Name: Utilizing a 3D Printed Laparoscopic Nissen Fundoplication Model to Shorten a Residents Learning Curve (Video) | JoVE Journal
Uploaded: 2025-08-15T14:10:00.000+00:00
Duration: 8 min 21 s
Description: Learn how a 3D printed laparoscopic model accelerates surgical training by enabling risk-free practice of complex procedures. This method improves resident proficiency and reduces complications.

ai_agent_IP

ai_agent

maintenance

instantTrialDurationMinutes

isBiopharma

enableNewMyJoveSectionDesign

educationFeatures

seoMetaApi

ai_copilot_institution_blacklist

ai_chat_institution_blacklist

freeAccessWindow

ssoRoleCapture

scheduledMaintenanceBanner

joveLabsFeatures

disable_autoplay_for_bots

extended_trial_duration

5 minutes

The authors would like to acknowledge the support of the Department of Hernia Surgery of Zhejiang Provincial Peoples Hospital for the opportunity to conduct this research project.

This study was approved by the Zhejiang Provincial People&#39;s Hospital Institutional Review Board and conducted in accordance with established ethical guidelines. Written informed consent was obtained from all human participants. The reagents and equipment used are listed in the Table of Materials.
1. Preparing the 3D printed LNF model
NOTE: The process of fabricating individual 3D-printed anatomical models with silicone has been discussed in detail in the previous report21.
<ol>
	<li>Perform 3D computed tomography scanning with a slice thickness of 0.5 mm.</li>
	<li>Obtain Digital Imaging and Communication in Medicine (DICOM) profiles of the specific organ.</li>
	<li>Convert DICOM profiles to STL format. Import the files into Magics 24 software (File &#62; Import). Repair the model as needed by running automatic fixing (Path: Menu bar &#62; Fix &#62; Auto Fix), performing partial manual fixing (Path: Menu bar &#62; Fix &#62; Manual Fixing), and removing noise shells and debris (Path: Menu bar &#62; Fix &#62; Remove Noise Shells).</li>
	<li>After repairing, add support structures (Path: Menu bar &#62; Orientation &#62; Create Support). Finally, export the repaired and supported model, performing cut layer export as needed (Path: Menu bar &#62; File &#62; Export &#62; STL).</li>
	<li>Use an SLA 3D printer to create the organ (liver) mold. Apply the following operational settings for precise mold fabrication: Squeegee start height: 4.5 mm, Squeegee speed: 60 mm/s, Z-axis speed: 2 mm/s, Temperature control: 30 &#176;C, Curing speed: 0.2 mm/s, Spot size: 0.07 mm, and Layer thickness: 0.1 mm.</li>
	<li>Clean the printed mold thoroughly in an ultrasonic cleaner using ethanol solvent at 40 kHz for 3-5 min.</li>
	<li>Complete secondary curing of the mold in a UV chamber. Ensure exposure to UV light with a wavelength of 405 nm at an intensity of 30 mW/cm2 for a curing time of 30 min to achieve full curing.</li>
	<li>Prepare two-component 0-degree silicone (Guoyuan Mix 750 g of Component A and 750 g of Component B). Place the mixture in an ambient temperature controlled at 22-25 &#176;C to avoid high temperature affecting the operational time.</li>
	<li>Place the mixture in a vacuum chamber to remove air bubbles. Set the vacuum level to -0.09 MPa for a defoaming time of 8 min.</li>
	<li>Pour the prepared silicone from the vacuum chamber into the organ (liver) mold. Observe to ensure the silicone fills the mold evenly and that no large air bubbles are visible on the surface.</li>
	<li>Allow for complete curing. This process should be carried out in an airtight environment at a temperature of 25 &#176;C &#177; 2 &#176;C for 1 h to ensure molding quality.</li>
	<li>After complete curing, apply a thin layer of petroleum jelly to the inner surface of the mold components to act as a release agent and carefully remove the mold to obtain the final silicone organ (liver) model.</li>
	<li>Check that the surface of the model is complete and that the anatomical structures remain clear. If the surface has collapsed or contains significant bubbles, the model should be remolded. 
	NOTE: This procedure is repeated for each organ, leading to the assembly of the LNF model (Figure 1).</li>
</ol>
2. Assembling the LNF model
<ol>
	<li>Place the 3D printed organ models as per the corresponding anatomical layout.</li>
	<li>Lay out the oesophagus attached to the stomach, entering the mediastinum through the opening between the crura and gastric fundus.</li>
	<li>Place the omentum, liver, and bile duct adjacent to the stomach, holding them up by pins. These parts are important in both visual and tactile aspects of the training for LNF.</li>
	<li>Place the skin onto the plastic platform, securing it with velcro and pins. Connect a light located within the platform to a power source to improve the lighting.</li>
	<li>Make 3 incisions on the skin for ergonomic trocar positioning. Establish the triangle of vision by inserting a 5-mm trocar for the 30-degree laparoscope at the center, with two 10-mm trocars on both sides for laparoscopic needle drivers, atraumatic graspers, and laparoscopic scissors.</li>
	<li>Secure the laparoscope using a clamp, and attach it to the USB port of a high-definition display screen on either a TV or laptop.</li>
	<li>Place a 2-0 silk suture within the model with a CT-1 needle.</li>
</ol>
3. Training curriculum
NOTE: The procedure is divided into five component tasks, with the importance of each task being preclinically determined by prior studies21,23. Crural closure and mesh suturing are foundational for large hiatal hernia repair, together with the limitations of the model itself.
<ol>
	<li>Cut open the silicone gel layer around the oesophagus to establish the posterior oesophagus tunnel. Ensure clear visualization, mobilizing the esophagus circumferentially for a length of at least 4-5 cm, with attention to the right and left crura of the diaphragm.</li>
	<li>Identify and suture the bilateral diaphragmatic crura with three interrupted sutures. Verify that the crura are securely closed without tension, ensuring adequate approximation of the diaphragmatic pillars.</li>
	<li>Correctly place the mesh and suture its sides symmetrically on the diaphragm. Confirm even placement and secure attachment of the mesh to the diaphragm, ensuring it lies flat without wrinkling and maintains a clear margin from the esophageal wall.</li>
	<li>Properly execute the &#39;shoe shine manoeuvre&#39; and align the gastric fundus to wrap over 2-3 cm of the oesophagus. Ensure a floppy, tension-free, 360-degree fundoplication wrap that is no more than 2 cm in length.</li>
	<li>Properly ensure closure of the wrap with three interrupted sutures over a length of 1.5 cm. Verify secure and consistent suture placement to maintain the integrity of the fundoplication, ensuring the wrap is not too tight by passing a bougie. 
	NOTE: Prior to the training, a step-by-step expert demonstration of the LNF on the 3D model is video recorded. This expert&#39;s video is timed and scored, providing the baseline/target performance metric. All training sessions are to be recorded; feedback is to be provided after every session by the expert surgeons. Training attempts are capped at eight attempts (Figure 2). The control group continues the normal rotation with no additional training on the 3D printed model.</li>
</ol>
4. Recruiting participants
<ol>
	<li>Recruit novice surgeons with Fundamentals of Laparoscopic Surgery (FLS) certification but no advanced laparoscopic surgical skills experience, and expert laparoscopic surgeons (&#62;100 Nissen Fundoplication).</li>
	<li>Assign the novice surgeons randomly to an experimental and a control group.</li>
	<li>Adhere to the training curriculum.</li>
</ol>
5. Assessing the performance
NOTE: An expert surgeon scored all training session videos based on the five-component procedure-specific score, which was adopted and modified from a previous study23, and is included in the Supplementary File 1.
<ol>
	<li>Conduct a final assessment on live operating room (OR) performance under expert surgeon supervision, which will be evaluated in real-time using the identical checklist.</li>
	<li>Additionally, assess the 3D printed LNF model training platform.</li>
</ol>
6. Data analysis
<ol>
	<li>Measure all outcomes, including overall technical performance scores, procedure-specific checklist scores, procedural completion time, learning curve trends, and 3D printed LNF training platform validity.</li>
	<li>Create a table with raw data from all experimental and final performance steps. Calculate both the mean and standard deviation of the experimental and control group.</li>
	<li>Perform statistical analysis using appropriate tests.</li>
	<li>Generate graphs visualising the learning curve progression, performance metrics comparisons using appropriate graphing software.</li>
</ol>

