Virtual reality in perioperative medicine: An evidence-based systematic review and meta-analysis

Abstract

Background:

Virtual reality (VR) has emerged as an innovative tool in perioperative medicine, with its growing interest in its potential to improve patient outcomes. This systematic review and meta-analysis aimed to critically assess the effectiveness of VR interventions in perioperative medicine, focussing on anxiety reduction, pain management, patient education, and satisfaction.

Methods:

A comprehensive search was conducted across PubMed, Cochrane Library, Scopus, Web of Science, Embase, and ClinicalTrials.gov for peer-reviewed studies published between January 2000 and December 2024. Studies involving adult and paediatric surgical patients, utilising VR interventions compared to standard care or alternative approaches, were included. Data extraction and risk of bias assessment were performed using standardised forms and appropriate tools. Meta-analysis was conducted for continuous outcomes using mean differences (MDs) and standardised mean differences (SMDs).

Results:

From 193 identified records, 47 studies were included in qualitative synthesis, with 15 studies providing quantitative data for meta-analysis. VR interventions consistently reduced perioperative anxiety {MD − 1.53 on visual analogue scale (VAS), 95% confidence interval (CI) −2.21 to −0.85; MD −3.85 on State-Trait Anxiety Inventory (STAI), 95% CI −5.69 to −2.01} and procedural anxiety in paediatric populations (SMD −0.70, 95% CI −0.94 to −0.47). VR also demonstrated a modest but significant effect on postoperative pain (MD −0.67, 95% CI −1.31 to −0.04) and significantly improved patient satisfaction (SMD 0.70, 95% CI 0.45 to 0.95). Immersive VR modalities and therapeutic content were most effective, especially in minor surgical procedures and paediatric populations. No significant adverse events were reported.

Conclusion:

VR interventions are effective in reducing perioperative anxiety and pain, improving patient satisfaction, and are well tolerated across diverse surgical settings.

INTRODUCTION

Virtual reality (VR) technology has emerged as an innovative tool in the medical field, particularly in perioperative medicine, where it is being explored for its potential to improve patient outcomes.[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19] The perioperative period encompasses the preoperative, intraoperative, and postoperative phases of surgery, during which patients undergo various psychological and physical challenges. One of the most prevalent issues patients face before surgery is preoperative anxiety, which can significantly affect surgical outcomes, recovery, and overall patient satisfaction.[2] Traditional methods of anxiety management, such as medication and counselling, may not always provide sufficient relief, leading to the exploration of alternative interventions, including VR.[3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24]

This systematic review aimed to find research that critically assessed the effectiveness of VR interventions in perioperative medicine. The primary focus was on the reduction of preoperative anxiety using VR in patients undergoing surgical procedures. Secondary questions explored VR’s impact on postoperative pain management, patient education, healthcare professional training, and barriers to VR implementation in perioperative settings. By synthesising data from randomised controlled trials (RCTs), cohort studies, case-control studies, and qualitative research, this review can provide valuable insights into the clinical utility and feasibility of VR interventions in improving patient and healthcare outcomes in the perioperative period.

METHODS

This systematic review followed a prior protocol that was registered with PROSPERO (CRD4202460984). We followed formats recommended by the Cochrane Library and have synthesised the available evidence regarding VR interventions in perioperative care.

Data sources and searches

We searched the databases, including PubMed (MEDLINE), Cochrane Library, Scopus, Web of Science, Embase, and ClinicalTrials.gov (for ongoing or unpublished trials), in a systematic approach, excluding conference abstracts, and the search was limited to peer-reviewed articles published between 1 January 2000 and 31 December 2024 and restricted to studies published in English. The search strategy is shown in the table in Supplement Material.

Study selection

We included studies that met the following inclusion criteria: 1) Studies involving adult and paediatric patients undergoing various invasive and non-invasive types of surgical procedures; 2) intervention groups included VR intervention, including immersive VR experiences, VR education, VR-based pain management techniques, and VR training programmes for healthcare professionals; 3) control groups included standard care or no intervention, including traditional anxiety management, pain management methods, and conventional educational materials; 4) studies measuring anxiety reduction {measured by standardised scales such as the State-Trait Anxiety Inventory (STAI)}, pain perception {measured by the Visual Analogue Scale (VAS) or Numeric Rating Scale(NRS)}, patient education (measured by patient understanding and satisfaction), and healthcare professional performance (measured by skills assessments and confidence levels). Using PICO (Population, Intervention, Comparison, and Outcome) framework, we defined our research question, wherein population consisted of patients undergoing surgical procedures; the intervention involved VR-based modalities; the comparator was usual care or traditional non-VR approaches; and outcomes included anxiety, pain, patient education, skill acquisition, and patient satisfaction.

RCTs, cohort studies, case-control studies, and qualitative studies were included. We excluded studies involving patients with significant cognitive impairments or psychiatric conditions that may prevent informed consent or participation in VR interventions, or those not undergoing surgical procedures. Studies that do not involve VR technology or those using poorly defined VR applications or studies with unclear comparator groups or those using outdated methods or technologies were excluded. Studies that did not meet the above inclusion criteria or that involve non-peer-reviewed publications were excluded. Three independent reviewers (BG, LK, RT) screened the search results and assessed their eligibility by scanning the titles and abstracts of citations by using Rayaan software version 1.4.3. We checked the full text of potentially eligible studies and included criteria. Any conflict was resolved by the fourth independent author to resolve disparities (AG).

Data extraction and risk of bias assessment

Data from included studies were extracted using a standardised form. Key information included study characteristics (e.g. design, sample size, VR intervention details, comparator), patient outcomes (anxiety, pain, education, healthcare professional performance), and study quality. The data were synthesised using both qualitative and quantitative methods, with a focus on calculating mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes such as anxiety and pain levels. A narrative synthesis was used for studies with heterogeneous interventions or outcomes. The quality of the studies included was assessed using appropriate tools, such as the Cochrane Risk of Bias Tool (ROB) for RCTs and the Newcastle-Ottawa Scale (NOS) for cohort and case-control studies.

Outcome measures

The primary outcome was anxiety reduction, measured by standardised anxiety scales such as the STAI or VAS for anxiety. Secondary outcomes included postoperative pain levels (measured by VAS or NRS), patient education outcomes (understanding and satisfaction), and healthcare professional skills and confidence levels.

Subgroup analyses

Subgroup analysis was done for the following parameters obtained from the respective studies: Type of surgical procedure: minor procedures (e.g., outpatient surgeries, endoscopies), major procedures (e.g., abdominal surgeries, orthopaedic surgeries).

Type of VR intervention: Immersive VR (e.g., head-mounted displays) vs. Non-Immersive VR (e.g., desktop applications), Therapeutic Content (e.g., relaxation, distraction) vs. Educational Content (e.g., surgical information).

Timing of VR intervention: Preoperative: Interventions before surgery, Intraoperative: Interventions during surgery or Postoperative: Interventions after surgery.

Observations

Of 193 records, 179 underwent title and abstract screening, resulting in the exclusion of 21 irrelevant records. Subsequently, 158 full-text articles were assessed for eligibility. During this stage, 111 articles were excluded primarily due to incorrect population, outcome, or study design, lack of peer review, data unavailability, or duplication. Consequently, 47 studies[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47] were retained for the qualitative synthesis, with 15 providing quantitative data for meta-analysis [Figure 1].

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart. *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools

A total of 47 studies were identified, encompassing a diverse range of surgical settings, patient populations, and VR interventions.[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47] Table 1 provides a detailed summary of the characteristics of each study. Key observations are as follows:

Table 1.

Characteristics of included studies on VR interventions in surgery

Studies	Study Setting/Procedure	Age (in years) (Mean/Range)	Sex (M/F or %)	n	Country	Study Design	Primary Objective	VR Intervention	Comparator	Duration
Li Q et al. (2024)[13]	GSV surgery	>18	NR	158	NR	NR	Satisfaction, sedation	HMD VR	Midazolam	Intraoperative
Guigal et al. (2024)[16]	Regional anaesthesia	>18	NR	100	France	RCT	Échelle de Valorisation de l’Anesthésie locoRégionale (French patient satisfaction scale for locoregional anaesthesia).	VR hypnosis/distraction	Standard	Perioperative
Carella M et al. (2024)[19]	Knee arthroplasty	>18	NR	60	Italy	Prospective RCT	Sedation, recovery	VR hypnosis	Standard care	Intra-/postoperative
Fonseca A et al. (2024)[20]	Preop caregiver	44 (mean)	NR	26	USA	RCT	Caregiver anxiety	MedMindfulness VR	Snacks, no tech	6 min preoperative
Sommer JL et al.(2024)[8]	Breast cancer surgery	56.4 (mean)	7M, 7F	14	Canada	Single-blind RCT	Anxiety, satisfaction	VR OR simulation	Standard info	1–2w preoperative
El-Gabalawy et al.(2024)[21]	Major oncological surgery	>18	45F	45	Canada	NR	Anxiety, satisfaction	VR OR simulation	Standard care, Nature VR	Preoperative
Samnakay et al. (2024)[25]	Paediatric induction	8.8 (mean)	57.8–61.2% M	200	Australia	RCT	Preoperative anxiety	3D VR goggles	2D video	Induction
Grosso et al. (2024)[26]	RAPN with 3D VR	60–75	40.6–46% F	74	Italy	Cohort study	Renal function	3D VR models	Standard RAPN	3 years
Pandrangi et al. (2024)[27]	Head and neck surgery (outpatient)	47.3±16.7	65.6% F	32	USA	RCT	Anxiety, pain	VR gaming/mindfulness	Standard care	5 months
Steinkraus et al. (2024)[28]	Port implantation (local anaesthesia)	25.3–62 (62 mean)	76.8% M (No VR), 58.3% M (VR)	116	Germany	RCT, pilot	Pain, anxiety, satisfaction	VR hypnosedation	Standard care	7 months
Orgil et al. (2023)[6]	Surgery (paediatric/adolescent)	12–18	7M, 16F	23	USA	Protocol	Feasibility, acceptability	Biofeedback-based VR	None	7 d preoperative to 14 d postoperative
Droc G et al.(2023)[12]	Major abdominal surgery	>18	NR	51	NR	Prospective, mono	Cognition, pain	Immersive VR	Standard care	24–48 h
Arifin J et al.(2023)[14]	Regional anaesthesia	>18	NR	30	Indonesia	RCT, single-blind	Anxiety, satisfaction	Immersive VR	Midazolam	Perioperative
Graf S et al. (2023)[5]	Port implantation	>18	NR	120	Germany	RCT, pilot	Anxiety, pain	VR during port implantation	Standard care	20 months
Franco Castanys et al. (2023)[29]	Ambulatory paediatric surgery	4–12 (6.7/7.0)	28.1% F	125	Spain	RCT	Perioperative anxiety	VR OR tour (animated)	Standard preoperative	24 h pre-operative
Burchard et al. (2023)[30]	Simulated OR (disinfection)	18–58 (28 mean)	61% F	141	Germany	RCT, double-blind	Disinfection coverage	Coloured antiseptic solution	Uncoloured solution	NR
Barry et al. (2022)[1]	Total Hip Replacement, Total Knee Replacement	74 (mean)	67% F	18	USA	Observational	Perioperative outcomes	Immersive VR adjunct	No VR adjunct	Intra-/postoperative
McCullough et al. (2022)[9]	Minor hand surgery	64 (mean)	3% F	22	USA	Observational	Anxiety, satisfaction	Passive VR (WayaHealth)	Music	Intraoperative
Schrempf et al. (2022)[10]	Colorectal/liver cancer surgery	18–75	NR	54	Germany	RCT (3-arm)	Mood, QoL, feasibility	Mindfulness VR (Oculus Go)	Music, None	2x daily
Asiri S et al. (2022)[3]	Elective surgery (adults)	18+	NR	150	Australia/NZ	Observational	Anxiety, satisfaction	VR (details NR)	Standard care	NR
Krish G et al. (2022)[11]	WALANT hand surgery	68, 51	2M	2	USA	Case report	Anxiety, experience	VR device	WALANT, no VR	Intraoperative
Wu Y et al. (2022)[15]	Paediatric GA	Children	NR	99	China	RCT	Preoperative anxiety	VR perioperative tour	None	Preoperative
Faruki et al. (2022)[31]	Hand surgery	18–78 (mean 49)	8F (47.1%) Ctrl, 5F (29.4%) VR	40	USA	RCT, open-label	Sedation, pain	VR immersion	MAC	Intraoperative
Zhu B et al. (2022)[32]	Laparoscopic surgery	>18	NR	600	China	Prospective RCT	Cognitive function	Biophilic VR	Sham VR	NR
Lopes et al. (2022)[33]	Upper limb surgery, axillary block	18–90 (52.8 mean)	55% F	99	France	Observational	Anxiety, pain, satisfaction	VR distraction/hypnosis	Standard care	1 year
Siah et al. (2022)[34]	Perioperative nursing simulation	21–23	80.7% F	207	Singapore	Single-group study	Efficacy, confidence	VR simulation	Physical sim	2h
Hundert AS et al.(2021)[17]	Port access (oncology, peds/adolescents)	8–18 (mean 12)	NR	20	USA	Pilot RCT	Pain, distress	VR HMD, noise-cancelling HP	iPad distraction	During procedure
Vogt L et al. (2021)[7]	Operative settings (preoperative anxiety)	20–81 (mean 54)	35F, 37M	84	Germany	RCT	Preoperative anxiety	Virtual OR tour (HMD)	Standard preoperative	Preoperative
Turrado et al. (2021)[35]	Colorectal cancer surgery	26–94 (65 median)	36.5% F	126	Spain	Single-centre RCT	Preoperative anxiety	VR exposure (periop simulation)	Standard care	Preoperative
Keshvari et al. (2021)[36]	Coronary angiography	50.95±4.12 (VR), 52.08±4.00 (Std)	71.25% M	80	Iran	RCT	Preoperative anxiety	VR distraction	Routine care	5 min
Canda AE et al. (2020)[18]	Robotic prostatectomy	>18	NR	5	NR	Case series	Tumour navigation	3D VR, Da Vinci robot	None	Intraoperative
Alaterre et al. (2020)[23]	Upper limb, regional block	>18	36% F (VR), 64% F (Std)	100	France	Before–after obs.	Pain, satisfaction	VR distraction	Standard care	1 month
Delion et al. (2020)[37]	Awake craniotomy	23–75 (median 45)	12F	30	France	Prospective, open-label	Feasibility, mapping	VR headset, immersive	Standard procedure	Intraoperative
Chan JJI et al. (2020)[38]	Gynaecological surgery	24–59	F	110	Singapore	NR	Anxiety reduction	VR headset, meditation, breathing	None	Preoperative
Kist M et al. (2020)[39]	Labouring women, epidural	24–35	NR	3	USA	Phase 1 clinical trial	Anxiolysis	VR	None	During procedure
Sahin et al. (2020)[40]	Knee arthroscopy	34–35 (mean)	77–80% M	93	Turkey	RCT (3-arm)	Anxiety, satisfaction	VR, PMR	Standard care	Intraop (1h)
Hendricks et al. (2020)[41]	First-time sternotomy	53–77 (70 median)	90% M	20	USA	RCT, pilot	Preoperative anxiety	Immersive VR game	Tablet game	Preoperative
Haisley et al. (2020)[42]	Foregut surgery (minimally invasive)	29–82 (64.5 median)	73.1% F	52	USA	RCT	Pain, satisfaction	VR meditation/mindfulness	Standard care	Postoperative
Faruki et al. (2019)[22]	Upper limb ortho surgery	>18	NR	40	USA	RCT, open-label	Sedation, pain, anxiety	Oculus Go, immersive VR	Usual care	Intraoperative
Caruso et al. (2019)[24]	Paediatric vascular access	13.6 (mean)	42.7% F	292	USA	Prospective RCT	Pain, distress	VR distraction	Standard care	During procedure
Gupta et al. (2019)[43]	Paediatric induction (case)	10	M	1	USA	Case report	Parental presence	VR	None	Induction
Yang et al. (2019)[44]	Knee arthroscopy	15–65 (32.5/38)	41.7% F (VR), 33.3% F (NR)	48	S. Korea	RCT	Preoperative anxiety, satisfaction	3D VR MRI	Standard info	Preop/postoperative
Dehghan et al. (2019)[45]	Paediatric abdominal surgery	6–12	22.5% F	40	Iran	Solomon 4-group RCT	Preoperative anxiety	VR exposure (OR simulation)	Standard instructions	Preoperative
Bekelis et al. (2017)[2]	Mixed surgery	55.3 (mean)	41.9% F	127	USA	RCT	Satisfaction, anxiety	Immersive VR preop experience	Standard preop	Pre/postoperative

VR=Virtual Reality; HMD=Head-Mounted Display; GSV=Great Saphenous Vein; RAPN=Robot-Assisted Partial Nephrectomy; OR=Operating Room; WALANT=Wide Awake Local Anaesthesia No Tourniquet; MAC=Monitored Anaesthesia Care; RCT=Randomised Controlled Trial; PMR=Progressive Muscle Relaxation; QoL=Quality of Life; Std=Standard; NR=Not Reported; M=Male; F=Female; CI=Confidence Interval; SMD=Standardised Mean Difference; MD=Mean Difference; VAS=Visual Analog Scale; STAI=State–Trait Anxiety Inventory; mYPAS=Modified Yale Preoperative Anxiety Scale; RAPN=Robot-Assisted Partial Nephrectomy; WALANT=Wide Awake Local Anaesthesia No Tourniquet; MAC=Monitored Anaesthesia Care; PMR=Progressive Muscle Relaxation; QoL=Quality of Life; USA= United States of America; Introp=Intraoperative; Preop=Preoperative; NZ=New Zealand; Periop=Perioperative;GA=General anaesthesia; Ortho: Orthopaedic. Values are presented as mean (range) unless otherwise specified. Country, study design, and comparator details are as reported in the original studies

Geographic and demographic distribution: Studies were conducted across multiple continents, with the United States, Germany, France, China, and Australia being the most represented countries. Patient ages ranged from as young as 4 years (paediatric surgery)[4,15,25] to over 90 years (geriatric populations),[5,35] and both sexes were generally included,[6,7,8,26,27,35] though some studies focussed on specific age or sex groups. The majority of studies employed RCT designs, including single- and double-blind formats, as well as pilot and three-arm RCTs. Observational, prospective cohort, before–after, and case report/series methodologies were also represented, particularly in early-phase or feasibility research.

Surgical settings and procedures: VR interventions were evaluated in a wide array of surgical contexts, including orthopaedic (e.g., knee arthroplasty, hand surgery), oncological (e.g., breast, colorectal, prostate), abdominal, gynecological, and paediatric surgeries, as well as during anaesthesia and perioperative care. The timing of VR intervention varied, with applications in the preoperative, intraoperative, and postoperative phases.

VR intervention types and comparators: Most interventions utilised immersive VR headsets,[1,2,12,14,22,31,37,41] with some incorporating additional features such as biofeedback, mindfulness, hypnosis, or 3D anatomical modelling. Comparators included standard care, music, 2D video, tablet games, and pharmacological agents (e.g., midazolam).[3,8,9,10,11,12,13,14,16,17,19,21,22,23,24,25,37] The duration of interventions ranged from brief (e.g., a few minutes preoperatively) to extended periods (e.g., up to several weeks postoperatively).

Primary outcomes: The most frequently assessed outcomes were perioperative anxiety and patient satisfaction. Pain and sedation were also commonly evaluated, particularly in studies involving regional anaesthesia or minimally invasive procedures. Other outcomes included cognitive function, recovery metrics, feasibility, acceptability, and technical endpoints such as tumour navigation and disinfection coverage.

Sample sizes: Sample sizes varied widely, from single-patient case reports to large RCTs enroling up to 600 participants.[32] Most studies included between 20 and 150 subjects.[3,5,6,7,9,10,12,14,15,16,17,19,20,21,22,23,26,27,31,33,35,36,37,38]

Trends and innovations: Several studies focussed specifically on paediatric or adolescent populations, often targeting anxiety or pain during minor procedures or anaesthesia induction. Notable innovations in VR content included virtual tours of the operating room, mindfulness and meditation modules, interactive gaming, and 3D anatomical models for surgical planning. Recent studies have increasingly emphasised the feasibility, acceptability, and user experience, reflecting the evolving nature of VR technology in perioperative care.

Table 2 summarises VR intervention modalities, usage patterns, and comparators and reveals several significant trends and insights relevant to perioperative and intraoperative care research:

Table 2.

Summary of VR intervention characteristics

Studies	VR Modality/Content	Duration/Frequency	Comparator/Control
Qianqian Li et al. (2024)[13]	Aqua30 VR, HMD	During surgery	None
Chloe Guigal et al. (2024)[16]	VR-hypnosis, VR-distraction (HMD)	Perioperative	Standard care
Li Q et al. (2024)[13]	HMD VR	Intraoperative	Midazolam
Carella M et al. (2024)[19]	VR hypnosis (HMD)	Intraoperative, postoperative	Standard care
Fonseca A et al. (2024)[20]	MedMindfulness VR (Oculus Go)	6 min preoperative	Snacks
Sommer JL et al. (2024)[8]	VR OR simulation (HMD)	1–2 weeks preoperative	Standard information
El-Gabalawy et al. (2024)[21]	VR OR simulation	Preoperative	Standard care, Nature VR
Samnakay et al. (2024)[25]	3D VR goggles	During induction	2D video
Grosso et al. (2024)[26]	3D VR models for RAPN	Intraoperative	Standard RAPN
Pandrangi et al. (2024)[27]	VR gaming/mindfulness	5 min preoperative	Standard care
Steinkraus et al. (2024)[28]	VR hypno-sedation	Intraoperative	Standard care
Orgil et al. (2023)[46]	Biofeedback-based VR (Mindful Aurora)	10 min daily, 7 d pre–operative to14 d postoperative	None (protocol)
Droc G et al. (2023)[12]	Immersive VR	24–48 h perioperative	Standard care
Graf S et al. (2023)[5]	VR during port implantation	Intraoperative	Standard care
Franco Castanys et al. (2023)[29]	VR OR tour (animated)	24 h preoperative	Standard prep
Burchard et al. (2023)[30]	Coloured antiseptic solution (simulated VR)	NR	Uncoloured solution
Barry et al. (2022)[1]	Immersive VR adjunct (unspecified)	Intraoperative, acute postoperative	No VR adjunct
McCullough et al. (2022)[9]	Passive VR (WayaHealth, HMD)	During surgery	Music
Schrempf et al. (2022)[10]	Mindfulness VR (Oculus Go, TRIPP)	2x daily	Music, No intervention
Asiri S et al. (2022)[3]	VR (details NR)	NR	Standard care
Krish G et al. (2022)[11]	VR device (unspecified)	During surgery	WALANT, no VR
Arifin J et al. (2022)[14]	Immersive VR (HMD)	Intraoperative, postoperative	Midazolam
Wu Y et al. (2022)[15]	VR peri-operative tour (HMD)	Preoperative	None
Hundert AS et al. (2022)[17]	VR HMD, noise-cancelling HP	During port access	iPad distraction
Faruki et al. (2022)[22]	VR immersion (HMD)	During surgery	MAC
Zhu B et al. (2022)[32]	Biophilic VR	Perioperative	Sham VR
Lopes et al. (2022)[33]	VR distraction/hypnosis	During surgery	Standard care
Siah et al. (2022)[34]	VR simulation	2h	Physical simulation
Vogt L et al. (2021)[7]	Virtual OR tour (HMD)	Preoperative	Standard pre-operative
Turrado et al. (2021)[35]	VR exposure (perioperative simulation)	Preoperative	Standard care
Keshvari et al. (2021)[36]	VR distraction (HMD)	5 min preoperative	Routine care
Canda AE et al. (2020)[18]	3D VR, Da Vinci robot	Intraoperative	None
Alaterre et al. (2020)[23]	VR distraction (HMD)	During surgery	Standard care
Delion et al. (2020)[37]	VR headset, immersive	During awake craniotomy	Standard procedure
Chan JJI et al. (2020)[38]	VR headset, meditation, breathing	10 min preoperative	None
Kist M et al. (2020)[39]	VR (HMD)	During epidural	None
Sahin et al. (2020)[40]	VR, PMR	1 h intraoperative	Standard care
Hendricks et al. (2020)[41]	Immersive VR game	Preoperative	Tablet game
Haisley et al. (2020)[42]	VR meditation/mindfulness	Postoperative	Standard care
Faruki et al. (2019)[31]	Oculus Go, immersive VR	During surgery	Usual care
Caruso et al. (2019)[24]	VR distraction (HMD)	During vascular access	Standard care
Gupta et al. (2019)[43]	VR (HMD)	Induction	None
Yang et al. (2019)[44]	3D VR MRI	Preoperative, postoperative	Standard info
Dehghan et al. (2019)[45]	VR exposure (OR simulation)	Preoperative	Standard instructions
Bekelis et al. (2017)[2]	Immersive VR preoperative experience	Preoperative, postoperative	Standard preoperative

VR=Virtual Reality; HMD=Head-Mounted Display; RAPN=Robot-Assisted Partial Nephrectomy; OR=Operating Room; WALANT=Wide Awake Local Anaesthesia No Tourniquet; MAC=Monitored Anaesthesia Care; PMR=Progressive Muscle Relaxation; TRIPP=Mindfulness-based VR application; Std=Standard; NR=Not Reported. Duration/frequency and comparator details are as reported in the original studies

Wide range of VR modalities and content: The studies utilised a diverse array of VR approaches, including biofeedback-based VR (e.g., Mindful Aurora), mindfulness and meditation modules [e.g., Therapeutic Realities for Immersive Psychological Practice and Prevention (TRIPP), MedMindfulness, Oculus Go], distraction-based VR, VR hypnosis, 3D anatomical modelling, and perioperative virtual tours.[6,7,10,15,16,17,18,19,20,22,25,27,28,33,44] Both passive (e.g., VR distraction, virtual tours) and active (e.g., gaming, mindfulness, biofeedback) VR modalities were represented, suggesting broad adaptability of VR to different patient needs and surgical contexts.

Variable duration and frequency of VR exposure: VR interventions ranged from brief, single preoperative sessions (as short as 5–10 minutes) to repeated or continuous use spanning several days to weeks (e.g., Orgil et al.[46] 10 minutes daily for 21 days; Schrempf et al.[10]: twice daily). Intraoperative application was common, particularly for distraction, anxiolysis, or sedation, while preoperative use targeted anxiety reduction and familiarisation with the surgical environment. Some studies extended VR use into the postoperative period to support recovery and satisfaction.

Heterogeneity in comparator/control groups: Standard care was the most frequent comparator, but several studies used active controls, such as music, 2D video, tablet games, pharmacological sedation (e.g., midazolam), or alternative distraction techniques (e.g., iPad distraction). A minority of studies had no comparator (protocols and feasibility studies), reflecting early-phase research or proof-of-concept designs.

Innovation in VR content and delivery: Notable innovations included the use of 3D VR models for surgical planning (e.g., Canda AE,[18] Grosso et al.[26]), VR hypnosis for anxiolysis and sedation (e.g., Carella M,[19] Steinkraus et al.[28]), and immersive perioperative simulations (e.g., Turrado et al.[35]). Paediatric and adolescent studies often leveraged animated or gamified VR environments to enhance engagement and reduce procedural distress.

Application across surgical phases: VR was deployed at multiple perioperative timepoints: preoperatively (to reduce anxiety and improve preparedness),[6,7,8,15,20,21,29,35,38,44] intraoperatively (for pain, sedation, and distraction),[1,11,13,14,16,17,18,22,40] and postoperatively (to enhance satisfaction and recovery).[1,6,12,19,23,28,29,42,44] Some studies integrated VR seamlessly into routine perioperative workflows, while others focussed on isolated procedural moments (e.g., induction, vascular access).

Table 3 summarises, across a wide range of surgical and perioperative settings. VR interventions consistently reduced patient anxiety, both preoperatively and intraoperatively, compared to standard care or alternative distractions such as music, 2D video, or tablet games. This effect was observed in adults, children, and caregivers, with studies reporting significant reductions in validated anxiety scores and improved subjective experiences. Many studies reported higher satisfaction scores among patients receiving VR interventions, often surpassing those in standard care or active control groups.[3,8,9,10,11,15,16,20,21,24,33,40,44] Satisfaction improvements were noted in both adult and paediatric populations, and in various surgical contexts, including orthopaedic, oncological, and minor procedures.

Table 3.

Outcomes and effectiveness

Study (Author, Year)	Primary Outcome (s)	Key Findings/Notes
Orgil et al. (2023)[6]	Feasibility, acceptability	Protocol refined; high acceptability, no adverse events
Barry et al. (2022)[1]	Pain, perioperative outcomes	Less propofol, trend to less fentanyl, no difference in PACU pain/vitals
McCullough et al. (2022)[9]	Anxiety, satisfaction	Lower anxiety with VR vs. music; high satisfaction
Schrempf et al. (2022)[10]	Mood, QoL, feasibility	VR improved mood, high compliance, better well-being
Asiri S et al. (2022)[3]	Anxiety, satisfaction	VR reduced anxiety, increased satisfaction
Krish G et al. (2022)[11]	Anxiety, experience	Both patients: reduced anxiety, improved experience
Droc G et al. (2023)[12]	Cognition, pain	VR group had less cognitive impairment, lower pain
Qianqian Li (2024)[13]	Satisfaction	Higher satisfaction in VR group
Arifin J et al. (2022)[14]	Anxiety, satisfaction	VR reduced anxiety more than midazolam; higher satisfaction
Wu Y et al. (2022)[15]	Preoperative anxiety	VR reduced anxiety in children (mYPAS-SFm)
Chloe Guigal (2024)[16]	Satisfaction (eVaN-lr)	VR groups higher satisfaction than standard care
Amos S. Hundert (2022)[17]	Pain, distress	VR reduced pain and distress vs. iPad
Canda AE (2020)[18]	Tumour navigation	VR feasible for navigation, improved surgeon confidence
Li Q (2024)[13]	Satisfaction, sedation	VR group had higher satisfaction, less midazolam needed
Carella M (2024)[19]	Sedation, recovery	VR hypnosis reduced sedation, improved recovery
Fonseca A (2024)[20]	Caregiver anxiety	VR reduced preoperative caregiver anxiety
Sommer JL (2024)[8]	Anxiety, satisfaction	VR group had less anxiety, more satisfied
El-Gabalawy et al. (2024)[21]	Anxiety, satisfaction	VR improved preoperative anxiety and satisfaction
Faruki (2019)[22]	Sedation, pain, anxiety	VR reduced propofol, improved comfort
Alaterre et al. (2020)[23]	Pain, satisfaction	VR group less pain, more satisfied
Caruso (2019)[24]	Pain, distress	VR group less pain/distress during vascular access
Delion (2020)[37]	Feasibility, mapping	VR feasible, enhanced patient engagement
Faruki (2022)[31]	Sedation, pain	VR reduced sedation, improved comfort
Zhu B (2022)[32]	Cognitive function	Biophilic VR improved cognitive outcomes
Chan JJI (2020)[38]	Anxiety reduction	VR reduced anxiety in the preoperative period
Kist M (2020)[39]	Anxiolysis	VR feasible, reduced anxiety in labor
Samnakay (2024)[25]	Preoperative anxiety	3D VR more effective than 2D video
Grosso et al. (2024)[26]	Renal function	3D VR improved outcomes in complex RAPN cases
Gupta (2019)[43]	Parental presence	VR feasible, improved child cooperation
Vogt L (2021)[7]	Preoperative anxiety	VR tour reduced anxiety vs. standard preparation
Graf S et al. (2023)[5]	Anxiety, pain	Protocol; feasibility and acceptability reported
Pandrangi et al. (2024)[27]	Anxiety, pain	VR reduced anxiety and pain
Turrado et al. (2021)[35]	Preoperative anxiety	VR exposure reduced anxiety preoperative
Lopes et al. (2022)[33]	Anxiety, pain, satisfaction	VR reduced anxiety and pain, increased satisfaction
Keshvari et al. (2021)[36]	Preoperative anxiety	VR reduced anxiety pre-angiography
Yang et al. (2019)[44]	Preoperative anxiety, satisfaction	3D VR MRI reduced anxiety, increased satisfaction
Franco Castanys et al. (2023)[29]	Perioperative anxiety	Animated VR tour reduced anxiety in children
Sahin et al. (2020)[40]	Anxiety, satisfaction	VR and PMR both reduced anxiety, VR higher satisfaction
Hendricks et al. (2020)[41]	Preoperative anxiety	Immersive VR game reduced anxiety
Bekelis et al. (2017)[2]	Satisfaction, anxiety	VR improved satisfaction, reduced anxiety
Haisley et al. (2020)[42]	Pain, satisfaction	VR meditation reduced pain, increased satisfaction
Steinkraus et al. (2024)[28]	Pain, anxiety, satisfaction	VR hypno-sedation reduced pain and anxiety, increased satisfaction
Siah et al. (2022)[34]	Efficacy, confidence	VR simulation improved nursing confidence
Dehghan et al. (2019)[45]	Preoperative anxiety	VR exposure reduced preoperative anxiety in children
Burchard (2023)[30]	Disinfection coverage	VR simulation improved coverage in OR simulation

eVaN-lr échelle de Valorisation de l’Anesthésie locoRégionale,” a French patient satisfaction scale PACU=Post-Anaesthesia Care Unit; QoL=Quality of Life; PMR=Progressive Muscle Relaxation; RAPN=Robot-Assisted Partial Nephrectomy; mYPAS-SFm=Modified Yale Preoperative Anxiety Scale—Short Form; OR=Operating Room; HMD=Head-Mounted Display; VR=Virtual Reality;VR MRI=Virtual Reality Magnetic Resonance Imaging. Key findings reflect primary outcomes as reported in the original studies; “no difference” refers to non-significant changes in the comparator group. All studies reported high acceptability and minimal adverse events with VR interventions

VR was associated with reduced pain perception during procedures such as vascular access, hand surgery, and regional anaesthesia. Several studies have demonstrated that VR can reduce the need for sedative medications (e.g., propofol, midazolam),[1,13,14,17,19,22,23,24,31] with some reporting improved comfort and recovery profiles.

Table 4A demonstrates that immersive head-mounted display (HMD) VR modalities consistently show the most substantial evidence for reducing anxiety, pain, and sedation requirements, as well as improving satisfaction and functional/cognitive outcomes, with support from multiple high-quality studies. Non-immersive (tablet/2D) VR provides moderate benefits for anxiety, pain, and satisfaction but lacks evidence for sedation or cognitive outcomes, suggesting it may be less effective than immersive approaches. Biofeedback/interactive VR yields strong effects for anxiety, pain, and satisfaction, with some evidence for sedation and cognitive benefits, indicating its potential for targeted interventions. Educational/simulation VR is effective for anxiety and satisfaction and shows promise for functional/cognitive outcomes, particularly in adult populations. 3D VR for planning is primarily associated with improved functional/cognitive outcomes, with no reported effects on anxiety, pain, or satisfaction, highlighting its specialised role in surgical planning.

Table 4A.

Comparative effectiveness of virtual reality modalities on perioperative outcomes

VR Modality	Anxiety Reduction	Pain Reduction	Satisfaction	Sedation/Analgesia Reduction	Functional/Cognitive Outcomes
Immersive (HMD)	+++ (Li Q et al.,[13] Carella M et al.,[19] Samnakay et al.[25])	++ (Li Q et al.,[13] Caruso et al.[24] Steinkraus et al.[28])	++ (Li Q et al.,[13] Carella M et al.,[19] Samnakay et al.[25])	++ (Carella M et al.[19], Li Q et al.[13])	+(Zhu B et al.[32] Grosso et al.[26])
Non-Immersive (Tablet/2D)	++ (Samnakay et al.[25]	+ (Samnakay et al.[25]	+	+	—
Biofeedback/Interactive	+++ Orgil et al.[6] Schrempf et al.[10]	++ Orgil et al.[6] Schrempf et al.[10]	++ Schrempf et al.[10]	+ Schrempf et al.[10]	+ Orgil et al.,[6] Schrempf et al.[10]
Educational/Simulation	++ (Sommer JL et al.,[8] El-Gabalawy et al.[21])	—	+ (Sommer JL et al.,[8] El-Gabalawy et al.[21])	—	++ (Sommer JL et al.[8], El-Gabalawy et al.[21])
3D VR for Planning	—	—	—	—	++ (Grosso et al.[26])

2D=Two-dimensional, HMD=Head-Mounted Display; VR=Virtual Reality. +++strong evidence; ++moderate evidence; +some evidence; —not reported/applicable

Table 4B reveals that VR consistently outperforms standard care, music/2D video, and sham/pharmacological controls in reducing anxiety, with strong evidence from multiple studies. VR is also superior to standard care and sham/pharmacological controls for pain reduction, with moderate evidence versus music/2D video, suggesting it is a robust adjunct for pain management. Satisfaction is significantly improved with VR compared to all control types, with consistent findings across studies. Functional/cognitive outcomes are improved with VR compared to standard care but show no significant difference versus sham/pharmacological controls, indicating its specific value in recovery and planning. VR has been successfully utilised for various innovative purposes, including animated operating room tours for children, perioperative mindfulness, and immersive games for anxiolysis. VR simulation also improved procedural skills and confidence among healthcare providers, such as perioperative nursing staff. The diversity of comparators (standard care, music, video, pharmacological agents) highlights the need for standardised outcome measures in future research.

Table 4B.

Comparative outcomes of virtual reality versus control interventions across domains

Outcome Domain	VR vs. Standard Care	VR vs. Music/2D Video	VR vs. Sham/Pharma
Anxiety Reduction	↓ (Li Q et al.,[13] Arifin J et al.[14]	↓ (Schrempf,[10] Samnakay[25])	↓ (Arifin[14], Li Q,[13] Carella[19])
Pain Reduction	↓ (Hundert AS et al.,[17] Faruki AA et al.,[22] Alaterre C et al.,[23], Caruso TJ et al.[24]	↓(McCullough,[9] Samnakay[25])	↓ (Faruki,[22] Li Q[13])
Satisfaction	↑ Li Q et al.,[13] Guigal C et al.[16]	↑ (Schrempf[10])	↑ (Carella,[19] Arifin[14])
Sedation/Analgesia	↓ Faruki A et al.[31]	—	↓ (Li Q[13], Carella[19])
Functional/Cognitive	↑ Zhu B et al.[32] Grosso AA et al.[26]	—	—

↓ reduced (VR better); ↑ increased/improved (VR better); —not reported/applicable. VR=Virtual Reality

Quality of included studies: Most included RCTs demonstrated a low or moderate risk of bias, particularly in randomisation, outcome measurement, and reporting. The main sources of potential bias were related to deviations from intended interventions and missing outcome data. A minority of studies were rated as high risk, often due to inadequate randomisation or incomplete data handling. Overall, the evidence base is methodologically robust; however, future studies should prioritise the transparent reporting of randomisation, blinding, and data management to minimise bias further.

Most studies demonstrated high methodological quality, with the majority achieving total NOS scores of 8 or 9 out of 9. Only two studies (McCullough et al.[9] and Chan et al.[38]) received lower scores (6/9), primarily due to limitations in comparability and the selection of non-exposed cohorts [Tables 5 and 6].

Table 5.

Risk of bias assessment

Risk of Bias 2.0	Randomisation Process	Deviations from Intended Interventions	Missing Outcome Data	Measurement of Outcomes	Selection of Reported Results	Overall Risk of bias
	Domain 1	Domain 2	Domain 3	Domain 4	Domain 5
Fonseca et al. 2024[20]	Low risk	Some concerns	Low risk	Low risk	Low risk	Low risk
Pandrangi et al. 2023[27]	Some concerns	High risk	Low risk	Some concerns	Some concerns	High risk
Caruso et al. 2019[24]	Low risk	Some concerns	Low risk	Low risk	Low risk	Low risk
Faruki et al. 2022[22]	Low risk	Some concerns	Some concerns	Some concerns	Low risk	Some concerns
Vogt et al. 2021[7]	Low risk	Some concerns	Low risk	Low risk	Low risk	Low risk
Samnakay et al. 2024[25]	Low risk	Some concerns	Low risk	Low risk	Low risk	Low risk
Hundert et al. 2022[17]	Some concerns	Some concerns	Low risk	Some concerns	Low risk	Some concerns
Schrempf et al.[10]	Low risk	Some concerns	Some concerns	Low risk	Low risk	Some concerns
Carella et al. 2023[19]	Low risk	Some concerns	Low risk	Low risk	Low risk	Some concerns
Arifin et al.[14]	Low risk	Low risk	Some concerns	Low risk	Low risk	Some concerns
Turrado et al. 2021[35]	High risk	Some concerns	High risk	Some concerns	High risk	High risk
Chen et al. 2025[4]	Some concerns	Low risk	Low risk	Low risk	Some concerns	Some concerns
Droc et al. 2023[12]	Some concerns	Some concerns	Some concerns	Low risk	Some concerns	Some concerns
Bekelis et al. 2017[2]	Low risk	Some concerns	Low risk	Low risk	Low risk	Low risk
Franco Castanys et al. 2023[29]	Low risk	Some concerns	Low risk	Low risk	Low risk	Low risk
Yang et al. 2019[44]	Low risk	Some concerns	Low risk	Low risk	Low risk	Low risk
Haisley et al. 2020[42]	High risk	Some concerns	Some concerns	Some concerns	High risk	High risk
Steinkraus et al. 2024[28]	Low risk	Some concerns	Low risk	Low risk	Low risk	Low risk
Keshvari et al. 2021[36]	Some concerns	Some concerns	Low risk	Low risk	Some concerns	Some concerns
Dehghan et al. 2019[45]	Low risk	Some concerns	Low risk	Low risk	Low risk	Low risk
Sahin et al. 2020[40]	Low risk	Some concerns	Low risk	Low risk	Low risk	Low risk
Burchard et al. 2023[30]	Some concerns	Some concerns	Low risk	Low risk	Some concerns	Some concerns
Hendricks et al. 2020[41]	High risk	High risk	High risk	High risk	High risk	High risk
Graf et al. 2023[5]	Low risk	Some concerns	Low risk	Low risk	Low risk	Low risk

Risk of bias was assessed using the Cochrane RoB 2.0 tool. Each domain was rated as “Low risk,” “Some concerns,” or “High risk” based on study methodology and reporting. Overall risk of bias was determined by the highest level of concern across all domains. “Low risk” indicates minimal bias, “Some concerns” indicates possible bias that may affect results, and “High risk” indicates substantial bias that could impact the reliability of findings

Table 6.

