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Use of procedure specific preoperative warm-up during surgical priming improves operative outcomes: A systematic review

Open AccessPublished:May 26, 2022DOI:https://doi.org/10.1016/j.amjsurg.2022.05.031

      Highlights

      • Procedure specific preoperative warm-up results in improved operative outcomes.
      • Surgical performance of primary operators was shown to improve post simulation-based surgical priming.
      • Use of preoperative warm-up should be considered to improve patient outcomes.

      Abstract

      Background

      Preoperative warm-up in preparation for surgery is a technique used in recognition of similarities between surgeons and performance based professionals. The aim of this review was to evaluate the use of simulation-based preoperative warm-up on surgical performance in the operating room and its impact on both clinical and patient outcomes.

      Materials and methods

      A systematic review of the literature was carried out in accordance with PRISMA guidelines between August–September 2021. In total 15 studies were retrieved.

      Results

      Seven studies across general surgery, urology, and vascular surgery used a procedure specific warm-up, with significant improvement in operative performance, rate of errors, radiological and patient-based outcomes. Variables including level of experience and specialty appeared to have no impact on the merits of preoperative warm-up demonstrated.

      Conclusions

      While heterogeneity in the benefit of generic warm-up procedures was noted, procedure specific warm-up methods consistently resulted in significantly better operative outcomes.

      Keywords

      1. Introduction

      Surgeons are oft compared to performance based careers including musicians, dancers, and athletes.
      • Kroft J.
      • Ordon M.
      • Arthur R.
      • Pittini R.
      Does surgical "warming up" improve laparoscopic simulator performance?.
      Willaert et al.
      • Willaert W.I.
      • Aggarwal R.
      • Daruwalla F.
      • et al.
      Simulated procedure rehearsal is more effective than a preoperative generic warm-up for endovascular procedures.
      noted the use of warm-up techniques is common in performance driven careers to promote both physical, psychological dexterity, instil confidence and suitably “prime” performers for the task ahead, however this has yet be widely adapted in everyday surgical practice. The introduction of surgical simulation on a virtually based platform has led to a recent surge in the use of simulation-based learning in surgical training to promote surgical skill acquisition,
      • Lakhani S.
      • Selim O.A.
      • Saeed M.Z.
      Arthroscopic simulation: the future of surgical training: a systematic review.
      • Pietersen P.I.
      • Bjerrum F.
      • Tolsgaard M.G.
      • Konge L.
      • Andersen S.A.W.
      Standard setting in simulation-based training of surgical procedures: a systematic review.
      • Huffman E.M.
      • Choi J.N.
      • Martin J.R.
      • et al.
      A competency-based laparoscopic cholecystectomy curriculum significantly improves general surgery residents' operative performance and decreases skill variability: cohort study.
      with a recent focus on its use in the perioperative period.
      • Kroft J.
      • Ordon M.
      • Arthur R.
      • Pittini R.
      Does surgical "warming up" improve laparoscopic simulator performance?.
      ,
      • Samuelson S.T.
      • Burnett G.
      • Sim A.J.
      • et al.
      Simulation as a set-up for technical proficiency: can a virtual warm-up improve live fibre-optic intubation?.
      ,
      • Lendvay T.S.
      • Brand T.C.
      • White L.
      • et al.
      Virtual reality robotic surgery warm-up improves task performance in a dry laboratory environment: a prospective randomized controlled study.
      Several studies have highlighted the use of simulation based training to evaluate the efficacy of the virtual platform in the preoperative period to promote surgical performance.
      • Plerhoples T.A.
      • Zak Y.
      • Hernandez-Boussard T.
      • Lau J.
      Another use of the mobile device: warm-up for laparoscopic surgery.
      • Rosser Jr., J.C.
      • Gentile D.A.
      • Hanigan K.
      • Danner O.K.
      The effect of video game "warm-up" on performance of laparoscopic surgery tasks.
      • Kahol K.
      • Satava R.M.
      • Ferrara J.
      • Smith M.L.
      Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect.
      While its use has been demonstrated to improve measured outcomes, significant limitations to the use of simulation derived metrics without in vivo assessment exist. Learning bias is a recognised limitation to assessment tools using machine automated scores,
      • Simmatis L.E.R.
      • Early S.
      • Moore K.D.
      • Appaqaq S.
      • Scott S.H.
      Statistical measures of motor, sensory and cognitive performance across repeated robot-based testing.
      with participants demonstrating improved performances and outcomes due to familiarity with the equipment.
      It is incumbent on clinicians to ensure adequate validation of novel educational or simulation based equipment is completed prior to implementation into clinical practice.
      • Cook D.A.
      • Hatala R.
      Validation of educational assessments: a primer for simulation and beyond.
      The step from the virtual platform to the operating room is the most significant to ensure that time and training given to simulation based tools is reflected in improved operative performance.
      • Stunt J.
      • Wulms P.
      • Kerkhoffs G.
      • Dankelman J.
      • van Dijk C.
      • Tuijthof G.
      How valid are commercially available medical simulators?.
      The aim of this review was to evaluate the use of simulation-based preoperative priming defined as simulation in the preoperative period on technical surgical performance carried out in the operating room and its impact on clinical and patient outcomes.

