Table 1.

Summary of characteristics of included studies

Study	Participants (n)	Benchmark measurements	Level of expertise	VR training modality	VR training performed	Control group	Assessment method	Recorded results
Aggarwal et al (2007)10	19	10 experienced surgeons completed 2 laparoscopic cholecystectomies	Novice	LapSim® (Surgical Sciences Sweden AB)	Proficiency based: Calot’s triangle dissection + 3 porcine laparoscopic cholecystectomies	5 cadaveric porcine laparoscopic cholecystectomies	5 porcine laparoscopic cholecystectomies	ROVIMAS; time taken, total path length, total number of movements, video rating scores
Ahlberg et al (2007)39	13	5 experienced surgeons performed 6 tasks in recorded results	Novice	LapSim	Proficiency based: 6 tasks performed under supervision until expert level attained	No additional training	10 laparoscopic cholecystectomies performed per trainee	Errors in exposure, clipping and tissue division, dissection errors, total errors, surgical time
Ahlborg et al (2013)3	28	Nil (No benchmark measurement)	Novice	LapSim	2-day practice on simulator	No additional training	3 supervised laparoscopic tubal occlusions	Visuospatial ability, flow scores, time
Ali et al (2014)11	60	Nil	Novice and expert	LapSim	LapSim group: camera navigation, instrument navigation, coordination, grasping, cutting, lifting, suturing, dissection. Box model group: excise a drawn circle, move pegs, cut the outer balloon, grasp and throw beans, peel an orange, suture and tie a knot, introduce an epidural catheter into an intravenous infusion tube.	No additional training	Supervised laparoscopic tubal occlusions	OSA-LS; operation time, total score, economy of movements, movements/instrument handling, economy of time, respect of tissue
Andreatta et al (2006)12	19	Nil	Novice	Lap Mentor™ (3D Systems)	Proficiency based: camera navigation, eye-hand coordination, clipping and grasping, cutting, electrocautery and translocation of objects	No additional training	Laparoscopic skills exercises on anaesthetised male pigs	Camera navigation, eye–hand coordination, time, efficiency of motion, instrument handling, perceptual ability, safe electrocautery, safe clipping
Calatayud et al (2010)13	10	Nil	Novice and expert	LapSim	Preoperative VR training termed as ‘warm-up’	No additional training	Supervised laparoscopic cholecystectomy	OSATS; respect for tissue, time and motion, instrument handling, knowledge of instruments, use of assistants, flow of operation, knowledge
Cosman et al (2007)14	10	10 experienced surgeons performed clipping task on the simulator	Novice	LapSim	Proficiency based: clipping task + training protocol for a maximum of 1 hour/day	No additional training	Supervised application of clips and divide cystic duct or cystic artery during a laparoscopic cholecystectomy	Errors, global score, time
Hogle et al (2009)27	33	Nil	Novice and expert	LapSim	Proficiency based: novice – camera navigation, instrument navigation, coordination, grasping, lifting and grasping, cutting and clip applying; expert – training on a laparoscopic simulator for 5 weeks	No additional training	Supervised laparoscopic cholecystectomy	GOALS; Depth perception, bimanual dexterity, efficiency, efficiency, tissue handling, autonomy, operative time
Hung et al (2012)28	24	Nil	Novice	DaVinci® Skills Simulator (Mimic Technologies Inc.)	17 simulator exercises over 10 weeks	No additional training	Porcine bowel resection, cystotomy and repair and partial nephrectomy using robotic system	GOALS; objects dropped, motion economy, excessive instrument force, instrument collisions, missed targets, time, broken vessels, blood loss
Hyltander et al (2002)5,22	24	Nil	Naïve	LapSim	4 simulator exercises: camera navigation, instrument navigation, instrument handling, manipulating items for 2 hours/week for 5 weeks	No additional training	Laparoscopic surgery on two anaesthetised pigs	Camera navigation, instrument navigation, combination, extended combination, time
Larsen et al (2009)23	21	Nil	Novice	LapSim	Oral introduction on simulator + simulator training in lifting and grasping and cutting + completion of a simulated right sided salpingectomy. Training cycles of 45–60 minutes.	No additional training	Supervised laparoscopic salpingectomy	Duration of training, time, score
