Intervention Review

You have free access to this content

Virtual reality training for surgical trainees in laparoscopic surgery

  1. Myura Nagendran1,
  2. Kurinchi Selvan Gurusamy2,*,
  3. Rajesh Aggarwal3,
  4. Marilena Loizidou4,
  5. Brian R Davidson2

Editorial Group: Cochrane Hepato-Biliary Group

Published Online: 27 AUG 2013

Assessed as up-to-date: 21 JUL 2012

DOI: 10.1002/14651858.CD006575.pub3


How to Cite

Nagendran M, Gurusamy KS, Aggarwal R, Loizidou M, Davidson BR. Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD006575. DOI: 10.1002/14651858.CD006575.pub3.

Author Information

  1. 1

    Department of Surgery, UCL Division of Surgery and Interventional Science, London, UK

  2. 2

    Royal Free Campus, UCL Medical School, Department of Surgery, London, UK

  3. 3

    Imperial College London, Department of Biosurgery and Surgical Technology, London, UK

  4. 4

    Royal Free Campus, UCL Medical School, Surgery and Interventional Science, London, UK

*Kurinchi Selvan Gurusamy, Department of Surgery, Royal Free Campus, UCL Medical School, Royal Free Hospital,, Rowland Hill Street, London, NW3 2PF, UK. kurinchi2k@hotmail.com.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 27 AUG 2013

SEARCH

 
Characteristics of included studies [ordered by study ID]
Ahlberg 2007

MethodsRandomised clinical trial.


ParticipantsCountry: Sweden.
Number randomised: 13.
Postrandomisation drop-outs: not stated.
Revised sample size: 13.
Average age: 32 years.
Women: 7 (53.8%).

Inclusion criteria:
1. Surgical residents from postgraduate year 1 or 2.
2. Experience in assisting with laparoscopic procedures.

Exclusion criteria:
1. Previous experience of performing laparoscopic cholecystectomy.


InterventionsParticipants were randomly assigned to two groups.
Group 1: virtual reality training (n = 7).
Group 2: no supplementary training (n = 6).

Details of virtual reality training:

1. LapSim virtual reality simulator (version 2.0).
2. Basic skills (camera navigation, co-ordination, clip application, lifting and grasping, cutting, and suturing) and dissection programmes (different anatomic variations of the hepatoduodenal ligament) with no haptic feedback.
3. The participants practised under supervision and received feedback given by the simulator as well as oral feedback given by the supervisor after each completed task until they showed proficiency on each of the 6 examination tasks at least twice.


OutcomesThe outcome reported was operating time.


NotesAssessment: The participants performed 10 laparoscopic cholecystectomies each after the period of training and the outcomes of 10th surgery were considered except for 2 where the outcomes of the 5th surgery were considered. The operating time was 58% longer in the control group than the virtual reality group (P = 0.0586).

We attempted to contact authors in October 2012. No replies were received.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: This information was not available.

Allocation concealment (selection bias)Unclear riskQuote: "...sealed-envelope method…."

Comment: Further details were not available.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: It is impossible to blind the participants to the groups.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskQuote: "...Video assessments were performed by 2 observers...blinded concerning the subjects’ training status…"

Comment: Although the video recording of the procedures was assessed by blinded observers, there is no information on whether any of the outcomes of interest for this review were assessed by observers blinded to the group of the participants.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: This information was not available.

Selective reporting (reporting bias)High riskComment: Some important outcomes which will generally be assessed were not reported.

Source of funding biasUnclear riskComment: This information was not available.

Grantcharov 2004

MethodsRandomised clinical trial.


ParticipantsCountry: Denmark.
Number randomised: 20.
Postrandomisation drop-outs: 4 (20%).
Revised sample size: 16.
Average age: 37 years.
Women: 6 (37.5%).

Inclusion criteria:
1. Surgeons with limited experience in laparoscopic surgery (< 8 cholecystectomies).


InterventionsParticipants were randomly assigned to two groups.
Group 1: virtual reality training (n = 8).
Group 2: no supplementary training (n = 8).

