Background

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform the surgery under the supervision of a trained surgeon. This is costly, time consuming, and is of variable effectiveness. Laparoscopic surgery involves use of instruments using key-hole incisions and is generally considered more difficult than open surgery. Training using box models (physical simulation) is an option to supplement standard laparoscopic surgical training. The impact of box model training in surgical trainees with limited prior laparoscopic experience is unknown. We sought to answer the question of whether the box model training is useful in such trainees in terms of improving technical outcomes by performing a thorough search of the medical literature for randomised clinical trials. Randomised clinical trials are commonly called randomised controlled trials and are the best study design to answer such questions. If conducted well, they provide the most accurate answers to questions about intervention effects. Two authors searched the medical literature available to May 2013 and obtained the information from the identified trials. The use of two authors decreases the errors in obtaining the information.

Study characteristics

We identified and included seven trials in which 249 surgical trainees with limited previous laparoscopic experience received either box model training in addition to their standard apprenticeship training (122 trainees) versus standard apprenticeship training alone (127 trainees). The choice of whether the trainees received supplementary box model training was made in a random method similar to the toss of a coin. Six trials were conducted in USA and one trial in Canada. After supplementary box model training or standard training, the performance of the trainees was evaluated on their first operation after supplementary box model training and during the first operation in humans after an equivalent time after standard training. Different trials assessed the performance in different operations and all these operations were minor to moderate operations.

Key results

Three trials including 168 trainees reported the complications that the patients developed during or immediately after the operation. There were no deaths in either group in 168 operations performed by 168 trainees and we could not tell whether laparoscopic box model training led to major complications (one major complication in one patient operated by a trainee who underwent standard training out of 86 operations performed by trainees who underwent standard training as compared with no major complications in 82 operations performed by trainees who underwent box model training). None of the trials reported patient quality of life. One trial reported a small reduction in operating time of just over six minutes in the supplementary box model training group. The remaining trials did not report operating time. In one trial, the proportion of patients who were discharged as day-surgery was significantly higher in the supplementary box model training group (24/24 (100%)) compared with the standard training group (15/26 (57.7%)). The remaining trials did not report the proportion of people who stayed overnight. None of the trials reported trainee satisfaction. The operating performance as assessed by surgical experts was significantly better in the supplementary box model training group compared with the standard training group. None of the trials compared box model training compared with animal model training or compared with different methods of box model training. Laparoscopic box model training appears to improve technical skills compared with standard surgical training in trainees with limited previous laparoscopic experience. It may also decrease operating time and decrease the proportion of patients who require overnight stay in the first hernia repair operation that the trainee performed after box model training. However, the duration of the benefit of box model training (ie, whether such benefit continues in subsequent operations) is unknown.

Quality of evidence

Only one trial including 50 trainees was at low risk of bias (no risk of arriving at wrong conclusions because of favouritism by the researchers). Overall, the quality of evidence was very low.

Future research

Further well-designed trials with less risk of bias because of poor study design or because of chance are necessary. Such trials should assess the long-term impact of box model training on clinical outcomes.