Standard surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform the surgery under the supervision of a trained surgeon. This is costly, time-consuming, and is of variable effectiveness. Laparoscopic surgery involves the use of instruments using keyhole and is generally considered more difficult than open surgery. Training using a virtual reality simulator (computer simulation) is an option to supplement standard laparoscopic surgical training. Virtual reality training improves the technical skills of surgical trainees. The impact of virtual reality training in supplementing standard laparoscopic surgical training in surgical trainees with limited prior laparoscopic experience on patients is not known. We define surgical trainees with limited prior laparoscopic experience as those who have helped senior surgeons in laparoscopic operations and would need supervision for performing laparoscopic operations on their own. We sought to answer the question of whether virtual reality training is useful for such surgical trainees in terms of improving surgical results and for improving the operative performance by performing a thorough search of the medical literature for randomised clinical trials. Randomised clinical trials are commonly called randomised controlled trials and are the best study design to answer such questions. If conducted well, they provide the most accurate answer.

Two authors searched the medical literature available until July 2012 and obtained the information from the identified trials. The use of two authors to identify studies and obtain information decreases the errors in obtaining the information. We identified and included eight trials covering 109 surgical trainees in this review. The trials compared virtual reality with no supplementary training or with box-trainer training (physical simulator using a camera to display the inside of the box and instruments). There were no trials that compared different forms of virtual reality training. All the trials were at high risk of bias (defects in study design that can lead to arriving at wrong conclusions with overestimation of benefits and underestimation of harms of virtual reality training or standard training). Operating time and operative performance were the only outcomes reported in the trials. The remaining outcomes such as death, complications, quality of life, and hospital stay after the operation were not reported in any of the trials. Overall virtual reality training appears to decrease the operating time (by about 10 minutes) and improve the operative performance of surgical trainees (difficult to quantify from the available reports) with limited laparoscopic experience when compared with no supplementary training or with box-trainer training. However, the impact of this decreased operating time and improvement in operative performance on patients or healthcare funders in terms of improved health or decreased costs is not known. Further well-designed trials are necessary, with less risk of arriving at wrong conclusions because of poor study design or because of chance. Such trials should assess the impact of virtual reality training on patients and healthcare funders.