AIM:
The aim of this study was to evaluate how simple it is to build a homemade low-cost simulator using a simple 5-step scheme.
METHODS:
A scheme explaining how to build an endoscopic surgery simulator in 5 easy steps was presented to 26 surgeons. The simulator required a pair of scissors and easy-to-find materials. Its total cost was less than €35. The participants assessed the simulator using common endoscopic training toys or ex vivo tissue and completed an anonymous query comparing it with other commercial simulators that they had experienced before.
RESULTS:
In all, 84.6% found the simulator really easy to build. Every participant felt that he or she could do the same simulator themselves. Comparing with other commercial available box simulators, the majority of participants found the homemade simulator easier to (a) mount and dismount, (b) transport, (c) clean, and (d) use when practicing alone.
CONCLUSIONS:
Anyone can build its own simulator for a small amount of money

Correia-Pinto, J

Moreira-Pinto, J

Ribeiro de Castro, JL

Silva, JG

English

Repositório Comum

Surgical InnovationXX(X) 1 –5© The Author(s) 2012 Reprints and permission:  sagepub.com/journalsPermissions.navDOI: 10.1177/1553350612440508http://sri.sagepub.comIntroductionSurgery has undergone a big transformation in the past 3 decades. Since 1987, when Dr Philippe Mouret performed the first laparoscopic cholecystectomy, minimally inva-sive surgery started spreading worldwide.1 At the same time, surgeons were forced to acquire new skills in order to perform surgical procedures through endoscopic, indi-rect visualization.Just as laboratory training and operative experience with open surgical technique allow surgeons to develop open surgical skills, laparoscopic skill acquisition requires practice. Gaining skills in laparoscopic surgery requires specific training. Besides animal hands-on courses, sur-geons have to spend a great amount of time practicing in simulators.2 Indeed, dedicated conscientious laparoscopic skill practice has been shown to improve the clinical per-formance of even experienced laparoscopists.3Commercially available endoscopic simulators are usually expensive and not available to the surgeon on a daily basis. For that, several homemade box simulators have been previously reported.4-8 However, a simple instruction guide to how to build one is lacking. For that, we designed a 5-step scheme showing how simple it is to build a homemade low-cost simulator.Material and MethodsA 5-step scheme explaining how to build an endoscopic surgery simulator was presented to 26 surgeons (8 residents and 18 senior surgeons) from different specialties (pediatric surgery, general surgery, gynecology, and urology).The endoscopic simulator required a laptop or desktop computer with 1 free USB port, a pair of scissors, and other easy-to-find cheap materials: a translucent plastic box, a webcam, a USB cable, adhesive tape, Velcro tape, and a rubber sheet (Figure 1).We used a medium-size translucent plastic box (25 × 30 × 40 cm). Using the pair of scissors, we cut the center 440508 SRIXXX10.1177/1553350612440508Moreira-Pinto et alSurgical Innovation1Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal2Pediatric Surgery Department, Centro Hospitalar do Porto, Porto, Portugal3General Surgery Department, Hospital Santa Maria Maior, Barcelos, Portugal4Pediatric Surgery Department, Hospital de Braga, Braga, PortugalCorresponding Author:João Moreira-Pinto, Surgical Sciences Research Domain, Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho–Campus de Gualtar, Braga 4710-057, Portugal Email: moreirapinto@ecsaude.uminho.ptFive Really Easy Steps to Build a Homemade Low-Cost SimulatorJoão Moreira-Pinto, MD1,2, João Guilherme Silva, MD3,  João Luís Ribeiro de Castro, MD2, and Jorge Correia-Pinto, MD, PhD1,4 AbstractAim. The aim of this study was to evaluate how simple it is to build a homemade low-cost simulator using a simple 5-step scheme. Methods. A scheme explaining how to build an endoscopic surgery simulator in 5 easy steps was presented to 26 surgeons. The simulator required a pair of scissors and easy-to-find materials. Its total cost was less than €35. The participants assessed the simulator using common endoscopic training toys or ex vivo tissue and completed an anonymous query