Acceptance and use of extended reality in surgical training: an umbrella review

Abstract

Background

Extended reality (XR) technologies which include virtual, augmented, and mixed reality have significant potential in surgical training, because they can help to eliminate the limitations of traditional methods. This umbrella review aimed to investigate factors that influence the acceptance and use of XR in surgical training using the unified theory of acceptance and use of technology (UTAUT) model.

Methods

An umbrella review was conducted in 2024 by searching various databases until the end of 2023. Studies were selected based on the predefined eligibility criteria and analyzed using the components of the UTAUT model. The quality and risk of bias of the selected studies were assessed, and the findings were reported descriptively.

Results

A total of 44 articles were included in this study. In most studies, XR technologies were used for surgical training of orthopedics, neurology, and laparoscopy. Based on the UTAUT model, the findings indicated that XR technologies improved surgical skills and procedural accuracy while simultaneously reducing risks and operating room time (performance expectancy). In terms of effort expectancy, user-friendly systems were accessible for the trainees with various levels of expertise. From a social influence standpoint, XR technologies enhanced learning by providing positive feedback from experienced surgeons during surgical training. In addition, facilitating conditions emphasized the importance of resource availability and addressing technical and financial limitations to maximize the effectiveness of XR technologies in surgical training.

Conclusions

XR technologies significantly improve surgical training by increasing skills and procedural accuracy. Although adoption is facilitated by designing user-friendly interfaces and positive social influences, financial and resource challenges must be overcome, too. The successful integration of XR into surgical training necessitates careful curriculum design and resource allocation. Future research should focus on overcoming these barriers, so that XR can fully realize its potential in surgical training.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-024-02723-w.

Introduction

Surgical training requires lifelong learning of cognitive and practical skills, such as comprehensive pattern identification and proficiency with distraction-minimization strategies during surgical operations [1]. In fact, both surgical skills and patient safety depend critically on these abilities [1]. Traditional surgical training techniques have many limitations and are practiced on cadavers or animal models. Beyond the risks of spreading infectious diseases, these approaches are expensive, ethically dubious, and not widely available [1, 2]. Similarly, while artificial models serve as valuable introductory tools, they may not be particularly effective at simulating realistic physiological responses [3]. Moreover, trainees experience more difficulties when using traditional surgical training methods due to inaccessibility of professional surgeons and the intrinsic challenges with surgical procedures [1]. Therefore, it seems that simulation environments are effective ways to overcome these challenges [3]. In fact, simulation systems provide a dynamic learning environment which offers a new opportunity to engage trainees with virtual patients [4]. With these technologies, users are immersed in virtual environments that either mimic or deviate from actual surgical scenarios [5]. However, it is very difficult to convert complex three-dimensional (3D) data, like manipulating medical equipment and anatomy, onto a two-dimensional (2D) display [4, 5].

Extended reality (XR) consists of virtual reality (VR), augmented reality (AR), and mixed reality (MR) technologies and provides a novel solution to the limitations of traditional surgical training [6, 7]. VR tools immerse users in fully digital environments, often simulating real-world settings, allowing them to interact with a virtual environment in a controlled space without real-world risks [8]. AR overlays digital content onto the real-world environment, enabling users to interact with virtual elements while maintaining a clear view of their physical surroundings [9]. MR blends both VR and AR, where digital and physical elements coexist and interact in real time, allowing users to manipulate virtual objects as if they were part of the real world [10].

The XR technologies enhance visualization and provide real-time error identification, fostering a deeper understanding of 3D anatomy, complex procedures, and surgical techniques [11]. Moreover, XR systems can be tailored to meet the unique needs of individual trainees, simulating specific anatomical scenarios for customized learning experiences [6, 11]. By allowing remote training and information sharing, XR immediately not only improves education but also signals a paradigm shift in surgical training [11, 12]. In addition, XR facilitates knowledge transfer between learners and instructors at different times and locations, which is particularly beneficial in areas with limited access to relevant expertise [13]. Despite the great potentials of XR, the adoption rate of this technology in surgical training has been limited. A major gap in the literature is related to the lack of an extensive understanding of the factors that may influence the widespread adoption and use of XR in surgical training [14].

Recently, several reviews have been published on the use of various XR technologies in different areas of surgical training [6, 12–14]. Although their overall results highlight the role of XR in surgical training, there are still factors influencing the widespread acceptance and use of this technology. The Unified Theory of Acceptance and Use of Technology (UTAUT) model is a widely accepted framework for understanding the key factors that influence the adoption of technologies. This model has four domains including performance expectancy, effort expectancy, social influence, and facilitating conditions which offer valuable insights into the drivers and barriers faced by users [15]. It seems that using this model along with synthesizing and analyzing findings from multiple systematic reviews and/or meta-analyses can help to highlight the impact of various factors on the acceptance and use of XR technologies in surgical training and can provide insights for future research. Therefore, this study aimed to conduct an umbrella review to investigate factors influencing the acceptance and use of XR in surgical training. The results of this study can be used in improving future research for the development, implementation, and effective use of XR-related technologies in surgical training.

Methods

Study design

This umbrella review adheres to the guidelines outlined in the Preferred Reporting Items for Overviews of Reviews (PRIOR) [16]. The National Ethics Committee of Biomedical Research (IR.IUMS.REC.1402.1208) reviewed and approved this study.

Information sources and search strategy

A comprehensive literature search was conducted across multiple databases including the Cochrane Database of Systematic Reviews, PubMed, Scopus, Web of Science, IEEE Xplore, Ovid, ProQuest, and Google Scholar. The search was limited to publications in English, focusing on the systematic reviews and meta-analyses up to December 31, 2023. The search strategy included key concepts and their synonyms like “systematic review,” “extended reality,” “training,” and “surgery,” combined with AND/OR logical operators (Supplementary Table S1). Additionally, manual search of citations and reference lists of the included studies were performed.

Eligibility criteria

The inclusion and exclusion criteria are presented in Table 1.

Table 1.

Inclusion and exclusion criteria

Study criteria	Inclusion criteria	Exclusion criteria
Study design	Systematic review or/and meta-analysis	Primary studies, conference abstracts, letters to editors, commentaries, or other types of literature review
Population	Medical students, medical residents, surgical trainees, general surgeons, or specialized surgeons	Any healthcare provider who was not a main participant in surgical training
Interventions	XR-related technologies (i.e., VR, AR, or MR)	Systematic review articles that did not focus on XR-related technologies as the main intervention
Comparators	No training, study baseline, or traditional training methods (e.g., conventional monitor, CT scan, self-study, wet lab, telemedicine, or training from the surgeon), or other simulation types (e.g., cadavers, box training)	Systematic review articles without comparators
Outcome	Factors influencing acceptance and use of XR-related technologies in surgical training	Studies that did not provide enough information about factors influencing acceptance and use of XR-related technologies in surgical training
Additional criteria	English language and full-text available studies	Non-English or unavailable full-text studies

Selection process

Following comprehensive database search and removing duplicates using EndNote 8, two authors (El. T. and Es. T.) independently reviewed the titles and abstracts of the retrieved studies to assess their relevance. Disagreements that arose during this stage were limited and primarily related to whether certain studies aligned with the inclusion criteria, such as surgical training and using XR technologies. In addition, a third author (H. A. or M. F.) was consulted to make the final decision, if it was necessary. After identifying the relevant studies, the full texts were independently reviewed by both authors (Es. T. and El. T.) to confirm their eligibility for inclusion based on the predefined criteria. Disagreements during this phase usually stemmed from questions about the scope of the interventions. These disagreements were resolved through discussions or, if necessary, by consulting the third author (H. A.).

Data collection process, data items, and synthesis method

Data extraction was conducted systematically by one of the authors (El. T.) using a predefined data extraction form, and the accuracy and completeness of the results were verified by second author (Es. T.). Extracted information included author name, publication year, country, research objective, a summary of the interventions, main results, participants, comparators, outcomes, searched databases, study design, qualitative assessment results, and risk-of-bias assessment.

In this study, conducting a meta-analysis was not possible. Significant heterogeneity was observed across the included studies. The variation occurred in outcome measures also differed substantially, with some studies focusing on technical skill acquisition, task completion times, and error rates, while others emphasized cognitive outcomes or knowledge retention. Different types of participants added to this heterogeneity, as a range of surgical trainees, from medical students to experienced surgeons participated in the studies, and each of them might require different surgical skill. This heterogeneity precluded a quantitative meta-analysis, prompting us to use a qualitative framework synthesis. We used the UTAUT [15] as a guiding framework to categorize and analyze factors influencing the acceptance and use of XR technologies in surgical training. The UTAUT framework comprises performance expectancy, effort expectancy, social influence, and facilitating conditions, providing a structured and theory-driven approach to analyzing the data.