<ol><li>Du, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+Nissen+%28total%29+versus+anterior+180+fundoplication+for+gastroesophageal+reflux+disease%3A+A+meta-analysis+and+systematic+review%5BTitle%5D)+AND+%22Medicine%22%5BJournal%5D)">Laparoscopic Nissen (total) versus anterior 180 fundoplication for gastroesophageal reflux disease: A meta-analysis and systematic review.</a> Medicine. 96 (37), e8085(2017).</li>
<li>Dagash, H., Chowdhury, M., Pierro, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((When+can+I+be+proficient+in+laparoscopic+surgery%3F+A+systematic+review+of+the+evidence%5BTitle%5D)+AND+%22J+Pediatr+Surg%22%5BJournal%5D)">When can I be proficient in laparoscopic surgery? A systematic review of the evidence.</a> J Pediatr Surg. 38 (5), 720-724 (2003).</li>
<li>Salminen, P., Hiekkanen, H., Laine, S., Ovaska, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Surgeons%27+experience+with+laparoscopic+fundoplication+after+the+early+personal+experience%3A+Does+it+have+an+impact+on+the+outcome%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Surgeons' experience with laparoscopic fundoplication after the early personal experience: Does it have an impact on the outcome.</a> Surg Endosc. 21, 1377-1382 (2007).</li>
<li>Watson, D., Baigrie, R., Jamieson, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+learning+curve+for+laparoscopic+fundoplication%3A+Definable%2C+avoidable%2C+or+a+waste+of+time%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">A learning curve for laparoscopic fundoplication: Definable, avoidable, or a waste of time.</a> Ann Surg. 224 (2), 198-203 (1996).</li>
<li>Menon, V., Manson, J., Baxter, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+fundoplication%3A+Learning+curve+and+patient+satisfaction%5BTitle%5D)+AND+%22J+R+Coll+Surg+Engl%22%5BJournal%5D)">Laparoscopic fundoplication: Learning curve and patient satisfaction.</a> J R Coll Surg Engl. 85 (1), 10(2003).</li>
<li>Gill, J., Booth, M., Stratford, J., Dehn, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+extended+learning+curve+for+laparoscopic+fundoplication%3A+A+cohort+analysis+of+400+consecutive+cases%5BTitle%5D)+AND+%22Ann+R+Coll+Surg+Engl%22%5BJournal%5D)">The extended learning curve for laparoscopic fundoplication: A cohort analysis of 400 consecutive cases.</a> Ann R Coll Surg Engl. 11 (4), 487-492 (2007).</li>
<li>Zacharoulis, D., O'Boyle, C., Sedman, P., Brough, W., Royston, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+fundoplication%3A+A+10-year+learning+curve%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Laparoscopic fundoplication: A 10-year learning curve.</a> Surg Endosc. 20, 1662-1670 (2006).</li>
<li>Tsuboi, K., Gazallo, J., Yano, F., Filipi, C., Mittal, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Good+training+allows+excellent+results+for+laparoscopic+Nissen+fundoplication+even+early+in+the+surgeon%27s+experience%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Good training allows excellent results for laparoscopic Nissen fundoplication even early in the surgeon's experience.</a> Surg Endosc. 24, 2723-2729 (2010).</li>
<li>Bais, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+or+conventional+Nissen+fundoplication+for+gastrooesophageal+reflux+disease%3A+Randomised+clinical+trial%5BTitle%5D)+AND+%22Lancet%22%5BJournal%5D)">Laparoscopic or conventional Nissen fundoplication for gastrooesophageal reflux disease: Randomised clinical trial.</a> Lancet. 355 (9199), 170-174 (2000).</li>
<li>Davidson, E., Penniston, K., Farhat, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Advancements+in+surgical+education%3A+Exploring+animal+and+simulation+models+in+fetal+and+neonatal+surgery+training%5BTitle%5D)+AND+%22Front+Pediatr%22%5BJournal%5D)">Advancements in surgical education: Exploring animal and simulation models in fetal and neonatal surgery training.</a> Front Pediatr. 12, 1402596(2024).</li>
<li>Zhu, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+randomized+cohort+study+on+the+use+of+3D+printed+models+to+enhance+surgical+training+in+suturing+techniques%5BTitle%5D)+AND+%22Sci+Rep%22%5BJournal%5D)">A randomized cohort study on the use of 3D printed models to enhance surgical training in suturing techniques.</a> Sci Rep. 15 (1), 636(2025).</li>
<li>Amadi, S., Wang, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Enhancing+robotic-assisted+surgery+training+with+3D-printed+bio-models%3A+A+new+era%5BTitle%5D)+AND+%22Innov+Med%22%5BJournal%5D)">Enhancing robotic-assisted surgery training with 3D-printed bio-models: A new era.</a> Innov Med. 1 (3), 100031(2023).</li>
<li>Xia, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Development+and+evaluation+of+a+portable+and+soft+3D-printed+cast+for+laparoscopic+choledochojejunostomy+model+in+surgical+training%5BTitle%5D)+AND+%22BMC+Med+Educ%22%5BJournal%5D)">Development and evaluation of a portable and soft 3D-printed cast for laparoscopic choledochojejunostomy model in surgical training.</a> BMC Med Educ. 23 (1), 77(2023).</li>
<li>Fried, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Proving+the+value+of+simulation+in+laparoscopic+surgery%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Proving the value of simulation in laparoscopic surgery.</a> Ann Surg. 240 (3), 518-528 (2004).</li>
<li>Mattar, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((General+surgery+residency+inadequately+prepares+trainees+for+fellowship%3A+Results+of+a+survey+of+fellowship+program+directors%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">General surgery residency inadequately prepares trainees for fellowship: Results of a survey of fellowship program directors.</a> Ann Surg. 258 (3), 440-449 (2013).</li>
<li>Athanasiadis, D., Anton, N., Karim, A., Colgate, C., Stefanidis, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Does+the+advanced+training+in+laparoscopic+suturing+enhance+laparoscopic+suturing+skill+beyond+fundamentals+of+laparoscopic+surgery%5BTitle%5D)+AND+%22Surgery%22%5BJournal%5D)">Does the advanced training in laparoscopic suturing enhance laparoscopic suturing skill beyond fundamentals of laparoscopic surgery.</a> Surgery. 170 (4), 1125-1130 (2021).</li>
<li>Desir, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Validity+and+reliability+evidence+support+task-specific+metrics+for+laparoscopic+fundoplication%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Validity and reliability evidence support task-specific metrics for laparoscopic fundoplication.</a> Surg Endosc. 38 (4), 2219-2230 (2024).</li>
