title: Does Warm-Up Training in a Virtual Reality Simulator Improve Surgical Performance? A Prospective Randomized Analysis.
abstract: BACKGROUND
  Virtual reality surgical simulators (VRSS) have been showing themselves as a valuable tool in laparoscopy training and education. Taking in consideration the effectiveness of the VRSS, new uses for this tool have been purposed. In sports, warming up before exercise clearly shows benefit in performance. It is hypothesized that warming up in the VRSS before going to the operating room may show benefit in surgical performance.
  
  
  OBJECTIVE
  Verify whether there is benefit in surgical performance with preoperatory warm-up using a VRSS.
  
  
  METHODS
  A total of 20 medical students with basic knowledge in laparoscopy were divided in 2 groups (I and II). Group I performed a laparoscopic cholecystectomy in a porcine model. Group II performed preoperative warm-up in a VRSS and then performed a laparoscopic cholecystectomy in a porcine model. The performance between both groups was compared regarding quantitative parameters (time for dissection of the gallbladder pedicle, time for clipping the pedicle, time for cutting the pedicle, time for gallbladder removal, total operative time, and aspirated blood loss) and qualitative parameters (depth perception, bimanual dexterity, efficiency, tissue handling, and autonomy) based on a previously validated score system, in which the higher the score, the better the result. Data were analyzed with level of significance of 5%.
  
  
  RESULTS
  The group that underwent preoperative warm-up (group II) showed significantly superior results as to the time for dissection of the gallbladder pedicle (11.91 ± 9.85 vs. 4.52 ± 2.89min, p = 0.012), time for clipping the pedicle (5.51 ± 2.36 vs. 2.89 ± 2.76min, p = 0.004), time for cutting the pedicle (1.84 ± 0.7 vs. 1.13 ± 0.51, p = 0.019), aspirated blood loss (171 ± 112 vs. 57 ± 27.8ml, p = 0.006), depth perception (4.5 ± 0.7 vs. 3.3 ± 0.67, p = 0.004), bianual dexterity (4.2 ± 0.78 vs. 3.3 ± 0.67, p = 0.004), tissue handling (4.2 ± 0.91 vs. 3.6 ± 0.66, p = 0.012), and autonomy (4.9 ± 0.31 vs. 3.6 ± 0.96, p = 0.028). There was no difference in time for gallbladder removal (11.58 ± 4.31 vs. 15.08 ± 4.51min, p = 0.096), total operative time (30.8 ± 11.07 vs. 25.60 ± 5.10min, p = 0.188), and efficiency (4 ± 0.66 vs. 3.6 ± 0.69, p = 0.320).
  
  
  CONCLUSIONS
  The practice of preoperative warm-up training seems to benefit surgical performance even in subject with mild laparoscopic experience.
authors.affiliation: Urology Department, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil; Center for Robotic Surgery, German Hospital Oswaldo Cruz, São Paulo, Brazil. Electronic address: arnaldoshiomi@yahoo.com.br.
authors.forename: José Arnaldo Shiomi
authors.initials: JAS
authors.lastname: da Cruz
authors.affiliation: Urology Department, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil.
authors.forename: Sabrina Thalita
authors.initials: ST
authors.lastname: Dos Reis
authors.affiliation: Urology Department, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil.
authors.forename: Rodrigo Marcus
authors.initials: RM
authors.lastname: Cunha Frati
authors.affiliation: Urology Department, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil.
authors.forename: Ricardo Jordão
authors.initials: RJ
authors.lastname: Duarte
authors.affiliation: Urology Department, Cardon Children Medical Center, Mesa, Arizona.
authors.forename: Hiep
authors.initials: H
authors.lastname: Nguyen
authors.affiliation: Urology Department, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil.
authors.forename: Miguel
authors.initials: M
authors.lastname: Srougi
authors.affiliation: Urology Department, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil; Center for Robotic Surgery, German Hospital Oswaldo Cruz, São Paulo, Brazil.
authors.forename: Carlo Camargo
authors.initials: CC
authors.lastname: Passerotti
mesh_terms: D000328:Adult; D000818:Animals; D016063:Blood Loss, Surgical; D017081:Cholecystectomy, Laparoscopic / Q000193:education / Q000379:methods; D004504:Education, Medical, Undergraduate / Q000379:methods*; D015444:Exercise / Q000502:physiology*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000193:education*; D008297:Male; D061646:Operative Time; D057234:Preoperative Period; D011446:Prospective Studies; D058996:Quality Improvement; D012016:Reference Values; D000066908:Simulation Training / Q000379:methods*; D013337:Students, Medical / Q000706:statistics & numerical data; D013552:Swine; D014584:User-Computer Interface
keywords: Practice-Based Learning and Improvement; Systems-Based Practice; laparoscopy; simulation training, warm-up exercise, work performance