Integration of instructional media with telementoring can be as effective for the development of surgical skills as local mentoring.     

Initial validation of the ProMIS surgical simulator as an objective measure of robotic task performance

Virtual reality robotic simulation has gained widespread momentum. In order to determine the value of virtual reality robotic simulation and its objective metrics, a reality-based robotic surgical training platform with similar analytic capabilities must be developed and validated. The ProMIS laparoscopic surgical simulator is a widely available reality-based simulation platform that has been previously validated as an objective measure of laparoscopic task performance. In this study, we evaluated the validity of the ProMIS laparoscopic surgical simulator as an objective measure of robotic task performance. Volunteers were recruited from two experience groups (novice and expert). All subjects completed three tasks (peg transfer, precision cutting, intracorporeal suture/knot) in the ProMIS laparoscopic simulator using the da Vinci robotic surgical system. Motion analysis data was obtained by the ProMIS computerized optical tracking system and objective metrics recorded included time, path length, economy of motion, and observer-recorded penalty scores. The novice group consisted of 10 subjects with no previous robotic surgical experience. The expert group consisted of 10 subjects with robotic experience. The expert group outperformed the novice group in all three tasks. Subjects rated this training platform as easy to use, as an accurate measure of their robotic surgical proficiency, and as relevant to robotic surgery. The experts described the simulator platform as useful for training and agreed with incorporating it into a residency curriculum. This study demonstrates that the ProMIS laparoscopic simulator is a face, content, and construct valid reality-based simulation platform that can be used for objectively measuring robotic task performance.     

Novices Outperform Experienced Laparoscopists on Virtual Reality Laparoscopy Simulator

Background and Objectives:

Virtual reality has been poorly studied among gynecologic surgeons. The aim of this study was to evaluate whether performance on the Minimally Invasive Surgery Trainer-Virtual Reality (MISTVR) laparoscopic trainer reflects laparoscopic experience among gynecologic surgeons and trainees.

Methods:

Twenty-six medical students, residents, and attending gynecologic surgeons completed a MIST-VR training program. A new simulated task was then presented to each participant, who repeated the task until proficiency was reached.

Results:

Attending physicians performed poorly when compared with medical students, requiring more than twice the number of attempts to reach proficiency (Mann-Whitney P<0.01). Among medical students and residents, there was an association between years of live laparoscopy experience and poor simulator performance (Spearman r P=0.01).

Conclusion:

Increased operating room experience and age were associated with worsening simulator performance. Several potential explanations for this trend are discussed, including lack of tactile and contextual feedback. Caution should be exercised when considering current virtual reality simulator technology as a measure of experience or ability among gynecologic surgeons.     

A randomized, controlled, prospective study validating the acquisition of percutaneous renal collecting system access skills using a computer based hybrid virtual reality surgical simulator: phase I

PURPOSE: The need to develop new methods of surgical training combined with advances in computing has led to the development of sophisticated virtual reality surgical simulators. The PERC Mentortrade mark is designed to train the user in percutaneous renal collecting system access puncture. We evaluated and established face, content and construct validation of the simulator in this task. MATERIALS AND METHODS: A total of 63 trainees underwent baseline testing on the simulator, consisting of percutaneous renal puncture followed by the introduction of a guidewire into the collecting system. Subjects were then randomized to an intervention arm, in which they underwent 2, 30-minute training sessions on the simulator, and a control arm, in which no further training was given, followed by repeat testing. Performance was assessed using a global rating scale and by virtual reality derived parameters. RESULTS: There were no significant differences between the 2 groups with respect to baseline measures. Subjects who underwent training with the simulator demonstrated significant improvement in objective and subjective parameters compared to their baseline performance and compared to the untrained control group. Spearman rank correlations demonstrated a significant relationship between multiple parameters of the objective and subjective data. CONCLUSIONS: Training on the simulator improves virtual reality skills. It may allow trainees to develop the basic skills necessary to perform percutaneous renal collecting system access. Face and content validity were demonstrated and construct validity was supported by establishing convergent validity.     

What is going on in augmented reality simulation in laparoscopic surgery?