Both authors (Es. T. and El. T.) independently coded the findings using qualitative software, MAXQDA (version 18.2.5), and any discrepancies in the coding were resolved through discussion. A third author (H. A.) was consulted for further resolution when necessary.

Critical appraisal assessments of the included reviews

Two authors (Es. T. and El. T.) independently assessed the methodological quality and risk of bias of each systematic review and meta-analysis using the Assessment of Multiple Systematic Reviews, version 2 (AMSTAR 2) and the Risk of Bias in Systematic Reviews (ROBIS) tool.

AMSTAR 2 was used to assess specific methodological domains within the included systematic reviews, such as protocol registration, study design, and data analysis methods [17]. AMSTAR 2 has not been designed to provide an overall score for the quality of systematic reviews; rather, it focuses on critical methodological aspects, helping to categorize studies into quality tiers (i.e., “high,” “moderate,” “low,” or “critically low”), based on their adherence to best practices in systematic review methodology. This distinction is crucial to avoid confusion, as AMSTAR 2 does not offer a single composite score of overall quality but assesses distinct domains that inform the rigor of each study’s methods.

ROBIS tool was used to ensure a comprehensive evaluation of bias across various stages of the review process [18]. This tool examines biases in study selection, data collection, and synthesis, providing a more holistic view of risk that complements AMSTAR 2 domain-specific approach. ROBIS involves three phases: (1) relevance of the review to the research question, (2) assessment of biases across four domains (study eligibility criteria, identification and selection of studies, data collection and appraisal, and synthesis and findings), and (3) an overall risk-of-bias judgment (high, low, or unclear). Together, these tools offer a comprehensive evaluation, ensuring that both methodological quality and bias were critically appraised.

To address overlapping primary studies included in multiple reviews, a citation matrix, as suggested by Pieper et al. [19], was created to represent primary study overlap across systematic reviews. The degree of overlap was narratively described, and we calculated the “corrected covered area” (CCA) to quantify the extent of overlap.

Results

Systematic review study selection

After considering inclusion and exclusion criteria, 44 articles [20–63] were included in this study. Figure 1 shows the screening process for the included articles. In addition, Table 2 and Supplementary Table S2 provide a summary of articles which were included in the study.

Fig. 1.

Article selection process based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [64]

Table 2.

