I would like to thank Khalifa et al. We too believe that simulation technology is here to stay and that it can only improve with its further development and more research in software validation, highlighting its strengths and weaknesses. To this aim, our group has completed one such validation trial which we hope to share with the published community shortly.
Regarding the cost of these systems, we agree that these are currently restrictive (although we have already witnessed a substantial drop in price). We think that, for this reason, simulation based training works better on a regional training basis rather than individual hospitals investing heavily for a limited number of trainees. However, the increased demand caused by higher trainee to machine ratios will raise issues regarding how much minimum training will be required and for how long. Studies plotting learning curves required to reach standards set by validation trials are thus beckoning. These will produce more targeted training rather than simply ‘the-more-the-better’ practising.
Although we are not there yet, once these initial obstacles are overcome there are multiple advantages to look forward to. Running costs are minimal; reduced complication rates due to out-of-theatre training would provide financial benefits and the more obvious reduction in morbidity; inbuilt validated scores would obviate the need for assessment by independent assessors thus minimising time constraints on more senior surgeons. Finally, we would be addressing the main issue highlighted regarding the growing number of factors that are limiting opportunities for resident surgical education.