Details of virtual reality training:

1. MIST-virtual reality (Minimally Invasive Surgical Trainer – Virtual Reality).
2. Ten repetitions of all six tasks of progressive complexity and designed to simulate the techniques used during laparoscopic cholecystectomy.


OutcomesThe outcome reported was operating time.


NotesAssessment: The participants performed a laparoscopic cholecystectomy each after the period of training. Only part of the procedure was assessed, starting from the point at which clips were applied to the cystic artery and cystic duct, and finishing with dissection of the gallbladder from the liver bed.

Two surgical trainees from each group were not included for analysis because there was a fault in the video-recording which was used for assessment.

We attempted to contact authors in October 2012. No replies were received.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: This information was not available.

Allocation concealment (selection bias)Unclear riskQuote: "using sealed envelopes"

Comment: Further details were not available.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: It is impossible to blind the participants to the groups.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskQuote: "The reviewers were blinded to the training status of the trainees"

Comment: Although the video recording of the procedures was assessed by blinded observers, there is no information on whether operating time was measured by observers blinded to the group of the participants.

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: There were postrandomisation drop-outs.

Selective reporting (reporting bias)High riskComment: Some important outcomes which will generally be assessed were not reported.

Source of funding biasUnclear riskQuote: "This work was supported by Sygekassernes Helsefond, Copenhagen, Denmark."

Comment: Unable to confirm whether funding source linked to private sector or charitable funds.

Hamilton 2002

MethodsRandomised clinical trial.


ParticipantsCountry: United States of America.
Number randomised: 19.
Postrandomisation drop-outs: 0 (0%).
Revised sample size: 19.
Average age: not stated.
Women: not stated.

Inclusion criteria:
1. Second-year general surgical residents (the study authors had included first-year and second-year surgical residents but the evaluation of laparoscopic cholecystectomies was performed in only the second-year surgical residents).


InterventionsParticipants were randomly assigned to two groups.
Group 1: virtual reality training (n = 10).
Group 2: box-trainer training (n = 9).

Details of virtual reality training:

1. Minimally Invasive surgical Trainer - virtual reality trainer.
2. All 6 tasks (grasping, grasping and transfer, hand co-ordination, replacing the laparoscopic instrument, diathermy - one hand, two hands) - 2 repetitions with each hand (except 3rd task which involved both hands).
3. Ten 30-minute sessions in 2 weeks.

Details of box-trainer training:

1. Video trainer.
2. Five tasks (suture foam, bean drop, triangle transfer, rope drill, checkerboard).
3. Ten 30-minute sessions in 2 weeks.


OutcomesThe outcome reported was operating time.


NotesAssessment: The participants performed a laparoscopic cholecystectomy each after the period of training.

We attempted to contact authors in October 2012. Authors replied in October 2012.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "Randomization was performed using a random digit assignment method"

Comment: Further details were not available.

Allocation concealment (selection bias)Low riskQuote: "Randomization was performed using a random digit assignment method"

Communication from author: "placed in sealed envelopes which were opened and said which group randomized to".

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: It is impossible to blind the participants to the groups.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Faculty evaluators were blinded to the resident's given training modality."

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: There were no postrandomisation drop-outs.

Selective reporting (reporting bias)High riskComment: Some important outcomes which will generally be assessed were not reported.

Source of funding biasHigh riskQuote: "Funding was provided by the Southwestern Center for Minimally Invasive Surgery as supported in part by an educational grant from United States Surgical Corporation, a division of Tyco Healthcare Group."

Comment: The trial was funded by a party with a vested interest in the results.

Hogle 2009

MethodsRandomised clinical trial.


ParticipantsCountry: United States of America.
Number randomised: 13.
Postrandomisation drop-outs: 1 (7.7%).
Revised sample size: 12.
Average age: not stated
Women: not stated

Inclusion criteria:
1. Surgical residents in their first year of surgical experience.


InterventionsParticipants were randomly assigned to two groups.
Group 1: virtual reality training (n = 6).
Group 2: no supplementary training (n = 6).

