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5 Intracorporeal suturing: A simple interrupted suture is placed using short (12‐ to 15 cm long) suture on a taper point needle through marked needle entry and exit points in a slitted Penrose drain segment. Three throws are placed, the first being a surgeon's (double) throw, by use of laparoscopic needle holders. The exercise is completed when the suture is cut (ssss1).

ssss1 Extracorporeal suture task. (A). A suture is placed in a Penrose drain segment. (B). The suture is exteriorized and a slip knot tied outside the box. (C). A knot pusher is used to cinch the knot. (D). Three intracorporeally tied suture throws are placed on top of the slip knot.

ssss1 Intracorporeal suture task.

The one major disadvantage with box training is the lack of instant feedback. Without automated feedback, an experienced surgeon needs to be available to critique the performance of the trainee, which becomes an important limitation because of the busy schedules of most surgeons. However, proficiency goals have been defined for MISTELS and VALS such that the trainee can monitor his or her progress by simple metrics such as time and errors [22, 24] With these goals in mind, the trainee can practice independently for the basic tasks of peg transfer, pattern cutting, and ligature loop placement. Laparoscopic suturing may require instructive sessions with an experienced surgeon. When suturing techniques have been learned, the trainee can continue to practice independently to reach an expert level of performance, as defined by the proficiency goals [22].