The main characteristics of the included studies

No.	Author(s), year*, country	Objective	Summary of innervations	Main results
1	McCloskey et al. (2023, USA) [20]	Review of the current applications of AR and VR technologies within surgical education, preoperative planning, and intraoperative guidance	VR simulator · Oculus Rift (used in lateral lumbar spinal access training) AR simulator · Microsoft HoloLens (applied in multiple procedures like rod bending and screw placement)	· VR-based surgical planning improved neurosurgical surgery outcomes by reducing complications, radiation usage, and operation time · Using AR in spinal fusion for rod bending yielded comparable results with less time than the control group
2	Suresh et al. (2023, UK) [21]	Provide an update on AR in surgical training and determine whether it improves surgical trainee performance when compared to traditional methods	AR simulators · Microsoft HoloLens (used to assist in drill positioning, burr-hole localization, and preoperative planning) · ProMIS simulator (used to assist in basic laparoscopy skills) · Google Glass (used in urology and basic gynecology surgical skills training) · STAR (projects operative instructions into the surgeon’s field of view for tasks like fasciotomy and cricothyroidotomy)	· AR-enhanced orthopedic training by speeding up learning, with most participants preferring it as part of a combined educational strategy · AR improved procedural times, knowledge, and trainee confidence in ureteroscopy and gynecological surgery · AR simulators overlaying a mentor’s instruments on a trainee’s monitor improved skill acquisition, reduced errors, and shortened learning curves · Compared to the box trainer, AR surgical training has lower realism, 3D perception, and immersive performance
3	Hey et al. (2023, USA) [22]	Provide a concise overview of the latest uses of AR systems in cranial and spinal neurosurgery for intraoperative assistance, as well as their recent applications in neurosurgical training	AR simulators · Microsoft HoloLens: Used for tumor border tracing, surgical planning, and rod manipulation in both cranial and spinal surgeries · AR on mobile devices/displays: Projects preoperative and real-time surgical data onto tablets or mobile devices to guide surgeries, enhancing visual acuity and target recognition · AR projection in surgical microscopes: Injects preoperative imaging data into surgical microscopes, allowing real-time navigation and improving precision in cranial and spinal procedures	· AR is primarily used in cranial neurosurgery to improve technical skills and assist in surgical planning. Additionally, AR can aid in locating brain structures, guiding surgical resections, and improving surgical trajectory accuracy · Surgeons using head-mounted AR systems demonstrated the potential for assisting in presurgical planning and surgical trajectory training, highlighting the ease of use and potential benefits of AR technology · Studies involving multiple surgeons with varying degrees of experience highlight the potential of AR, specifically HoloLens AR, for improving neurosurgical training and clinical practice · Positive feedback from experienced surgeons can influence the acceptance and adoption of AR technology among peers and trainees, emphasizing its utility and efficacy in enhancing surgical skills and procedures
4	Dubron et al. (2023, Belgium) [23]	Review of the current state of XR technology and provide additional insights for its advancement in clinical practice and education	VR simulator · Touch surgery (used as a VR tool for orbital floor surgeries in a controlled, immersive simulation environment) AR simulator · HuaxiAR1.0 software system (used to assist with unilateral orbitozygomatic maxillary complex surgery training)	· AR provides valuable data to the surgeon without requiring significant changes or adaptations of the surgical technique, giving immediate feedback · The ergonomic friendliness of VR systems makes them more user-friendly and intuitive for surgeons, reducing cognitive load and facilitating their integration into surgical workflows · Some surgeons could not interact with 2D and 3D AR renderings
5	Capitini et al. (2023, Italy) [24]	Provide an overview of the current state of XR technology and provide additional insights for its advancement in clinical practice and education	VR simulators · ARTHRO VR (high-fidelity VR arthroscopic simulator improved diagnostic arthroscopy skills) · ArthroS VR (VR training enhanced diagnostic arthroscopy performance) · LAP Mentor VR & ARTHRO Mentor VR (used to explore cross-skill transferability between laparoscopy and arthroscopy)	· The ability to transfer skills from a VR knee simulator (sawbones) to the operating room demonstrates the perceived effectiveness of simulation training in enhancing surgical skills and performance · The VR group outperformed both the benchtop group and the untrained group after 6–8 h of training, indicating the perceived efficacy of VR in improving surgical proficiency · Trainees may not show performance improvements when transitioning from VR training to benchtop simulator training, indicating potential differences in the perceived ease of use or learning curve between the two types of simulators
6	Su et al. (2023, China) [25]	Conduct a comparative analysis between XR training and conventional methods in total hip arthroplasty about implant positioning and surgical duration	· AR simulators (used for real-time guidance during surgical training, improving accuracy and efficiency through visual overlays (e.g., phantom models, radiopaque pelvis)) · VR simulators (simulates surgical procedures using cadaver or bone models, providing immersive learning through operation manuals, videos, and interactive environments)	· VR training improves residents’ surgical skills, with the most significant improvement observed in technical skills related to total hip arthroplasty · XR training demonstrated better accuracy of inclination and shorter surgical duration compared to conventional methods in total hip arthroplasty
7	Santona et al. (2023, Italy) [26]	Describe the training solutions for endoscopic transsphenoidal surgery, including their technical details, costs, utility for surgical skill development, and validation	VR simulators · NeuroVR (simulates endoscopic transnasal procedures using MRI data for patient-specific features) · VOXEL-MAN Sinus (simulates paranasal sinus surgery with a focus on visual and haptic accuracy) AR simulators · PHACON Sinus Trainer (detects injuries to high-risk structures during neurosurgical simulations)	· VR training simulators are perceived to provide neurosurgeons with the most complete visual experience, allowing for realistic and repeatable simulations · The ability to simulate surgeries repeatedly can make the cost per training session relatively low if the VR system is used frequently · AR simulators with cadaver heads need a potentially cost-effective alternative · VR training in percutaneous transformational endoscopic discectomy and pedicle screw insertions reduces errors and fluoroscopy use as well as increases accuracy compared to traditional training methods
8	Patel et al. (2023, UK) [27]	Identify simulation-based training models from various neurosurgery subspecialties from existing literature	VR simulators · ImmersiveTouch (simulates thoracic pedicle screw placement and percutaneous spinal placement) · Virtual Surgical Training System (used for cervical pedicle screw placement) · VIST (a VR-based neuro-interventional radiology simulator used for tasks like carotid stenting and angioplasty)	· VR simulators allow neurosurgeons to practice endovascular techniques, enhance procedural skills, and simulate complex scenarios encountered in interventional neuroradiology · VR extends beyond technical skill development to encompass nontechnical skills training in neurosurgery, such as teamwork, decision-making, communication, and situational awareness · VR training programs have demonstrated significant benefits in resource-limited regions, where access to traditional training opportunities may be limited · VR training is particularly beneficial for pediatric neurosurgery, where limited caseloads and technical challenges pose training obstacles
9	Jung et al. (2023, Canada) [28]	Assess the present state of advanced visualization techniques in the field of spine surgical education	AR simulators · Microsoft HoloLens (assists in pedicle screw placement by providing visual guidance to improve placement accuracy) VR simulators · ImmersiveTouch (simulates pedicle screw and spinal needle placements with automated evaluation of placement accuracy based on pre-defined targets) · Oculus Rift (provides detailed feedback on performance and errors during lateral lumbar access surgery simulations) MR simulator · 3D Slicer (combines mixed reality with 3D-printed models to improve the accuracy of percutaneous endoscopic discectomy)	· Improved accuracy of pedicle screw placements on cadaver models for trainees who underwent practice trials with XR training simulators compared to standard teaching sessions · Reduced screw penetration rates and greater rates of pedicle screw placement without breaching the anterior wall of vertebrae are observed after extended reality training compared to traditional teaching methods · MR training reduced fluoroscopy time and improved the accuracy of percutaneous transformational endoscopic discectomy on 3D-printed models · XR technologies can benefit both novice and experienced surgeons in spine surgery training
10	Joseph et al. (2023, Switzerland) [29]	Assess the efficacy and user-friendliness of various training methodologies, as well as the feasibility of acquiring practical experience in intracranial aneurysm surgery	VR simulators · Surgical theater (used for patient-specific surgical rehearsal to simulate detailed anatomical procedures) · Dextroscope (creates patient-specific virtual environments for rehearsing complex surgeries) · ImmersiveTouch (provides an immersive, tactile-feedback VR simulator for practicing surgical techniques)	· VR systems are highly recommended for planning aneurysm clipping surgeries, focusing on force feedback, distance visualization, and craniotomy approach · VR systems do not have preservation problems and can be accessed remotely, potentially increasing accessibility to training resources for surgeons in aneurysm clipping · Clear visualization of vessels and the ability to estimate bone removal at the clinoid were possible, indicating that the VR simulation facilitates efficient and effective surgical planning and execution · VR simulators lack realistic haptic feedback, tactility, and pulsatile flow, limiting their ability to simulate the feel and challenges of real-life intracranial aneurysm procedures
11	Farah et al. (2023, USA) [30]	Assess the existing literature and offer suggestions for incorporating simulation-based learning into residency curricula	· VR simulators (used for simulating procedures such as anterior lumbar fusion, thoracic pedicle screw placement, and decompression surgeries) · MR simulators (combine real-world interaction with computer-generated simulations, allowing realistic training for placement and other spine surgeries)	· VR simulators are infinitely reusable and can train any pathology, making them highly accessible and cost-effective compared to traditional methods · MR-based surgical simulators like immersive touch and virtual surgery training systems provide residents with realistic 3D anatomy, haptic feedback, and immersive training for spine surgery
12	Fahl et al. (2023, Netherlands) [31]	Examine the effects of temporal spacing in VR simulator training on the acquisition of surgical psychomotor skills	VR simulators · MIST VR simulator (used for laparoscopic tasks such as object transfer) · Visible ear (simulates mastoidectomy, assessing completion and accuracy of the procedure) · Mimic dV-Trainer (simulates suturing anastomosis, focusing on time to completion and performance improvements) · AccuTouch (used for bronchoscopy, assessing procedural accuracy and scope handling skills)	· VR simulator, spaced training led to greater skill improvement, faster learning, and higher efficiency compared to massed training, suggesting it is perceived as more effective compared to traditional teaching methods · The optimal interval for VR simulator-based psychomotor training sessions varies across studies, with differences in training schedules, durations, and skills trained
13	Co et al. (2023, China) [32]	Assess the evidence about the efficacy of XR-based systems in the context of surgical education	· VR simulation (improves motor skills, technical performance, and confidence across various surgical fields, reduces stress, enhances live surgical performance, and offers hands-on practice, particularly benefiting junior surgeons) · AR simulation (provides comparable precision to expert-guided training in orthopedic arthroplasty) · MR simulation (delivers technical skill acquisition comparable to in-person training in laparoscopic surgery)	· VR simulation training demonstrates successful skill transfer to ex vivo tissue and live surgery, implying positive trainee perception of its effectiveness in improving surgical competency and operative outcomes · VR simulation training outperforms traditional methods by enhancing technical skills acquisition, transferability, and surgeon confidence in laparoscopic procedures · Studies have shown non-superior or even inferior outcomes of VR simulation training compared to dry lab simulation in laparoscopic performance, arthroscopic procedures, and robotic surgery · XR simulation can effectively train surgeons, even those new to procedures, and even unsupervised VR training with feedback can maintain skill level
14	Thavarajasingam et al. (2022, UK) [33]	Provide a detailed account, comparison and assessment of the utilization of AR in endoscopic and microscopic transsphenoidal surgery	AR simulations (integrates imaging from CT, MRI, or CBCT with endoscopic views, using various registration, segmentation, and tracking techniques to align anatomical structures, with hybrid AR displays enhancing intraoperative guidance, landmark identification, and surgical safety)	· A positive surgeon perception and experience with AR navigation in transsphenoidal surgery translates into improved confidence, performance, and decision-making, especially for navigating complex cases with critical structures, while also reducing mental workload and promoting a more streamlined surgical approach · Neurosurgery increasingly employs AR optical tracking systems for accurate instrument localization and real-time navigational assistance · AR-navigation systems effectively decrease operative time, enabling quicker and more accurate surgeries in transsphenoidal surgery · In transsphenoidal surgery, AR’s diverse toolbox of imaging, registration, segmentation, tracking, and display techniques empowers surgeons to create personalized intraoperative navigation systems optimized for each unique procedure
