Evaluation of a progressive laparoscopic training program for clinical professional master’s degree residents in china: skill improvement and educational implications

Abstract

Background

With the ongoing reform of clinical medical education in China, the training model for Clinical Professional Master’s Degree Residents (CPMDRs) has become a crucial component of medical education. as a core technique in modern surgical practice, plays a pivotal role in standardized residency training. However, CPMDRs often face challenges in efficiently mastering laparoscopic skills within a limited training period. This study aims to evaluate the effectiveness of a progressive laparoscopic training program in enhancing the skills of CPMDRs and to explore its implications for clinical medical education in China.

Methods

A three-month progressive laparoscopic training program was designed, incorporating multiple teaching methods such as knowledge acquisition, box trainer training, virtual reality (VR) simulation, ex vivo organ training, and animal-based surgical training. A total of 25 CPMDRs participated in the program. Their laparoscopic skills were evaluated before and after the training using task completion times and standardized performance metrics. In addition, a questionnaire was administered to assess participants’ satisfaction with the program and their perceived improvement in competency.

Results

Following the training, participants demonstrated significant reductions in task completion times across all laparoscopic tasks (P < 0.001), particularly in visual targeting, precision transfer drills, and interrupted suturing. The program received high satisfaction ratings, with 80% of participants strongly agreeing that it stimulated their interest in learning. Furthermore, participants reported marked improvements in basic laparoscopic techniques, VR-based surgical skills, and animal-based procedural abilities.

Conclusion

The progressive laparoscopic training program effectively enhanced the laparoscopic skills of CPMDRs and received high approval from participants. By employing a multidimensional teaching approach, this training model is adaptable to the resource conditions of different regions in China, demonstrating broad potential for widespread adoption. This study provides scientific evidence and practical support for optimizing the laparoscopic skills training system for CPMDRs in China.

Introduction

In recent years, China’s clinical medical education system has undergone profound reforms aimed at improving the quality and efficiency of medical talent cultivation to meet the growing demands of healthcare services [1]. With the rapid development of minimally invasive surgical techniques, laparoscopic surgery has become an essential component of modern surgical practice. Laparoscopic surgery offers significant advantages, including minimal trauma, faster recovery, and shorter hospital stays, making it widely applicable in general surgery, urology, gynecology, and other fields [2]. However, laparoscopic surgery places high technical demands on operators, requiring excellent hand-eye coordination, spatial awareness, and precise operative skills [3]. As a result, laparoscopic skills training has become a core component of standardized residency training for surgeons. The Chinese standardized residency training guidelines explicitly require residents to master basic laparoscopic skills, including the use of laparoscopic instruments, fundamental surgical techniques (such as suturing, knot tying, and cutting), and the ability to perform common laparoscopic procedures (such as cholecystectomy and appendectomy) [4].

In this context, the National Health Commission and the Ministry of Education of China jointly promoted the “Four-Certificate Integration” training model for clinical professional master’s degree residents(CPMDRs). CPMDRs, as a significant outcome of China’s medical education reform, exhibit distinct characteristics in their training model. Upon completion, CPMDRs simultaneously receive a graduation certificate, a master’s degree certificate, a medical practitioner qualification certificate, and a standardized residency training certificate, reflecting the “Four-Certificate Integration” policy [5, 6]. Upon completing their studies, these residents receive a graduation certificate, a master’s degree certificate, a medical practitioner qualification certificate, and a standardized residency training certificate. Compared to traditional academic master’s degree programs, clinical professional master’s degree programs place greater emphasis on enhancing clinical practice skills, aiming to cultivate well-rounded medical professionals who are both clinically competent and capable of conducting research. This model not only aligns with international trends in medical education but also contributes to the delivery of high-quality clinical doctors to China’s healthcare system [7, 8].

Traditionally, the standardized residency training pathway requires medical students to complete a three-year training program after obtaining their bachelor’s or master’s degree. In contrast, the “Four-Certificate Integration” model integrates residency training with graduate education, shortening the overall training cycle to three years. However, despite providing systematic clinical training opportunities, this model presents unique challenges for CPMDRs in laparoscopic training. Due to the shorter training period and the dual demands of clinical practice and research tasks, efficiently mastering laparoscopic skills within a limited time frame has become a significant challenge [9, 10].

Meanwhile, laparoscopic surgery training remains challenging in China due to its high technical demands and the uneven distribution of medical training resources. Many centers lack access to advanced simulation and animal-based training equipment [11, 12]. Although ex vivo organ and animal-based training can improve realism, their adoption is hindered by high costs and ethical issues [13]. In contrast, international models like the U.S. FLS (Fundamentals of Laparoscopic Surgery) offer standardized pathways but are resource-intensive, limiting application in developing countries [14].

