title: The effect of warm-up on surgical performance: a systematic review.
abstract: BACKGROUND
  The concept of warming-up before a performance has been accepted across many disciplines including sports and music. In contrast, it is uncommon for a surgeon to "warm-up" prior to operating.
  
  
  OBJECTIVE
  To date, few studies from various specialties have attempted to answer this question whether warm-up improved the intraoperative performance of the surgeon. However, there has not been a systematic review of these studies. The aim of our systematic review is to assess the effect of warming-up preoperatively on the laparoscopic performance of the surgeon.
  
  
  METHODS
  Pubmed and scopus were searched to identify all published prospective observational studies, which involved either residents, fellows or attending surgeons. We excluded case reports, reviews, non-English studies, and medical student participation. Study risk of bias were assessed regarding sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other biases, using a validated Cochrane Collaboration's tool.
  
  
  RESULTS
  Out of 241 studies, 6 met the inclusion criteria. All included studies were randomized with half of them being randomized controlled studies and the rest randomized crossover studies. The total number of operative cases was 196, including 98 warm-up and 98 non warm-up. The total number of participants was 87, with the largest number in a single study being 38 and the average sample size of all studies was 14. All six studies assessed various aspects of laparoscopic surgical performances. Significant improvement in the intraoperative laparoscopic performance was observed with warming-up preoperatively in five out of six studies (p < 0.05). The sixth study failed to reach statistical significance (p > 0.05).
  
  
  CONCLUSIONS
  Warming-up before an operative procedure improve a trainee's technical, cognitive, and psychomotor performance. Further studies are necessary to assess the ways in which warm-up could impact a surgeon's performance, and to identify the optimal timing and duration of warm-up prior to operating.
authors.affiliation: Department of Surgery, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Suite 399A, 4940 Eastern Avenue, Baltimore, MD, 21224, USA, gabdalla1421@gmail.com.
authors.forename: Gamal
authors.initials: G
authors.lastname: Abdalla
authors.forename: Erin
authors.initials: E
authors.lastname: Moran-Atkin
authors.forename: Grace
authors.initials: G
authors.lastname: Chen
authors.forename: Michael A
authors.initials: MA
authors.lastname: Schweitzer
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Magnuson
authors.forename: Kimberley E
authors.initials: KE
authors.lastname: Steele
mesh_terms: D004502:Education, Medical, Continuing / Q000379:methods*; D015444:Exercise / Q000502:physiology*; D013502:General Surgery / Q000193:education*; D006801:Humans; D007396:Internship and Residency; D057234:Preoperative Period; D012649:Self Concept; D066231:Surgeons / Q000592:standards*; D011795:Surveys and Questionnaires