<li>Jin, C., Dai, L., Wang, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+application+of+virtual+reality+in+the+training+of+laparoscopic+surgery%3A+A+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Int+J+Surg%22%5BJournal%5D)">The application of virtual reality in the training of laparoscopic surgery: A systematic review and meta-analysis.</a> Int J Surg. 87, 105859(2021).</li>
<li>Al-Jabir, A., Aydin, A., Al-Jabir, H., Khan, M., Dasgupta, P., Ahmed, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Current+status+of+wet+lab+and+cadaveric+simulation+in+urological+training%3A+A+systematic+review%5BTitle%5D)+AND+%22Can+Urol+Assoc+J%22%5BJournal%5D)">Current status of wet lab and cadaveric simulation in urological training: A systematic review.</a> Can Urol Assoc J. 14 (11), E594(2020).</li>
<li>Nasher, O., Smith, K., Jobson, M., Carter, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Virtual+teaching+of+paediatric+surgical+skills+during+the+COVID-19+pandemic%3A+A+feasibility+report%5BTitle%5D)+AND+%22Bull+R+Coll+Surg+Engl%22%5BJournal%5D)">Virtual teaching of paediatric surgical skills during the COVID-19 pandemic: A feasibility report.</a> Bull R Coll Surg Engl. 106 (4), 195-199 (2024).</li>
<li>Zhang, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Validity+of+a+soft+and+flexible+3D-printed+Nissen+fundoplication+model+in+surgical+training%5BTitle%5D)+AND+%22Int+J+Bioprint%22%5BJournal%5D)">Validity of a soft and flexible 3D-printed Nissen fundoplication model in surgical training.</a> Int J Bioprint. 8 (2), 546(2022).</li>
<li>Ghazi, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Will+hydrogel+models+fabricated+using+3D+printing+technology+replace+cadavers+as+the+ideal+simulation+platform+for+robotic+surgery+training%5BTitle%5D)+AND+%22Robotic+Surg%22%5BJournal%5D)">Will hydrogel models fabricated using 3D printing technology replace cadavers as the ideal simulation platform for robotic surgery training.</a> Robotic Surg. , 257-269 (2021).</li>
<li>Botden, S., Christie, L., Goossens, R., Jakimowicz, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Training+for+laparoscopic+Nissen+fundoplication+with+a+newly+designed+model%3A+A+replacement+for+animal+tissue+models%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Training for laparoscopic Nissen fundoplication with a newly designed model: A replacement for animal tissue models.</a> Surg Endosc. 24, 3134-3140 (2010).</li>
<li>Xu, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Multifunctional+high-simulation+3D-printed+hydrogel+model+manufacturing+engineering+for+surgical+training%5BTitle%5D)+AND+%22Int+J+Bioprint%22%5BJournal%5D)">Multifunctional high-simulation 3D-printed hydrogel model manufacturing engineering for surgical training.</a> Int J Bioprint. 9 (5), 766(2023).</li>
<li>Fuchs, K. -H., Eypasch, E. Gastroesophageal reflux disease-update 2006. <a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=author%3aFuchs%2C+K-H+%22EAES+Guidelines+for+Endoscopic+Surgery%3A+Twelve+Years+Evidence-Based+Surgery+in+Europe%22">EAES Guidelines for Endoscopic Surgery: Twelve Years Evidence-Based Surgery in Europe</a>. , Springer. 125-142 (2006).</li>
<li>Yoo, S. -J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((3D+printing+in+medicine+of+congenital+heart+diseases%5BTitle%5D)+AND+%223D+Print+Med%22%5BJournal%5D)">3D printing in medicine of congenital heart diseases.</a> 3D Print Med. 2, 1-12 (2016).</li>
<li>Wang, J. -L., Yuan, Z. -G., Qian, G. -L., Bao, W. -Q., Jin, G. -L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((3D+printing+of+intracranial+aneurysm+based+on+intracranial+digital+subtraction+angiography+and+its+clinical+application%5BTitle%5D)+AND+%22Medicine%22%5BJournal%5D)">3D printing of intracranial aneurysm based on intracranial digital subtraction angiography and its clinical application.</a> Medicine. 97 (24), e11103(2018).</li>
<li>Schlottmann, F., Herbella, F., Patti, M., Techniques, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Simulation+for+foregut+and+bariatric+surgery%3A+Current+status+and+future+directions%5BTitle%5D)+AND+%22J+Laparoendosc+Adv+Surg+Tech%22%5BJournal%5D)">Simulation for foregut and bariatric surgery: Current status and future directions.</a> J Laparoendosc Adv Surg Tech. 31 (5), 546-550 (2021).</li>
<li>Xia, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Assessment+of+laparoscopic+intracorporeal+intestinal+anastomosis+training+using+simulation-based+3D+printed+models%3A+Exploring+surgical+performance+and+learning+curves%5BTitle%5D)+AND+%22Int+J+Surg%22%5BJournal%5D)">Assessment of laparoscopic intracorporeal intestinal anastomosis training using simulation-based 3D printed models: Exploring surgical performance and learning curves.</a> Int J Surg. 109 (10), 2953-2961 (2023).</li>
<li>Ghazi, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+call+for+change.+Can+3D+printing+replace+cadavers+for+surgical+training%5BTitle%5D)+AND+%22Urol+Clin+North+Am%22%5BJournal%5D)">A call for change. Can 3D printing replace cadavers for surgical training.</a> Urol Clin North Am. 49 (1), 39-56 (2022).</li>
<li>Ma, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+high-water+retention%2C+self-healing+hydrogel+thyroid+model+for+surgical+training%5BTitle%5D)+AND+%22Mater+Today+Bio%22%5BJournal%5D)">A high-water retention, self-healing hydrogel thyroid model for surgical training.</a> Mater Today Bio. 29, 101334(2024).</li>
<li>Aydın, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effect+of+simulation-based+training+on+surgical+proficiency+and+patient+outcomes%3A+A+randomised+controlled+clinical+and+educational+trial%5BTitle%5D)+AND+%22Eur+Urol%22%5BJournal%5D)">Effect of simulation-based training on surgical proficiency and patient outcomes: A randomised controlled clinical and educational trial.</a> Eur Urol. 81 (4), 385-393 (2022).</li>
<li>Hiyoshi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((%28MANGOU+%28Miyazaki+Advanced+New+General+Surgery+of+University%29+wet+lab+training+relieves+anxiety+about+surgical+skills+in+surgical+education%3A+A+cross-sectional+study%5BTitle%5D)+AND+%22Cureus%22%5BJournal%5D)">(MANGOU (Miyazaki Advanced New General Surgery of University) wet lab training relieves anxiety about surgical skills in surgical education: A cross-sectional study.</a> Cureus. 16 (5), e61273(2024).</li>
</ol>

