Background: Human cadaver simulation is vital in medical training, offering realistic experience crucial for skill development, especially in laparoscopic surgery. Traditional cadaver types, like fresh frozen and embalmed, have limitations. Fix4Life (F4L), a novel embalming technique, aims to overcome these drawbacks by providing flexible, pliable tissue without discoloration. This study evaluates the realism and face validity of the F4L embalmed cadaver model for laparoscopic training, aiming to enhance surgical education and patient safety. Methods: Surgical residents and expert surgeons from Amsterdam UMC participated in a hands-on laparoscopy course, performing laparoscopic appendectomy, cholecystectomy, and totally extraperitoneal (TEP) hernia repair on Fix4Life cadavers. Prior to this, residents completed questionnaires immediately after training, while experts reviewed procedure videos and provided evaluations. Ethical approval was obtained, and written consent was acquired from participants. Procedures were supervised, recorded, and securely shared for assessment. Face validation forms were filled by both novices and experts, assessing realism and key aspects of laparoscopic surgery. Statistical analysis included non-parametric tests due to non-normal data distribution. Results: Both residents and experts rated the laparoscopic procedures positively, with the TEP receiving particularly high scores. Residents rated the laparoscopic appendectomy and cholecystectomy as “Good” for all assessment points, while the TEP was frequently rated as “Very Good”. The experts also rated the procedures in the majority of cases as “Good”. Furthermore, novices tended to rate the procedures more favorably than experts, particularly in terms of lifelike tissue manipulation (p < 0.001), tissue color (p = 0.014), and comparability to reality (p = 0.046). Conclusion: The Fix4Life embalming method provides a realistic training modality for laparoscopic appendectomy, laparoscopic cholecystectomy, and TEP.

Objective: To systematically evaluate the economic impact of disposable versus reusable instruments in minimally invasive surgery (MIS), and to summarize the limited available evidence on environmental impact. Background: The increasing use of disposable instruments in MIS has raised concerns regarding healthcare costs and environmental sustainability. While reusable instruments may reduce per-procedure costs and waste, their economic and environmental performance is influenced by procedure type, workflow, and reprocessing requirements. Evidence integrating these factors across surgical specialties remains limited. Methods: A systematic review was conducted in accordance with PRISMA guidelines. Studies published since 2014 comparing disposable and reusable instruments in MIS were identified using predefined PICOS criteria. Data extraction focused on cost components, including instrument costs, sterilization, operating room time, and total procedural costs. Environmental outcomes were recorded when available. Results: Nine studies encompassing 4,724 procedures across multiple surgical specialties met inclusion criteria. In general surgery, reusable instruments were consistently associated with lower per-procedure costs, with reported savings ranging from $16 to $388. In selected subspecialties, including gynecology, thoracic surgery, and spinal surgery, disposable instruments were associated with reduced operative time, indirectly lowering total costs in specific settings. Only one included study directly assessed environmental impact, providing limited, low-level evidence that reusable instruments may confer environmental benefit primarily when used repeatedly. Conclusion: Reusable instruments appear to be associated with lower per-procedure costs in general surgery, while disposable instruments may offer context-specific economic advantages in selected subspecialties. Conclusions regarding environmental impact are limited by the scarcity of primary data. Future studies incorporating standardized cost definitions and robust environmental assessments, including life-cycle analyses, are needed to support evidence-based and sustainable instrument selection in MIS.

Background: Performing an intestinal anastomosis is a challenging part of laparoscopic surgery, and ensuring adequate closure is essential to prevent anastomotic leakage. The aim of this study was to develop an objective method for quantitative assessment of laparoscopic intestinal anastomosis during simulation training. Methods: A modular intraluminal air leakage device, the LeakChecker, was designed and validated by comparing laparoscopic intestinal anastomoses performed by laparoscopic novices and experts. The MaxForce, MeanNon-zero force, PathLength and DepthPerception parameters from the Lapron box-trainer vs MaxPressure and PressureArea from the LeakChecker were used for comparison. Results: A functional prototype was built and the data of 10 laparoscopic novices and seven experts were included. Anastomoses made by the experts tolerated a higher MaxPressure (3,10(2,51-7,24)kPa vs 0,98(0,81-1,35)kPa; p=0.010) and showed a higher pressureArea (24,89(16,13-100,04)kPa*t vs 5,99(4,78-9,23)kPa*t; p=0.032). The Lapron box trainer data showed significant differences between the experts and novices for almost all including force and motion parameters. Conclusion: The LeakChecker can quantify anastomotic leakage during training as it objectively distinguishes between novices and experts. Implementing this kind of smart training task in a training program with objective skill assessment would inform participants of both their instrument handing skills and the quality of their execution.

