# Stress responses and experiences of surgical trainees in simulation-based training of advanced laparoscopic procedures in highly realistic environments

## TL;DR

This study examines how surgical trainees respond to stress during advanced laparoscopic training in different simulation environments.

## Contribution

The study compares stress responses in box-trainer and realistic operating room simulations using both physiological and qualitative data.

## Key findings

- No significant physiological differences were found between box-trainer and operating room simulations.
- Trainees reported higher perceived stress in realistic operating room environments.
- Stress was linked to realism, task alignment, and interpersonal dynamics in immersive settings.

## Abstract

Simulation-based training facilitates learning of advanced laparoscopic surgical procedures. Such procedures are challenging to master due to their technical complexity, which can elicit stress responses in surgical trainees. Previous research has demonstrated the impact of stress on trainees’ learning processes in skills lab. However, there is limited data comparing trainees’ stress responses during advanced procedural training using box-trainers in skills lab, to those experienced during operating training in realistic simulation environments. This study aims to explore the physiological responses, self-reported stress responses, and experiences of stress of surgical trainees during advanced laparoscopic procedural training in two different simulation environments. Insights into stress mechanisms may suggest improvements for the design of future training courses.

This observational study explored participants’ stress experiences through semi-structured interviews and investigated their stress responses by measuring the heart rate variability, saliva cortisol levels, and trainees’ self-reported stress using a validated instrument. Participants performed advanced laparoscopic procedures on box-trainers and live animal models in operating room settings.

Twelve experienced surgical trainees were included in the study. No differences were observed for physiological parameters between training activity on the box-trainer simulator and live animal models. In interviews, trainees reported experiencing higher stress levels during procedural training in operating room environment. The main themes related to elevated stress were realism and functional task alignment, perceived level of risk, and interpersonal dynamics in simulation environments. The trainees perceived the increased stress response levels as beneficial for their focus and for performing advanced procedures.

In this study, no significant differences were identified in trainees’ physiological or self-reported stress responses across the two simulation settings. However, qualitative interview data revealed that trainees perceived greater stress when training with animal models in highly realistic operating room environments, suggesting the potential educational value of such immersive simulation environments.

The online version contains supplementary material available at 10.1186/s41077-025-00400-z.