Details of virtual reality training:

1. LapSim virtual reality trainer (camera navigation, instrument navigation, co-ordination, grasping, lifting and grasping, cutting, and clip applying).
2. The training curriculum was fully completed when level 3 was passed for each module.


OutcomesThe outcome reported was operative performance.


NotesAssessment: Global Operative Assessment of Laparoscopic Skills (GOALS) during laparoscopic cholecystectomy.

We attempted to contact authors in October 2012. Authors replied in October 2012.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskCommunication from author: "Random sequence was generated using a random number generator found in the back of a statistics text book. Odd numbers were decided a priori to be assigned to the no-training group. Even numbers were assigned to training group."

Allocation concealment (selection bias)Low riskCommunication from author: "Randomization envelopes were produced. The outside of each envelope was labelled with the name of the study, the name of the Principal Investigator and the envelope Number. A card on the inside of each envelope stated “Training Group” or “No Training Group”. Envelopes were assigned sequentially. Study participants were asked not to discuss their study group designation with anyone else including other study participants, surgeons, residents, fellows or technical/study support staff. Only the subject and the study coordinator knew the randomization assignment."

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: It is impossible to blind the participants to the groups.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The supervising attending surgeon evaluated their performance using GOALS. The video tapes then were used for subsequent blinded evaluation and scoring with GOALS"

Communication from author: "Only the subject and the study coordinator knew the randomization assignment."

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: There were postrandomisation drop-outs.

Selective reporting (reporting bias)High riskComment: Some important outcomes which will generally be assessed were not reported.

Source of funding biasLow riskCommunication from author: "All three studies were non-funded. Internal resources were used and no monetary compensation was given to investigators or participants."

Larsen 2009

MethodsRandomised clinical trial.


ParticipantsCountry: Denmark.
Number randomised: 24.
Postrandomisation drop-outs: 3 (12.5%).
Revised sample size: 21.
Average age: 33 years.
Women: 22 (91.7%).

Inclusion criteria:
1. Trainees in gynaecological specialty training years 1 and 2 with no experience of advanced laparoscopy (defined as all laparoscopic procedures involving co-ordination of more than 1 instrument). 


InterventionsParticipants were randomly assigned to two groups.
Group 1: virtual reality training (n = 11).
Group 2: no supplementary training (n = 10).

Details of virtual reality training:

1. LapSim Gyn 3.0.1.
2. Training in the 2 basic skills of “lifting and grasping” and “cutting”  and one procedure-specific task in which the trainee had to carry out a complete right-sided salpingectomy while preserving the ovary.
3. The training in basic skills was done once in each training cycle of 45 - 60 minutes and the salpingectomy repeated continually during the remainder of the cycle.
4. The simulator provided the trainees with instant feedback on time, path length and angular path of the instruments’ movements, bleeding, cutting of uncoagulated arteries, and use of diathermy on non-target tissue.
5. The training sessions were repeated until the expert criterion level was reached in 2 consecutive and independent simulations.


OutcomesThe outcomes reported were operating time and operative performance.


NotesAssessment: Surgical performance during elective laparoscopic salphingenctomy. 


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "The Clinical Trial Unit at Copenhagen University independently randomised the trainees by computer to intervention or control groups."

Allocation concealment (selection bias)Low riskQuote: "The randomisation procedure was concealed and achieved by using the trainees’ unique personal identification number".

Blinding of participants and personnel (performance bias)
All outcomes
High riskQuote: "it was not possible to blind the trainees to their allocated group, but all involved departments, supervisors, and staff in the operating theatres were blinded to the trainee’s group".

Comment: It is impossible to blind the participants to the groups.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "All involved departments, supervisors, and staff in the operating theatres were blinded to the trainee’s group, and the assessors of outcome were blinded to both the trainee and their allocated group."

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: There were postrandomisation drop-outs.

Selective reporting (reporting bias)Low riskComment: All important outcomes were reported.

Source of funding biasLow riskQuote: "This project was supported by Copenhagen University Rigshospitalet Hospital. Trygfondet supplied various materials including computer hardware. Det Calssenske Fidecommis’ Jubilaeumsfond provided travel expenses. Aase and Ejner Danielsens foundation provided software maintenance and updates, DVD recorders, and a TV monitor. The Danish Society for the Protection of Laboratory Animals provided computer hardware and software. All phases of the present work including design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, and approval of the final manuscript were done independent of the funders."