15	Rossi et al. (2022, Italy) [34]	Provide a concise and comprehensive elucidation of the AR systems employed in the field of orthopedic surgery	AR simulators · AR-KNEE (utilizes imageless navigation and real-time smartphone visualization for femoral and tibial alignment in surgeries) · Camera-augmented mobile C-arm (intraoperative assessment of limb alignment using X-ray images) · Knee+ (displays tibial and femoral axis on the surgical field through smart glasses without the need for preoperative images)	· AR training improves implant placement accuracy in hip, shoulder, and elbow arthroplasty, potentially leading to better surgical outcomes due to reduced errors and improved component positioning (as shown in studies on total hip, reverse shoulder, and total elbow arthroplasty) · Surgeons perceive AR as a faster and more user-friendly training tool compared to conventional methods, with its integration into C-arm imaging enhancing real-time visualization and operative efficiency
16	Pelly et al. (2021, UK) [35]	An overview of simulation in hernia repair surgery and, whenever feasible, evaluate and compare the educational value and validity of various simulation models	VR simulator · VREST (simulate the open hernia repair using the Lichtenstein method, aimed at enhancing surgical education by providing a detailed procedural simulation)	VR open hernia repair models demonstrate the potential to enhance learning for novice surgeons through immersive training and an improved grasp of surgical anatomy and techniques
17	Humm et al. (2022, UK) [36]	Assess the relative effectiveness of VR compared to simulated training or no additional training in the context of laparoscopic cholecystectomy	VR simulator · VR LC (virtual reality-based laparoscopic cholecystectomy simulations used as a post-intervention model)	VR appears to be a promising adjunct to surgical training curricula, particularly for laparoscopic cholecystectomy
18	Berthold et al. (2022, USA) [37]	Perform a comprehensive analysis to ascertain the effectiveness of VR in the training of orthopedic surgeons	VR simulators · HTC Vive (VR simulation to train novice total hip arthroplasty trainees, resulting in improved procedural competency and reduced errors) · Oculus Rift (used for total hip arthroplasty and tibial nail placement training, showing improvement in technical performance in postgraduate orthopedic residents) · Osso VR (used for tibial intramedullary nail placement and unicompartmental knee arthroplasty training)	· VR training in orthopedics leads to demonstrably better performance outcomes compared to traditional methods, with VR trainees achieving higher scores in assessments and demonstrating greater accuracy during procedures · Orthopedic trainees report positive perceptions of VR training, highlighting its immersive nature as a potential tool to improve engagement and potentially reduce the perceived difficulty of acquiring surgical skills · In orthopedic training, VR simulations create a controllable environment for repetitive surgical practice, facilitating personalized and self-directed learning with real-time feedback for error identification and correction
19	Arjomandi Rad et al. (2022, UK) [38]	Assess the existing uses of XR, VR, and AR in the field of thoracic surgery	VR simulators · SimSurgery SEP (used to simulate nephrectomy via VR in thoracic surgery training. Participants practiced on the VR platform before performing a thoracoscopic lobectomy on a porcine model) · LapSim (a VR video-assisted thoracic surgery simulator used to train participants on right upper lobectomy) AR simulators · MDCT virtual bronchoscopy (uses AR for preoperative virtual bronchoscopy in children to detect tracheobronchial foreign bodies) MR simulator · VatSim-XR (a simulator combining 3D display, haptic-enabled thoracoscopic instruments, and a VR headset for thoracic tasks)	· XR technology is emerging as a valuable tool for thoracic surgeons, improving their grasp of patient anatomy during surgery and providing real-time navigation guidance for tasks like tumor removal and lymph node biopsies · XR technology, especially with 3D lung anatomy renderings from CT scans, improves thoracic surgery by reducing preoperative planning time, and workload, and enhancing accuracy for thoracic surgeons · XR training environments provide thoracic surgery trainees with the opportunity for self-directed skill mastery through immersive practice and immediate feedback, thereby expediting proficiency development and potentially reducing dependence on senior surgeons · Thoracic surgeons are interested in using XR technology, specifically virtual lung mapping, to navigation during surgery, with existing research on virtual bronchoscopy using multi-detector CT scans showing potential for accurate detection of foreign bodies inhaled into the airways
20	Wang et al. (2022, USA) [39]	Examine the effects of 3D printing, VR, and AR technologies on prostate cancer procedures, specifically prostate biopsy, and resection	VR simulators · Transrectal ultrasound-guided prostate VR (developed for resident training using 3D models of the prostate, urethra, and bladder to practice prostate biopsy procedures) · Robotic surgery VR simulator (designed to train surgeons in robotic surgery, helping to shorten the learning curve and improve performance in procedures like robotic radical prostatectomy) AR simulator · HA3D AR system (uses preoperative MRI-based 3D models to overlap with real-time intraoperative views, guiding nerve sparing, and lesion localization during radical prostatectomy)	· VR simulators for prostate biopsy demonstrably improve resident understanding and reduce procedure times, and VR-based robotic surgery simulators effectively shorten the learning curve and enhance skill acquisition for robotic prostatectomy · AR navigation systems for laparoscopic radical prostatectomy have been shown effective in both controlled and real-world settings by addressing tissue deformation and incorporating preoperative MRI data to improve 3D visualization, leading to more accurate tumor targeting and potentially better surgical outcomes
21	Taba et al. (2022, Brazil) [40]	This study aims to examine the impact of VR simulations on the acquisition of laparoscopic skills among medical students and physicians	VR simulators · LapSim (used to assess laparoscopic surgery skills, especially cholecystectomy, improving procedure time and economy of movement) · LAP Mentor (focused on training laparoscopic skills, with a significant improvement in surgery performance speed and precision) · MIST-VR (used for laparoscopic skills training, emphasizing hand movements and speed, though results were inconclusive)	· High acquisition costs, ongoing updates, and a lack of conclusive evidence on VR’s superiority over traditional training methods hinder its widespread adoption in surgical education despite potential benefits like reduced need for supervision and materials · The integration of VR simulation into laparoscopic surgical training programs remains controversial due to questions about its effectiveness compared to traditional methods like box training, with factors like limited study sizes, participant experience variations, and assessment methodology inconsistencies potentially hindering its widespread adoption
22	Schmidt et al. (2021, Germany) [41]	Provide up-to-date evidence on the transfer of skills and the ability to predict skill between robotic VR simulation and real operating room performance	VR simulator · da Vinci VR simulator (used for tasks like peg board, ring walk, and camera targeting to train robotic-assisted surgery skills. Also focuses on cognitive skills and task proficiency for residents, fellows, and surgeons)	· Participants undergoing training on robotic VR simulators reported reduced workload, indicating that the simulation training was perceived as less mentally and physically demanding · VR training on robotic surgery simulators may decrease operating room time, potentially supporting the incorporation of VR into robotic-assisted surgery curricula
23	Rothschild et al. (2021, Australia) [42]	Assess the impact of VR simulation on actual outcomes of cataract surgery	VR simulator · Eyesi (used extensively in ophthalmology to simulate cataract surgeries. It allows trainees to practice surgical procedures (e.g., capsulorhexis and posterior capsule rupture) without real-life risks, providing exposure to challenging scenarios like vitreous loss)	· VR reality training in ophthalmology residency proves beneficial, offering safe practice and potentially reducing complications in cataract surgery · VR simulation integration in ophthalmology training reduces complications like posterior capsule rupture and vitreous loss · VR provides a platform for trainees to practice surgical techniques repeatedly and receive structured feedback, enhancing their confidence and proficiency in performing cataract surgeries
24	Kovoor et al. (2021, Australia) [44]	Assess the credibility and efficacy of AR in the context of surgical education	AR simulators · ProMIS (used in training fundamental laparoscopic skills such as laparoscopic suturing and peg transfer) · ImmersiveTouch (used in training thoracic pedicle screw placement and percutaneous trigeminal rhizotomy) · NeuroTouch (used in endoscopic third ventriculostomy training)	· AR systems effectively differentiated between participants of varying surgical experience · AR demonstrably improved surgical skill acquisition and mentoring, suggesting its potential as a significant advancement in surgical education, particularly with its promising application in facilitating effective remote mentorship
25	Clarke (2021, UK) [45]	Understanding of VR simulation as a valuable teaching tool through the provision of ongoing trend analysis in orthopedic surgery training	VR simulators · ArthroSim (trainees practice locating virtual shapes or structures within the knee joint space to develop proficiency in using the arthroscope) · ARTHRO VR (trainees perform tasks that mimic actual procedures such as probing and navigating through joint spaces to locate specific anatomical features) · insightARTHRO (practitioners learn to visualize and identify key anatomical structures within the joint, improving hand-eye coordination and arthroscopic skills)	· VR simulations significantly improve orthopedic surgical skill acquisition compared to standard training methods · Standalone VR training raises concerns about adequately preparing future orthopedic surgeons for the full range of their duties
26	Alrishan Alzouebi et al. (2021, UK) [46]	Utilization of optical head-mounted devices, such as Google Glass, within the domain of urological surgical education	AR simulators · Sony SmartEyeglass (enables real-time communication between surgeon and medical students) · Google Glass (assists in understanding urological surgical procedures and anatomy. Also, used as a vital sign monitor during urological surgery simulations)	· AR simulations with optical head-mounted displays like Sony HMD and Google Glass in surgical training improve medical student education by fostering a more inclusive learning environment that increases motivation, reduces hesitation, and enhances technical skill perception · A high cost of AR simulations with optical head-mounted displays hindered general adoption in urologic surgical training programs · AR simulations with optical head-mounted displays are user-friendly and foster improved learning by enhancing awareness of vital signs, anatomical knowledge, and the overall urological educational experience · Urologic training with AR simulations with optical head-mounted displays may be hindered by technical limitations such as short battery life and overheating, causing potential discomfort for users
27	Williams et al. (2020, UK) [47]	Overview of the present status of AR in surgical training	AR simulators · ProMIS and LapSim (assist in laparoscopic surgery training to provide enhanced realism and haptic feedback) · AR training systems for myoma localization, ligament suspension, and fixation to enhance gynecology surgical precision · AR training system for positioning critical components, needle placement, and reducing associated tissue damage in orthopedic interventions	· AR has the potential to improve surgical training outcomes, with surgeons generally favoring its use · Cadaveric models are favored over AR simulations due to the difficulty of replicating the intricacies of real human tissue feedback in a digital environment
28	Vitale et al. (2020, Italy) [48]	Efficacy of virtual simulators in enhancing the acquisition of hysteroscopic skills among surgeons	VR simulators · HystSim (provides a virtual patient for realistic practice and an adapted hysteroscope to simulate real-life surgical handling) · VR uterine resectoscopic simulator (mimics actual surgical tools to offer a tangible sense of instrument handling and navigation within the endometrial cavity) · Essure Sim (enables practice of accurate device placement and handling within a simulated uterine environment)	· VR gynecological surgery simulators (HystSim VR and Essure Sim) had a high degree of realism and training effectiveness, supporting the potential of VR technology to enhance surgical skill acquisition · VR simulators showed that both novices and experts enhanced their performance on metrics like time, path length, and successful procedure completion, signifying that VR training effectively cultivates practical skills · VR training alongside novices and experts in gynecological procedures revealed VR’s positive influence on skill acquisition for novices, suggesting a social learning aspect to VR simulation’s effectiveness in surgical skill development · VR simulators facilitated improved surgical skill acquisition and performance by enabling deliberate practice, personalized feedback, and skill refinement within a controlled environment