      2. Materials and methods

      2.1 Search strategy

      A comprehensive search strategy was performed of electronic databases including PubMed, Ovid Medline, EMBASE, Google Scholar, with study selection identification from August 2021–September 2021. Broad search terms to ensure adequate capture were used; with a combination of “warm*”, “prim*”, “performance”, “surg*”, “outcomes”, using Boolean characters “AND” and “OR”. The search was carried out in accordance with PRISMA guidelines. Two independent reviewers performed a literature search in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • et al.
      The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
      and reviewed the search results, with a senior author arbitrating in the event of a disagreement, based on a protocol agreed on by all authors. Use of Assessing the Methodological Quality of Systematic Reviews (AMSTAR) was applied to retrieved studies to evaluate quality of articles retrieved. This review was registered with PROSPERO under registration number CRD42021285522.

      2.2 Eligibility criteria

      The inclusion criteria consisted of (i) in-vivo studies (ii) use of simulation as a warm-up method pre-operatively (iii) English or full translation freely available. The exclusion criteria included (i) case reports (ii) use of simulation-based assessment to analysis effect of pre-operative warm-up (iii) warm-up techniques not involving simulation-based practice.

      2.3 Outcomes analysed and statistical analysis

      Ad-hoc tables were designed to summarize data from the included studies. Study design, surgical specialty and level of participant experience were collected. Comparison groups if used were also noted, in addition to the warm-up regimen employed by each study. Evidence of any change in surgical performance by participants following priming were recorded in addition to subjective or objective tools used. and any differences in study outcomes recorded. Risk of bias was assessed using the ROB (Risk of Bias) and ROBINS-I (Risk of Bias in Non randomised Studies) tools. No deviations from protocol were noted during data collection and collation.

      2.4 Objectives and aims

      The objective is to review and collectively compare the impact of virtual reality simulation in the preoperative period on technical surgical performance in the operating room.

      3. Results

      In total 15 study fulfilling outlined criteria were included for analysis (Fig. 1).

      3.1 Risk of bias assessment

      Risk of Bias using ROB2 and ROBINs-I tools was calculated. Risk of bias arising due to randomisation where applicable, deviation from intended intervention, missing data, outcome measurements, and selection of reported results was assessed for each study. No studies were identified as containing a high risk of bias. A moderate risk of bias was identified due to bias in measurement of outcomes,
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      and risk due to confounding factors
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      each in a single domain in two studies.

      3.2 Study design

      Six studies
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      included used a randomised crossover design, with intraparticipant scores recorded for comparison (Table 1.). Two studies randomised patients to warm-up and control groups, with surgical teams undergoing warm-up according to the grouping status of the patient.
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      ,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      Paschold et al.
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      used an observational pre-post study design, with Mucksavage et al.
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      evaluating outcomes via a retrospective review. Five studies used a randomised control study design.
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      Table 1Studies included for analysis.
      AuthorsStudy Design

      Population
      Specialty

      Grade
      MethodsOperationAssessmentComparisonOutcomeSimulator
      Lee et al. (2012)
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • et al.
      The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
      Crossover interventional study n:7Urology

      Senior residents
      Subjects completed two laparoscopic renal surgery cases having completed electrocautery simulation task on LapMentor and laparoscopic suturing on a box trainer on one occasionRenal surgical cases including nephrectomy (radical and partial), pyeloplasty, renal cyst decorticationEEG monitoring, pupillary eye-tracking, operative assessment tool (not validated)Trainees acted as own controlGreater hand smoothness (p < 0.03), tool smoothness (p < 0.05), posture (p < 0.05), attention (EEG) (<0.02), mental workload scores (p < 0.001)LAPMentor (Simbionix Ltd) + pelvic box trainer
      Chen et al. (2013)
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      RCT

      N: 184
      O + G
      Obstetrics + Gynaecology ° Abdominal Aortic Aneurysm.