Hence, there is an urgent need for a cost-effective, comprehensive, and structured training model suitable for China’s CPMDRs. To address these challenges, this study designed a three-month progressive laparoscopic training program that combines multiple teaching methods, including foundational knowledge acquisition, box trainer training, virtual reality simulation, ex vivo organ training, and animal-based surgical training. This comprehensive program covers training content ranging from basic skills to complex surgical procedures.

Materials and methods

General information

This study recruited 25 resident physicians enrolled in the standardized residency training program at The University of Hong Kong–Shenzhen Hospital from August 2021 to December 2024. Participants were selected based on the following inclusion criteria: (1) current enrollment as Clinical Professional Master’s Degree Residents (CPMDRs) at The University of Hong Kong–Shenzhen Hospital; (2) absence of any hand function or visual impairments that could interfere with laparoscopic procedures; (3) no prior formal training in laparoscopic surgery; and (4) voluntary participation with signed informed consent.

Exclusion criteria included: (1) a documented history of severe motor coordination disorders or psychiatric illness; (2) withdrawal from the training program due to personal reasons or failure to complete all required modules; and (3) previous participation in specialized laparoscopic training or related research.

The cohort comprised 21 male and 4 female participants, aged 23 to 27 years, with a median age of 25 years (interquartile range: 24–26). All participants were CPMDRs from Shenzhen University. Residency year distribution was as follows: third-year residents (n = 6), second-year residents (n = 15), and first-year residents (n = 4). All participants were right-handed.

Methods

Faculty and training team

The laparoscopic training program was collaboratively developed and executed by the Clinical Skills Training Center of The University of Hong Kong-Shenzhen Hospital and the Shenzhen Skills Training Center. A multidisciplinary team of experts was responsible for designing the curriculum, establishing standardized training protocols, and defining assessment criteria. The program was structured to deliver comprehensive laparoscopic skills training over a three-month period, ensuring a systematic and progressive learning experience for participants.

Training equipment

The training curriculum incorporated a variety of advanced equipment to facilitate skill acquisition. This included laparoscopic simulation boxes for basic skill development, a complete set of laparoscopic instruments for hands-on practice, and consumable materials for repetitive exercises. Additionally, a state-of-the-art virtual reality (VR) laparoscopic training system was employed to simulate complex surgical scenarios. To bridge the gap between simulation and real-world surgery, the program incorporated ex vivo animal organs for tissue handling and suturing practice, as well as live pigs for both ex vivo and in vivo surgical training, thereby providing participants with a highly realistic surgical environment.

Course design (Fig. 1)

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Knowledge acquisition phase

During this initial phase, seasoned instructors delivered comprehensive lectures on the fundamental functions and operational principles of laparoscopic equipment. The primary objectives were to equip participants with proficiency in surgical instrument handling, deepen their understanding of abdominal anatomy, and familiarize them with standardized surgical protocols.

Box trainer training phase

In this phase, participants engaged in a series of foundational laparoscopic exercises designed to enhance hand–eye coordination, spatial awareness, and precision. The training included the following tasks:

Visual Targeting: Participants used a 30° laparoscope to identify and locate specific letters and numbers, improving spatial orientation and camera manipulation skills.

3D Spatial Ring Placement: This task involved placing ring-shaped objects onto columns positioned at varying angles to enhance three-dimensional spatial perception.

Interrupted Suturing: Participants practiced interrupted sutures and knot tying on silicone models to develop suturing proficiency and hand stability.

Circular Cutting: Using laparoscopic graspers and curved scissors, participants cut along pre-marked circular patterns on rigid paper, refining bimanual dexterity and instrument control.

Precision Transfer Drill: Participants transferred green beans from a box to designated grooves on a column, further developing hand–eye coordination and fine motor skills (Fig. 2A–E).

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Virtual reality simulation phase

Participants engaged in VR-based surgical simulations, which included exercises in electrocautery and laparoscopic procedures such as appendectomy, cholecystectomy, nephrectomy, and bladder repair. These simulations were designed to enhance procedural fluency, improve preoperative planning, and develop decision-making skills in a risk-free environment (Fig. 2F-H).

Ex vivo organ training phase

This phase involved hands-on training using ex vivo animal organs, focusing on procedures such as cholecystectomy, gastric perforation repair, and bladder rupture repair. The primary objectives were to refine participants’ tissue handling abilities, enhance suturing techniques, and foster effective team coordination in a controlled setting (Fig. 3A).

