**6. Simulation in colorectal surgery**

Over the last three decades, laparoscopic colorectal surgery (LCS) has grown in popularity, with Jacobs et al. credited with performing the first laparoscopic-assisted colectomy in 1991 [51]. There are several modalities for simulation training in LCS (**Table 6**).

#### **6.1 Right-sided colectomy**

An *ex vivo* porcine model has been developed to aid in training with laparoscopic right hemicolectomies [19]. A box trainer was used to house the animal model. Porcine bowel was used to replicate the right colon, ileocaecal junction, omentum, and peritoneal attachments. The ileocolic pedicle was simulated with a porcine ureter filled with red dye. A limitation of this model is a lack of simulated bleeding so learners could not practice vascular control and hemostasis. Also, porcine bowel is thinner than human bowel so places different demands on the operating surgeon for human tissue. The model for right hemicolectomy costs \$95 USD. The feedback from 16 colorectal trainees who used the model was positive. However, this model has not been validated to assess the effect on the learning curve and performance in the operating theatre.

#### **6.2 Left-sided colectomy**

Laparoscopic sigmoid colectomy has a long learning curve and simulation has been shown to improve this [16]. LeBlanc et al. [52] performed sigmoid colectomies on a cadaver and on an AR simulator. Technical skill scores on the simulator were significantly higher than on the cadaver for trainers and trainees. The cadaver model received higher overall satisfaction than the simulator model.

A high anterior resection laparoscopic trainer was developed using porcine tissues [19]. Human colon, omentum, peritoneal attachments, retroperitoneum, ureters, and the inferior mesenteric artery are all modeled using porcine tissue. The tumor position in the distal colon is marked with ink and the aortic bifurcation and bladder