The authors declare that they have no conflict of interest. This article does not contain any studies on animals. This work was supported by the fund of The Science and Technology Cooperation Project of Zhejiang Provincial Department of Science and Technology (2024C04027) and The Special Project for Key R&#38;D Tasks of the Xinjiang Uygur Autonomous Region (Project No.2023B03010-1).

These 3D printed models allow the training and assessment of essential key techniques crucial for an ideal LNF, such as crural closure with creation and execution of a fundal wrap around the oesophagus. This is crucial as studies have demonstrated that both the length and tightness of a fundoplication strongly influence the distal oesophageal sphincter pressure, potentially elevating it up to three times its preoperative levels, which may lead to dysphagia25. As demonstrated, the resident&#39;s performance trajectory from the early training sessions to the final operating room performance showed significant improvement. The procedure time closely approached the expert&#39;s benchmark of 34 min. This marked improvement in technical proficiency was observed through iterative training sessions.
The 3D printed model offers the opportunity to practice procedure-specific advanced laparoscopic surgical skills in a safe, controlled environment26,27. The use of these models for training purposes has gained traction over the past decade, with Zhu et. al. demonstrating their adequate realism, cost effectiveness, sustainability, and capacity for maintaining operative skills acquisition for training of medical students11. Multiple studies have confirmed the realism and application of these models&#39; fidelity through simulation programs, validity studies, and participants&#39; feedback21,22,28.
Analysis of training sessions revealed high standard deviations, especially during the earlier training sessions, training 1&#38;&#60;2, indicating performance inconsistencies across the assessed metrics. This variability highlights the importance of model design optimization, as some tasks involving intracorporeal suturing, such as crural closure score and mesh fixing score, were lower compared to fundoplication and inspection scores. This disparity reflects the increased complexity and learning requirements for specific technical skills within one procedure. Prior studies corroborate this relationship and offer evidence showing task-specific metrics could be used to differentiate between different surgeon levels. Xia et al. showed this distinction utilizing 3D printed models to simulate laparoscopic intracorporeal intestinal anastomosis using a modified anastomosis objective structured assessment of technical skills to help distinguish expert, intermediate, and novice surgeons29.
The performance variability, especially in technical manoeuvres posed by intracorporeal suturing, highlights the need for procedural troubleshooting. For trainees struggling, expert proctors can ensure additional targeted drills on specific weaknesses, which is more effective than simple repetition. The design of the models allows for easy reusability and repeatable exercise, unlike animal organs and living tissue, which present storage challenges or reusability due to animal tissue friability, making them less cost-effective. With the 3D model, the peritoneal layer over the crura and the omentum, with the short gastric vessels, are the only things that should also be replaced after multiple practices. Furthermore, its low-cost production is maintained as the current material used is silicone, making it affordable30. To address the model&#39;s reusability, we must consider its durability. While formal mechanical testing was not a part of this study&#39;s protocol, we made several observations based on informal experience during repeated training sessions. We noted that durability depended heavily on the participant&#39;s technique. For crural repair, a single model could typically accommodate approximately 10 suture placements before cumulative damage from needle penetration necessitated replacement. For fundoplication training, the limiting factor appeared to be mechanical stress from suture tension; the model generally withstood 6-8 instances of strong pulling force before showing signs of structural damage. Based on this observation, trainees should be instructed to apply moderate, controlled tension, as excessive pulling can cause premature model failure and does not reflect appropriate surgical technique. There is further research exploring the use of advanced materials like hydrogel polymers to further increase realism and enable the ability of perfusion and more advanced laparoscopic techniques, such as cautery24,31. Nevertheless, the low maintenance cost per training, portability, and easy preservation ensure its accessibility to all training centres, schools, and hospitals.
The study&#39;s most critical validation suggests that the 3D-printed model training offers exceptional potential in bridging the gap between simulation-based training and actual operating performance. Previous studies have mentioned the need to showcase transferability as it would not only encourage usage but also offer great insight into its application in an actual live operation and patient outcomes32. It is imperative to acknowledge the inherent exploratory nature of utilizing 3D printed models in advanced suturing training. While statistically significant findings are encouraging, they necessitate cautious interpretation, requiring further validation with a larger cohort for more statistically definitive conclusions.
Possible limitations to these models include the design being as realistic as animal tissue; intricate anatomical features, which might be encountered in surgery, such as greater omentum, endothoracic fascia, endoabdominal fascia, mesoesophagus, and vagus nerve, were not included. However, certain design choices were deliberately made to increase the training&#39;s rigor and applicability. The curriculum focuses on hiatal hernia repair requiring mesh because mastering these complex techniques provides residents with the skills necessary to handle any type of hernia. Furthermore, the intentionally confined workspace prepares trainees for the most spatially challenging abdomens, ensuring their skills are robust and adaptable. Another question that arose was whether the number of laparoscopic cases or the quality of training made the residents better. Traditionally, the more laparoscopic cases a resident performs in their training, the better their skills get. However, as is evident, the duration spent in the skills laboratory is similarly invaluable, particularly relevant for residents with limited early exposure to advanced laparoscopic procedures33.
Future research should also focus on a formal cost-effectiveness analysis, weighing the cost of this training program against the financial impact of longer OR times and managing postoperative complications. Furthermore, the ultimate goal is to validate that proficiency on this 3D model directly translates to improved patient outcomes, which would require a long-term study tracking metrics like operative time, complication rates, and hernia recurrence for patients of trained residents. Future work could involve standardized material fatigue analysis to provide quantitative data for the durability claim.
In summary, 3D printed models represent cost-effective, customizable, efficient tools that have a distinct effect in helping reach learning curves in a more expedited fashion. Impacting the clinical surgical education and patient outcomes.