comparing it with other commercial simulators that they had experienced before. Results. In all, 84.6% found the simulator really easy to build. Every participant felt that he or she could do the same simulator themselves. Comparing with other commercial available box simulators, the majority of participants found the homemade simulator easier to (a) mount and dismount, (b) transport, (c) clean, and (d) use when practicing alone. Conclusions. Anyone can build its own simulator for a small amount of money.Keywordsergonomics and/or human factors study; simulation; surgical education2  Surgical Innovation XX(X)of the box’s top leaving a 2 cm margin. Then, we cut the rubber sheet to fit the box’s top, and we taped it together using strong adhesive tape. An articulated webcam (C-123B, Mitsai, Matosinhos, Portugal) was fixed to the inner anterior wall of the box using Velcro tape. The web-cam was connected to the computer using an USB cable passed through a small hole in the bottom of the plastic box. We used a laptop computer running Windows XP operating system, which recognized the webcam auto-matically. By double clicking the webcam’s icon on “My Computer” folder, one could get the preview image com-ing from the webcam. The articulated webcam optic was directed to the middle of the box, and various endoscopic toys and ex vivo animal tissues were put in the center of the image. After closing the box, two 5 mm trocars (Ethicon Endosurgery, Cincinnati, OH) were introduced through different incisions on the rubber sheet, depending on the surgeon’s preference. Regular laparoscopic dis-posable instruments and trocars were used to perform dif-ferent training tasks.The total cost of this homemade endoscopic simulator was €33.67 (Table 1).After looking at the 5-step scheme, the participants assessed the homemade endoscopic simulator using Figure 1. How to build a homemade endoscopic simulator in 5 steps(1) Cut the top of a medium-size translucent plastic box, leaving a 2 cm margin. (2) Cut a rubber sheet to fit the box’s top, and tape them together. (3) Fix an articulated webcam to the box’s inner anterior wall using Velcro tape. (4) Connect the webcam to your computer using a USB cable passed through a small hole in the plastic bottom, and point it to the centre of the box. (5) Close the box and insert 2 trocars in the rubber sheet and start practicing.Moreira-Pinto et al. 3common endoscopic training toys or ex vivo tissue. Then, they completed an anonymous query evaluating the 5-step scheme and comparing the homemade endoscopic simulator to other commercially available simulators that they had experienced before, either during laparoscopy courses or in their hospital’s training laboratory (Table 2).ResultsIn all, 84.6% of the surgeons questioned found the simu-lator very easy to build, and the remaining 15.4% found it easy to build. All participants felt that they could build the same simulator on their own. All participants admit-ted that owning an endoscopic simulator is important for initial laparoscopy training. In fact, 69.2% of them answered that it was very important. Ninety-six percent agreed that the simulator was cheap, 4% found it was more or less expensive, and none found it expensive.Participants’ answers comparing the homemade endo-scopic simulator to other commercially available box simulators are resumed in Table 3. The majority of par-ticipants (88.5%) found the homemade endoscopic simu-lator easier to mount and dismount, easier to transport (88.4%), easier to clean (80.4%), and easier to use (84%) when practicing alone. The majority of the participants found quality of light, image, material resistance, and overall endoscopic environment at least as good as the commercially available box simulators that they had experienced before.DiscussionVarious endoscopic simulators have been presented to improve laparoscopic surgeons’ skill. Some of these sim-ulators incorporate virtual reality software that both simu-lates an operative endoscopic environment and monitors surgeons’ skills.9 The limitations of such complex devices are cost, mobility, and availability. Commercially avail-able endoscopic simulators are very expensive. Not every hospital can afford one, and when there is that possibility, endoscopic simulators are usually stationed in