29	Rangaranjan et al. (2020, UK) [49]	Educational efficacy of haptics in VR surgical simulation	VR simulators · MIST (used to simulate basic laparoscopic tasks such as object translocation (peg transfer, object lifting), cutting, diathermy, suturing, dissection, and knot tying) · LapSim (used to simulate laparoscopic tasks like instrument navigation, grasping, fine dissection, and suturing) · Phantom (use of high-fidelity haptic feedback for bimanual pushing and cutting tasks in general surgery)	· Haptic feedback in VR training significantly improves task performance, evidenced by faster completion times, enhanced skill acquisition, and superior results in high-fidelity haptic conditions · The effectiveness of VR haptic feedback in enhancing surgical skill acquisition is influenced by several factors, including task complexity, learning curve, timing of haptic exposure, and individual preferences · Individual preferences and past experiences with VR technology influenced negative perceptions of VR haptic technology
30	Portelli et al. (2020, UK) [50]	Compare VR training with apprenticeship laparoscopic surgery training to ascertain whether it serves as a replacement or supplement tool	VR simulators · LapSim® (used for proficiency-based training in laparoscopic surgeries, it allows surgeons to practice various tasks in a controlled environment to enhance their skills and accuracy) · LAP Mentor (helps learners to navigate camera and hand-eye coordination skills through simulated laparoscopic skills exercises) · da Vinci Skills Simulator (utilized for robotic surgical education for complex procedures like bowel resections and nephrectomy)	· VR training systems, while potentially more immersive, incur significantly higher setup and maintenance costs compared to traditional box trainers · VR simulation training significantly improves laparoscopic surgical technical skills, efficiency of movement, and tissue handling, compared to traditional surgical training · VR training effectively teaches basic laparoscopic skills like camera control and tool manipulation, with variable difficulty for staged learning, but it lacks the sense of touch for tissue manipulation
31	Polce et al. (2020, USA) [51]	Evaluate the empirical effects of orthopedics training simulators on surgical proficiency	VR simulators · ARTHRO VR (VR training for practicing detailed and realistic knee arthroscopy tasks) · ArthroS VR (used for participating trainees in consecutive repetitions of arthroscopic tasks for tracking improvements in technical execution and skill retention over time) · ArthroSim (simulate various knee arthroscopic procedures to offer real-time feedback and detailed motion analysis)	· VR-trained subjects generally outperformed actual cadaveric procedures and non-trained subjects in knee arthroscopy simulations, showing better outcomes in time-to-task completion, hand movements, and probing skills
32	Lohre et al. (2020, USA) [52]	Utilization of VR, AR, and MR simulators in minimally invasive spine surgery and spinal endoscopic training	AR simulators · Microsoft HoloLens (assists in providing safe needle trajectories and intuitive insertion, enhancing training through visual overlays) VR simulator · Dextroscope (supports microsurgical endoscopic-assisted transpedicular corpectomy by rendering surface and volume images of patient spine CT data) MR simulators · Novint Falcon (simulate real operating room environments with procedural mannequins for vertebroplasty training)	· Simulator training with XR improved knowledge, and technical skills, and reduced errors, task time, and fluoroscopy use to support spine surgery trainers · XR technologies offer potential advantages in preoperative planning and surgical execution of minimally invasive spine procedures compared to traditional methods
33	Sayadi et al. (2019, USA) [53]	Examine the diverse applications of VR and AR in plastic surgery, categorizing them into preoperative planning, intraoperative tools, and plastic surgical education	· AR simulators (utilized to superimpose 3D virtual models of anatomical structures onto the surgical site, facilitating precise localization and guidance during procedures, such as displaying blood vessels with the HoloLens or projecting thermal maps for flap planning) · VR simulators (utilized to create immersive simulations of surgical procedures, allowing trainees to interact with virtual anatomy, enhance their understanding of complex structures, and practice skills in a controlled environment)	· AR/VR surpasses traditional plastic surgical training by offering interactive anatomy and immersive simulations with haptics, boosting comprehension, skills, and trainee confidence · AR/VR surgical training, limited by touch simulation, needs improvement to fully realize its potential as a core educational tool for realistic plastic surgery simulations · AR/VR emerges as a valuable addition to plastic surgical training, prompting educators and trainees to adopt it for improved learning
34	Javid et al. (2019, UK) [54]	Assess microsurgery simulators and training models, examining their validation status, and establishing recommendations based on the findings	VR simulator · NeuroTouch (simulator for brain tumor removal using craniotomy approach, offering a highly realistic surgical experience) · Eyesi (developed to improve basic ophthalmic microsurgical skills, offering a comprehensive training platform) · Endodontic surgical simulator (VR simulator for endodontic surgery practice, demonstrating improved surgical performance in actual procedures after virtual practice)	· VR simulators in neurosurgery, such as the cerebral aneurysmal clipping simulator and NeuroTouch, offered realistic virtual environments for practicing complex procedures like brain tumor removal and cerebral anastomosis, likely motivating trainees to engage more actively in learning · VR training simulations like Eyesi and endodontic surgery simulators show promise in both accurately assessing trainee skill levels and improving their performance outcomes
35	Stew et al. (2018, Australia) [55]	Conduct a descriptive analysis of previously validated endoscopic sinus surgery simulators	VR simulators · Madigan Endoscopic Sinus Surgery Simulator (used a high-fidelity haptic system with novice, intermediate, and advanced task modes to provide objective feedback and improve surgical performance) · McGill Simulator for Endoscopic Sinus Surgery (simulate ethmoidectomy and sphenoidotomy procedures, with significant differences in task completion and precision between novice and expert surgeons) · Flinders Sinus Surgery Simulator (employs advanced virtual graphics and phantom haptic devices to simulate realistic mucosal texture and deformable tissues)	· VR simulators for endoscopic sinus surgery are perceived as highly effective in improving surgical performance for residents and new surgeons by offering various difficulty levels, and realistic scenarios, and promoting psychomotor skills, confidence, and proficiency · VR simulators for endoscopic sinus surgery are perceived by surgeons as user-friendly and realistic training tools, with haptic feedback promoting skill development
36	Alaker et al. (2016, UK) [56]	Effectiveness of VR as a training tool in laparoscopic surgery, comparing its efficacy against no training, box trainers, and video trainers	VR simulators (used for training surgical skills by simulating surgical tasks and procedures, to show improvement in performance measures such as time to complete tasks, error rates, and motion efficiency)	Laparoscopic virtual reality simulators with haptic feedback improve surgical skills by reducing time, minimizing wasted motions, and optimizing path efficiency
37	Aim et al. (2016, France) [57]	Investigate the effects of training on VR simulators in orthopedic surgery, with the hypothesis that such training could enhance technical skills in the operating room	VR simulators · Insight ARTHRO VR Simulator (used for shoulder arthroscopy training where users are tasked with identifying and probing anatomic structures and conducting more advanced tasks like repairing a Bankart lesion) · Sheffield Knee Arthroscopy Training System (focused on knee arthroscopy, the simulator tasks learners with identifying loose bodies in the knee and controlling arthroscopic tools) · ArthroSim (used for knee diagnostic arthroscopic procedures, simulating realistic knee examinations and operations)	· VR training is beneficial for novice surgeons, as evidenced by significant improvement in both task completion metrics (time, path length, tip contact) during training and reduced surgical errors (arthroscopy time, camera movement, depth of collisions) in real orthopedic surgery · VR arthroscopy simulators show promise as user-friendly, effective training due to improved speed in inexperienced surgeons and skill differentiation in trainees
38	Thomsen et al. (2015, Denmark) [58]	Equip ophthalmologists with a tool for selecting surgical training and assessment models while also offering recommendations for prioritizing future research in the field	VR simulators · Eyesi Simulator (used for cataract surgery, pars plana vitrectomy, and capsulorhexis) · Endoscopic endonasal surgery simulator (used for endoscopic endonasal procedures, including dacryocystorhinostomy) · Retinal photocoagulation simulator (used for training in laser retinal procedures) · Silicone eyes (used in inanimate model training for corneal and lid suturing)	· VR cataract surgery simulators outperform traditional wet-lab methods in surgeon performance, leading to fewer complications and faster, more efficient procedures · VR simulators significantly decreased the number of errant continuous curvilinear capsulorhexis and reduced complications after intensive training while potentially reducing overall training time
39	Arora et al. (2014, UK) [59]	Collect and conduct a thorough analysis of evidence about VR simulation in the context of Otolaryngology training	VR simulators · Optical tracker (used for myringotomy surgery, aiding in blade navigation and targeting) Stereoscopic glasses and control handle · Dextroscope (used for endoscopic sinus surgery, offering a stereoscopic view and manual control for navigation and anatomical identification in a simulated environment)	· VR simulation allows for proficiency-based training in otolaryngology through repeated practice, error correction, and feedback, but successful curriculum development requires standardized metrics for task selection, difficulty, and performance objectives, alongside expert trainer guidance · VR simulation offers effective training, especially for complex surgeries like temporal bone and sinus procedures, with its efficacy depending on user experience and focusing on psychomotor skills for advanced trainees · The integration of VR simulation into otolaryngology curricula requires the establishment of training session duration, frequency, and study subjects’ support
40	Larsen et al. (2012, Denmark) [60]	Conduct a comprehensive analysis of randomized controlled trials that examined the effectiveness of VR simulation training in comparison to traditional or no training	VR simulators · LapSim (used for practice on basic laparoscopic skills such as dissection, tissue manipulation, salpingectomy, and cholecystectomy) · MIST-VR (used to train surgical residents on a fixed number of repetitions, gallbladder dissection, and tissue handling tasks) · -LAP Mentor (used for practice camera navigation, instrument handling, and safe tissue manipulation in laparoscopy training)	VR simulator training demonstrates a significant positive impact on surgical efficiency and enhances trainee proficiency through improved performance scores and reduced error rates in laparoscopy training
41	Ikonen et al. (2012, Finland) [61]	Provide a current analysis of computer-based VR simulators used in training for laparoscopic cholecystectomies	VR simulators · LapSim (used for basic laparoscopic skills like cutting, clip placement, and grasping) · LAP Mentor (provide tasks focused on laparoscopic dissection, camera handling, and precision in cholecystectomy procedures) · VRMSS (provides training for psychomotor skills without the need for instructor supervision)	· Laparoscopic cholecystectomy VR simulator training demonstrates concordant improvement in both technical skill perception by trainees and objective performance metrics · Effective utilization of VR simulation in laparoscopic cholecystectomies training necessitates its incorporation within a structured curriculum outlining pre-set learning goals
42	Gurusamy et al. (2008, UK) [62]	Assess the potential of VR training as a supplementary or alternative method to traditional laparoscopic training for surgical trainees who possess limited or no prior experience in laparoscopic procedures	VR simulators (used to simulate surgical tasks for training, allowing participants to practice procedures and improve performance accuracy, error scores, and movements without operating on real patients)	· VR laparoscopic surgery training showed promise in improving both accuracy and perceived speed of task completion compared to traditional methods · Due to variations in software package training durations, training length, and the uncertainty of VR’s overall effectiveness, pinpointing the best training method in laparoscopic surgery remains challenging
43	Haque et al. (2006, USA) [63]	To assess the efficacy of VR training in the operating room, specifically for patient surgery or examination, compared to traditional training methods	VR simulators · LapSim (used for training in basic laparoscopic skills such as cutting, clip placement, and orientation with the camera) · MIST-VR (focuses on manipulation and electrocautery, enhancing task efficiency for laparoscopic surgeries) · LAP Mentor (provides realistic tactile feedback during laparoscopic tasks like dissections and simulating real-life surgery scenarios)	· VR training demonstrably improves task completion speed compared to traditional methods, with error rate analysis in VR simulations emerging as a promising tool for quantitatively assessing trainee progress and providing targeted feedback · VR simulations were found to be effective for skill development due to user-friendliness, realistic portrayal of tasks, and ability to provide error-specific feedback