Background: Predictive models in surgery promise to improve clinical care by anticipating complications, guiding decision-making, and supporting personalized treatment strategies. Although their potential to enhance outcomes and efficiency is substantial, their integration into clinical practice also raises profound ethical challenges. Ethical Framework: These challenges span the entire lifecycle of predictive models from data collection and development to validation and clinical use. They touch upon patient privacy, algorithmic bias, transparency, and the shifting responsibilities of clinicians. Importantly, the ethical concerns are not isolated to one group but shared across patients, developers, and clinicians within a dynamic stakeholder relationship. Analysis: Key risks include biased or unrepresentative datasets, privacy breaches, opaque decision-making processes, and the danger of deskilling surgeons if reliance on algorithms becomes excessive. To mitigate these risks, strategies, such as out-of-distribution detection, standardized data collection, parallel model development, and continuous auditing, are essential. Beyond technical safeguards, embedding predictive models within a framework of accountability and patient-centered care is necessary to sustain trust and equity. Conclusion: The integration of predictive models into surgery requires more than technical excellence, and it demands ethical vigilance. Preparing future clinicians through education that emphasizes both clinical reasoning and ethical awareness is critical. By aligning predictive model development with human-centered values, healthcare systems can ensure that these innovations enhance surgical practice while safeguarding equity, transparency, and patient trust.

Background: Preoperative planning of patients diagnosed with pancreatic head cancer is difficult and requires specific expertise. This pilot study assesses the added value of three-dimensional (3D) patient models and computer-aided detection (CAD) algorithms in determining the resectability of pancreatic head tumors. Methods: This study included 14 hepatopancreatobiliary experts from eight hospitals. The participants assessed three radiologically resectable and three radiologically borderline resectable cases in a simulated setting via crossover design. Groups were divided in controls (using a CT scan), a 3D group (using a CT scan and 3D models), and a CAD group (using a CT scan, 3D and CAD). For the perceived fulfillment of preoperative needs, the quality and confidence of clinical decision-making were evaluated. Results: A higher perceived ability to determine degrees and the length of tumor–vessel contact was reported in the CAD group compared to controls (p = 0.022 and p = 0.003, respectively). Lower degrees of tumor–vessel contact were predicted for radiologically borderline resectable tumors in the CAD group compared to controls (p = 0.037). Higher confidence levels were observed in predicting the need for vascular resection in the 3D group compared to controls (p = 0.033) for all cases combined. Conclusions: “CAD (including 3D) improved experts’ perceived ability to accurately assess vessel involvement and supports the development of evolving techniques that may enhance the diagnosis and treatment of pancreatic cancer”.

Background: Laparoscopic surgery requires a complex set of motor skills. Currently, basic laparoscopic skills training is performed in a static environment, while intraoperatively, abdominal tissue is often moving. The aim of this study was to develop a dynamic training platform and evaluate its impact on laparoscopic skills acquisition in a box trainer. Methods: The Dynamic Laparoscopic Platform (DyLaP) includes a moving base which has been intergrated with the Lapron box trainer and the ForceSense objective measurement system. Dynamic training was evaluated in a comparative study where novices were divided into a static and dynamic training group, performing six training trials of a peg transfer task with the DyLaP. Afterwards, both groups performed a dynamic exam task. Task manipulation (force) and instrument efficiency (path length and time) were measured. Results: Participants (n = 12) exhibited a significant difference (p < 0.05) in time, path length, and maximum force between the static and dynamic groups in the first trial. Learning curves were most prevalent in the dynamic group. Conclusions: The DyLaP can be used to provide a challenging and realistic training environment. From the comparative peg transfer study, it can be concluded that dynamic training significantly affects laparoscopic skill acquisition. More research is needed to evaluate dynamic training effects in force-based training tasks.