Background  To prevent unnecessary errors and adverse results of laparoscopic surgery, proper training is of paramount importance. A safe way to train surgeons for laparoscopic skills is simulation. For this purpose traditional box trainers are often used, however they lack objective assessment of performance. Virtual reality laparoscopic simulators assess performance, but lack realistic haptic feedback. Augmented reality (AR) combines a virtual reality (VR) setting with real physical materials, instruments, and feedback. This article presents the current developments in augmented reality laparoscopic simulation. Methods  Pubmed searches were performed to identify articles regarding surgical simulation and augmented reality. Identified companies manufacturing an AR laparoscopic simulator received the same questionnaire referring to the features of the simulator. Results  Seven simulators that fitted the definition of augmented reality were identified during the literature search. Five of the approached manufacturers returned a completed questionnaire, of which one simulator appeared to be VR and was therefore not applicable for this review. Conclusion  Several augmented reality simulators have been developed over the past few years and they are improving rapidly. We recommend the development of AR laparoscopic simulators for component tasks of procedural training. AR simulators should be implemented in current laparoscopic training curricula, in particular for laparoscopic suturing training.     

Validated robotic laparoscopic surgical training in a virtual-reality environment

Background  A robotic virtual-reality (VR) simulator has been developed to improve robot-assisted training for laparoscopic surgery and to enhance surgical performance in laparoscopic skills. The simulated VR training environment provides an effective approach to evaluate and improve surgical performance. This study presents our findings of the VR training environment for robotic laparoscopy. Methods  Eight volunteers performed two inanimate tasks in both the VR and the actual training environment. The tasks were bimanual carrying (BC) and needle passing (NP). For the BC task, the volunteers simultaneously transferred two plastic pieces in opposite directions five times consecutively. The same volunteers passed a surgical needle through six pairs of holes in the NP task. Both tasks require significant bimanual coordination that mimics actual laparoscopic skills. Data analysis included time to task completion, speed and distance traveled of the instrument tip, as well as range of motion of the subject’s wrist and elbow of the right arm. Electromyography of the right wrist flexor and extensor were also analyzed. Paired t-tests and Pearson’s r were used to explore the differences and correlations between the two environments. Results  There were no significant differences between the actual and the simulated VR environment with respect to the BC task, while there were significant differences in almost all dependent parameters for the NP task. Moderate to high correlations for most dependent parameters were revealed for both tasks. Conclusions  Our data shows that the VR environment adequately simulated the BC task. The significant differences found for the NP task may be attributed to an oversimplification in the VR environment. However, they do point to the need for improvements in the complexity of our VR simulation. Further research work is needed to develop effective and reliable VR environments for robotic laparoscopic training.     

Effectiveness of endoscopic surgery training for medical students using a virtual reality simulator versus a box trainer: a randomized controlled trial

Background The first step toward increasing the level of patient safety in endoscopic surgery is for all endoscopic surgeons to acquire fundamental skills, including psychomotor skills, in the preoperation stage of training. The current study aimed to evaluate the effectiveness of virtual reality (VR) simulator training and box training for training the fundamental skills of endoscopic surgery. Methods For this study, 35 medical students at Kyushu University were divided into three groups: simulator (SIM) group (n = 20), box trainer (BOX) group (n = 20), and control group (n = 15). None of the students had any experience assisting with endoscopic surgery or any previous training for endoscopic surgery. The students in the SIM group underwent training using a VR simulator, the Procedicus MIST, 2 h per day for 2 days. The students in the BOX group underwent training using a box trainer 2 h per day for 2 days. The students in the control group watched an educational video for 30 min. The endoscopic surgical skills of all the students were evaluated before and after training with a task of suturing and knot tying using a box trainer. Results Although no significant differences were found between the three groups in the total time taken to complete the evaluation task before training, there were significant improvements in the SIM and BOX groups after training compared with the control group. Box training increased errors during the task, but simulator training did not. Conclusion The findings showed that box training and VR training have different outcomes. The authors expect that the best curriculum for their training center would involve a combination that uses the merits of both methods.