Abbreviations: VR virtual reality, AR Augmented reality, MR Mixed reality, STAR System for telementoring with augmented reality, VIST Virtual Interventional Simulation Trainer, CT Computed tomography, MRI Magnetic resonance imaging, CBCT Cone beam computed tomography, HTC High-Tech Computer Corporation, VR LC Virtual reality laparoscopic cholecystectomy, HA3D haptic-assisted 3D, VRMSS Virtual reality minimally invasive surgery simulator, MDCT Multidetector computed tomography, OssoVR Orthopedic surgery simulation in virtual reality

Characteristics of the systematic reviews

As Table 2 shows, in total, 44 systematic reviews were included, of which 37 studies were conducted as systematic reviews [20–24, 26–35, 37–40, 42, 44–49, 51, 53–62], 4 studies as meta-analyses [36, 41, 50, 63], and 3 studies as systematic review and meta-analyses [25, 43, 52]. Most of these studies were conducted in the UK (n = 15, 34%) [21, 27, 33, 35, 36, 38, 45–47, 49, 50, 54, 56, 59, 62], the USA (n = 9, 20%) [20, 22, 30, 37, 39, 51–53, 63], Italy (n = 4, 9%) [24, 26, 34, 48], and Australia (n = 3, 6.8%) [42, 44, 55]. China [25, 32], Denmark [58, 60], and Canada [28, 43] each contributed to publish two studies. Other studies were conducted in Finland [61], the Netherlands [31], Belgium [23], Germany [41], Switzerland [29], Brazil [40], and France [57] each conducting one study. Furthermore, most of the included studies (n = 13, 29.5%) were published in 2023 [20–32].

In most studies, XR-related technologies were used to improve training in various surgical areas including orthopedics (n = 15) [20, 22, 25, 27, 28, 30, 32, 34, 37, 44, 45, 47, 51, 52, 57], neurology (n = 9) [21, 22, 27, 29, 30, 33, 44, 47, 52], laparoscopy (n = 9) [32, 36, 40, 50, 56, 60–63], genitourinary (n = 8) [21, 39, 41, 44, 46–48, 63], and otorhinolaryngology (n = 4) [26, 38, 55, 59]. Furthermore, compared to other XR-related technologies, VR was the most reported intervention in surgical training (n = 26) [24, 29–31, 35–37, 40–43, 45, 48–51, 54–63]. In these studies, the main aim was to improve the trainee’s operative performance (n = 9), reduce the time to complete the tasks (n = 8), improve patient clinical outcomes (n = 5), and surgical skill transfer (n = 5).

In seven studies, AR surgical training tools [21, 22, 33, 34, 44, 46, 47] were used as interventions which aimed to improve patient clinical outcomes (n = 3), training effectiveness (n = 3), and surgical accuracy (n = 2). Other review studies (n = 11) [20, 23, 25–28, 32, 38, 39, 52, 53] reported applications of AR, VR, or MR tools in surgical training.

Primary study overlap

A citation matrix mapped the overlapping primary studies, identifying that 19 reviews shared at least 1 primary study. The extent of overlap ranged from minimal (overlap in only 1–2 studies) to significant (overlap in more than 10 studies). In this study, the CCA was 3.75% which indicates a low level of primary study overlap across the included reviews. The CCA formula is as follows:

$$CCA=\frac{N-r}{rc-r}=\frac{217-83}{83\times 44-83}=0.0375$$

N = total number of occurrences of primary studies in all systematic reviews

r = number of unique primary studies across all systematic reviews

c = number of systematic reviews included in the analysis

The overlap predominantly occurred in studies examining XR-based surgical training interventions, particularly in laparoscopic surgery and orthopedics. To minimize bias, we discussed the results of overlapping studies only once in our analysis. The overall findings presented in the UTAUT model categories were adjusted to account for these overlaps.

Quality and risk of bias in the studies

The quality of the studies was assessed using the AMSTAR 2 [17]. According to the defined criteria, most of the included studies (n = 39) were rated as “critically low” quality [20–23, 25–30, 32, 34–44, 46–55, 57–63]. Other studies were rated as “low” (n = 3) [31, 33, 45], “moderate” (n = 1) [56], or “high” (n = 1) [24] quality. The main reasons for low-quality ratings were linked to the specific AMSTAR 2 items. First, many reviews did not include a registered protocol (Item 2), which introduced potential bias due to unreported changes in the methodology during the review process. In addition, several studies failed to report the sources of funding for the included studies (Item 9) which compromised the transparency of the research. Another key issue was related to the inadequate risk-of-bias assessment in the individual studies (Item 10), which undermined the reliability of the conclusions. Finally, many studies did not provide adequate explanations for heterogeneity across their findings (Item 13), affecting the robustness of the results. Additional details about quality assessment were provided in Fig. 2 and Supplementary Table S3.

Fig. 2.

