# A Review of Training and Guidance Systems in Medical Surgery
## 3 Methods
### Synthesis of the Selected Works
#### 3.8.4 Laparoscopy  
Laparoscopy, besides endoscopy, is one of the medical areas that has benefited from advances in technology. Some studies have focused on the recreation of commercial solutions in virtual environments [67]. [PERSON] et al. created the Base Laparoscopic Surgical Trainer (VBLaST). It recreates the Fundamentals of Laparoscopic Skills (FLS) simulator, developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Tasks simulated by VBLaST are peg transfer, pattern cutting, placement of lighting loop, and suturing with intracorporeal or extracorporeal knot tying. The user performs the tasks by using two Geomagic Touch haptic devices that have graspers as end-effectors. To measure user performance, the simulator analyzes video captures of the session to extract the timing of procedure and errors. This experiment was made to check if VBLaST can be as effective as FLS for laparoscopy training. Students used FLS and VBLaST, and results showed that faster learning could be obtained with VBLaST than FLS due to its haptic feedback approach. On the side of teleoperated surgery training, [PERSON] et al. created a training station to practice surgical skills using a Geomagic Touch haptic device [68]. The simulation was developed using the Robot Operating system environment and VTK. The simulator was considered to have augmented reality functionality. The application lets the user practice in different tasks: explore a kidney tumor on an AR scenario, interact with the contour of the renal artery during a nephrectomy procedure on a virtual scenario, and additional basic tests, such as explore primitive shapes. Guidance is provided during the exploration of virtual anatomy. Visual aid let the user know the distance between the organs and the interaction tool, as path guidance. Moreover, the authors used a Fuzzy-PD controller to provide force assistance during the tasks. To validate their work, twenty-seven non-medical participants tested their simulator. Results state that there is a meaningful difference among users that tested the environment with force assistance. Another development area that has been considered by researchers is low-cost laparoscopy simulators [69]. [PERSON] et al. developed a low-cost cholecystectomy simulator. The authors made their system using laptops, a Microsoft Kinect camera, and two Nintendo Wiimote controllers. The Kinect was used to capture the user's motor actions to display it on the virtual scene. Wiimotes were used to provide tactile feedback during the process. The simulator was constructed using video-laparoscopic recordings from real surgeries. [PERSON] et al. built an expert knowledge database to constitute their simulator as an interactive video tutorial. For evaluation, HMMs are used to compare actions recorded by the Kinect and compare them with those stored in the database. Even though Wiimotes do not provide strictly haptic feedback per se, the simulator created by [PERSON] et al. can be considered as an in-home novel training application due to its low cost, which is around 180 USD. In the area of evaluation systems in laparoscopy, works like the one of [PERSON] et al. and [PERSON] can be mentioned [70; 71]. SINERGIA simulator, made by [PERSON] et al., is another system that enters the field of evaluation systems for laparoscopy. [PERSON] et al. created SINERGIA to provide a virtual solution with an educational approach. SINERGIA lets users control the camera, grasp, pull, cut, dissect, and do suture in the virtual environment. It was created using the Blender framework, and its workstation consists of a monitor and two haptic devices that have surgical grippers as handlers. In the area of appendectomy, [PERSON] and [PERSON] created a virtual system to assess trainees' skill level. The simulator provides a virtual advisor, which instructs users when improper actions happen in the simulation. The system records training data during the virtual procedure to keep track of the user's learning process.