Background: Technological innovations have significantly enhanced the objective assessment of technical skills in minimally invasive surgery, offering substantial potential for proficiency-based training. However, the integration of these innovative tools into surgical education curricula remains limited. This study aims to evaluate the adoption and implementation of data-driven assessment tools within laparoscopic simulation training. Methods: A systematic search of PubMed and Embase was conducted following PRISMA guidelines, identifying studies that employed objective assessments of technical skills in surgical training curricula. Eligible studies utilized data-driven assessment methods as part of structured training programs for surgical residents. A descriptive analysis was performed on the included studies. Results: From 2814 identified articles, 718 were eligible for full-text screening, and 35 studies met the inclusion criteria. These studies described the implementation of 14 different data-driven tools in laparoscopic skills training. Most tools focused on assessing instrument handling, measuring parameters such as motion speed, path length, and accuracy. Only three studies evaluated tissue handling skills using metrics like knot quality, tissue handling forces, and anastomotic integrity. Conclusions: The adoption of data-driven tools in laparoscopic simulation training is progressing slowly and exhibits considerable variability. Most technologies emphasize instrument handling, while tools for assessing tissue manipulation and force application are limited. To improve training outcomes, a combination of motion- and force-based assessment tools should be considered, enabling a more comprehensive evaluation of technical skills in minimally invasive surgery.

Surgeons performing robotic-assisted laparoscopic surgery experience physical stress and overuse of shoulder muscles due to sub-optimal arm support during surgery. The objective is to present a novel design and prototype of a dynamic arm support for robotic laparoscopic surgery to evaluate its ergonomics and performance on the AdLap-VR simulation training device. The prototype was designed using the mechanical engineering design process: Technical requirements, concept creation, concept selection, 3D-design and built of the prototype. A crossover study was performed on a marble sorting task on the AdLap-VR. The first group performed four trials without the arm support, followed by four trials with the arm support, and the other group executed the sequence vice versa. The performance parameters used were time to complete (s), path length (mm), and the number of collisions. Afterward, the participants filled out a questionnaire on the ergonomic experience regarding both situations. 20 students executed 160 performed trials on the AdLap-VR Significant decreases in the subjective comfort parameters mental demand, physical demand, effort and frustration were observed as a result of introducing the novel arm support. Significant decreases in the objective performance parameters path length and the number of collisions were also observed during the tests. The newly developed dynamic arm support was found to improve comfort and enhance performance through increased stability on the robotic surgery skills simulator AdLap-VR.

Collision feedback about instrument and environment interaction is often lacking in robotic surgery training devices. The PoLaRS virtual reality simulator is a newly developed desk trainer that overcomes drawbacks of existing robot trainers for advanced laparoscopy. This study aimed to assess the effect of haptic and visual feedback during training on the performance of a robotic surgical task. Robotic surgery-naïve participants were randomized and equally divided into two training groups: Haptic and Visual Feedback (HVF) and No Haptic and Visual Feedback. Participants performed two basic virtual reality training tasks on the PoLaRS system as a pre- and post-test. The measurement parameters Time, Tip-to-tip distance, Path length Left/Right and Collisions Left/Right were used to analyze the learning curves and statistically compare the pre- and post-tests performances. In total, 198 trials performed by 22 participants were included. The visual and haptic feedback did not negatively influence the time to complete the tasks. Although no improvement in skill was observed between pre- and post-tests, the mean rank of the number of collisions of the right grasper (dominant hand) was significantly lower in the HVF feedback group during the second post-test (Mean Rank = 8.73 versus Mean Rank = 14.27, U = 30.00, p = 0.045). Haptic and visual feedback during the training on the PoLaRS system resulted in fewer instrument collisions. These results warrant the introduction of haptic feedback in subjects with no experience in robotic surgery. The PoLaRS system can be utilized to remotely optimize instrument handling before commencing robotic surgery in the operating room.

Introduction: Although robotic-assisted surgery is increasingly performed, objective assessment of technical skills is lacking. The aim of this study is to provide validity evidence for objective assessment of technical skills for robotic-assisted surgery. Methods: An international multicenter study was conducted with participants from the academic hospitals Heidelberg University Hospital (Germany, Heidelberg) and the Amsterdam University Medical Centers (The Netherlands, Amsterdam). Trainees with distinctly different levels of robotic surgery experience were divided into three groups (novice, intermediate, expert) and enrolled in a training curriculum. Each trainee performed six trials of a standardized suturing task using the da Vinci Surgical System. Using the ForceSense system, five force-based parameters were analyzed, for objective assessment of tissue handling skills. Mann–Whitney U test and linear regression were used to analyze performance differences and the Wilcoxon signed-rank test to analyze skills progression. Results: A total of 360 trials, performed by 60 participants, were analyzed. Significant differences between the novices, intermediates and experts were observed regarding the total completion time (41 s vs 29 s vs 22 s p = 0.003), mean non zero force (29 N vs 33 N vs 19 N p = 0.032), maximum impulse (40 Ns vs 31 Ns vs 20 Ns p = 0.001) and force volume (38 N³ vs 32 N³ vs 22 N³p = 0.018). Furthermore, the experts showed better results in mean non-zero force (22 N vs 13 N p = 0.015), maximum impulse (24 Ns vs 17 Ns p = 0.043) and force volume (25 N³ vs 16 N³p = 0.025) compared to the intermediates (p ≤ 0.05). Lastly, learning curve improvement was observed for the total task completion time, mean non-zero force, maximum impulse and force volume (p ≤ 0.05). Conclusion: Construct validity for force-based assessment of tissue handling skills in robot-assisted surgery is established. It is advised to incorporate objective assessment and feedback in robot-assisted surgery training programs to determine technical proficiency and, potentially, to prevent tissue trauma.