Comment: Funded by various organisations which do not appear to have a vested interest in the results of the trial

McClusky 2004

MethodsRandomised clinical trial.


ParticipantsCountry: United States of America.
Number randomised: 12.
Postrandomisation drop-outs: not stated.
Revised sample size: 12.
Average age: not stated.
Women: not stated.

Inclusion criteria:
1. Surgical residents (postgraduate years 1 and 2). 


InterventionsParticipants were randomly assigned to two groups.
Group 1: virtual reality training (n = 6).
Group 2: no supplementary training (n = 6).

Details of virtual reality training:

1. Minimally Invasive Surgical Trainer - Virtual Reality trainer (MIST-VR).
2. Expert established performance criterion levels on the manipulation diathermy task of the MIST-VR.


OutcomesThe outcome reported was operating time.


NotesAssessment: The participants performed a laparoscopic cholecystectomy each after the period of training. 

We attempted to contact authors in October 2012. No replies were received.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: This information was not available.

Allocation concealment (selection bias)Unclear riskComment: This information was not available.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: It is impossible to blind the participants to the groups.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskQuote: "Recordings were assessed by two blinded surgeon investigators"

Comment: Although the video recording of the procedures was assessed by blinded observers, there is no information on whether any of the outcomes of interest for this review were assessed by observers blinded to the group of the participants.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: This information was not available.

Selective reporting (reporting bias)High riskComment: Some important outcomes which will generally be assessed were not reported.

Source of funding biasUnclear riskComment: This information was not available.

Sendag 2009

MethodsRandomised clinical trial.


ParticipantsCountry: Turkey.
Number randomised: 24.
Postrandomisation drop-outs: not stated.
Revised sample size: 24.
Average age: not stated.
Women: not stated.

Inclusion criteria:
1. Novice residents with no prior experience of laparoscopy.


InterventionsParticipants were randomly assigned to three groups.
Group 1: virtual reality training (n = not stated).
Group 2: box-trainer training (n = not stated).

Group 3: no supplementary training (n = not stated).

Details of virtual reality training:

1. LapSim.
2. Training for 3 weeks (60 minutes each week).


OutcomesThe outcomes reported were operating time and operative performance.


NotesAssessment: The participants performed a laparoscopic bilateral tubal ligation each after the period of training.
The global rating scores were statistically significantly higher and the operating time was statistically lower in the virtual reality group than control group. The operating time was statistically significantly lower in the virtual reality group than the box-trainer training group. It is not clear from the report whether the global rating score was significantly different between virtual reality group and box-trainer training group.

We attempted to contact authors in October 2012. No replies were received.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: This information was not available.

Allocation concealment (selection bias)Unclear riskComment: This information was not available.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: It is impossible to blind the participants to the groups

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: This information was not available.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: This information was not available.

Selective reporting (reporting bias)High riskComment: Some important outcomes which will generally be assessed were not reported.

Source of funding biasUnclear riskComment: This information was not available.

Seymour 2002

MethodsRandomised clinical trial.


ParticipantsCountry: United States of America.
Number randomised: 16.
Postrandomisation drop-outs: not stated.
Revised sample size: 16.
Average age: not stated.
Women: 5 (31.3%).

Inclusion criteria:
1. Surgical residents in postgraduate years 1 to 4. 


InterventionsParticipants were randomly assigned to two groups.
Group 1: virtual reality training (n = 8).
Group 2: no supplementary training (n = 8).

Details of virtual reality training:

1. Minimally Invasive Surgical Trainer - Virtual Reality (MIST-VR).
2. Expert established performance criterion levels on the manipulation diathermy task of theMIST-VR.
3. Training sessions lasted approximately 1 hour.
4. The criteria levels were achieved in 3 - 8 training sessions.


OutcomesNone of the outcomes of interest for this review were reported in this trial.