Lucas et al (2008)25	32	Nil	Naïve	Lap Mentor	8 simulator exercises: camera manipulation, hand–eye coordination, clipping, grasping, 2-handed manoeuvres, cutting, fulguration and object translocation. 6 unsupervised training sessions of 30 minutes each.	No additional training	Porcine laparoscopic nephrectomy	OSATS; respect for tissue, time and motion, instrument handling, knowledge of instruments, use of assistants, flow of operation, knowledge
Lucas et al (2008)24	32	Nil	Naïve	Lap Mentor	8 simulator exercises: camera manipulation, hand–eye coordination, clipping, grasping, 2-handed manoeuvres, cutting, fulguration and object translocation. 6 unsupervised training sessions of 30 minutes each.	No additional training	Supervised simple laparoscopic cholecystectomy	OSATS; respect for tissue, time and motion, instrument handling, knowledge of instruments, use of assistants, flow of operation, knowledge
Madan & Frantzides (2007)40	65	Nil	Naïve	MIST-VR	Simulator exercises: acquire and place, transfer and place, transversal, withdraw and insert, diathermy, manipulate and diathermy. 10 sessions of 20 minutes each for both simulator and box-trainer groups.	No additional training	Four tasks assessed in a porcine laboratory	Tissue handling, placing bowel in retrieval bag, liver biopsy, stapling, ‘running’ the bowel
Maschuw et al (2011)15	50	Nil	Novice	LapSim	Proficiency based simulator exercises + virtual laparoscopic cholecystectomy for twice a week sessions for 3 months	No additional training	VR simulation assessing predefined criteria	Time, path length, angular path, tissue damage, economy of motion
McClusky et al (2004)6	12	Experienced surgeons performed laparoscopic cholecystectomy	Novice	MIST-VR	Simulator exercises: manipulation and diathermy	No additional training	Supervised laparoscopic cholecystectomy	OSATS; time, path length, angular path, operative steps, score
Palter et al (2012)21	25	Nil	Novice	LapSim	Proficiency based: simulator exercises + video instruction for a duration of 5 months	No additional training	Supervised laparoscopic right hemicolectomy	OSATS; respect for tissue, time and motion, instrument handling, knowledge of instruments, use of assistants, flow of operation, knowledge
Palter et al (2013)16	18	Nil	Novice	LapSim	Theoretical training + case-based learning + simulator training for 6 months	No additional training	5 laparoscopic cholecystectomies in operating theatre, VR assessment and simulated crisis scenario	Time, path length, angular path, number of errors
Sergio et al (2014)26	14	Nil	Naïve	Lap Mentor	Virtual sigmoid colectomy: 2-hour training on simulator	No additional training	Laparoscopic sigmoid resection on anaesthetised pig	Tissue handling, dexterity, instrument handling, exposure, haemostasis, flow of tasks, technical skills score
Seymour et al (2002)29	16	4 experienced surgeons performed the 10 trials in recorded results	Novice	MIST-VR	Proficiency based: two trials performed with both hands. Training sessions lasted approx. 1 hour.	No additional training	Supervised laparoscopic cholecystectomy	Number of errors
Tanoue et al (2005)18	30	Nil	Naïve	MIST-VR	1 simulator exercise - one stitch and two ties including left- and right-hand repetitions for 2 hours/day for 2 days	No additional training	One stitch and two ties including left and right repetitions in a box trainer	Improvement rate
Tanoue et al (2008)17	35	Nil	Naïve	MIST-VR	3 simulator/box trainer exercises: suturing, knot tying and diathermy including left- and right-hand repetitions for 2 hours/day for 2 days	Watched an educational video for 30 minutes	Stitch needle to place one stitch and two ties between dots printed on a rubber sheet in a box trainer	Time, speed
Verdaasdonk et al (2008)19	20	Nil	Novice	Simendo®	Proficiency based: knot-tying repeated for 10 times	No additional training	Laparoscopic knot on an anaesthetised porcine model	Instrument handling, needle and suture drops, attempted loops, knot tightening
Youngblood et al (2005)20	46	Experienced surgeons performed laparoscopic techniques	Naïve	LapSim and tower trainer	3 simulator tasks: grasping and placing gallstones in endo bag, running the bowel, clipping and cutting an artery. 4 supervised, 45-minute training sessions.	No additional training	Laparoscopic assessment in porcine laboratory	Time, accuracy

GOALS, global operative assessment of laparoscopic skills; MIST-VR, minimally invasive surgery trainer – virtual reality; OSA-LS, objective structured assessment – laparoscopic salpingectomy; OSATS, objective structured assessment of technical skills; ROVIMAS, RObotics VIdeo and Motion Assessment Software; VR, virtual reality