Introduction: Robot-assisted surgery is often performed by experienced laparoscopic surgeons. However, this technique requires a different set of technical skills and surgeons are expected to alternate between these approaches. The aim of this study is to investigate the crossover effects when switching between laparoscopic and robot-assisted surgery. Methods: An international multicentre crossover study was conducted. Trainees with distinctly different levels of experience were divided into three groups (novice, intermediate, expert). Each trainee performed six trials of a standardized suturing task using a laparoscopic box trainer and six trials using the da Vinci surgical robot. Both systems were equipped with the ForceSense system, measuring five force-based parameters for objective assessment of tissue handling skills. Statistical comparison was done between the sixth and seventh trial to identify transition effects. Unexpected changes in parameter outcomes after the seventh trial were further investigated. Results: A total of 720 trials, performed by 60 participants, were analysed. The expert group increased their tissue handling forces with 46% (maximum impulse 11.5 N/s to 16.8 N/s, p = 0.05), when switching from robot-assisted surgery to laparoscopy. When switching from laparoscopy to robot-assisted surgery, intermediates and experts significantly decreased in motion efficiency (time (sec), resp. 68 vs. 100, p = 0.05, and 44 vs. 84, p = 0.05). Further investigation between the seventh and ninth trial showed that the intermediate group increased their force exertion with 78% (5.1 N vs. 9.1 N, p = 0.04), when switching to robot-assisted surgery. Conclusion: The crossover effects in technical skills between laparoscopic and robot-assisted surgery are highly depended on the prior experience with laparoscopic surgery. Where experts can alternate between approaches without impairment of technical skills, novices and intermediates should be aware of decay in efficiency of movement and tissue handling skills that could impact patient safety. Therefore, additional simulation training is advised to prevent from undesired events.

Background: Objective force- and motion-based assessment is currently lacking in laparoscopic skills curricula. This study aimed to evaluate the added value of parameter-based assessment and feedback during training. Methods: Laparoscopy-naïve surgical residents that took part in a 3-week skills training curriculum were included. A box trainer equipped with the ForceSense system was used for assessment of tissue manipulation- (MaxForce) and instrument-handling skills (Path length and Time). Learning curves were established using linear regression tests. Pre- and post-course comparisons indicated the overall progression and were compared to predefined proficiency levels. A post-course survey was carried out to assess face validity. Results: In total, 4,268 trials, executed by 24 residents, were successfully assessed. Median (interquartile range) MaxForce outcomes improved from 2.7 Newton (interquartile range 1.9–3.8) to 1.8 Newton (interquartile range 1.2–2.4) between pre- and post-course assessment (P ≤ .009). Instrument Path length improved from 7,102.2 mm (interquartile range 5,255.2–9,025.9) to 3,545.3 mm (interquartile range 2,842.9–4,563.2) (P ≤.001). Time to execute the task improved from 159.8 seconds (interquartile range 119.8–219.0) to 60.7 seconds (interquartile range 46.0–79.5) (P ≤ .001). The learning curves revealed during what training phase the proficiency benchmarks were reached for each trainee. In the survey outcomes, trainees indicated that this curriculum should be part of a surgical residency program (mean visual analog scale score of 9.2 ± 0.9 standard deviation). Conclusion: Force-, motion-, and time-parameters can be objectively measured during basic laparoscopic skills curricula and do indicate progression of skills over time. The ForceSense parameters enable curricula to be designed for specific proficiency-based training goals and offer the possibility for objective classification of the levels of expertise.