Laparoscopic Nissen fundoplication (LNF) has emerged as the gold standard surgical intervention for gastroesophageal reflux disease (GERD)1, increasingly supplanting lifelong medical anti-reflux therapy. LNF&#39;s technical complexity necessitates a steep learning curve, with a minimum of 20 procedures for achieving surgical proficiency2. Significantly impacting patient outcomes3 with complication rates ranging from 24% to 55% during a surgeon&#39;s initial procedures4,5,6, particularly within the first five operations. Subsequent evidence demonstrates a decline in complications to approximately 10% during procedures 15-254,6. The most common complications reported during the initial 20 cases predominantly involve deficiencies in technical skills; specifically, challenges with dissection of the posterior window of the oesophagus, short gastric vessels division and fundal mobilization, closure of the diaphragmatic crura, and suturing of the fundoplication7,8. Mastering these steps correlates with reduced complication rates of 2%-10%3,8,9.
Currently, surgical education presents multiple simulation training platforms to enable trainees to overcome the learning curve quickly10. However, a standardized curriculum for advanced laparoscopic training remains unestablished11,12,13,14. Evidence demonstrates that residency program completion frequently results in insufficient confidence for independent advanced laparoscopic procedure execution, necessitating fellowship pursuit for technical proficiency acquisition15. Importantly, despite the establishment of the Fundamentals of Laparoscopic Surgery (FLS) implementation in residency programs, studies have identified significant disparities between residents&#39; simulation-based intracorporeal suturing proficiency and operative room (OR) performance, suggesting that an intermediate training platform is warranted to bridge the gap between the FLS and OR suturing16. Moreover, after achieving proficiency in FLS, there is a clear need to improve the skills and confidence of surgery residents prior to their graduation with respect to advanced laparoscopic surgery, beyond FLS.
To address this, technological advancements have presented potential training solutions. Dry lab simulators such as Virtual Reality (VR) offer detailed anatomical representations and deliberate practice opportunities characteristic of LNF17. However, the cost of establishing and maintaining a VR simulator lab is a significant challenge18. Traditional wet lab simulators encompassing cadavers and live animal models, while optimal proctors for many procedures, present limitations in anatomical fidelity, ethical and health safety protocols19, especially pertinent in post-COVID-19 contexts alongside cost, logistical, and scheduling challenges10,20.
To offer an alternative, we developed an anatomical model of the upper abdomen utilizing three-dimensional (3D) printing technology based on an actual CT-modeled reconstruction and silicone material fabrication for LNF training. This model offers high reusability, with key components like the peritoneal layer and short gastric vessels replaceable after multiple practice sessions, and individual training sessions typically involving up to 8 attempts. Validation studies of comparable self-manufactured models have demonstrated significant efficacy in operative skills acquisition, as documented by Wang et al.21 and A.ghazi et al.22.
This 3D printed model can be combined with an instruction video and step-by-step demonstration videos to potentially mitigate early learning curve challenges in the clinical setting. This study aimed to demonstrate the efficacy and implementation of this training paradigm for LNF skill acquisition.

