by Shamyl Bin Mansoor, Osman Hasan and Dr Asif Zafar

Minimally invasive surgery (MIS) has revolutionized surgical care and treatment by reducing trauma to the patient, decreasing the need for pain medication, shortening recovery times and hospital stays, and improving cosmetic results. Laparoscopic surgery is accomplished by gaining access to the abdominal cavity, visualizing the cavity using a laparoscope, and performing diagnostic and therapeutic procedures.  The term “laparoscopy” comes from the Greek words “laparo” (the flank) and “skopein” (to examine). As surgeons became skilled in laparoscopic cholecystectomy, they began to use laparoscopy to perform other advanced abdominal operations.

Surgical techniques have rapidly evolved in the past few decades because of the advent of electronics and computers in the area of medicine. Traditionally, surgical procedures were primarily based on creating wide incisions into the human body.  Over the years, this kind of conventional open surgery has evolved to laparoscopic or Minimally Invasive Surgery (MIS), where operations in the abdomen area are performed using very small incisions (typically 0.5–1.5 cm), as illustrated in Figure 1.

Figure 1: Traditional vs. Minimally invasive Surgery

MIS or laparoscopic surgery involves less pain, as the chances of damaging tissues are almost negligible when compared to the traditional open surgery methodologies. Tissue damage is the major cause for post-operative complications and thus MIS facilitates quick patient recovery and avoids long hospital stays. Moreover, the chances of post-surgery infections are also minimized due to the use of smaller incisions.  These factors lead to a reduction in the usage of pain medication and hospital stays for the patients, which in-turn lowers the health care costs significantly.

Laparoscopic surgery relies heavily upon various electronic and mechanical tools to assist the surgeons in performing all surgical procedures within the constraints of the smaller incisions. The recent advancements in the area of robotics have also been utilized and, nowadays, robots are utilized to aid surgeons in MIS. Controlling a set of robotic arms, surgeons can operate on patients while sitting in front of their computer consoles, receiving high definition video feedback. This way, not only is the accuracy of surgical procedures significantly improved but the fatigue factor for surgeons may also be reduced.

Due to the above-mentioned benefits of robotics-based laparoscopic surgery, more and more countries are adopting these techniques. The biggest challenge towards this trend being that surgeons are still accustomed to the traditional ways and need to go through extensive training procedures before using laparoscopic and robotic surgery techniques. Acquiring such expertise is not very straightforward because

  • It is unethical to learn and practice skills in the operation theater (OT),
  • It is impossible to master laparoscopic surgical skills, like hand eye coordination and depth perception, while practicing on an animal or any other object.

Computer-based simulators have been proposed as a solution to this problem and nowadays are being widely used for training purposes in the west. These simulators allow surgeons to practice their skills in a virtual environment over and over again until a certain level of expertise is acquired after which they can start practicing in OTs with the help of experts. The problem with such simulators is their enormous cost, e.g., state-of-the-art simulators for laparoscopic surgery, like LapSim and ProMIS, cost thousands of dollars, which makes their wide-spread usage in developing countries, like Pakistan, very difficult. Commercial Minimal Invasive Surgical simulators like LapSim costs start from $50,000. A commercial surgical like daVinci costs $1.5 to 2 million, whereas a training system for robotic surgery starts from around $100,000. In fact, to the best of our knowledge, Dr Asif Zafar’s Telemedicine and eHealth Training Center at the Holy Family Hospital, Rawalpindi, is the only center in Pakistan that has acquired such simulators and thus maintains the sole training lab for MIS.

School of Electrical Engineering & Computer Science (SEECS) at the National University of Sciences and Technology (NUST) in collaboration with Holy Family Hospital, Rawalpindi is trying to solve this problem by developing a cost-effective training system for laparoscopic and robotic surgery in Pakistan. The proposed system, illustrated in Fig. 2, includes a simulator for MIS and a set of robotic arms controlled over a network for practicing robotic surgery from several remote machines at distant locations.

Figure 2: Proposed MIS Training System

The proposed system can be divided into three main modules. A simulator for laparoscopic training, a set of input controls to manipulate the laparoscopic instruments within the simulator and a set of robotic arms that will be controlled using these input controls. The surgeon will be able to physically manipulate objects using the robotic arms. The same exercises would be performed in a virtual environment in a simulator and then performed in reality using the robotic arms. This will allow the user to not only practice for laparoscopic surgery but also for robotic surgery. The key behind the cost-effectiveness of our new proposed system of training is the usage of open-source tools and libraries for software development and the availability talented human resources in Pakistan.

The system will have a minimal invasive surgery simulator, a robotic surgery simulator as well as emulator (a set of robotic arms working over a mannequin) and input controls with haptic feedback. For the simulator, real life complications and videos of laparoscopic surgery collected by Holy Family Hospital, will be simulated in the simulator. Therefore the training system will have basic as well as advanced training.

For the robotic arms, commercial systems like daVinci have custom robotic arms with custom laparoscopic instruments. We will be designing our robotic arms around conventional laparoscopic instruments (which are mass produced in Sialkot) that will lead to a very cost effective system. Our design will significantly reduce the costs and would be totally new and built from scratch.

This project is being funded by Ministry of Information Technology’s National ICT R&D fund and is expected to be completed by June 2013. Once developed, all major hospitals of Pakistan would be able to acquire these training facilities at a very affordable price, which would certainly improve the health care facilities in Pakistan.

Historically, Sialkot has been a center for developing and exporting surgical instruments all over the world. As surgery has moved towards MIS and robotics assisted techniques, Pakistan’s surgical instrument industry has not been able to keep pace with the global competition. Its sales for 2008-2009 were $250 Million. Through this project, know how for design, development and manufacturing of state-of-the-art surgical tools will be transferred to the Sialkot industry through the joint efforts of Holy Family Hospital Rawalpindi and NUST Islamabad. These commercialization opportunities will in turn lead to a large number of highly skilled knowledge workers in Sialkot, Pakistan.

A good overview of laparoscopic surgery can be seen in this video.

About the authors

Dr Asif Zafar is one of the pioneers of Ehealth, Tele-medicine and MinimaI Invasive Surgical methods in Pakistan. He is the joint Project Director for this project and has numerous funded projects completed in various fields under his belt. His work for the 2005 Earthquake relief in Pakistan was recognized the world over including ITU, who signed an MOU with his team to share their expertise in case of similar earthquakes around the world. Dr Asif is currently the Professor of Surgery (Rawalpindi Medical College), director of Telemedicine and eHealth Training Center and Head of Surgical Unit II at Holy Family Hospital, Rawalpindi.

Osman Hasan has a PhD in Electrical Engineering from Concordia University Canada. He is the project director for this initiative. He is currently serving as an Assistant Professor in School of Electrical Engineering & Computer Science, NUST and leads the research group SAVE.

Shamyl Bin Mansoor has an Electrical Engineering & Computer Science degree from Seoul National University, South Korea. He is a recipient 2 year MS scholarship by HEC and a 1 year research grant from Korea Research Foundation. Currently he is a lecturer at School of Electrical Engineering & Computer Science, NUST, and leads the research group SMART lab.

For those interested in pursuing this further can contact Dr. Arshad Ali ( or Dr Asif Zafar (

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4 Responses to “Cost Effective Training System for Laparoscopic and Robotic Surgery”

  1. Izaz Haque on July 6th, 2010 6:17 pm

    Finally, someone is connecting the dots. Sialkot needs support. It’s held it’s own thru decades of negligence. Lets hope this plays out the way its envisioned.

    regards, Izaz Haque

  2. alan churchill on July 17th, 2012 6:24 pm

    I would like to learn more about your operation, for our hospitals here in Jacksonville Florida. Can you please send me information on virtual reality simulators.

    Thank You
    Alan Churchill

    Shamyl Reply:

    Thank you for your comment Alan. Some information can be found on our website, I can send you more information on your email address if you kindly share it with me.


  3. Steven Olson on August 1st, 2012 8:20 pm

    Its fantastic as your other blog posts : D, thankyou for putting up. “A gift in season is a double favor to the needy.” by Publilius Syrus.