Table 1 Characteristics of the included studies

Hedman et al. [10]

Journal of

endoscopic

surgery

Sweden

LAP

54

54 Novice surgeons (medical students in surgery training) with no previous simulator experience

Women m=24.8

Male m=25.7

Medicine + Psychology

Visual Spatial abilities correlation for novice performing complex laparoscopic simulator tasks

MT* Vanderberg and Kuse (MRT-A & MRT-C)

GSA* BasIQ test

Procedicus KSA (Instrument Navigation & Manipulate and Diathermy)

Pearson’s product-moment correlation & regression analysis & paired T-test and Wilcoxon

High-level visual abilities predicted performance on spatially complex tasks on the simulator.

After 10 min on a simulator, those with low abilities scored the same on the second trail as those with high abilities.

Conrad et al. [19]

Journal of endoscopic surgery

America

LAP

10

Surgical residents (n = 6) & attending surgeons (n = 4) with prior simulation experience.

Not disclosed

Medicine

Mental rotation and mental scanning on camera rotation angle

None used

‘Specially constructed laparoscopic box’ stationary 10-mm, 0° laparoscope, 12 cm away from task at 35° angle was used to assess threading and knot tying skills.

Linear regression analysis, correlation coefficient

Angle increase from 15° to 90° resulted in 10–30% increase in error and time and performance.

Performance decreased in directional-spatial motor tasks.

DeLucia et al. [20]

Human

factors and

ergonomics

meeting

America

MIS

368

Psychology undergraduate students.

Not disclosed

Psychology

Depth perception and spatial navigation

None used

E1 = Box with a customized colon + borescope

E2 = Computer angle simulation (Pentium III 550 MHz)

ANOVA, mixed- ANOVA + Tukey’s (HSD)

Developing a mental model of the surgical environment and the tools pre-operatively, aids spatial navigation as it provides additional depth cues.

Hassan et al. [21]

Childs nervous system journal

Germany

LAP

24

F = 9,

M = 14

Novice surgeons (medical students) with no previous VR experience

Mean = 34

Medicine + Psychotherapy

Spatial perception and VR laparoscopic simulator

SV* Lameris Toegepaste Natuurwetenscha ppeljik Onderzoek (TNO)

SP* Stumpf-Fay Cube Prespective Test

LapSim (Surgical Science) laparoscopic simulator on cutting, clip application and coordination.

Descriptive statistics + Mann-Whitney test.

Those with higher levels of spatial perception were faster, had better performance and adopted faster to non-stereo environment than those with low levels.

Haveran et al. [23]

Journal of endoscopic surgery

America

LAP

24

Experienced (Surgical residence between 3-6th training year) & medical students

Not specified

Medicine + Psychology

Perceptual distortion on laparoscopic camera and monitor positions

None used

Self designed canopy endosurgical simulator (wooden box with objects inside) with alternating angles borescope.

Used Proc mixed procedure

ANOVA with Tukey’s (HSD) test

Kolmogoro v-Smirnov goodness of fit.

Highlighted importance of monitor and camera positioning in laparoscopy (camera at 0° and monitor at 180°) located direct opposite the surgeon

Monitor position at angles of 120° or 140° significantly declined performance

Even minor camera changes decreased spatial awareness.

Hedman et al. [22]

Journal of endoscopic surgery

Sweden

LAP

28

Medical students attending basic surgery course with no previous simulator experience

Mean = 27

Medicine + Psychology

Visual working memory in VR

MT* Vanderberg and Kuse (MRT-A) test

The Procedius MIST-VR PC based simulator & GI Mentor II simulator (gastro endoscopy simulator)

Pearson’s product correlation

Visual-spatial ability was found to correlate with performance, although intense training on simulator outweighed those.

