title: Virtual reality training for surgical trainees in laparoscopic surgery.
abstract: BACKGROUND
  Standard surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time-consuming, costly, and of variable effectiveness. Training using a virtual reality simulator is an option to supplement standard training. Virtual reality training improves the technical skills of surgical trainees such as decreased time for suturing and improved accuracy. The clinical impact of virtual reality training is not known.
  
  
  OBJECTIVE
  To assess the benefits (increased surgical proficiency and improved patient outcomes) and harms (potentially worse patient outcomes) of supplementary virtual reality training of surgical trainees with limited laparoscopic experience.
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE and Science Citation Index Expanded until July 2012.
  
  
  METHODS
  We included all randomised clinical trials comparing virtual reality training versus other forms of training including box-trainer training, no training, or standard laparoscopic training in surgical trainees with little laparoscopic experience. We also planned to include trials comparing different methods of virtual reality training. We included only trials that assessed the outcomes in people undergoing laparoscopic surgery.
  
  
  METHODS
  Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5 analysis. For each outcome we calculated the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals based on intention-to-treat analysis.
  
  
  RESULTS
  We included eight trials covering 109 surgical trainees with limited laparoscopic experience. Of the eight trials, six compared virtual reality versus no supplementary training. One trial compared virtual reality training versus box-trainer training and versus no supplementary training, and one trial compared virtual reality training versus box-trainer training. There were no trials that compared different forms of virtual reality training. All the trials were at high risk of bias. Operating time and operative performance were the only outcomes reported in the trials. The remaining outcomes such as mortality, morbidity, quality of life (the primary outcomes of this review) and hospital stay (a secondary outcome) were not reported. Virtual reality training versus no supplementary training: The operating time was significantly shorter in the virtual reality group than in the no supplementary training group (3 trials; 49 participants; MD -11.76 minutes; 95% CI -15.23 to -8.30). Two trials that could not be included in the meta-analysis also showed a reduction in operating time (statistically significant in one trial). The numerical values for operating time were not reported in these two trials. The operative performance was significantly better in the virtual reality group than the no supplementary training group using the fixed-effect model (2 trials; 33 participants; SMD 1.65; 95% CI 0.72 to 2.58). The results became non-significant when the random-effects model was used (2 trials; 33 participants; SMD 2.14; 95% CI -1.29 to 5.57). One trial could not be included in the meta-analysis as it did not report the numerical values. The authors stated that the operative performance of virtual reality group was significantly better than the control group. Virtual reality training versus box-trainer training: The only trial that reported operating time did not report the numerical values. In this trial, the operating time in the virtual reality group was significantly shorter than in the box-trainer group. Of the two trials that reported operative performance, only one trial reported the numerical values. The operative performance was significantly better in the virtual reality group than in the box-trainer group (1 trial; 19 participants; SMD 1.46; 95% CI 0.42 to 2.50). In the other trial that did not report the numerical values, the authors stated that the operative performance in the virtual reality group was significantly better than the box-trainer group.
  
