Virtual reality robotic surgery warm-up improves task performance in a dry laboratory environment: A prospective randomized controlled study

Thomas S. Lendvay, Timothy C. Brand, Lee White, Timothy Kowalewski, Saikiran Jonnadula, Laina D. Mercer, Derek Khorsand, Justin Andros, Blake Hannaford, Richard M. Satava

Research output: Contribution to journalArticlepeer-review

89 Scopus citations


Background: Preoperative simulation warm-up has been shown to improve performance and reduce errors in novice and experienced surgeons, yet existing studies have only investigated conventional laparoscopy. We hypothesized that a brief virtual reality (VR) robotic warm-up would enhance robotic task performance and reduce errors. Study Design: In a 2-center randomized trial, 51 residents and experienced minimally invasive surgery faculty in General Surgery, Urology, and Gynecology underwent a validated robotic surgery proficiency curriculum on a VR robotic simulator and on the da Vinci surgical robot (Intuitive Surgical Inc). Once they successfully achieved performance benchmarks, surgeons were randomized to either receive a 3- to 5-minute VR simulator warm-up or read a leisure book for 10 minutes before performing similar and dissimilar (intracorporeal suturing) robotic surgery tasks. The primary outcomes compared were task time, tool path length, economy of motion, technical, and cognitive errors. Results: Task time (-29.29 seconds, p = 0.001; 95% CI, -47.03 to -11.56), path length (-79.87 mm; p = 0.014; 95% CI, -144.48 to -15.25), and cognitive errors were reduced in the warm-up group compared with the control group for similar tasks. Global technical errors in intracorporeal suturing (0.32; p = 0.020; 95% CI, 0.06-0.59) were reduced after the dissimilar VR task. When surgeons were stratified by earlier robotic and laparoscopic clinical experience, the more experienced surgeons (n = 17) demonstrated significant improvements from warm-up in task time (-53.5 seconds; p = 0.001; 95% CI, -83.9 to -23.0) and economy of motion (0.63 mm/s; p = 0.007; 95% CI, 0.18-1.09), and improvement in these metrics was not statistically significantly appreciated in the less-experienced cohort (n = 34). Conclusions: We observed significant performance improvement and error reduction rates among surgeons of varying experience after VR warm-up for basic robotic surgery tasks. In addition, the VR warm-up reduced errors on a more complex task (robotic suturing), suggesting the generalizability of the warm-up.

Original languageEnglish (US)
Pages (from-to)1181-1192
Number of pages12
JournalJournal of the American College of Surgeons
Issue number6
StatePublished - Jun 2013

Bibliographical note

Funding Information:
This study was supported by the Department of Defense US Army Medical Research and Materiel Command under award number W81XWH-09-1-0714 (principal investigator: Lendvay). The views, opinions, and endorsement by the author(s) do not reflect those of the US Army or the Department of Defense.

Funding Information:
The Seattle Children's Core for Biomedical Statistics is supported by the Center for Clinical and Translational Research at Seattle Children's Research Institute and grant UL1RR025014 from the NIH National Center for Research Resources .


  • FLS
  • Fundamentals of Laparoscopic Surgery
  • ICC
  • MIS
  • OR
  • VR
  • interclass correlations
  • minimally invasive surgery
  • operating room
  • virtual reality


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