Letter to the editor on “Effects of Systematically Guided vs. Self-Directed Laparoscopic Box Training on Learning Performances”

The study by Neubacher et al. investigates the effects of systematically guided versus self-directed laparoscopic box training on learning outcomes among medical students. As minimally invasive surgery (MIS) becomes increasingly prominent across surgical specialties, understanding the optimal training approaches for skill acquisition is critical. The authors contribute significantly to this field by examining two distinct training modalities—systematic, supervised training and self-directed learning—among a cohort of medical students. While the study presents meaningful data and highlights the benefits of structured training, there are several areas where the methodology, analysis, and implications could be improved. Additionally, situating the findings within the broader body of surgical education literature underscores the study’s strengths and limitations.

This study represents a valuable addition to the growing body of research on laparoscopic training for several reasons. First, it directly compares systematically guided and self-directed training, filling a gap in the literature where these modalities have rarely been contrasted with such methodological detail. The use of objective metrics—time, force, and path length—adds robustness to the analysis, ensuring that results are measurable and reproducible.

Moreover, the study’s inclusion of over 3500 training sessions makes it one of the largest observational investigations in this domain. The large dataset allows for more reliable statistical analyses and enhances the generalizability of certain findings, particularly those related to skill progression. The finding that the structured cohort demonstrated more consistent improvement, even with fewer training sessions, underscores the critical role of supervision and collaboration in skill acquisition. This is consistent with existing literature, which highlights the value of guided feedback and structured learning environments in surgical education [1].

The structured cohort’s performance improvement over time supports the notion that institutionalized training with regular feedback can lead to better learning outcomes. This finding has significant implications for the design of medical curricula, especially in surgical specialties, where skill acquisition is heavily reliant on repetition and feedback.

Limitations and Methodological Concerns

Despite its strengths, several aspects of the study limit its impact and necessitate further refinement in future research.

The observational design of the study introduces inherent limitations, as it lacks the rigor of a randomized controlled trial (RCT). Selection bias is evident in the differing characteristics of the two groups. For instance, the self-directed group consisted of last-year medical students, while the structured group included students in their third to fifth years. This discrepancy in educational stage and clinical exposure likely influenced the results. While the authors acknowledge this limitation, a baseline assessment of participants’ skills prior to the intervention could have mitigated its impact and allowed for a more accurate comparison.

Furthermore, the self-directed group was permitted to train at their discretion, leading to significant variability in training frequency, duration, and intensity. This lack of control contrasts with the structured cohort, whose training was standardized and supervised. These differences likely contributed to the observed outcomes but complicate the ability to attribute performance differences solely to the training modality.

Another limitation lies in the disparity between the training environments of the two groups. The structured cohort trained under consistent supervision, with feedback provided by experienced surgeons and peers. In contrast, the self-directed cohort lacked this supervision and was not given clear guidelines regarding the number of repetitions or session durations. This variability could have affected the quality of their practice and, consequently, their performance.

Additionally, the self-directed participants were allowed to decide which results to save, introducing potential bias in the recorded data. While the authors encouraged participants to save their best results, the absence of monitoring makes it unclear whether this recommendation was consistently followed.

The study focuses on objective metrics such as time, force, and path length, which are important indicators of technical proficiency. However, these metrics provide only a partial picture of skill acquisition. Other relevant outcomes, such as error rates, stress levels, and qualitative measures like confidence and self-perceived competence, were not assessed. Including these metrics would have provided a more comprehensive understanding of the participants’ learning experiences and outcomes.

Furthermore, while the authors report higher consistency in the structured cohort’s performance, the underlying reasons for this consistency are not thoroughly explored. Factors such as reduced cognitive load, enhanced motivation, or improved stress management in the structured environment could have played a role but were not investigated.

Context in the Scientific Literature

The findings of this study align with existing research highlighting the benefits of structured training programs in surgical education. Numerous studies have demonstrated that guided feedback, peer collaboration, and reduced cognitive load are critical for skill acquisition, particularly in complex motor tasks like laparoscopy. For example, studies by Hardon et al. [2] [3] and Rahimi et al. [4] emphasize the importance of objective metrics in tracking learning curves and tailoring training to individual needs. The current study builds on these findings by showing that structured training leads to more consistent improvement. However, it does not address the broader implications of individual variability in learning curves, a topic that has been explored in detail in other studies.

Additionally, the issue of skill retention remains underexplored. While the study demonstrates short-term improvement in the structured cohort, it is unclear whether these gains persist over time. Longitudinal studies are needed to assess the durability of training outcomes and the extent to which they translate into clinical competence.

To address the limitations of the current study, future research should employ randomized controlled trials to eliminate selection bias and ensure equal baseline characteristics across groups. RCTs would provide stronger evidence for the efficacy of structured versus self-directed training and allow for more definitive conclusions.