NotesAssessment: The participants performed a laparoscopic cholecystectomy each after the period of training. 

We attempted to contact authors in October 2012. No replies were received.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: This information was not available.

Allocation concealment (selection bias)Unclear riskComment: This information was not available.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: It is impossible to blind the participants to the groups

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskQuote: "Each procedural video was viewed without audio by two surgeon-investigators blinded to operating team members."

Comment: Although the video recording of the procedures was assessed by blinded observers, there is no information on whether any of the outcomes of interest for this review were assessed by observers blinded to the group of the participants.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: This information was not available.

Selective reporting (reporting bias)High riskComment: Some important outcomes which will generally be assessed were not reported.

Source of funding biasUnclear riskComment: This information was not available.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Banks 2007Not virtual reality training.

Bensalah 2007No assessment of operative procedure performed by the 2 groups.

Beyer 2011Not a randomised clinical trial.

Catalyud 2010Some of the participants had experience of performing more than 100 laparoscopic cholecystectomies and hence cannot be considered as surgical trainees as far as this procedure is concerned.

Cosman 2007The trainees were asked to perform only a minor part of the procedure.

Gala 2009Not virtual reality training.

Gauger 2010Training included virtual reality training and box-trainer training.

Gobern 2010Not virtual reality training.

Grantcharov 2007Not a randomised clinical trial.

Hamilton 2001Not virtual reality training.

Howells 2008Not virtual reality training.

Lee 2012Training involved a combination of virtual reality trainer and box trainer.

Mohan 2009Unclear whether this is virtual reality training or box-trainer training.

Moldovanu 2011Not assessing the effect of virtual reality training in surgical trainees.

Orejuela 2010Not virtual reality training.

Orzech 2012The participants performed only a very small part of the procedure in humans.

Palter 2011Not virtual reality training.

Palter 2012Training includes virtual reality training and cadaveric training.

Parent 2010Not virtual reality training.

Sroka 2010Not virtual reality training.

Van Sickle 2008Training includes virtual reality training and box-trainer training.

Zendejas 2011Not virtual reality training.

Zorn 2011Comment about a trial which did not meet the inclusion criteria.

 
Characteristics of studies awaiting assessment [ordered by study ID]
Neary 2008

MethodsRandomised clinical trial.

ParticipantsYears 3 - 5 postgraduation registrars, specialist registrars or residents in surgery.

InterventionsProficiency-based virtual reality simulation training versus standard training.

OutcomesLaparoscopic colectomy operation duration and number of errors.

NotesAuthors contacted, awaiting response.

 
Characteristics of ongoing studies [ordered by study ID]
Aggarwal 2010

Trial name or titleAn evaluation of the cost effectiveness of virtual reality surgical simulation to shorten the learning curve for real laparoscopic procedures.

MethodsRandomised clinical trial.

Participants1. Specialist general surgery trainee doctors, i.e. ST1 through to ST5.
2. Have performed fewer than 50 laparoscopic cases (ie appendicectomy and cholecystectomy) as primary operator.

InterventionsThe LapMentor™ virtual reality surgical simulator shall be used for training the intervention group in laparoscopic technical skills, under the guise of an evidence-based training curriculum.

The training arm will undergo a training curriculum. This will be in 3 phases, ie:
1. Knowledge - a structured knowledge-based online training and assessment tool (including text, diagrams and video).
2. Technical Skills - a step-wise, structured and proficiency-based virtual reality training curriculum (incorporating technical skills, procedural tasks and full procedures).
3. Attitudes - a 1-day session in the simulated Operating Room to perform 2 complete laparoscopic cases with a full operative team. This will be scheduled in the simulated operating room.

The control arm will not undergo any of the above.

The duration of treatment for the training arm will be approximately 2 weeks. The duration of follow-up for each subject (ie, both arms of the trial) will be approximately 2 months.