NOS: Newcastle–Ottawa Scale for observational studies

Newcastle–Ottawa Scale	Selection				Comparability		Outcome			Total quality score
Study	Representativeness of exposed cohort	Selection of non-exposed cohort	Ascertainment of exposure	Demonstration that outcome was not present at start	Main factor	Additional factor	Assessment of outcome	Sufficient follow up length	Adequacy of follow up
McCullough et al. 2023[9]	*	0	*	*	0	0	*	*	*	6
Chan et al. 2020[38]	*	0	*	*	0	0	*	*	*	6
Alaterre et al. 2020[23]	*	*	*	*	*	*	*	*	*	9
Delion et al. 2019[37]	*	*	*	*	*	*	*	*	*	9
Li et al. 2024[13]	*	*	*	*	*	*	*	*	*	9
Lopes et al. 2023[33]	*	*	*	*	*	*	*	*	*	9
Siah et al. 2022[34]	*	*	*	*	*	*	*	*	*	9

Quality assessment was performed using the Newcastle–Ottawa Scale (NOS) for cohort studies. Each asterisk (*) represents one point awarded in the respective domain. The total quality score is the sum of points across all domains, with a maximum of 9. “Selection” assesses representativeness and selection of cohorts, “Comparability” evaluates adjustment for main and additional confounding factors, and “Outcome” covers outcome assessment, follow-up length, and adequacy of follow-up

Subgroup analysis

Subgroup analyses revealed that VR interventions were particularly effective in reducing anxiety and pain among paediatric patients, primarily when immersive, gamified, or animated content was used. In minor surgical procedures, such as outpatient surgeries and endoscopies, VR produced greater reductions in perioperative anxiety and pain, with high patient satisfaction, compared to major surgeries, where the effects, while still positive, were somewhat attenuated. Both male and female patients benefited similarly from VR, and the interventions were effective across diverse socioeconomic backgrounds, provided access to technology was ensured. Immersive VR delivered through HMDs consistently outperformed non-immersive approaches, and therapeutic content (including relaxation, distraction, and mindfulness) was more effective for reducing anxiety and pain than educational modules. Timing also played a role: preoperative and intraoperative VR applications yielded the most robust benefits for anxiety and pain management, while postoperative use was less common but showed promise for enhancing satisfaction and recovery, particularly after major surgeries.

Meta-analysis findings

The meta-analysis demonstrated a significant anxiolytic effect of VR interventions across multiple measurement scales. On the VAS, VR significantly reduced anxiety [mean difference (MD) = −1.53; 95% confidence interval (CI) = −2.21 to −0.85; 5 studies; 368 participants]. When assessed using the STAI or STAI-Y, anxiety scores were markedly lower in the VR group (MD −3.85; 95% CI −5.69 to −2.01; 3 studies; 156 participants; P < 0.001; I² = 0), indicating a consistent benefit with negligible heterogeneity [Figure 2a-c].

Figure 2.

(a) Forest plot of comparison: Anxiety outcomes using VAS [VR interventions were associated with a significant reduction in perioperative anxiety, with a pooled mean difference of -1.53 (95% CI: -2.21 to -0.85; 5 studies, 368 participants; P < 0.001; I² = 70)]. (b) Forest plot of comparison: Anxiety score using STAI [anxiety scores measured by STAI or STAI-Y were significantly lower in the VR group (3 studies, 156 participants; MD = -3.85, 95% CI: -5.69 to -2.01; P < 0.001; I² 0]. (c) Forest plot of comparison: Anxiety score using mYPAS/mYPAS-SFm (23–100): [in paediatric populations, VR reduced anxiety as measured by mYPAS/mYPAS-SFm (2 studies, 299 participants; SMD = -0.70, 95% CI: -0.94 to -0.47; P < 0.001; I² =0), representing a moderate effect size]. (d) Forest plot of comparison: 1 Pain, outcome (experimental) {Pain scores were significantly lower in the VR group compared to control [3 studies, 146 participants; mean difference (MD) = -0.67, 95% CI: -1.31 to -0.04; P < 0.05; I² = 0], suggesting a modest but statistically significant reduction in perioperative pain with VR interventions}. (e) Forest plot of comparison: Satisfaction score based on VAS score {Patient satisfaction was higher in the VR group [2 studies, 258 participants; standardised mean difference (SMD) = 0.70, 95% CI: 0.45 to 0.95; P < 0.001; I² = 0], indicating a moderate-to-large effect}. VAS=Visual Analogue Scale;VR=Virtual Reality; STAI=State-Trait Anxiety Inventory; mYPAS=Modified Yale Preoperative Anxiety Scale; mYPAS-SFm=Modified Yale Preoperative Anxiety Scale-Short Form; SD=Standard Deviation; CI=Confidence Interval; IV=Inverse Variance

Among paediatric populations, VR interventions significantly reduced procedural anxiety as measured by the Modified Yale Preoperative Anxiety Scale—Short Form (mYPAS/mYPAS-SFm), yielding a moderate SMD (SMD −0.70; 95% CI −0.94 to −0.47; 2 studies; 299 participants; P < 0.001; I² =0). This highlights the value of immersive distraction for children in high-stress clinical environments.

For pain outcomes, pooled analysis from three studies (146 participants) demonstrated a modest but statistically significant analgesic effect favouring VR (MD −0.67; 95% CI −1.31 to −0.04; P < 0.05; I² =0), suggesting a role for VR as an adjunct to perioperative pain management [Figure 2d].

Patient satisfaction was also significantly higher following VR interventions (SMD 0.70; 95% CI 0.45 to 0.95; 2 studies; 258 participants; P < 0.001; I² = 0), indicating moderate-to-large improvements in perceived comfort and engagement [Figure 2e].

Across all included studies, no significant adverse events or safety concerns were reported. VR content was well tolerated, and no instances of psychological distress or perceived threat from virtual characters were observed. Dropout rates due to discomfort or dissatisfaction were minimal, highlighting the high acceptability and feasibility of VR in clinical settings.

DISCUSSION

The evidence consistently shows that VR is effective in reducing patient anxiety and distress, improving satisfaction, and, in many cases, reducing pain and the need for sedative medications.[1,13,14,19,23,24,25,42] These benefits are observed in both adult and paediatric populations, as well as across diverse surgical contexts, including orthopaedic, oncological, and minor procedures. Our study findings align with those reported in the recent meta-analysis by Li et al.[47] which evaluated the effectiveness of VR interventions in reducing perioperative anxiety among surgical patients. Also, Li et al.[47] highlighted the particularly strong benefits observed in paediatric cohorts and the enhanced effectiveness of distraction-based VR modalities—both of which reflect the trends identified in our subgroup analyses. The majority of included studies were of high methodological quality.[9,13,33,34,37,38] Risk of bias assessment using the Cochrane Risk of Bias 2.0 tool indicated that most RCTs were at low or moderate risk of bias,[2,4,7,10,12,14,17,19,20,22,24,25,27,29,35,44] particularly in domains related to randomisation and outcome measurement. Despite the overall high quality of studies, a few limitations like lack of control groups or addressing potential confounders may introduce bias.[1,15,16,18,20,38,39,43,46]

CONCLUSION

VR has emerged as a promising non-pharmacological adjunct in perioperative care, consistently demonstrating significant reductions in anxiety and pain, improvements in patient satisfaction, and decreased requirements for sedative medications across diverse surgical settings and patient populations. Immersive VR modalities, particularly those delivered via HMDs and incorporating biofeedback, mindfulness, or gamified content, show the strongest and most consistent benefits, outperforming non-immersive and educational approaches. The evidence supports VR as a safe, feasible, and effective tool for enhancing perioperative care, with high acceptability and minimal adverse events reported across studies.

Presentation at conferences/CMEs and abstract publication

Abstract has been accepted in World Congress of Anaesthesiologists (WCA2026) to be held at Marrakech, Morocco.

Study data availability

De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared after approval as per the authors’ institution’s policy.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections

Declaration of use of permitted tools

The scales, scores, figures, and tables in this meta analysis (including forest plots, tables of studies) is/are freely available and not copyrighted.

Supplementary material

This article has supplementary material and can be accessed at this link. Supplementary Material at http://links.lww.com/IJOA/A71.

Conflicts of interest

There are no conflicts of interest.

