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Underground: A serious game for laparoscopic surgery

by Wai Yen Tang on 01/19/15 01:19:00 pm

The following blog post, unless otherwise noted, was written by a member of Gamasutra’s community.
The thoughts and opinions expressed are those of the writer and not Gamasutra or its parent company.


A wii videogame called ‘Underground‘ was developed by Grendel Games as a serious game for laparoscopic surgery. According to a recent Nintendo Life interview, the developers were approached by Dr. Henk ten Cate Hoedemaker (University Medical Center Groningen) to create the game as existing laparoscopic simulators were not fun which discourage them from using them unless they’re told to. Drs. Maarten Jalink, Jetse Goris, Erik Heineman, Jean-Pierre E. N. Pierie, and Henk ten Cate Hoedemaker published two studies in Surgical Endoscopy regarding the effectiveness of Underground.

The game uses a custom-designed game peripheral that mimics laparoscopic equipment as shown below. The developer did mention that it can be played with the Wii U’s gamepad.

The gameplay involves the player’ interactions through two extended mechanical arms that mimics laparoscopic equipment. The game world is an underground mine involving robots. You use these arms to grab, drag or break objects, kind of like Surgeon Simulator 2013 (well more easy to use). The objectives is to create a path for allied non-player characters who must reach a destination (Nintendolife review).


The authors’ first study assessed the game’s construct validity, that is the degree to which the game measures what is supposed to be measuring. How closely does Underground test laparoscopic surgery skills? The authors travelled around the Netherlands, they asked 15 laparoscopic experts and 15 other doctors who had no laparoscopy experiences to try out the game. At the time, the authors had only a prototype of the game and its peripheral.

The participants had to drill out 10 pieces of metal scrap, pick them up and drop them into a melting pot as quickly as possible and with few mistakes as possible. Any mistakes would incur a 17 second penalty. Maximum match time is 5 minutes.

The experts finished the game on average 99 seconds (SD = 31s) where as the novices average times was 209 seconds (SD = 95s). The experts had a clear advantage because of their experience in laparoscopic surgery and how much the game taps into that experience. Nevertheless, their times should be compared to another test that has been used in the medical field for concurrent validity, that is whether the game is testing the same thing as another test should. To assess concurrent validity, the authors had the participants perform a test from the Fundamentals of Laparoscopic Surgery curriculum, the peg transfer test (see video below).

The experts finished the test on average at 87 seconds (SD = 5s) whereas the novices took 200 seconds (SD = 19s). The authors correlated the times between the game and the peg transfer and arrived at a correlation of r = 0.812, a very high correlation and is quite clear that Underground is tapping the same set of skills for laparoscopic surgery.

The authors’ second study was examining how the game could “warm up” the surgeons before surgery just like how athletes do warm up exercises before the main event. The authors recruited 29 laparoscopic experts at the University Medical Center Groningen for their study. At this time, the authors had an updated version of the game and used the peripheral as was shown earlier.

The authors wanted to see if using the game prior to surgery was a result of warming up or levelling up their skills. So they had the participants separated into two groups, one group did their gaming warm up on one day and no gaming warm up on the next day. The other group did their gaming warm up on the next day. If improvements in skills were due to learning, then the group who started the warm up on the first day would have better performance scores on the nest day. All participants were tested as soon as they started their workday or at least before they performed any actual laparoscopic surgery and played with videogames.

The participants warm up with the game for 15 minutes. Afterwards, they complete the Peg transfer test and the cobra rope drill test (see video).

The authors found that the game did indeed warm up the surgeons to be faster in the peg transfer and cobra rope drill test as compared to those who did not warm up, such as an average of 20.54 second faster on the peg transfer and scoring higher on the cobra rope drill test by 19.61% for one of the groups.

Those studies suggestively demonstrate the potential of serious gamers in the medical field. The game being useful for training and warming up. It should be noted that the authors tested the games with a few doctors, but then again there are not many doctors as there are many gamers. The issue of generalizability is at hand and further replication is needed, but I suppose it can be done relatively quickly by other doctors, since they need to buy the peripheral, the game and maybe borrow or buy a wii.

There is one lingering limitation that has yet to addressed by the authors. This limitations is whether the game was fun to play, whether the participants enjoyed themselves and would want to play it again.


Jalink, M. B., Goris, J., Heineman, E., Pierie, J. P. E. N., & ten Cate Hoedemaker, H. O. (2013). Construct and concurrent validity of a nintendo wii video game made for training basic laparoscopic skills. Surgical Endoscopy, 28 (2), 537-542. DOI: 10.1007/s00464-013-3199-6

Jalink, M. B., Heineman, E., Pierie, J. P. E. N., & ten Cate Hoedemaker, H. O. (2014). The effect of a preoperative warm-up with a custom-made nintendo video game on the performance of laparoscopic surgeons. Surgical Endoscopy, (pp. 1-7). DOI: 10.1007/s00464-014-3943-6

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