The primary focus of the OR team should always be patient safety and the effective performance of each procedure and these should also be the main objectives of both the trainer and trainee for a training case. However, training in the operating room should be conducted in an environment that is supportive to training and promote learning. Nevertheless, even with close supervision, inexperienced trainees will often take longer to perform a MAS procedure. This can create a conflict between the trainer, the trainee and the rest of the OR team. Dedicated operating training lists provide the best training environment in technically challenging surgery such as MAS. However, this warrants consideration of the financial pressures facing hospitals, with targets and the reduction of the training time (due to the adoption of European working time directive). Hence, these expectations and conflicts need to be addressed before, during and after the normal operating lists.

Before an operating list, the trainer needs to ensure the list is appropriately scheduled for training purposes and that the OR team are aware that some parts or the entire list will be used for training. Opportunity now exists, with the widespread use the WHO checklists, to address these issues and come to a common agreement and understanding for the whole team. During an operating list, the expectations and priorities of the trainee will need re-adjustment by the trainer if a case or cases have taken longer than expected. After completion of the case/ list, a sign out process can allow the team to draw together the useful learning points that make future training cases run smoothly.

Attributes of an ideal training environment are summarised in Table 1.1. These may vary from the trainer, trainee and OR staff’s point of view. The team brief is an ideal opportunity to discuss how the operating list should run for the mutual benefit of all and align all views of the entire team, in order to generate a safe environment for performance and training. Novices to MAS will be more susceptible to reduced performance in the presence of interference and the OR training environment should allow a trainee to focus on the task in hand with minimal interruptions.

A training environment outside the OR is designed to attain the attributes of ensuring a safe practice and optimum environment prior to undertaking surgery, usually through simulation techniques. One of the factors that underpin the success of a simulated training environment is the degree of realism where coaching is conducted. Technology is continually striving to provide an ever more realistic simulated environment for clinical training, which is resulting in very impressive systems. However, these systems are only available to a limited number of centres and thus to a limited number of learners. It will be necessary to be pragmatic about what facilities can be made available to the large numbers of surgical trainees who need to acquire MAS skills in a safe and effective manner. Very high fidelity learning environments will certainly have their place for the most advanced learners, multi-professional groups and perhaps for assessment and re-validation in the longer term. However, for the majority of learning episodes, it is unlikely to be possible to provide the highest level of realism.

When considering MAS, one could question the need for some elements that are included in a high fidelity simulated OR. For example, the room lights are often only used during the initial access and final closing aspect of a case. However, essential elements include: