Just over a year ago, One Surgery published our story on the origins and aspirations of Surgeon Box. We expressed our motivations and desires to develop standardized, low-budget laparoscopic trainers and modules for trainees around the globe, but especially for those in areas of dire need of trained surgeons transitioning towards adopting minimally invasive techniques. Although minimally invasive operations have become the standard of care in many developed countries due to their shorter hospital stay, decreased infection rates, and morbidity, the transition has long outpaced that of the developing world. Ameliorating global surgical disparities not only require increased access to surgical treatment but also access to the equivalent standard of surgical care. Although learning to perform laparoscopy is inherently challenging, simulation-based training is increasingly recognized as a promising supplement to on-the-job training in fostering a broad range of skills and expertise outside the operating room. Reduced depth perception by two-dimensional rendering, degraded visual information from a single-point camera, bi-manual dexterity, handling long instruments across a fulcrum, and reduced tactile feedback all contribute to challenges in mastery. Among the various types of simulation, box trainer exercises have proven pivotal in developing fundamental MIS coordination. Although laparoscopic trainers have a less realistic interface, they establish a foundation of generic skills and hand-eye-screen coordination required for minimally invasive operations. The primary obstacle in the expansion of fundamental MIS skills towards broader use is access to such equipment and instruction. Several projects have demonstrated resourceful low-cost trainer box designs; however, few offer a standardized scalable design that is both low-cost, lighity and storage weight and readily reproducible from raw materials. The aim of Surgeon Box was to design and create a low-cost laparoscopic trainer cost-effective for large scale production. The design proposed here is a product of inter-professional innovation and may be an effective means of overcoming the major limitations of cost and portability in the expansion of surgical simulation exercises to low- and middle- income countries. The multiple camera and instrument ports enable coordination training from different viewing and ergonomic axes allow participants to simulate various types of surgeries. The dimensions (43cm x 32cm x 23cm) provide adequate capacity for a relevant range of motion coordination and ensure that the diagonal measurement of 56cm to accommodate the standard laparoscopic instrument for more efficient portability and storage. The versatility of this design and activity boards empower the creativity and resourcefulness of the user to develop new tasks and protocols or follow well-established curriculums such as the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills. We believe the innovations described here to have broader implications beyond and apply to larger organizations aiming to expand surgical education. Aside from the United States, low-cost trainers described are now being used in Canada, Mexico, Honduras, Argentina, Chile, Brazil, Spain, Greece, Czech Republic, Afghanistan, Saudi Arabia, Uganda, Kenya, Singapore, and Australia. The low-weight design further enhances the cost efficiency by reducing shipping cost and the volume rate can also be further optimized when shipping collapsed units in bulk to be assembled on-site.
A global surgery education outreach program aiming to provide hundreds of units for trainee personal-use or to aid in transition towards minimally invasive procedures may opt to invest in local manufacturing options to help meet immediate demands. On the other hand, a single trainee hoping to create their own standardized box trainer and training modules may do using common materials. The USB cameras used in this study are available on common market sites and have even been substituted in other studies using phone and tablet cameras. Laparoscopic instruments training instruments are also commercially accessible but are becoming more widely available for donation from medical centers as the market continues towards more single-use disposable tools. Future initiatives expanding on and translating different laparoscopic teaching methods and mediums such as written, diagram, video, and in- person or live-stream video conferencing could further the impact of low-cost box trainers in expanding the field towards a more common and effective means of intervention. Furthermore, tele-teaching has gained an increasing amount of support as the video feed from the computer can be shared with an experienced surgeon located far away to provide insightful tips and mentorship. We believe a standardized simulator box will encourage and improve surgical education research in developing countries by providing a universal foundation for comparison and tracking, whether that be the proposed design here, and adapted version, or something entirely different. As Peter Decker famously quoted, “you can’t manage what you don’t measure”. In conclusion, our inter-professional team created an affordable laparoscopic training box constructed with low cost materials. By making laparoscopic trainers more affordable and open source, we hope to reduce financial barriers to giving trainees around the globe the opportunity to perfect their laparoscopic skills and encourage industry investment and surgical education research in developing countries transitioning towards minimally invasive techniques and operations.
