**1. Introduction**

Laparoscopic surgery has been increasingly applied to complex digestive surgery because of the many advantages over open surgery, such as reduced postoperative pain, reestablishment of bowel function, shorter hospital stays, and earlier return to work and full activities [1].

However, the high level of technical complexity of advanced laparoscopic digestive surgical procedures and the steep learning curve pose many challenges for surgeons, surgical trainees, and their teams. There have been studies that suggest a volume-outcome relationship for numerous procedures [2, 3]. For certain gastrointestinal malignancies, particularly those originating in the foregut, surgical resection is only indicated in a minority of cases [4]. Since most minimally invasive surgery for gastrointestinal malignancies occurs in low-volume hospitals [5], this presents a significant impediment to surmounting the learning curve and maintaining competencies. As a result, simulation has become an important tool in training in complex laparoscopic surgery.

This chapter focuses on current concepts of procedural simulation in complex laparoscopic digestive surgery. Examples of the different types of complex procedures


**Table 1.**

*List of basic and complex laparoscopic digestive operations.*

can be seen in **Table 1**. Simulation and training in nontechnical skills, such as communication and team-building, necessitate a separate in-depth analysis. This chapter explores challenges in complex laparoscopic surgery and how simulation may address these. It provides a background to simulation in surgery and evidence-based examples of simulation in upper gastrointestinal (UGI), hepatopancreaticobiliary (HPB), and colorectal (CR) surgery. Finally, the limitations of simulation and possible future directions have been reviewed.