Inclusion of Broader Metrics

Future studies should include a wider range of outcome measures to capture the multifaceted nature of surgical skill acquisition [5] [6]. In addition to objective metrics like time and force, qualitative measures such as confidence, stress levels, and feedback responsiveness should be incorporated. These measures would provide a more holistic understanding of the learning process and its impact on trainees.

The study highlights the variability in individual learning curves, suggesting that a one-size-fits-all approach may not be optimal. Personalized training programs that adapt to the learner’s pace and skill level could enhance outcomes. For example, predictive models, as demonstrated by Rahimi et al. [4], could be used to identify trainees who would benefit most from structured interventions.

Combining elements of self-directed and structured training may offer a balanced approach, leveraging the flexibility of self-directed learning with the benefits of guided feedback. Such hybrid models could be particularly valuable in resource-limited settings where continuous supervision is not feasible. Longitudinal studies are needed to assess the durability of training outcomes and their impact on clinical performance. Understanding the long-term effects of structured versus self-directed training will help determine the best approaches for integrating laparoscopic training into medical curricula.

The study underscores the importance of institutionalizing laparoscopic training within medical curricula. Simply providing access to training equipment is insufficient to maximize learning outcomes. Structured programs with clearly defined objectives, regular feedback, and collaborative learning opportunities are essential. Medical schools and training institutions should consider implementing such programs to ensure that trainees develop the skills needed for minimally invasive surgery.

Nevertheless, self-directed learning concepts go far beyond the mere provision of a training device. They require a conscious design of framework conditions that provide students with the necessary orientation to organize their learning effectively and purposefully on the one hand and leave them sufficient freedom to benefit from the advantages of self-organized learning on the other. These framework conditions include, for example, clear guidelines on the scope of training to be completed, specific target competences to be achieved by a defined time and concrete tasks to be completed. These elements create a structured basis on which learners can set their individual priorities – be it by working specifically on personal weaknesses, by consolidating strengths or by adapting the learning process to their preferred learning styles and methods. Pintrich et al. define four different areas which are important for a successful learning process: Forethought, planning, and activation, Monitoring, Control as well as Reaction and Reflection [7]. The provision of guidance and support to students throughout this process could facilitate the development of effective strategies for future self-directed life-long learning beyond medical school [8].

A well-balanced combination of self-directed learning and clear guidelines is essential to ensure that all necessary competences are achieved at the end of the curriculum. While the freedom for self-directed learning gives students the opportunity to take responsibility for their own learning process, a surrounding framework helps to maintain orientation and guarantee the quality and completeness of the skills acquired.

However, the present study does not sufficiently address this balance and thus misses the opportunity to make a differentiated comparison between self-directed and more structured learning. Due to the lack of specific guiding guidelines, the potential to analyze the synergies and limitations of self-organized learning approaches in a well-founded manner is not fully exploited. As a result, it remains unclear under which conditions self-organized learning can be optimally promoted, and the results of the study can only contribute to the further development of learning formats to a limited extent.

Additionally, the study highlights the role of supervision in reducing stress and enhancing learning outcomes [9]. Providing a supportive training environment where novices can practice without fear of making mistakes is crucial. Incorporating peer-assisted learning and mentoring into training programs could further enhance their effectiveness.

Conclusion

Neubacher et al.’s study provides valuable insights into the benefits of structured training for laparoscopic skill acquisition. While the findings align with existing literature and highlight the importance of guided learning, the study’s limitations underscore the need for further research. Addressing these limitations through randomized controlled trials, broader outcome measures, and personalized training programs will help optimize laparoscopic training and ensure its effectiveness in preparing medical students and young surgeons for clinical practice.

In conclusion, the study reaffirms the importance of structured, institutionalized training programs in surgical education. As minimally invasive surgery continues to evolve, developing evidence-based training methodologies will be critical to ensuring that future surgeons are equipped with the skills needed to provide high-quality patient care.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

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• 3 Hardon SF, Van Gastel LA, Horeman T. et al. Assessment of technical skills based on learning curve analyses in laparoscopic surgery training. Surgery 2021; 170: 831-840
• 4 Rahimi AM, Hardon SF, Uluç E. et al. Prediction of laparoscopic skills: objective learning curve analysis. Surg Endosc 2023; 37: 282-289
• 5 Hopper AN, Jamison MH, Lewis WG. Learning curves in surgical practice. Postgrad Med J 2007; 83: 777-779
• 6 Stefanidis D, Sevdalis N, Paige J. et al. Simulation in Surgery: What’s Needed Next?. Ann Surg 2015; 261: 846-853
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• 9 Tjønnås MS, Muller S, Våpenstad C. et al. Stress responses in surgical trainees during simulation-based training courses in laparoscopy. BMC Med Educ 2024; 24: 407

Publikationsverlauf

Artikel online veröffentlicht:
15. Mai 2025