**Table 6.**

*Methods of simulation in laparoscopic colorectal surgery (LCS).*

*Perspective Chapter: Simulation in Complex Laparoscopic Digestive Surgery DOI: http://dx.doi.org/10.5772/intechopen.108224*

are also simulated. The *ex vivo* porcine tissue is mounted on an internal tray held in place by a plastic bowl, which models the sacral promontory and pelvis. Neoprene is used to replicate the anterior abdominal wall. During the simulation, three to four laparoscopic ports are employed. The distal end of the box features a hole to replicate the anus and allows the circular stapler for bowel anastomosis to enter. This simulator costs a total of \$120 USD to make and additional porcine tissue costs \$30 USD.

An increasing number of VR simulators are available to assist with training in LCS. Commercially available VR simulators, such as LapSimTM (Surgical Science, Göteborg, Sweden) [55], provide modules to learn basic laparoscopic surgery skills (**Figure 2**). LapMentorTM (Simbionix Corporation, Cleveland, Ohio, USA) [33] offers comprehensive laparoscopic sigmoidectomy training via two modules [13]. The first module covers medial peritoneal dissection, inferior mesenteric vascular division, medial to lateral colonic mobilization, and colonic transection with a laparoscopic stapler. The development of an intraperitoneal circular stapled colorectal anastomosis is required in the second module. Wynn et al. [13] assessed the validity and effects of a structured VR laparoscopic sigmoid colectomy curriculum. A median of 14 attempts was required to complete the curriculum. Metrics, including time to finish the process, number of movements of the right and left instruments, and total route length of right and left instrument movements all showed evidence of validity and distinct learning curves.

More recently, a VR simulation system, Lap-PASS LP-100 (Mitsubishi Precision Co., Ltd, Tokyo, Japan) [53], focuses on training to create proper tension on the tissue in laparoscopic sigmoid colectomy dissection (**Figure 3**) [54]. This system was validated by asking 44 surgeons (ranging from expert to novice) and six non-medical professionals to carry out a medial dissection of the sigmoid mesocolon on the simulator. There were significant differences in depth perception, bimanual dexterity, efficiency, and tissue handling, between the non-medical professionals and surgeons.

**Figure 2.** *Intracorporal knotting. LapSim® basic tasks module ([56], with permission).*

**Figure 3.** *Lap-PASS LP-100 simulator ([54], with permission).*

This system can also produce patient-specific models using actual computed tomography (CT) or magnetic resonance imaging (MRI) data, allowing users to engage in surgical training for specific patients and their procedures.

At Bournemouth University, a virtual colorectal surgery simulator for laparoscopic colectomies was developed [57]. Anatomical models were created using MRI images, and realistic soft tissue deformation was achieved using a hybrid mechanical model of the intestine. The user could also receive haptic feedback from the simulator. Another study from Beihang University used real-time simulation of soft tissue deformation and electro-cautery simulation with smoke and haptic feedback to create a VR simulator for laparoscopic radical rectal cancer surgery [58]. Both simulators have yet to be tested in a clinical setting.

Currently, VR simulation lacks realism and the learning curve is less challenging. This suggests that cadaver and animal models play an important role in simulation in laparoscopic colorectal surgery [59]. Virtual reality simulator training alone may not be sufficient to meet training demands, at least until more realistic training models are developed. VR training should be supplemented with cadaveric or animal models to obtain optimal learning curve reductions.