<table><tbody><tr><td>Graphing Software GraphPad Prism</td><td>GraphPad Prism</td><td>Prism 10</td><td>Used for graph generation https://www.graphpad.com/scientific-software/prism/</td></tr><tr><td>Graspers Atraumatic graspers</td><td>Kangji</td><td>101.096, &amp;Oslash;5.5&amp;times;460mm, or 108Y.208 (22mm jaw)</td><td>Standard laparoscopic instruments https://www.kangjimed.com/products</td></tr><tr><td>Laparoscope 10-mm 30-degree laparoscope</td><td>Kangji</td><td>130.032A &amp;Phi;5&amp;times;300mm 30&amp;deg;</td><td>Standard laparoscopic equipment https://www.kangjimed.com/products</td></tr><tr><td>Needle Drivers&amp;nbsp; Laparoscopic needle drivers</td><td>Kangji</td><td>&amp;nbsp;101.029, &amp;Oslash;5&amp;times;330mm</td><td>Standard laparoscopic instruments https://www.kangjimed.com/products</td></tr><tr><td>Scissors Laparoscopic scissors</td><td>Kangji</td><td>101.032A Straight</td><td>Standard laparoscopic instruments https://www.kangjimed.com/products</td></tr><tr><td>Silicone</td><td>Guoyuan</td><td>Not specified</td><td>SLA printing material</td></tr><tr><td>SLA 3D Printer</td><td>UnionTech</td><td>Lite800</td><td>Large-format professional SLA 3D printer https://www.uniontech3d.com/products/lite-800-industrial-resin-sla-3d-printer/</td></tr><tr><td>Statistical Software SPSS</td><td>IBM</td><td>version 25.0</td><td>Used for data analysis https://www.ibm.com/products/spss-statistics</td></tr><tr><td>Sutures&amp;nbsp; Ethibond sutures</td><td>Ethicon</td><td>G680H for 2-0 Ethibond</td><td>2-0 Ethibond with CT-1 needle https://www.ethicon.com/na/epc/search/platform/wound%20closure</td></tr><tr><td>Ultrasonic cleaner</td><td>Dingyu</td><td>DY-020</td><td>Used for cleaning printed parts</td></tr><tr><td>UV curing chamber</td><td>DHC</td><td>DHC48</td><td>Used for post-processing</td></tr><tr><td>Vacuum chamber</td><td>Junzai</td><td>5305-0609</td><td>Used for post-processing</td></tr></tbody></table>