Klein et al. [8]

Journal of Stress and Endoscopic Surgery

America

LAP

54

Undergraduates students with no previous with endoscopic/laparoscopic simulator

Mean = 22

Psychology

Perceptual-motor abilities – effect of stress on novice performing endoscopic/lapar oscopic tasks on the simulator

ST* Dundee stress state questionnaire (DSSQ)

Edinburgh Handedness Inventory

Fundamentals of Laparoscopic surgery (FLS) with McGill Inanimate System for Training and Evaluation of Laparoscopic skills (MISTELS)- including pegtransfer, circle cutting, loop placement

ANOVA with Tukeys post hoc, mixed ANOVA

Perceptual-motor disruptions are caused by the reduction in depth information and transformed spatial mapping, responsible for reducing the performance on the endoscopic or laparoscopic simulator.

The loss of depth information and disrupted eye-hand coordination was found to increased stress.

Hsu et al. [24]

Journal of Endoscopic Surgery

Canada

LAP

40

27 novice and residence, 9 experienced – 5 fellow/staff, 4 PGY 3-3y)

Not specified

Medicine

Cognitive decisions and technical skill automatization when using cognitive distractions (mathematical algorithmic questions during simulator.

None used

FLS simulator (lighted, enclosed laparoscopic trainer box in a fixed position)

Descriptive statistics, Student’s T-test

Cognitive distraction reduced the performance of a novice, but not an experienced surgeon (Due to the technical of the task).

Keehner [3]

Spatial Cognition

United Kingdom

LAP

40

F = 22,

M = 18

Undergraduates Psychology students

Mean = 20

Psychology

Visual-spatial abilities and frame of reference

MT* Mental rotation test, The paper folding test and Card rotation tasks.

Self-made simulator to mimic laparoscopic conditions using laparoscopic two camera angles (90° and 270°)

Independen t samples T-test,, one samples ttest, correlationa l analysis

Seeing the back of your hand in a 90° o the monitor increased performance.

270° angle decreased performance

Komesu et al. [14]

American Jo urnal of Obst etrics & Gyn ecology

America

ENDO

68

Surgical residents

Control group M = 29.3

Imagery group M = 28.7

Medicine

Mental imagery practice in improving preoperative cytosopic procedure (minimally invasive endoscopic procedure)

The Global Scale of Operative Performance (GSOP)

None used

Power analysis, T-test for continuous variable, Fisher exact for categorical variables, Wilcoxon rank for ordinal variables & ANOVA.

Residents who practiced mental imagery preoperatively, showed superior performance as compared to the control group.

Suggested that mental imagery would show greater effect if performed prior to complicated procedures which involve complex cognitive components.

Sodergren et al. [13]

The Annals of Surgery

United Kingdom

LAP

21

M = 19,

F = 2

Surgeons (4 attending surgeons, 3 senior residents and 14 junior residents)

Mean = 31.6

Medicine

Spatial orientation and strategies in laparoscopic cholecystectomy

None used

Used eye-tracking Tobii ET 1750,an infrared video-based binocular eye tracking system.

Non parametric Kruskal Wallis test and Mann Whitney U test Coefficient correlation of determinati on

Laparoscopic surgeons create discernable visual strategies to orientate themselves. The homogeneity of performance suggested that laparoscopic surgeons do at some point reach a plateau consistent with their innate abilities. Experie nced surgeons made spatial disorientation errors 22% of the time.

Age and gender were found to be predictors of performance.

Arora et al. [15]

American college of Surgeons

United Kingdom

LAP

18

Novice surgeons recruited by random sampling.

Mental practice group = mean 22

Control group = mean 22

Medicine

Mental practice and indirectly mental imagery to reduce stress when training novice surgeons on a laparoscopic VR simulator

MT* Mental Imagery Questionnaire (MIQ)

ST* Imperial Stress Assessment Tool (ISAT), State Trait Anxiety Inventory (STAI)

MIST-VR simulator used to compare participants

The LAP mentor VR laparoscopic surgical simulator used for the actual task

Descriptive statistics, Mann- Whitney U test, Spearman rho correlation

Performing a short mental practice training preoperatively was found to reduced stress intraoperative, both psychologically and physiologically.

