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Effect of virtual reality training on laparoscopic surgery: randomised controlled trial

BMJ 2009; 338 doi: (Published 15 May 2009) Cite this as: BMJ 2009;338:b1802

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  1. Christian R Larsen, clinical research fellow1,
  2. Jette L Soerensen, assistant professor and consultant2,
  3. Teodor P Grantcharov, assistant professor and consultant3,
  4. Torur Dalsgaard, consultant4,
  5. Lars Schouenborg, consultant4,
  6. Christian Ottosen, consultant4,
  7. Torben V Schroeder, professor and consultant5,
  8. Bent S Ottesen, managing director and professor at the Juliane Marie Centre6
  1. 1Department of Gynecology, Juliane Marie Centre for Children, Women and Reproduction, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100 OE, Copenhagen, Denmark
  2. 2Department of Obstetrics, Juliane Marie Centre, Copenhagen
  3. 3Division of General Surgery, St Michael’s Hospital, Toronto, ON, Canada
  4. 4Department of Gynecology, Juliane Marie Centre, Copenhagen
  5. 5Department of Vascular Surgery, Abdominal Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen
  6. 6Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
  1. Correspondence to: C R Larsen crl{at}
  • Accepted 21 January 2009


Objective To assess the effect of virtual reality training on an actual laparoscopic operation.

Design Prospective randomised controlled and blinded trial.

Setting Seven gynaecological departments in the Zeeland region of Denmark.

Participants 24 first and second year registrars specialising in gynaecology and obstetrics.

Interventions Proficiency based virtual reality simulator training in laparoscopic salpingectomy and standard clinical education (controls).

Main outcome measure The main outcome measure was technical performance assessed by two independent observers blinded to trainee and training status using a previously validated general and task specific rating scale. The secondary outcome measure was operation time in minutes.

Results The simulator trained group (n=11) reached a median total score of 33 points (interquartile range 32-36 points), equivalent to the experience gained after 20-50 laparoscopic procedures, whereas the control group (n=10) reached a median total score of 23 (22-27) points, equivalent to the experience gained from fewer than five procedures (P<0.001). The median total operation time in the simulator trained group was 12 minutes (interquartile range 10-14 minutes) and in the control group was 24 (20-29) minutes (P<0.001). The observers’ inter-rater agreement was 0.79.

Conclusion Skills in laparoscopic surgery can be increased in a clinically relevant manner using proficiency based virtual reality simulator training. The performance level of novices was increased to that of intermediately experienced laparoscopists and operation time was halved. Simulator training should be considered before trainees carry out laparoscopic procedures.

Trial registration NCT00311792.


  • We thank Jorn Wetterslev at the Copenhagen Trials Unit for critical revision of the research protocol, assistance with the power calculation, and the concealed computer based randomisation of the participants.

  • Contributors: CRL (principal investigator) acquired the data, drafted the paper, did the statistical analysis, and obtained funding. TPG and JLS provided administrative support and critically revised the manuscript. JLS had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. TD acquired the data, provided technical support, and critically revised the manuscript. LS and CO acquired the data, provided administrative support, and critically revised the manuscript. TVS and BSO provided administrative support and supervised the study, critically revised the manuscript, and obtained funding. All authors conceived and designed the study and analysed and interpreted the data.

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

  • Competing interests: None declared.

  • Ethical approval: The investigation fully complied with the Helsinki II declaration on biomedical research. The study was approved by the Danish National Committee on Biomedical Research Ethics (approval code (KF) 01 28 37 56). All study participants and patients were provided with written study documentation and were included in the trial after informed consent. The Danish Data Protection Agency approved the collection, analysis, and storage of the DVD recordings (approval code: 2005-41-5817).

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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