an endo-scopic training facility, where access is limited by time, scheduling, and availability of accessory equipment, such as video monitor, endoscopic camera, and laparoscopic instruments.7 For that, several homemade box simulators have been presented before.4-6 Recently, Chung et al7 reported the effectiveness of a cardboard box simulator with a webcam system for laparoscopy training. Beatty8 presented a similar simulator, but he used a translucent plastic box, making it more resistant and avoiding the need of a lamp inside the box. Having these in mind, we designed 5 steps to building a homemade endoscopic simulator, so that anyone could build one as well as mount and dismount it easily.We designed a homemade endoscopic simulator with cheap and easy-to-find materials. A plastic box was pre-ferred over other materials (eg, cardboard) because of its lightness, resistance, and easy washability. The former is especially important if one wants to train using ex vivo tissue. The box was translucent in order to receive light from the exterior, which proved to be enough for good visualization. There are webcams that have a light source incorporated that could obviate the need of translucent plastic, but these are harder to find for most surgeons. By fixing the webcam with Velcro tape, we made the simula-tor easy to mount/dismount, so that one could wash it after using ex vivo tissues. Finally, the rubber sheet over the top of the box mimics the thoracic/abdominal wall not only for its texture and bulging movements but also by block-ing surgeon’s direct visualization from the outside. The rubber sheet also permits inserting trocars in different places, depending on the tasks one intends to practice.As pointed out by Chung et al,7 webcam permits zoom-ing in, recording training sessions, and transmitting them through the Internet in real time, which opens new perspec-tives on laparoscopic training, such as telementoring, group discussions, and creation of hands-on courses at low cost.Our aim was not only to make an easy-to-build laparo-scopic simulator but also to design a 5-step scheme that would be easy for any surgeon to follow. By answering the query, all surgeons said that they could follow our scheme and make their own homemade simulator, and most of them said it was very easy to do. Of course, it would be better to actually see if they could do it by giv-ing them the tools and materials that they would need but that would take us lot of plastic boxes, and probably sur-geons would not be keen on spending time cutting the plastic box as we did while doing this study. From the answers we got, we found that most surgeons think that it is important to own an endoscopic simulator in order to develop initial laparoscopic skills.We did not query participants which commercially avail-able endoscopic box simulator they had experienced before for comparison, because most had trained in more than one and would not remember their names. So participants judged our homemade endoscopic simulator based on their Table 1. List of Materials and Its PricesMaterials Price (€)Translucent plastic box (25 × 30 × 40 cm) 4.45Rubber sheet (21 × 36 cm) 1.5Adhesive tape 3.29Velcro tape 4.95Webcam (650 × 480 pixels) 11.99USB (universal serial bus) cable 7.49Total cost 33.674  Surgical Innovation XX(X)previous experience with various different types of box simulators. Concerning this judgment, we found that mounting/dismounting, cleaning, transportation, and single- surgeon training was better than in commercially available endoscopic simulators. On the other hand, most critics were concerned about image light and overall endoscopic envi-ronment. These 2 aspects depend largely on webcam’s defi-nition and the light source used. In laparoscopy, light source comes from the scope. Thus, shadow is always behind the structures we are focusing. In our homemade simulator, light was coming from all the sides, creating shadows from different directions. As said before, we could use a light incorporated in the webcam, but this would be harder to find and is more expensive. Concerning webcam’s defini-tion, our webcam had 640 × 480 pixels definition. A higher definition camera could be used, but again it would be more expensive. The majority of participants answered that image light and endoscopic environment provided by our homemade simulator was at least as good as the one pro-vided by commercially available ones.ConclusionsWe describe 5 easy steps on how to build a homemade low-cost endoscopic simulator. This simple scheme is an affordable way for surgeons and medical students to make their own simulator, comparable with those com-mercially available, which they should use to practice and perfect their laparoscopic skills.Authors’ NoteThe current study was presented at the May 2011 Annual Meeting of the International Pediatric Endosurgery Group, Prague, Czech Republic.Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of inter-est with respect to the research, authorship, and/or publication of this article: Professor Jorge Correia-Pinto is consultant for Karl Storz, Germany. The remaining authors do not have finan-cial interests to declare.Table 2. Query on Homemade Endoscopic Simulator1. After looking at this 5-step scheme, how easy do you find it to reproduce? (a) very easy, (b) easy, (c) medium difficulty, (d) difficult, (e) very difficult2. After looking at this 5-step scheme, could you make an endoscopic simulator of your own? (a) yes, (b) no3. How important is it to have your own endoscopic simulator for initial laparoscopic training? (a) not important at all, (b) not important, (c) important, (d) very important4. Do you find this homemade endoscopic simulator expensive? (a) yes, (b) more or less, (c) no5.  Comparing to other commercially available endoscopic simulators, how do you find this homemade endoscopic simulator    concerning mounting/dismounting: (a) far worse, (b) worst, (c) same; (d) better, (e) much better transporting: (a) much worse, (b) worst, (c) same, (d) better, (e) much better cleaning: (a) much worse, (b) worst, (c) same, (d) better, (e) much better resistance: (a) much worse, (b) worst, (c) same, (d) better, (e) much better one surgeon practice: (a) much worse, (b) worst, (c) same, (d) better, (e) much better image light: (a) much worse, (b) worst, (c) same, (d) better, (e) much better overall endoscopic environment: (a) much worse, (b) worst, (c) same, (d) better, (e) much betterTable 3. Answers Comparing the Homemade Endoscopic Simulator to Commercially Available OnesaMuch Worse Worse Same Better Much BetterMounting/dismounting — — 3 (11.5) 15 (57.7) 7 (30.8)Transporting — — 3 (11.5) 16 (61.5) 7 (26.9)Cleaning — — 5 (19.2) 17 (65.4) 4 (15.4)Resistanceb — 6 (24.0) 15 (60.0) 4 (15.4) —One-surgeon practicea — — 4 (16.0) 14 (56.0) 7 (28.0)Image lighta — 4 (16.0) 17 (68.0) 3 (12.0) 1 (4.0)Endoscopic environment 2 (7.7) 5 (19.2) 16 (61.5) 3 (11.5) —aData are presented as n (%).bOne response missing (n = 25).Moreira-Pinto et al. 5FundingThe author(s) received no financial support for the research, authorship, and/or publication of this article.References1. Spaner SJ, Warnock GL. A brief history of endoscopy, lap-aroscopy, and laparoscopic surgery. J Laparoendosc Adv Surg Tech A. 1997;7:369-373.2. Gallagher AG, Smith CD, Bowers SP, et al. Psychomotor skills assessment in practicing surgeons experienced in performing advanced laparoscopic procedures. J Am Coll Surg. 2003;197:479-488.3. Seymour NE. VR to OR: a review of the evidence that virtual reality simulation improves operating room perfor-mance. World J Surg. 2008;32:182-188.4. Mughal M. A cheap laparoscopic surgery trainer. Ann R Coll Surg Engl. 1992;74:256-257.5. Gue S. Home-made videoscopic trainer for operative lapa-roscopic surgery. Aust N Z J Surg. 1995;65:820-821.6. Chandrasekera SK, Donohue JF, Orley D, et al. Basic lapa-roscopic surgical training: examination of a low-cost alter-native. Eur Urol. 2006;50:1285-1290.7. Chung SY, Landsittel D, Chon CH, Ng CS, Fuchs GJ. Lap-aroscopic skills training using a webcam trainer. J Urol. 2005;173:180-183.8. Beatty JD. How to build an inexpensive laparoscopic webcam-based trainer. BJU Int 2005;96:679-682.9. Madan AK, Frantzides CT, Shervin N, Tebbit CL. Assess-ment of individual hand performance in box trainers compared to virtual reality trainers. Am Surg. 2003;69: 1112-1114.

Five really easy steps to build a homemade low-cost simulator

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Five really easy steps to build a homemade low-cost simulator

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