Before implementing a new technique or technology, it is essential for the surgeon to gain basic knowledge of appropriate patient selection and indications, proper pre-operative preparation, patient positioning and trocar placement, types of complications and their management, as well as to understand the new devices and equipment. Trainees should be fully aware of procedural steps for a new technique.

In this regard, the manufacturer of the da Vinci robotic surgical system has established training centers worldwide to provide an introduction to the robotic surgical system and preparation for its use, as basic product training before clinical training. Thus, trainees have the opportunity to acquire knowledge and understanding of the technology, devices, basic functions and limitations of the system.

Inanimate models (box trainers) are available for minimal access surgery, and can be helpful to trainees. An inherent problem with training on these models, however, is that the training is heavily dependent on the trainee. Unless a mentor is available to monitor a given trainee’s progress on an inanimate trainer, which is usually not the case, the trainees are left to assess their own surgical skills, and overestimation of skill acquisition is likely.

A virtual reality (VR) simulator is a useful training tool, particularly for minimal access surgical techniques and robotic surgery. It has now been proven with level 1 evidence that VR simulation-based training can improve operating room performance among surgical residents who are preparing for laparoscopic cholecystectomy [14]. In contrast to the inanimate trainer, a VR simulator provides a computer-based platform with artificially generated virtual environments. It can also provide a virtual instructor and apply standardized metrics to assess performance and identify errors and areas of improvement to promote proficiency.

A number of factors in the current surgical environment have prompted the development of simulators. Concerns about operative times and economic issues can limit a surgical trainee’s experience in the operating room, and having the novice surgeon achieve a certain level of competency before participating in actual operating room procedures has been proposed as method of improving efficiency and safety in the operating room [15–17]. Other issues surrounding surgical training include medico-legal concerns, limits to the number of work hours permitted for trainees, and ethical considerations related to a trainee learning basic skills on humans and animals [18]. Since developments in computer technology have now led to the introduction of VR simulators that allow standardized and objective training and evaluation of surgical skills, many of these issues can potentially be avoided [19].

Robotic surgical training presents some unique challenges in comparison to laparoscopic training. While good hand-eye-coordination is necessary for laparoscopic surgery, robotic techniques require different skills involving foot-hand-eye coordination in order for the surgeon to manage the robotic console. Dry laboratory practice with robotic instruments for exercise of these psychomotor skills requires the purchase of a separate robot system for training purposes. Robotic surgical training with a live animal model or a fresh frozen cadaver is generally too expensive for regular training practice. Furthermore, traditional supervised interventions on patients are potentially hazardous during robotic surgical training. During conventional laparoscopic surgery, the mentoring surgeon is adjacent to the trainee, has the same view of the procedure, and can take over at any given moment where patient safety may be compromised. However, as only one surgeon can be at an operating console (although some alternatives are discussed below), this is usually not the case in robotic procedures [20].

Therefore, the use of a VR simulator is an appealing option for robotic surgical training. The VR simulator provides surgeons with safe and extensive training in preparation for surgery on patients, and presently it offers the greatest potential for improved surgical skills. Surgical skills training in a virtual environment has a significant learning effect and the learned skills are consistent with and transferable to actual robotic procedures [21–23].

There are several commercially available high-fidelity VR simulators. The Ross^TM, manufactured by Simulated Surgical Systems (Williamsville, NY, USA), has both validated basic orientation modules and basic skill modules. It is the only robotic surgery simulator featuring full-length surgical procedures and has a patent-pending procedural task for robotic prostatectomy. Other procedural components are also being developed [24].

The dV-Trainer^TM by Mimic Technologies (Seattle, WA, USA) was the first commercially available simulator for robotic surgery. Several validation studies have demonstrated face, content, construct, and concurrent validity (chapter 2) of this VR simulator [25–28]. Through a partnership with Intuitive Surgical, Inc. (Sunnyvale, CA, USA), the manufacturer of the da Vinci robotic surgical system, the dV-Trainer^TM uses the da Vinci robot kinematics, instrument design, and vision display. The dV-Trainer^TM software is suitable for use within the robotic console, allowing virtual tasks to be performed in a real-life environment. There are more than 50 exercise modules, but currently there are no procedural components.

The da Vinci Skills Simulator^TM was presented by Intuitive Surgical in partnership with Mimic Technologies to integrate the software of the dV-Trainer^TM into the da Vinci Si console through the backpack. Thus, there is no actual hardware for this VR simulator, and the actual da Vinci Si console becomes the hardware. As with dV-Trainer^TM, there are no procedural components.

The live animal simulation model has been considered one of the most important components of training in robotic surgery and has been incorporated in several courses [29–31]. Although the anatomy is different, operating on an animal model provides good replication of the visco-elastic properties of human tissue and its response to manipulation, dissection, ligation, and other operative manoeuvres. However, live animal simulation models are costly and veterinary assistance and separate equipment and location are required. Furthermore, it may raise ethical concerns.

Nonetheless, the live animal model is still considered the simulation model with the highest fidelity in terms of close replication of intra-operative conditions, even as wet laboratories are limited and many surgical trainees will complete their training without an opportunity to operate on an animal model.

The fresh frozen cadaver simulation model has the advantage of presenting real human anatomy and can be useful for procedural training. Surgical anatomy, tissue consistency, and anatomical planes are usually well preserved, and participants report high levels of satisfaction [32].

However, such a training programme is not easily reproducible, and is costly, requiring special preparation and separate equipment, as with the live animal simulation model. Another limitation is the lack of in vivo physiology such as bleeding and actual tissue compliance. There is a paucity of studies exploring the true effectiveness of fresh frozen cadaver training [33].