utilizing a 3d printed laparoscopic nissen fundoplication model to shorten a resident's learning curve

Utilizing a 3D Printed Laparoscopic Nissen Fundoplication Model to Shorten a Resident's Learning Curve

Laparoscopic Nissen fundoplication (LNF) requires extensive training for surgical proficiency, with significant early learning curve complications. A structured training protocol utilizing a 3D-printed anatomical model is described and designed to accelerate the acquisition of advanced laparoscopic skills. The protocol entails the production and assembly of models incorporated into an LNF-specific training curriculum focused on critical components involving advanced suturing skills. The model includes anatomically accurate landmarks, all fabricated using specialized silicone materials. A step-by-step training curriculum is presented, focused on mastering the most challenging components of LNF, including crural closure, mesh suturing, and the fundoplication wrap. Representative results from a pilot participant demonstrate a quantifiable learning curve, with total performance scores improving from 21 to 42 and procedural time decreasing from 95 to 34 min across six sessions, systematically approaching the expert benchmark. The overall efficacy of this training paradigm was validated in a comparative study, where the 3D-printed model-trained group demonstrated significantly superior Objective Structured Assessment of Technical Skills (OSATS) scores in the operating room (26.25 &#177; 1.67 vs. 17.50 &#177; 2.07) and shorter procedure durations (76.25 &#177; 2.49 vs. 110.13 &#177; 3.36 min) compared to a control group, confirming the protocol&#39;s positive impact on clinical skills. This validated protocol provides a reproducible method for implementing an effective LNF training program capable of measuring and facilitating progressive skill development.

This study describes how 3D printed models effectively accelerate the rate at which advanced laparoscopic surgery skills used in Nissen Fundoplication are mastered by surgical residents during residency training, thereby enhancing future preparedness.

Laparoscopic Nissen fundoplication (LNF) requires extensive training for surgical proficiency, with significant early learning curve complications. A ...

Our research evaluates whether a realistic 3D printing model can help surgical residents master complex laparoscopic surgical skills faster and more safely before they enter the operating theater. Residents often lack confidence in advanced procedures after standard training. We address the gap between basic simulation and the complexities of real operating room performance and suturing.Our protocol uses a low-cost, reusable, and anatomically accurate model. It allows for risk-free practice of critical surgical steps, which isn't always feasible with other methods. Our finding provides a validated training pathway that shorten the learning curve.This can directly lead to improve surgical proficiency, reduce complications, and ultimately better patient outcome. After performing 3D computed tomography, convert the DICOM profiles into STL format. Import the STL files into Magics 24 software by selecting File and then Import.Run automatic fixing through the menu bar. Select Fix and choose Auto-Fix. Afterward, select menu bar, orientation, and create support to add support structures.Next, to export the repaired and supported model, select the menu bar, File, Export, and STL. Using an LCD 3D printer, open the Chitubox software and click on Slice Settings under the Resin tab. Set the layer thickness to 0.1 millimeters.Adjust the number of bottom layers to eight. Set the bottom layer lift speed to 90 millimeters per minute, and the lift speed to 80 millimeters per minute. Now, clean the printed mold thoroughly in an ultrasonic cleaner using ethanol solvent at a frequency of 40 kilohertz for three to five minutes.Complete the secondary curing of the mold in a UV chamber. After curing, apply a thin layer of petroleum jelly to the inner surfaces of the mold components to act as a release agent. Next, prepare two component zero degree silicone.Place the mixture in an environment maintained at an ambient temperature of 22 to 25 degrees Celsius to prevent high temperatures from affecting the operational time. Place the silicone mixture into a vacuum chamber set to a vacuum level of minus 0.09 megapascal for a defoaming time of eight minutes. Pour the prepared silicone from the vacuum chamber into the organ mold and observe to ensure that the silicone fills the mold evenly and that no large air bubbles are visible on the surface.Allow the silicone to fully cure in an airtight environment maintained at approximately 25 degrees Celsius for one hour. After curing, carefully remove the mold to obtain the final silicone organ model. Examine the surface of the silicone model to ensure completeness and clarity of anatomical structures.Place the 3D printed organ models according to the corresponding anatomical layout. Lay out the esophagus attached to the stomach so that it enters the mediastinum through the opening between the crura and the gastric fundus. Now, place the omentum, liver, and bile duct adjacent to the stomach, securing them in position with pins.Then place the skin onto the plastic platform and secure it. Connect the internal platform light to a power source to enhance visibility. Next, make three incisions on the skin for ergonomic trocar positioning.Insert a 12 millimeter trocar for the 30 degree laparoscope at the center to establish the triangle of vision. Position two 12-millimeter trocars on either side for laparoscopic needle drivers, atraumatic graspers, and laparoscopic scissors. Then secure the laparoscope using a clamp and connect it to the USB port of a high-definition display screen on either a television or laptop.Place a 2-0 silk suture with a CT-1 needle inside the model. Gently pass a Penrose Drain behind the already mobilized posterior esophagus to serve as a retractor. Apply gentle traction to the drain to retract the esophagus, ensuring clear visualization of the right and left crura of the diaphragm.Then identify the bilateral diaphragmatic crura and place five interrupted sutures to approximate them securely without tension. Verify that the crura are firmly closed and adequately aligned to ensure proper approximation of the diaphragmatic pillars. Next, place the mesh symmetrically on the diaphragm.Suture the sides of the mesh evenly to the diaphragm to ensure it lies flat without wrinkling, while maintaining a clear margin between the mesh and the esophageal wall. After passing the bougie through the esophagus into the stomach, perform the shoe shine maneuver to mobilize and align the gastric fundus. Wrap the fundus over two to three centimeters of the esophagus, ensuring a floppy, tension-free, 360 degree fundoplication wrap no longer than two centimeters.Then close the wrap with three interrupted sutures over a 1.5 centimeter length and inspect thoroughly to ensure that the wrap is firmly secured. Conduct a final assessment of live operating room performance under expert surgeon supervision, ensuring all steps meet procedural standards. The experimental group achieved significantly higher OSAT scores compared to the control group, while also completing the procedure in a notably shorter duration.Training session performances showed a consistent increase in total scores from session one to session six, reaching values close to the expert benchmark. Median performance scores improved steadily across training sessions. Session starting from 4.5 in session one and reaching 9.0 in session six.A strong inverse relationship was observed between procedure completion time and total score, with completion time decreasing as scores increased. Expert evaluations confirmed the model was easy to use, highly suitable for surgical training, and effective in improving surgical skills.

