# Using Virtual Reality Simulators to Enhance Laparoscopic Cholecystectomy Skills Learning
## 1 Introduction  
Medical educational strategies have continuously evolved, especially in surgical education [1]. The advent of laparoscopic cholecystectomy and the subsequent surge in minimally invasive surgery (MIS) have challenged the adequacy of traditional surgical training and competency evaluation [2]. After 1989, as MIS gained popularity, it became apparent that surgeons, especially those with limited experience, faced a significantly elevated risk of complications during laparoscopic procedures, especially laparoscopic cholecystectomy [3]. The shift towards more effective medical training has been driven by a combination of factors, including stricter duty-hour regulations, a focus on cost-effective care, and a heightened emphasis on patient safety. As a result, training has expanded beyond the traditional confines of the operating room and wards. The most effective training environment and learning strategies have been the subject of ongoing discussion [4, 5].  
This has motivated the exploration of alternative training methods, such as simulation tools, ranging from simple table-top models to complex virtual reality (VR) simulators and porcine cadavers [6; 7; 8; 9]. Such alternative training tools could provide the number of necessary repetitions to gain proficiency in surgical techniques in a risk-free environment with no patient health in jeopardy [6; 10; 11; 12].  
Simulation training has proven to be an effective method for developing surgical skills [12; 13; 14; 15; 16], especially for laparoscopic cholecystectomy [11]. Simulation allows surgeons to practice techniques without risking patient safety by providing a safe and immersive learning environment. Multiple studies have shown that surgeons trained using simulation exhibit improved technical proficiency in the operating room [13; 14; 15; 16]. Using VR simulation in surgical education is an effective tool for enhancing the performance of surgical trainees in laparoscopic surgery. When employing alternative training methods for teaching and learning, it is important to establish benefits, as well as limitations [6].  
Previous reviews showed the superiority of simulation over no intervention (609 studies) and non-simulation instruction (92 studies) [17; 18; 16]. Additionally, these reviews have compared different simulation interventions (289 studies) to identify evidence-based best practices [19]. While simulation offers a promising training modality for novice surgeons, simulators and laboratories alone are insufficient to establish a comprehensive training program. This review sought to explore the current trends in laparoscopic surgical skills training, focusing on the increasing adoption of VR systems as an educational tool.  
This meta-analysis aimed to comprehensively evaluate the effectiveness of Virtual reality training (VRT) for laparoscopic cholecystectomy skills acquisition. We sought to compare VRT against a range of control interventions, including no additional training, conventional training methods, and VRT enhanced with further feedback. By synthesizing the available evidence from relevant clinical trials, we aimed to determine the overall impact of VRT on laparoscopic surgical performance and to explore whether specific VRT protocols or the addition of feedback confer any advantages for future surgeons.