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Animal-Based surgical training phase

Under the guidance of senior instructors, participants performed routine laparoscopic procedures at the Animal Skills Training Center of The University of Hong Kong-Shenzhen Hospital. Each three-member team rotated roles as the primary surgeon, receiving continuous technical feedback throughout the process. The procedures included laparoscopic gastric perforation repair, cholecystectomy, inguinal hernia repair, splenectomy, sigmoid colon mobilization, and nephrectomy. Following the completion of all surgical tasks, humane euthanasia was performed on the experimental animals in strict compliance with ethical standards. The training concluded with a feedback session, during which instructors reviewed video recordings of the procedures, conducted technical analyses, and provided personalized guidance for skill enhancement (Fig. 3B-H).

All participating residents signed informed consent forms. Written informed consent was obtained from all participants depicted in Fig. 3 for publication of their images. All live animal experiments in this study were conducted in accordance with ethical guidelines and were approved by the Medical Ethics Committee of The University of Hong Kong-Shenzhen Hospital (Ethics Approval No.: 2021-14(A)). The study strictly adhered to relevant ethical regulations and the principles of the Declaration of Helsinki.

Outcome measures

Objective evaluation

To objectively evaluate the training outcomes, participants’ performance was assessed by measuring the time taken to complete specific laparoscopic tasks both before and after the training. The tasks included Visual Targeting, Precision Transfer Drill, 3D Spatial Ring Placement, Circular Cutting, and Interrupted Suture. The completion times (in seconds) for each task were recorded and analyzed to quantify skill improvement. All assessments were conducted by two independent senior laparoscopic instructors. Task performance was video-recorded and independently timed using standardized digital stopwatches. Discrepancies were resolved by consensus. Only completion time was used as the primary outcome metric.

Course satisfaction and competency improvement assessment

Upon completion of the training, participants were asked to complete a structured questionnaire designed to evaluate their satisfaction with the course and their perceived improvement in competency. The questionnaire comprised two modules: Module 1 (Course Satisfaction): This module assessed participants’ perceptions of the training program, including the clarity of the training plan, appropriateness of the difficulty level, time allocation, progression strategy, ability to stimulate interest, and overall satisfaction with the course (6 items, 5-point Likert scale). Module 2 (Competency Improvement): This module evaluated participants’ self-reported improvements in key areas, including basic laparoscopic skills, VR-based surgical skills, live animal surgical skills, the effectiveness of intraoperative guidance, clinical performance in the operating room, and adaptability to the clinical environment (6 items, 5-point Likert scale) [15]. The questionnaire was developed by a multidisciplinary team including surgical educators and medical education researchers, and was adapted from validated instruments in prior studies (e.g [15]).,. A pilot version was tested with five residents for clarity and reliability prior to full-scale implementation.

Statistical analysis

All statistical analyses were conducted using SPSS 26.0 software. Continuous variables following a normal distribution were presented as mean ± standard deviation (x ± s). Paired-sample t-tests were employed to compare pre- and post-training performance data. A p-value of less than 0.05 (p < 0.05) was considered statistically significant.

Results

Improvement in laparoscopic skills

Following the training, participants exhibited significant improvements in laparoscopic skills across all evaluated tasks (Table 1). The time required to complete tasks such as visual targeting, precision transfer drill, 3D spatial ring placement, circular cutting, and interrupted suture was significantly reduced, with statistically significant differences observed (P < 0.001).

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Course satisfaction and competency improvement evaluation

Course satisfaction evaluation

Based on the questionnaire results, the majority of the 25 residents rated the progressive laparoscopic training program favorably, with most selecting “Agree” or “Strongly Agree” across multiple aspects of the course. The highest proportion of “Strongly Agree” responses was attributed to the course’s ability to stimulate learning interest. However, a small number of residents expressed “Neurtal” regarding the clarity of the training plan and whether the course met or exceeded expectations. Additionally, the appropriateness of the course’s difficulty level and its progressive structure received predominantly positive feedback (Table 2).

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Competency improvement evaluation

The questionnaire results indicated that residents perceived significant enhancements in their clinical skills following participation in the progressive laparoscopic training program. A majority of respondents selected “Good” or “Significant” across multiple competency improvement domains. Notably, improvements in basic laparoscopic skills and clinical environment adaptability were particularly well-received. However, some residents reported a “Moderate” response regarding their perceived improvement in clinical operative performance (Table 3).

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Discussion

This study demonstrated significant improvements in participants’ laparoscopic skills, as evidenced by reduced task completion times across all evaluated tasks. For instance, the average time for visual targeting decreased from 268.16 s pre-training to 168.44 s post-training (P < 0.001), while precision transfer drill times decreased from 194.52 s to 124.76 s (P < 0.001). These results indicate that the progressive training model effectively enhances laparoscopic skills, particularly in basic and advanced surgical tasks.

