The Wii U Game That Makes You a Better Keyhole Surgeon

By Leon Hurley on at

Laparoscopy is a fancy name for keyhole surgery – that thing you see being done with little robot arms going into a person through a tiny hole. Underground, on the Wii U, might not look like it at first but actually started life as a training tool for doctors to perfect their "laparoscopic surgery motor skills".

The game itself has echoes of Lemmings as you try to manipulate and clear obstacles and build a path for the game's characters: a collection of dumbly marching robots. You achieve that using a range of tools, perched on long arms, like pincers to collect and move resources, drills to destroy things and a zapping probe to attack snail-like enemies. From a gameplay point of view that all makes perfect sense, but the idea itself actually started out, more or less, as an electronic version of this:

That's the FLS (Fundamentals of Laparoscopic Surgery) Peg Transfer Task, a crucial training tool for would-be and practising keyhole surgeons. Underground's cutesy puzzle solving evolved from an attempt to engineer a gameplaying extension of the motor skills developed from things like this. Except developer Grendel Games thought the resulting tool was fun enough to then develop in to a full retail game, making the move away from the 'serious' category of educational training software, and into entertainment territory.

The original version even used customised Wii controllers built into a laparoscopic set up. The released game might use the more traditional analogue sticks, but the 'surgical' option is still in the menus and Grendel Games are making a retail version of the training controls available (which you can see below).  No word on a price yet but I'm told the specially designed unit is currently in production and due to release at the end of January.

This is more than a gimmick, too. As Tim Laning, one of the project leads, points out: "if you can make a game that runs on consumer-grade hardware, that actually practices medical skills, it becomes possible and viable to train a lot of people, and people in those countries that don't have a lot of money".


What's perhaps most interesting is the original Wii version has been scientifically tested. The original paper, Construct and concurrent validity of a Nintendo Wii video game made for training basic laparoscopic skills, states that: "before such a video game can be implemented into a surgical training program, it has to be validated according to international standards". This was accomplished by testing the skills of experts (surgeons, urologists, and gynaecologists) and complete novices (internists). The results? "The prototype setup of the Wii Laparoscopy possesses solid construct and concurrent validity" concludes the study.

And now you can play it at home, although the Wii U version probably won't qualify you for theatre on its own. It is at least a step in the right direction if anyone's considering a sudden and frankly unlikely career change.


It's a great example of the application and evolution of a piece of educational software, and how training can be gamified. In the video below project team members Henk ten Cate Hoedemaker, Tim Laning and Jetse Goris explain the design choices in making a game that's also a valid training tool; things like mirroring the limited lighting of actual keyhole surgery through the in-game view, for example. (There's also some gameplay around the 19-minute mark.) Seeing something with such serious real world implications being broken down into an obvious game mechanic, involving wheezing alien slugs and robots, is an interesting perspective on an area of gaming you don't always see.

Underground is out on Wii U via the EU eShop on January the 8th.