Quality assessment of the included studies (AMSTAR 2)

The included studies were also assessed for the risk of bias using the ROBIS tool [18], which examines biases across four domains: study eligibility criteria, identification and selection of studies, data collection and appraisal, and synthesis and findings. The results showed that 45.4% were classified as having a “low risk” of bias (n = 20), 20.4% had an “unclear risk,” and 34% had a “high risk” of bias. The primary reasons for a high risk of bias were mainly related to Domain 3 (items 4 and 5), which described concerns over inadequate data collection and appraisal methodologies. In Domain 4 (items 3, 5, and 6), problems emerged concerning the synthesis and presentation of the findings, including a failure to account for heterogeneity and insufficient justification for the conclusions drawn. Moreover, regarding the judgment of overall risk of bias (items 2 and 3), inconsistencies in the application of bias assessment criteria across the included studies frequently impacted the overall review quality. More details about risk-of-bias assessment were provided in Fig. 3 and Supplementary Table S4.

Fig. 3.

Risk-of-bias assessment (ROBIS tool)

Factors influencing acceptance and use of XR technology in surgical training

Based on the UTAUT model, factors influencing the acceptance and use of XR technology in surgical training were divided into four domains: performance expectancy, effort expectancy, social influence, and facilitating conditions. The following sections outline the results of the reviewed studies for each of these categories.

Performance expectancy

The findings indicated a positive correlation between VR training and the improvement of surgical skills in various fields including laparoscopy [32, 36, 50, 60–62], orthopedics [24–26, 37, 45, 51], otolaryngology [32, 55, 57, 59], neurology [26, 27, 54], plastic surgery [53], and urology [27, 39, 46, 48]. VR technologies provide trainees with a controlled and safe environment for repeated practice of complex surgeries [38, 54] and improve both mental and motor skills in experienced surgeons [59]. VR simulations also support preoperative planning [38] and reduce the risks associated with live surgeries by allowing trainees to practice complex procedures, such as aneurysm clipping, hernia repair, and cataract surgery [29, 35, 42, 53, 58]. The realistic 3D images provided by VR help improve technical skills and decision-making [26, 29, 35, 36, 42, 48] and reduce operating room time and complications [20]. Moreover, VR training enhances nontechnical skills like teamwork and communication [27], improves surgical anatomy understanding [42], and effectively simulates the operating room environment by offering auditory, visual, and sensory feedback [35, 48, 54].

Additionally, VR reduces surgical task completion time [43, 50, 51, 62, 63], increases movement efficiency [50, 51, 63], improves handling of surgical instruments [63], and minimizes intraoperative errors [26, 63]. Compared to traditional training methods, VR enables better supervision, decreases training costs [26, 38], reduces fatigue, enhances learning experiences [41, 50], provides targeted training programs [24, 32, 37, 40], and fosters better comprehension and confidence [21, 46, 53]. Overall, studies affirm VR simulators improve surgical skills for all experience levels [22, 44, 46, 48, 54, 56], as evidenced by metrics such as time, path length, successful procedure completion, and trainee confidence [43, 48, 55, 56].

AR technologies also make significant contributions to surgical training by improving comprehension, precision, and confidence, particularly in complex surgeries [22, 23, 33, 47]. AR-based systems offer real-time visualizations [22, 33], personalized navigation, and feedback [21, 23, 28, 33, 44], allowing surgeons to enhance accuracy [20, 22, 33, 34] and minimize errors [28] in procedures like implant placement [39] and neurosurgery [22, 33].

Furthermore, XR technologies provide an immersive training environment, improving surgical skills and precision while potentially reducing errors across various surgical disciplines [28, 29, 32, 38, 52, 53]. Studies highlight the effectiveness of XR in reducing operation time and workload in thoracic surgeries [38], enhancing accuracy in procedures like femoral stem screw placement and total hip arthroplasty [25, 28], and reducing fluoroscopy time in minimally invasive percutaneous surgeries [28].

Effort expectancy

According to the results, both VR and AR interfaces are commonly regarded as intuitive, especially for users with different degrees of technical expertise [63]. This is especially accurate for VR, as the interfaces are specifically designed to be user-friendly and simple to understand and navigate [63]. Surgeons view AR as a more efficient and user-friendly teaching tool in comparison to traditional approaches [31, 34, 43]. The incorporation of preexisting technologies such as C-arm imaging improves the ease of use and provides real-time visualization during AR training [34].

VR simulations are highly effective in creating realistic environments that replicate real-world surgical situations, allowing trainees to improve their skills in a secure setting with prompt feedback [63]. AR, particularly when using head-mounted displays (HMDs), also offers realistic task representations beneficial for pre-surgical training [22, 23, 34, 46]. However, AR may lack realism, 3D perception, and immersive performance compared to VR and standard box trainers [21]. Positive feedback from experienced surgeons can enhance the acceptance and utilization of XR technologies among trainees, highlighting their value in improving surgical skills [20]. Despite these benefits, more research is needed to fully realize the potential of AR and VR in realistic training, especially in delicate procedures like plastic surgery, due to current limitations in surgical simulation [53].

Social influence

Studies showed that VR simulations incorporating virtual instructors or peers, particularly experts, can improve skill acquisition for novice surgeons, as evidenced in research on gynecological procedures [48]. However, widespread VR adoption is hindered by financial constraints [41]. The initial investment required for VR equipment, which includes not only the HMDs but also any additional hardware or software required for an effective VR experience, represents a significant financial barrier for both individual and institutional users, potentially limiting accessibility [41]. This concern is reflected in AR simulation research, which has identified high HMD costs as a major barrier to adoption [46]. Further research into more cost-effective options, such as AR simulations that use cadaver heads, is critical to addressing these restrictions and ensuring VR and AR technologies reach a wider audience within surgical training programs [26].

Facilitating conditions

The results showed that VR is effective in teaching essential laparoscopic skills and allows for deliberate practice in a controlled environment, fostering focused skill development [48, 50]. Furthermore, VR training is accessible and beneficial in resource-constrained areas [27]. Also, immersive VR training is potentially improving performance, especially in developing cognitive abilities under stress [43]. However, successful integration requires careful curriculum design, particularly for less complex procedures like laparoscopic cholecystectomies [61]. In addition, customizing session duration, frequency, and learner support mechanisms can enhance the effectiveness of VR surgical training tools [31, 59]. Factors such as task complexity and prior VR experiences also influence user perception and training effectiveness [49].

However, concerns about the transferability of skills from VR to the operating room remain due to difficulties in simulating real-world issues [32] and the entire surgical workflow [29, 45]. It is particularly beneficial in specialized teaching areas like pediatric neurosurgery, where case availability and technical limitations pose challenges [27]. Nevertheless, VR’s limitations include reproducing the entire surgical workflow, tactile feedback, and pressure sensations [50], which reduce its effectiveness in complex procedures like intracranial aneurysm repair [29]. Also, concerns about the difference between VR’s visual fidelity and the operating room environment require further research [26].

In AR surgical training tools, studies reported that user interaction with 2D/3D anatomical overlays is particularly challenging [23]. Technical constraints like as battery life and overheating in HMDs might cause user discomfort during training sessions [46]. Furthermore, issues in giving realistic haptic feedback as compared to traditional training techniques based on cadaveric models must be overcome before AR widely adoption [47].

Synthesis of the results

The adoption of XR technologies in surgical training, based on the UTAUT model, is influenced by several key factors across four domains: performance expectancy, effort expectancy, social influence, and facilitating conditions. Performance expectancy refers to the value of VR and AR technologies in enhancing both technical and nontechnical skills, particularly in high-risk surgeries. These technologies provide immersive, realistic environments that improve decision-making, accuracy, and confidence in surgical trainees. From an effort expectancy perspective, XR technologies are generally considered user-friendly, although VR tools are often viewed as more immersive and realistic compared to other XR technologies. Social influence emphasizes the role of expert endorsement in promoting the adoption of XR among trainees. Facilitating conditions highlight the importance of well-designed curricula and access to resources, although challenges such as skill transfer to real-world settings and technical limitations, like haptic feedback and system realism, still hinder the full integration of XR technologies.

Discussion

Principle findings

This umbrella review explored the potential key factors influencing the acceptance and use of XR in surgical training based on the UTAUT model which included performance expectancy, effort expectancy, social influence, and facilitating conditions. Performance expectancy reveals that VR and AR significantly enhanced surgical skills across disciplines by offering immersive, realistic simulations that improve psychomotor skills, decision-making, and procedural accuracy while reducing risks and operating room time. Effort expectancy highlighted XR interfaces’ user-friendly and intuitive nature, especially VR, making them accessible to trainees with various technical expertises. Social influence underscores the experienced surgeons play a key role in promoting XR adoption by providing positive feedback and serving as advocates for the technology, which helps build trust and encourages use among trainees. Facilitating conditions emphasize the necessity for careful curriculum design, resource availability, and addressing technical limitations to maximize the effectiveness of XR technologies in surgical training. Moreover, financial constraints, particularly the high cost of hardware and software, remain a significant barrier.