OutcomesPrimary outcomes:

1. Procedure time taken (for intra-abdominal part of procedure), measured during the operative intervention.
2. Quality of operative procedure by Global Rating Scale, measured within 1 week of the operative intervention

Secondary outcomes:

1. Knowledge (multiple-choice test), measured within2 weeks of recruitment to the study for the control group, and within 2 weeks of completion of the training curriculum for the intervention group.
2. Attitudes (surgical team measurements, ie NOTTS and OTAS), measured during operative intervention.
3. Clinical - death, deep vein thrombosis or pulmonary embolism, re-intervention (percutaneous, endoscopic or surgical), blood transfusion, unplanned ITU/HDU admission, failure to be discharged within 30 days, bile duct injury within 30 days of intervention.

Starting dateFebruary 2011.

Contact informationDr Rajesh Aggarwal

Department of Surgery and Cancer
10th Floor, QEQM Building
St Mary's Hospital Campus
Imperial College London
Praed Street

UK.

Notes

Farley 2012

Trial name or titlePart- vs whole-task mastery simulation training for laparoscopic hernia repair: A randomised trial.

MethodsRandomised clinical trial.

ParticipantsOnly residents who have achieved mastery of the TEP training curriculum (in either arm) will be eligible for Operating Room assessment

InterventionsGroup 1: Online video curriculum.
Group 2: Whole task mastery training.
Group 3: Part task mastery training.

OutcomesOperation duration.

Starting dateJune 2012.

Contact informationDavid R. Farley, Co-Director of the Mayo Simulation Center, Professor of Surgery, Mayo Clinic.

NotesMay not be virtual reality training.

Gala 2011

Trial name or titleAn evaluation of validated laparoscopic skills simulators and the impact on operating room performance.

MethodsRandomised clinical trial.

ParticipantsOb/Gyn residents in postgraduate years 1 to 4 from ACGME accredited programmes.

InterventionsGroup 1: Laparoscopic simulation training (5 x 30-minute faculty-directed sessions at the laparoscopic simulator lab).

Group 2: Traditional surgical training.

OutcomesOperative performance.

Starting dateAugust 2005.

Contact informationRajiv B Gala, University of Texas Southwestern Medical Center.

NotesThis may be the same trial as Gala 2009, a trial excluded because the simulator was not a virtual reality training simulator.

 
Comparison 1. Virtual reality training versus no training

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Operating time349Mean Difference (IV, Fixed, 95% CI)-11.76 [-15.23, -8.30]

 2 Operating time (sensitivity analysis)237Mean Difference (IV, Fixed, 95% CI)-11.82 [-15.31, -8.33]

 3 Operative performance233Std. Mean Difference (IV, Fixed, 95% CI)1.65 [0.72, 2.58]

 4 Operative performance (sensitivity analysis)1Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

 
Comparison 2. Virtual reality training versus box-trainer training

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Operative performance1Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

 
Summary of findings for the main comparison.

Virtual reality training for surgical trainees in laparoscopic surgery

Patient or population: surgical trainees training in laparoscopic surgery.

Settings: secondary care.

Intervention: virtual reality training.

Comparison: either no supplementary training or box-trainer training.

OutcomesControlVirtual reality trainingNo of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Virtual reality training versus no supplementary training

Operating timeThe median operating time in the control group was 39 minutes.The mean operating time in the intervention group was 11.76 minutes lower (8.30 to 15.23 lower).49

(3)
⊕⊝⊝⊝
very low1,2
Two other trials also showed reduction in operating time in the virtual reality training group (statistically significant in one trial and not statistically significant in the second trial). The magnitude of the effect was not reported.

Operative performanceThe mean performance score in the intervention group was 1.65 standard deviations higher (0.72 to 2.58 higher).33

(2)
⊕⊝⊝⊝
very low1,2,3
One other trial also showed statistically significant improvement in operating performance. The magnitude of the effect was not reported.

Virtual reality training versus box trainer training

Operative performanceThe mean performance score in the intervention group was 1.46 standard deviations higher (0.42 to 2.5 higher).19
(1)
⊕⊝⊝⊝
very low1,2
One other trial also showed statistically significant improvement in operating performance. The magnitude of the effect was not reported.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1The trial(s) was (were) of low risk of bias.
2There were too few trials to assess publication bias.
3There was significant heterogeneity.