utilizing-3d-printed-laparoscopic-nissen-fundoplication-model-to

Research

JoVE Journal

Medicine

Practicing the specific skills required for fetoscopic laser coagulation of monochorionic placental anastomoses on realistic models can aid less experienced surgeons in overcoming the steep learning curve associated with this procedure that is now regarded as the standard of care for twin-twin transfusion syndrome.

Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators

Here, we present a protocol to use three dimensional printed models for pre-operative planning and intra-operative reorganization of complicated vascular locations when handling a congenital aortic anomaly.

Three-Dimensional Printing of a Complex Aortic Anomaly

The purpose of this paper is to illustrate how to organize a reproducible laboratory for laryngeal surgery on affordable and closely similar animal laryngeal models in order to improve anatomical and surgical knowledge and skills.

Learning Modern Laryngeal Surgery in a Dissection Laboratory

Surgical myotomy with a partial fundoplication may be used in selected patients as a definitive treatment for achalasia. This article provides a step-by-step description of a robotic myotomy and partial fundoplication in a 32-year-old patient with megaesophagus.

Robotic Myotomy and Partial Fundoplication for Achalasia

This study aims to create a 3D-printed model of a patient-specific lumbar vertebra, which contains both the vertebra and spinal nerve models fused from high-resolution computed tomography (HRCT) and MRI-Dixon data.

3D Printing Model of a Patient's Specific Lumbar Vertebra

This study presents a standardized, fully navigated 3D CT O-Arm-guided workflow for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF), aiming to improve workflow, surgical accuracy, and efficiency with full utility of 3D navigation in maximum steps.

Optimizing Minimally Invasive Spine Surgery: A Fully 3D CT O-Arm Navigated Workflow in MIS TLIF

Transcranial magnetic stimulation (TMS) is a non-invasive tool to gain insight on the physiology and function of the human nervous system.  Here, we present our TMS techniques to study cortical excitability of the upper limb and lumbar musculature.

Utilizing Transcranial Magnetic Stimulation to Study the Human Neuromuscular System

We explore the use of repetitive transcranial magnetic stimulation (rTMS) to improve language abilities in patients with chronic stroke and non-fluent aphasia.  After identifying a site in the right frontal gyrus for each patient that responds optimally to stimulation, we target this site during ten days of rTMS treatment.

Utilizing Repetitive Transcranial Magnetic Stimulation to Improve Language Function in Stroke Patients with Chronic Non-fluent Aphasia

Invasion of surrounding normal tissues is a defining characteristic of malignant tumors. We provide here a simple, semi-automated micro-plate assay of invasion into a natural 3D biomatrix that has been exemplified with a number of models of advanced human cancers.

Three-Dimensional (3D) Tumor Spheroid Invasion Assay

This method evaluates cancer cell invasion from spheroids into a surrounding 3D matrix.  Spheroids are generated via the hanging drop culture method and then embedded in a matrix comprised of basement membrane materials and type I collagen.  Invasion out of the spheroids is subsequently monitored.

A Cancer Cell Spheroid Assay to Assess Invasion in a 3D Setting

Learn how a 3D printed laparoscopic model accelerates surgical training by enabling risk-free practice of complex procedures. This method improves resident proficiency and reduces complications.

Utilizing a 3D Printed Laparoscopic Nissen Fundoplication Model to Shorten a Resident's Learning Curve

Explore More Videos