Mental practice was found to improve cognitive skills.

Zhang et al. [18]

Proceedings of the Human Factors in Ergonomics Society

America

LAP

24

Laypeople with no prior experience in performing laparoscopic surgery or VR related simulation

Between 22 and 45

Human factors & Ergonomics

Effects of visual-motor misalignment on laparoscopic surgery performance

None used

DynaMITE simulator, consisting Stryker Endoscopy system and the Dynamic Minimally Invasive Training Environment (DynamMITE)

A 2-way ANOVA with Tukey’s HSD post hoc analysis using a Bonferroni adjustment.

Performance was best when the image was rotated at 0°.

Performance was best with endoscope at −45° and worst at 180°.

DeLucia et al. [17]

Journal of Experimental Psychology

America

LAP

36

Psychology undergraduate students who received course credit.

Not stated

Psychology

Effect of camera arrangement on Perceptual motor performance in MIS

None used

Self made wooden box with bullet cameras and surgical graspers

Mixed ANOVAs with Tukeys HSD

Viewing an image from the camera perspective degraded performance, compared to direct viewing.

Sodergren et al. [13]

British Journal of Surgery Society

United Kingdom

LAP

30

M = 21,

F = 9

Medical students (Final year)

Control Group (median = 23),

Intervention Group (median = 22)

Medicine

Spatial orientation in laparoscopic cholecystectomy

None used

No simulator used – used laparoscopic video

Used eye-tracking Tobii ET 1750,an infrared video-based binocular eye tracking system.

Kurskal- Wallis test with Mann- Whitney

Teaching orientation strategies to novice surgeons significantly increases their performance and reduces the cognitive burden

Kolozsvari et al. [25]

Journal of Endoscopic Surgery

Canada

LAP

32

M = 19,

F = 13

Medical and dental students with no previous surgical experience

Mean = 23

Medicine

Exploring gender differences on laparoscopic surgical skill acquisition whilst testing for visual-spatial, spatial orientation, spatial scanning & perceptual abilities

VS* The Ekstrom-French Kit of Factorreferenced cognitive test SPT* Card Rotation and Cube Comparison test. SS* Map planning test SP* Pictorial Surface Orientation (PicSOr)

Fundamentals of Laparoscopic surgery (FLS) on a peg transfer, circle cut, placement loop and tying.

Controlled for handiness (r = 30, l = 2), interest in surgery (high = 12, moderate = 15) and video game experience

Used SPSS

Nonlinear regression, ANOVA and univariate analysis factors

No gender difference was found, indicating that gender does not affect the learning curve.

Interest in surgery and perceptual abilities did influence the early-simulated performance only.

Klein et al. [8]

Journal of Stress and Endoscopic Surgery

America

MIS

15

M = 13,

F = 2

First year medical students

Mean = 25

Psychology

Mental workload and Stress perceived by novice surgeons in Laparoscopic and Robotic surgery

MW* Multiple Resources Questionnaire (MRQ)

ST* Dundee Stress State Questionnaire (DSSQ)

Fundamentals of Laparoscopic surgery (FLS) trainer box with a DaVinci surgical system – on a peg transfer task

Descriptive statistics, Bonferroni-corrected t-test, a 2 × 7 and 2 × 11 ANOVA.

The Da Vinci system allowed for an overall better performance compared to the laparoscopic system.

No difference in mental workload score was found between the two systems, although the DaVinci did reduced stress.

Luursema et al. [28]

Learning and Individual Differences

The Netherlands

LAP

24

F = 19,

M = 5

University students in Technical Medicine (participation in this study was required as part of the course).

Aged either 21 or 22

Medicine + Psychology

Exploring visual-spatial, Spatial relations, flexibility of closure and perceptual speed abilities on duration, motion efficiency and damage on the laparoscopic simulator tasks.