Participants also reported high satisfaction with the program, with 80% strongly agreeing that the course stimulated their learning interest and 64% stating it exceeded their expectations. However, some participants expressed concerns about the clarity of the training plan and course objectives, highlighting areas for improvement. These findings are consistent with international studies—such as those conducted in the United States—showing that combining VR simulation with animal-based training significantly improves residents’ surgical skills and confidence [16, 17].

The proposed training model offers multiple advantages and innovations. First, its progressive design—from basic box trainer exercises to complex animal-based procedures—aligns with the natural learning curve of surgical skill acquisition. Second, the multidimensional framework integrates box training, VR simulation, ex vivo organ practice, and animal-based training to comprehensively cover foundational to advanced skills. While box trainers develop basic techniques and VR familiarizes trainees with workflows and emergency scenarios, ex vivo and animal-based components bridge simulation with real-world clinical practice. This approach aligns with international findings demonstrating that VR and animal training enhance both surgical competency and team collaboration [18, 19].

Moreover, ex vivo and animal-based sessions helped trainees cultivate teamwork and emergency decision-making skills through collaborative procedures. Senior instructors provided real-time technical feedback, enabling error correction and improving precision. Postoperative video reviews facilitated deeper technical reflection and skill refinement [20].

Beyond technical proficiency, the training program also contributed to the enhancement of non-technical skills, particularly team coordination and communication. During animal-based surgical sessions, participants were required to work in surgical teams under time constraints, simulating real-world intraoperative collaboration. These settings encouraged the development of situational awareness, task delegation, and mutual support among trainees. This is consistent with previous studies showing that such immersive simulations foster both technical and non-technical competencies simultaneously [18, 19]. Although the current study did not include direct measurements of teamwork outcomes, qualitative feedback and observed interactions during sessions indicated noticeable improvements in communication, role clarity, and decision-making under pressure. Future research should incorporate structured assessment tools (e.g., NOTSS—Non-Technical Skills for Surgeons) to quantitatively evaluate these non-technical dimensions.

The training model holds significant potential for widespread adoption in the education of CPMDRs in China. First, given the uneven distribution of medical resources across different regions, the model’s flexibility in adjusting the weight of training components (e.g., increasing the proportion of box trainer exercises) ensures its applicability in resource-limited areas. To maintain the program’s core multi-modular structure—comprising knowledge delivery, box training, VR simulation, and tissue handling/teamwork—while optimizing resource efficiency under constraints, we implemented several adaptive strategies. High-cost modules, such as live animal surgery, are optimized by grouping trainees from different specialties to perform representative procedures in rotation, maximizing trainee exposure per animal. Simultaneously, lower-cost alternatives, including ex vivo organ practice and high-fidelity simulated models, are expanded to supplement hands-on training. Core modules like box training and VR must be retained, although the frequency of animal use may be reduced. These adaptations preserve the program’s progressive design and translational value while maintaining essential clinical skill components. Second, the model efficiently enhances both basic laparoscopic skills and clinical translation capabilities within a short timeframe, aligning with the training objectives and requirements of CPMDRs [21, 22]. By integrating clinical practice with research tasks, CPMDRs not only acquire laparoscopic skills but also gain a deeper understanding of surgical principles and innovations from a research perspective, fostering the development of well-rounded medical professionals.

Despite its promising results, this study has several limitations. The small sample size and relatively short training period may restrict the generalizability of the findings, and the absence of long-term follow-up data prevents the assessment of the training’s sustained impact [23]. Moreover, the study only evaluated overall skill improvements before and after the entire program, without conducting phase-specific assessments to determine the relative contribution of each training module to overall competency gains. To address these limitations, future research should expand the sample size, extend the training duration, and perform multicenter studies to further validate the model’s effectiveness. In addition, long-term follow-up studies are recommended to evaluate trainees’ performance in real clinical settings, providing a comprehensive understanding of the training’s lasting benefits.

Conclusion

This study confirms that a progressive laparoscopic training model effectively improves CPMDRs’ laparoscopic skills. Integrating knowledge acquisition, box trainer use, VR simulation, ex vivo organ training, and animal-based procedures, the model supports rapid mastery of techniques across all skill levels. Results show significantly reduced task completion times and high participant satisfaction, aligning with international findings and validating this multidimensional approach.

Furthermore, its adaptability to diverse regional resources—especially via increased box trainer emphasis in low-resource settings—demonstrates broad applicability. The model meets CPMDRs’ specific training needs, enhances clinical translation skills, and offers practical guidance for optimizing laparoscopic education in China.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

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