  
  CONCLUSIONS
  Virtual reality training appears to decrease the operating time and improve the operative performance of surgical trainees with limited laparoscopic experience when compared with no training or with box-trainer training. However, the impact of this decreased operating time and improvement in operative performance on patients and healthcare funders in terms of improved outcomes or decreased costs is not known. Further well-designed trials at low risk of bias and random errors are necessary. Such trials should assess the impact of virtual reality training on clinical outcomes.
authors: UCL Division of Surgery and Interventional Science, Department of Surgery, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
authors: Myura
authors: M
authors: Nagendran
authors: Kurinchi Selvan
authors: KS
authors: Gurusamy
authors: Rajesh
authors: R
authors: Aggarwal
authors: Marilena
authors: M
authors: Loizidou
authors: Brian R
authors: BR
authors: Davidson
mesh_terms: D003198:Computer Simulation; D003194:Computer-Assisted Instruction / Q000379:methods*; D013502:General Surgery / Q000193:education*; D006801:Humans; D010535:Laparoscopy / Q000193:education*; D061646:Operative Time; D016032:Randomized Controlled Trials as Topic
references: J Minim Invasive Gynecol. 2006 Mar-Apr;13(2):114-20
references: 16527713
references: Am J Surg. 2001 Dec;182(6):725-8
references: 11839347
references: Ann Surg. 2005 Feb;241(2):262-8
references: 15650636
references: Am J Surg. 1999 Jan;177(1):28-32
references: 10037304
references: Anat Clin. 1985;7(2):93-102
references: 4041278
references: Ann Intern Med. 2001 Dec 4;135(11):982-9
references: 11730399
references: Lancet. 1998 Aug 22;352(9128):609-13
references: 9746022
references: BMC Med Res Methodol. 2009 Dec 30;9:86
references: 20042080
references: Surg Endosc. 2005 Dec;19(12):1523-32
references: 16252077
references: Ann Surg. 2007 Aug;246(2):201-6
references: 17667497
references: Am J Surg. 2010 Jan;199(1):72-80
references: 20103069
references: Control Clin Trials. 1986 Sep;7(3):177-88
references: 3802833
references: Stud Health Technol Inform. 2007;125:76-81
references: 17377238
references: Surg Endosc. 2004 Mar;18(3):485-94
references: 14752633
references: Stat Med. 2002 Jun 15;21(11):1539-58
references: 12111919
references: World J Surg. 2007 Apr;31(4):764-72
references: 17361356
references: Ann Surg. 2006 Mar;243(3):291-300
references: 16495690
references: Ann Surg. 2012 Jul;256(1):25-32
references: 22664557
references: J Clin Epidemiol. 2008 Jan;61(1):64-75
references: 18083463
references: J Bone Joint Surg Br. 2008 Apr;90(4):494-9
references: 18378926
references: J Am Coll Surg. 2010 Jun;210(6):984-9
references: 20510808
references: Stat Med. 1987 Apr-May;6(3):341-50
references: 3616287
references: Surgery. 2010 May;147(5):640-5
references: 20403516
references: Urology. 2005 Nov;66(5 Suppl):105-7
references: 16194715
references: Ann Surg. 2004 Aug;240(2):374-81
references: 15273564
references: Med J Armed Forces India. 2009 Apr;65(2):113-7
references: 27408214
references: J Am Coll Surg. 2008 Oct;207(4):560-8
references: 18926460
references: J Endourol. 2012 May;26(5):545-50
references: 22192095
references: Ann Surg. 2011 May;253(5):886-9
references: 21394017
references: Stat Med. 2001 Feb 28;20(4):641-54
references: 11223905
references: Endoscopy. 1999 May;31(4):310-3
references: 10376458
references: Cochrane Database Syst Rev. 2009 Jan 21;(1):CD006575
references: 19160288
references: Ann R Coll Surg Engl. 2005 Sep;87(5):373-8
references: 16176700
references: Endoscopy. 2003 Jul;35(7):569-75
references: 12822091
references: Ann Surg. 2005 Jun;241(6):879-82; discussion 882-4
references: 15912037
references: IEEE Trans Inf Technol Biomed. 2006 Jan;10(1):51-8
references: 16445249
references: Acad Med. 2010 Oct;85(10 Suppl):S5-8
references: 20881704
references: Int J Technol Assess Health Care. 2003 Fall;19(4):591-603
references: 15095765
references: J Surg Res. 2006 May 15;132(2):159-63
references: 16412471
references: Ann Intern Med. 2012 Sep 18;157(6):429-38
references: 22945832
references: BJU Int. 2011 Nov;108(10):1652-6; discussion 1657
references: 21470359
references: JAMA. 1995 Feb 1;273(5):408-12
references: 7823387
references: Am J Surg. 2010 Jan;199(1):115-20
references: 20103076
references: Ann Surg. 2012 May;255(5):833-9
references: 22504187
references: Urology. 2007 Nov;70(5):873-7
references: 18068442
references: Cochrane Database Syst Rev. 2006 Oct 18;(4):CD006231
references: 17054285
references: Surg Radiol Anat. 1999;21(5):325-7
references: 10635096
references: BMJ. 1997 Sep 13;315(7109):629-34
references: 9310563
references: Arch Surg. 2004 Apr;139(4):366-9; discussion 369-70
references: 15078701
references: Surg Endosc. 2002 Mar;16(3):406-11
references: 11928017
references: Surg Endosc. 2009 Jul;23(7):1476-82
references: 19263128
references: Am J Surg. 2005 Jun;189(6):758-61
references: 15910733
references: Surg Endosc. 2004 Feb;18(2):328-33
references: 14691708
references: Int J Epidemiol. 1992 Oct;21(5):837-41
references: 1468842
references: Ann Surg. 2010 Jun;251(6):1181-5
references: 20485133
references: Am J Surg. 2011 Sep;202(3):265-72
references: 21658672
references: Clin Epidemiol. 2010 Aug 09;2:57-66
references: 20865104
references: Health Technol Assess. 2012 Sep;16(35):1-82
references: 22989478
references: Iowa Orthop J. 2001;21:31-5
references: 11813948
references: Int J Epidemiol. 2009 Feb;38(1):276-86
references: 18824467
references: Am J Surg. 2005 Jan;189(1):53-5
references: 15701492
references: Br J Surg. 2009 Apr;96(4):342-9
references: 19283747
references: BMJ. 2008 Mar 15;336(7644):601-5
references: 18316340
references: Surg Endosc. 2002 Sep;16(9):1324-8
references: 11988802
references: Ann Surg. 2011 Sep;254(3):502-9; discussion 509-11
references: 21865947
references: Br J Surg. 2004 Feb;91(2):146-50
references: 14760660
references: BMJ. 2009 May 14;338:b1802
references: 19443914
references: J Clin Epidemiol. 2008 Aug;61(8):763-9
references: 18411040
references: Cochrane Database Syst Rev. 2012 Dec 12;12:MR000033
references: 23235689
references: J Am Coll Surg. 2000 Sep;191(3):272-83
references: 10989902
references: BMJ. 2004 Feb 21;328(7437):418-9
references: 14976074
references: Br J Surg. 2008 Sep;95(9):1088-97
references: 18690637
references: Int J Epidemiol. 2009 Feb;38(1):287-98
references: 18824466
references: JSLS. 2011 Oct-Dec;15(4):533-8
references: 22643511
references: Ann Surg. 2005 Jul;242(1):83-91
references: 15973105
references: Am J Surg. 2007 Jun;193(6):797-804
references: 17512301
references: Qual Saf Health Care. 2004 Oct;13 Suppl 1:i2-10
references: 15465951
references: J Urol. 2002 Nov;168(5):1928-32
references: 12394678
references: Ann Surg. 2002 Oct;236(4):458-63; discussion 463-4
references: 12368674
references: Am J Obstet Gynecol. 2007 Nov;197(5):541.e1-5
references: 17980202