Demographic questionnaire

VS* Vandenberh and Kuse test

SR* Cards test

FC* Hidden Objects test

LapSim v.3.0.10 simulator with Immersion VLI hardware, running on PC on grasping and instrument navigation tasks.

Training course lasted for 2 months (8 weekly for 30 min)

Repeated measures analysis, repeated measures ANCOVA (Mauchly’s test of sphericity was not assumed)

Visualization abilities impacted performance on damage and motion. Perceptual speed only predicted the speed factors and not complexity. Training on the simulator outweighed the innate visual abilities.

Mistry et al. [9]

Journal of Surgical Education

Canada

LAP

31

First-and-second year medical students with no laparoscopic experience.

Not stated

Medicine

Visual-spatial abilities and manual dexterity (in connection to stereoscopic vs. monoscopic) effect o surgical skill acquisition in novice surgeons.

VS* Vandenberg and Kuse Mental Rotation Test

Manual dexterity* Purdue Pegboard Test

Fine and Gross Stereoscopic vision*

Schmetterlings Test and Graded Circle Test (KAVITA)

Fundamentals of Laparoscopic surgery (FLS) with McGill Inanimate System for Training and Evaluation of Laparoscopic skills (MISTELS)- including peg-transfer, circle cutting, loop placement

Data tabulation, MANOVA, correlation coefficient

No significant difference between the stereoscopic and monoscopic vision on laparoscopic tasks was found, except in peg-transfer where monoscopic visualization was found to improve performance.

External stimuli (haptic or auditory) did increased the cognitive load (mental effort)

Roach et al. [12]

Anatomical Sciences Education

Canada

LAP

20

M = 13,

F = 7

First-and-second year medical students with no previous surgical specific and no laparoscopic experience.

Uses the sample from Mistry et al., 2013

Mean = 23

Medicine

Visual-spatial abilities and laparoscopic skills in novice surgeons, comparing stereoscopic and monoscopic visualizations.

MT* Vandenberg and Kuse MRT-A test

Vision* Stereo Butterfly test and Graded Criclr test

Fundamentals of Laparoscopic surgery (FLS) with McGill Inanimate System, including peg-transfer, circle cutting, loop placement

Data tabulation, ANOVA, correlation coefficient

Those with high visual-spatial (HVs) outperformed those with lower-spatial abilities (LVs) and gained technical skills more rapidly.

Louridas et al. [16]

British

Journal of Surgery Society

Canada

LAP

20

Senior surgical trainees (Postgraduate year 3 and 4 general surgery residents)

Not stated

Medicine

Mental practice in enhancing laparoscopic surgical performance

MP* Mental Imagery Questionnaire Revised second version (MIQ-RS)

ST* State-Trait Anxiety Inventory (STAI)

Non-Technical Skills for Surgeons (NOTSS)

Self-made box trainer, using a porcelain bowel model

Nonparametric tests, Wilcoxon rank sum test and Mann-Whitney U test.

Mental practice (with script and voice-over) improved mental imagery and advanced laparoscopic technical skill acquisition.

Surgeons who practiced mental practice showed better response to intra-operative stress.

Groenier et al. [26]

Advances in Health Sciences Education

The Netherlands

LAP

53

Undergraduate students in Technical Medicine program with no previous laparoscopic experience.

Mean = 22

Multidisciplinary (Science and Technology, Psychology and Medicine)

Exploring the relationship between spatial memory, perceptual speed and general reasoning ability in laparoscopic simulator training

VS* Vandenberg and Kuse, Paper Folding test, the surface

Development test and The Rotating Shapes test.

SM* Corsi Block Tapping test

PS* The Number Comparison test, Identical Pictures test

Global Reasoning: Raven Advance Progressive Matrices test

Verbal Reasoning: Groninger Intelligence Test

LapSim v.3.0.10 Surgical Science using Immersion’s VLI hardware

Correlation coefficient, MANCOV A & Regression analysis

No relationship between cognitive aptitude, duration of training or steepness of the learning curve was found.