The results showed a positive correlation between VR training and enhanced surgical skills across various disciplines. VR provides a controlled, safe environment for surgeons to practice complex procedures, improving proficiency and reducing error rates [65, 66]. Studies emphasize VR’s role in reducing the learning curve for endoscopic sinus surgery through realistic anatomical visualizations and haptic feedback, which enhance procedural accuracy and confidence [67, 68]. Recent advancements in VR technology, such as artificial intelligence (AI) integration, have further improved the realism and interactivity of simulations, making virtual environments closely resemble real-world surgical environments [69]. Different immersive technologies serve distinct roles in surgical training: fully immersive VR offers comprehensive sensory engagement for intricate procedures, semi-immersive VR integrates virtual and real-world elements for collaborative training, and non-immersive VR is practical and cost-effective for initial training stages [70, 71].

AR significantly enhances trainee comprehension, skills, and confidence. Similarly, studies showed that AR-based navigation systems improve the accuracy of surgical interventions and reduce operative times in neurosurgery [72]. A study also found that AR improves the precision of orthopedic surgical procedures [73]. In AR, marker-based systems provide precise visual guidance beneficial in orthopedic surgeries [74], while marker-less AR offers greater flexibility in dynamic settings such as maxillofacial surgery [75].

Effort expectancy, including the ease of use and learning associated with XR technologies, is essential for their adoption. As the results showed, both VR and AR interfaces are generally perceived as intuitive, enhancing the learning curve for surgical trainees. This has been highlighted by McKnight et al., too [76]. Fully immersive VR is ideal for complex surgical training due to its comprehensive sensory engagement and makes it easier to use in surgical training [77]. In addition, studies showed that marker-based AR systems provide precise overlays in surgical training but require physical markers that make them complex to use, while marker-less AR offers greater flexibility using computer vision techniques [71]. Advanced haptic feedback in AR systems shows promise in enhancing realism and training effectiveness [75].

Social influence significantly affects the adoption of XR technology in surgical training. Similarly, studies showed that incorporating virtual instructors or peers, particularly experts, in VR simulations significantly improves skill acquisition [76, 78]. According to the current findings, the area of adoption received less attention, and the impact of XR proficiency on enhancing a surgeon’s image or status within an organization remains unclear. It is essential for organizational culture and reference groups to value surgeons’ ability to work with these technologies [79]. Surgeons often rely on their peers and colleagues to validate the relevance and benefits of using XR technologies. This social dynamic is particularly influential in environments where early adopters advocate for XR use and respected colleagues demonstrate its value in practice [80]. Studies have shown that when surgeons observe peers successfully using XR for complex surgical simulations, they are more likely to integrate it into their own practice [6, 11]. In such settings, peer-led training sessions or informal mentoring plays a significant role in overcoming initial skepticism. For instance, orthotics residents have cited the influence of peers demonstrating improved surgical precision and reduced operative time using VR as a turning point for their adoption of the technology [81].

According to the literature, working with XR is often viewed as ineffective or time-consuming [82]. However, other research highlights the crucial effectiveness of XR in surgical environments [6, 13]. Studies demonstrated that institutions prioritizing traditional training methods saw lower uptake of XR, particularly when surgical trainers felt pressured to maintain efficiency without significant investment in training [83, 84]. An example can be drawn from the study by Nanashima et al., which found that in a traditional hospital setting, only 18% of digestive surgery trainers reported adopting VR, compared to 64% adoption in a more technologically progressive hospital where VR was systematically integrated into daily surgical training programs [85]. Therefore, new strategies should be organized to improve understanding among key influencers in the surgical field regarding the benefits of XR. Social VR platforms enable collaborative learning in shared virtual environments, overcoming geographical barriers and facilitating global interaction [86]. Avatars and virtual representations enhance presence and engagement, making training experiences more immersive and realistic [87].

Facilitating conditions, including resource availability and support for XR technologies, are crucial for adoption. Similar to current study findings, studies reported VR is effective in increasing the performance of surgical training in resource-constrained areas [66, 83]. To design XR technologies compatible with the values and needs of surgeons in the current environment, these considerations must be addressed [70, 88]. In addition, special instructions and facilitating conditions need to be provided to improve trainees’ attitudes towards the adoption of XR [11]. Integrating MR technologies enhances training by blending real and virtual elements, improving spatial understanding and surgical accuracy [89]. Advanced technologies like AI and cloud computing facilitate XR adoption by providing intelligent feedback and adaptive learning pathways, reducing cost barriers through sophisticated applications without expensive local hardware [69, 71, 90]. Moreover, incorporating advanced hardware tools, such as haptic devices and motion capture systems, enhances the realism of XR training and skill acquisition [71].

While XR offers a number of benefits, including immersive simulations that enhance psychomotor skills, procedural accuracy, and decision-making, the initial cost of implementing these tools may limit their widespread use. A review study demonstrated the potential of affordable XR tools, such as using mobile-based AR or low-cost VR headsets that offer similar training advantages at a fraction of the cost of high-end systems [91]. For example, mobile-based VR applications like smartphone-compatible devices can provide useful anatomical overlays without using expensive headsets or operating room modifications [92]. Moreover, adopting a phased implementation strategy, where lower-cost XR solutions are gradually integrated into training programs, can help institutions to manage the financial impact [93]. This approach allows trainees to benefit from fundamental XR capabilities while reducing the upfront investment. A successful example is the integration of basic VR simulators for the initial stages of surgical training, with more advanced, expensive systems reserved for senior surgical trainees focusing on the complex procedures [94].

Implication for practice and future studies

According to the findings, it seems that social influence and facilitating conditions received less attention in designing XR technologies, despite the well-accepted and understood importance of effort and performance expectancy among XR designers. To leverage XR technologies effectively in surgical training, developers should invest in user-friendly and intuitive VR and AR interfaces to make adoption smoother for trainees of various medical expertises. Financial investment and cost-effective solutions are needed to overcome the initial cost barriers of XR hardware. Implementing new curriculums that incorporate VR and AR training modules can significantly enhance the skill acquisition process, especially for complex surgical procedures. In addition, customization of training sessions to fit individual learner’s requirements can optimize the learning experience.

Future research should focus on improving the realism of VR and AR simulations, particularly in replicating tactile feedback and pressure sensations, which are critical for certain surgical procedures. Developing more advanced haptic feedback systems and addressing technical limitations like battery life and overheating in AR headsets will enhance user experience. Moreover, future research should prioritize longitudinal studies and randomized controlled trials to assess the long-term effectiveness and skill transferability of XR on surgical performance, as the current body of evidence is largely based on short-term studies. Such research is critical to understanding how XR technologies translate into real-world performance and whether the initial gains in skill acquisition are sustained over time. These studies should aim to measure the retention of surgical skills over extended periods and determine whether XR-based training leads to lasting improvements in clinical outcomes, such as reduced operating room times and fewer complications in actual surgeries.

Study limitations

This study had some limitations. Firstly, non-English articles were excluded mainly due to the limited resources for translation and analysis. Secondly, original research studies included in the selected reviews were not analyzed directly. This may have affected capturing the full range of evidence on the factors affecting XR adoption in surgical training. In future, original studies can be examined to explore factors influencing the acceptance and use of XR technologies in surgical training.

Conclusion

This study highlighted factors influencing the acceptance and use of XR interventions in the surgical settings. XR has demonstrated effectiveness in various surgical disciplines, reducing risks and time in the operating room while boosting trainee’s confidence and proficiency. The intuitive nature of these technologies promotes their acceptance among trainees. However, financial constraints and technical limitations hinder widespread adoption. Further research is essential to address these challenges and validate their long-term impact on surgical training and performance.

Authors’ contributions

Conceptualization, EsT, ElT, MF, and HA; methodology, EsT, ElT, MF, and HA; validation, HA and EsT; formal analysis, ElT and EsT; investigation, ElT and EsT; writing—original draft, EsT; writing—review and editing, EsT and HA; and supervision, HA. All authors have read and agreed to publish the manuscript.

Funding

This research was funded and supported by the Iran University of Medical Sciences, Tehran, Iran (1402–4-99–28214).

Data availability

The data that support the findings of this study are available from the corresponding author (H. A.), upon reasonable request.

Declarations

Ethics approval and consent to participate.

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the Iran University of Medical Sciences (IR.IUMS.REC.1402.1208). Not applicable.

Consent for publication

All authors agreed with publication.

Competing interests

The authors declare that they have no competing interests.