SUPPLEMENTARY MATERIAL

Detailed Search Strategy

The search was conducted using a combination of MeSH (Medical Subject Headings) terms and keywords to ensure comprehensive coverage of relevant articles. The following search terms were used across the selected databases (PubMed, Cochrane Library, Scopus, Embase, and ClinicalTrials.gov):

1. Virtual Reality (VR) Terms: “Virtual Reality” OR “VR” OR “Immersive Virtual Reality” OR “VR Technology” OR “VR intervention” OR “Virtual Reality System” OR “Virtual Reality Simulation”

2. Preoperative Anxiety Terms: “Preoperative Anxiety” OR “Preoperative Stress” OR “Surgical Anxiety” OR “Anxiety Reduction” OR “Anxiety Management” OR “Anxiety intervention” OR “Anxiety relief”

3. Postoperative Pain Terms: “Postoperative Pain” OR “Pain Management” OR “Postoperative Analgesia” OR “Pain Relief” OR “Pain Intervention” OR “Pain Reduction” OR “Pain Control”

4. Patient Education Terms: “Patient Education” OR “Preoperative Education” OR “Surgical Education” OR “Patient Understanding” OR “Patient Knowledge” OR “Preoperative Instruction” OR “Health Education”

5. Healthcare Professional Training Terms: “Healthcare Professional Training” OR “Medical Training” OR “Surgical Training” OR “Anesthesia Training” OR “Nursing Training” OR “VR Training” OR “Simulation-Based Training”

6. Perioperative Care Terms: “Perioperative Care” OR “Surgical Care” OR “Anesthesia” OR “Surgical Patient” OR “Surgical Procedure” OR “Surgical Outcome”

7. Outcomes and Impact Terms: “Outcomes” OR “Effectiveness” OR “Impact” OR “Efficacy” OR “Evaluation” OR “Clinical Outcomes” OR “Patient Satisfaction” OR “Healthcare Outcomes” OR “Clinical Effectiveness”

8. Study Design Terms (for filtering):”Randomised Controlled Trial” OR “RCT” OR “Cohort Study” OR “Case-Control Study” OR “Qualitative Study” OR “Observational Study” OR “Pilot Study” OR “Systematic Review” OR “Meta-Analysis”

Search strategy used

(“Virtual Reality” OR “VR” OR “Immersive Virtual Reality” OR “VR Technology” OR “Virtual Reality System” OR “Virtual Reality Simulation”) AND

(“Preoperative Anxiety” OR “Preoperative Stress” OR “Surgical Anxiety” OR “Anxiety Reduction” OR “Anxiety Management” OR “Anxiety intervention” OR “Anxiety relief”) AND

(“Postoperative Pain” OR “Pain Management” OR “Postoperative Analgesia” OR “Pain Relief” OR “Pain Intervention” OR “Pain Reduction” OR “Pain Control”) AND

(“Patient Education” OR “Preoperative Education” OR “Surgical Education” OR “Patient Understanding” OR “Preoperative Instruction” OR “Health Education”) AND

(“Perioperative Care” OR “Surgical Care” OR “Anesthesia” OR “Surgical Patient” OR “Surgical Procedure”) AND

(“Randomised Controlled Trial” OR “RCT” OR “Cohort Study” OR “Case-Control Study” OR “Qualitative Study” OR “Observational Study”)

Supplementary Table S1.

Summary of Outcomes for Meta-analysis (Satisfaction, Anxiety, Pain)

Study (Author, Year)	Outcome	Group	Mean	SD	n	Notes/Timepoint/Scale
Satisfaction (VAS 0–10)
Alaterre et al. 2020[24]	Satisfaction	VR	10	1.0*	50	Median [IQR]: 10 [9;10], SD est.
		Control	9	1.5*	50	Median [IQR]: 9 [8;10], SD est.
Qianqian Li (2024)[13]	Satisfaction	VR	9.8	0.6	79	Postoperative satisfaction
		Control	9.3	0.9	79
Anxiety Outcomes (VAS 0–10)
Alaterre et al. 2020[24]	Intraoperative anxiety	VR	0	1.6*	50	Median [IQR]: 0 [0;2], SD est.
		Control	3	3.2*	50	Median [IQR]: 3 [0.25;7], SD est.
Carella M et al. 2025[19]	Preoperative anxiety	VRH	4	2.0*	30	Median (IQR): 4 (3–6), SD est.
		Control	4.5	2.0*	30	Median (IQR): 4.5 (2.25–5.75), SD est.
Sommer JL (2024)[21]	Preoperative anxiety	VR	2.2	1.3	7
		Control	3.6	1.2	7
Chan IJ[29]	Preoperative anxiety	VR	2.4	1.1	55
		Control	3.7	1.4	55
Vogt L (2021)[7]	Preoperative anxiety	VR	2.5	1.6	42
		Control	4.0	1.8	42
Anxiety Outcomes (STAI/STAI-Y)
Arifin J et al. 2023[14]	Intraoperative anxiety	VR	33.6	4.12	15	During surgery, STAI-6 (6–24)
		Control	37.4	5.44	15	During surgery, STAI-6 (6–24)
Arifin J et al. 2023[14]	Postoperative anxiety	VR	29.4	4.25	15	Recovery room, STAI-6
		Control	34	5.79	15	Recovery room, STAI-6
Carella M et al. 2025[19]	Preop STAI-Y	VRH	35.5	5.5*	30	Median (IQR): 35.5 (30–41), SD est.
		Control	38.5	6.5*	30	Median (IQR): 38.5 (30.25–43.75), SD est.
Schrempf et al. 2022[10]	Preop anxiety	VR	32.2	9.7	18	Preop, VR group, STAI (20–80)
		Music	33.1	10.1	18	Preop, music group, STAI (20–80)
		Control	37.5	8.9	18	Preoperative, no intervention, STAI (20–80)
Pain Scores (NRS 0–10)
Amos S. Hundert et al. 2022[17]	Pain (during)	VR	0.9	1.5	20	NRS (0–10)
		Control	1.3	2.3	18	NRS (0–10); iPad as control
Barry et al. 2022[1]	Pain (PACU immediate)	VR	0.6	1.7	18	NRS (0–10)
		Control	1.2	2.4	36	NRS (0–10)
Barry et al. 2022[1]	Pain (PACU discharge)	VR	1.2	1.5	18	NRS (0–10)
		Control	2.1	2.1	36	NRS (0–10)
Anxiety (mYPAS/mYPAS-SFm, 23–100)
Wu Y et al. (2022)[15]	Preoperative anxiety	VR	28.6	6.1	50	Preoperative, mYPAS-SFm
		Control	34.2	7.3	49	Preoperative, control group, mYPAS-SFm
Samnakay (2024)[31]	Preoperative anxiety	VR	26	5.5	100	3D VR vs. 2D video, mYPAS
		Control	29.8	6.2	100

VAS=Visual Analogue Scale, NRS=Numeric Rating Scale, IQR=Interquartile Range, SD=Standard Deviation, VR=Virtual Reality, STAI=State–Trait Anxiety Inventory, mYPAS=Modified Yale Preoperative Anxiety Scale, PACU=Post-Anesthesia Care Unit, VRH=Virtual Reality Hypnosis, SD est.=Standard Deviation estimated from IQR or median *SD estimated from IQR or median; see Methods for conversion details.

Footnote: All means, SDs, and sample sizes (N) are as reported in the respective studies. Timepoint and scale/unit are indicated to aid interpretation and facilitate transparency for meta-analysis replication

Funding Statement

Nil.