Visual-spatial and reasoning abilities were associated with performing a task faster. Perceptual speed was to be found positively associated with efficiency of moments, whilst spatial memory and perceptual speed were associated with the amount of damage.

Utesch [6]

Behavioral

Sciences and Cognitive Psychology

LAP

28

M = 3,

F = 25

Psychology University students with no prior laparoscopic experience

Mean = 22

Cognitive Psychology and Behavioral sciences

Exploring the relationship between visualspatial, spatial memory, reasoning ability and processing speed and the VR laparoscopic simulator

SR* Raven’s Progressive Matrices

MT* Paper Folding Test, Vandenberg and Kuse

SM* Corsi Block Tapping Test

PS* Identica

Pictures tests

SR* Rotating shape test

PA* PicSOr test

LapSim simulator with a LapSim 2013 software on cutting and clip applying tasks (under difficult level)

A multiple regression analysis, Linear regression

A weak relationship between all cognitive aptitudes and the initial performance and errors made was found

The perceptual speed strongly correlated with the time taken to complete the task and tissue damage.

Fan et al. [7]

Journal of Endoscopic Surgery

The Netherlands

MIS

24

M = 12,

F = 8

Undergraduate and PhD students with no previous experience with minimal invasive surgery and the Endo- PaC simulator

Mean = 25.5

Biomechanical Engineering

Investigating two effects of spatial disorientation – “control-display compatibility” and “local disorientation” in minimally invasive surgery

A performance questionnaire

Custom-developed Endo-PaC simulator was + custom designed software with a 3D-curved tunnel

One-way repeated measures analysis ANOVA with post hoc & One-way independent ANOVA with post hoc & paired t-test

A visible endoscopic camera on the monitor improved performance, workload and path length by serving as a guide regarding the direction of the instrument. This ultimately improved the spatial orientation of the surgeon.

Groenier et al. [27]

Journal of Surgical Education

The Netherlands

LAP

98

M = 46,

F = 52

Undergraduate student in Technical Medicine with no previous laparoscopic experience. Participation was required as part of a curriculum.

Combined a sample of 53 students taken from Groenier et al. 2014 study

Mean = 23

Medicine

Study the influence of both cognitive and psychomotor abilities on the training duration and learning in novice practicing laparoscopic tasks.

VS* Vandenberg and Kuse test, the Paper folding test, the Surface development test and the Rotating shapes test.

SM* The Corsi block tapping test

PS* the Number comparison test, Identical pictures test

SR* The Raven advanced progressive matrices test, Groninger intelligence test

Immersion’s VLI hardware with LapSim simulator

Descriptive statistics

Kaiser- Meyer- Olkin measure of sampling adequacy & Principle component analysis, Cox proportional hazards model

Found perceptual speed and psychomotor ability to successfully predict the rate of skill acquisition on a laparoscopic simulator. Those with higher PC abilities reached skill proficiency fater, than trainees with lower PS. No relationship between VS abilities and performance was found.

Schlickum et al. [11]

International Journal of Medical Education

Sweden

LAP

30

F = 12,

M = 18

Medical students with no experience in VR and high motivation for surgery

Mean = 25

Clinical Sciences and Psychology

Exploring if Visual-Spatial abilities predict performance, and if surgical simulation performance and previous video gaming experience correlates with motivation to further train on a simulator.

Demographic questionnaire

VS* Vandenberg and Kuse MRT-A test

Situation Motivation Scale (SIMS)

Minimal Invasive Surgery Trainer Virtual Reality (MIST-VR) simulator using the manipulative diathermy medium task.

Power analysis, student t-test, MANOVA, Shapiro Wilk’s test,

Regression analysis, Pearson correlation coefficient

Visual-spatial ability was found to be more important than motivation for predicting performance on the simulator

Previous video game experience showed a correlation between simulator training and motivation.