      Residents
      Procedures were randomised to be carried out by a participant who had warmed-up on a simulator using “bead transfer”, “rubber band placement”, “run the rope” or one who had not completed a warm-up.Major: Supercervical and total hysterectomies

      Minor: adnexal and tubal surgery
      Global Rating Scale- OSATs (Objective Structured Assessment of Technical Skills)Procedures were randomised to warm-up or no warm-upImproved resident performance intraoperatively following warm-up compared to control group (p 0.001)TASKIT laparoscopic trainer (Ethicon Endo-Surgery)
      Moran-Atkin et al. (2014)
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      Crossover RCT

      N: 40
      General Surgery

      Residents
      Participants were randomised to undergo warm up on simulator using one of 4 tasks: peg transfer, pattern cutting, endoloop, intracorporal suturing before 1st case of the day over 5 days or perform the operation without simulated warm up. Participants than crossed over to the other arm.Major: Colon resections, laparoscopic inguinal hernia repair, laparoscopic bariatric surgery

      Minor: laparoscopic appendicectomies, laparoscopic cholecystectomies
      Global rating scale OSATs (Objective Structured Assessment of Technical Skills), and Global Rating Scale of LSC operative performanceTrainees acted as own controlImproved depth perception (p = 0.02), bimanual dexterity (p = 0.01), efficient movement (p = 0.03)Fundamentals of Laparoscopic Surgery training box
      Troncoso-Bacelis et al. (2017)
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      Single-blinded CT n:16General Surgery

      Specialist
      Participants recruited to undergo 2 laparoscopic cholecystectomies, one of which carried out with standard preoperative preparation, and one with a simulated warm-up on a simulator consisting of 5 tasks: Transference, cuts, endoloop, Extracorporeal and intracorporal knots.Laparoscopic CholecystectomyOperative time, blood loss, perforation, drainage, postoperative pain, haematoma formationNo VR warm-upLess bleeding (p = 0.01), reduced operative time (p = 0.019)LAPA-PRO
      Paschold et al. (2014)
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      Observational pre-post designGeneral Surgery

      Residents
      Participants underwent virtual laparoscopic tasks consisting of fine dissection, Cholecystectomy II, Peg transfer before and after each operation. Scores from each attempt were compared to evaluate comparative improvement in surgical skills after laparoscopic surgeryLaparoscopic appendicectomy

      Laparoscopic cholecystectomy
      Virtual reality derived scores from Preparation task, virtual procedural task, instrument coordination task, and operative timeNoneSignificant improvement demonstrated in performances completed postoperatively, with a greater effect seen in more experienced surgeons (p = 0.03)LapSim
      Araujo et al. (2014)
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      Single-blinded RCT n:14General Surgery

      Novices
      Participants were randomised to warm-up consisting of a virtual laparoscopic sigmoid resection or no warm up prior to undertaking a laparoscopic sigmoid colectomy on pigs. Performance assessed by colorectal surgeons blinded to the grouping status of participants.Laparoscopic sigmoid colectomyGeneric laparoscopic technical skills scores, and specific skills related to sigmoid colectomyNo VR warm-upWarm-up group significantly outperformed control in generic (p = 0.002) and specific skills (p = 0.001)LapMentor (Simbionix)
      Moldovanu et al. (2011)
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      Crossover RCT n:1General Surgery

      Specialist
      A surgical team carried out laparoscopic cholecystectomies having undergone warm-up on a VR or not. Warm-up consisted of camera navigation, coordination, clip application, clipping and grasping, electrocautery, cystic pedicle dissection, clipping and cutting. Blinded reviewers assessed performance using GRS toolLaparoscopic CholecystectomyModified Global Rating ScoreNo VR warm-upRespect for tissues significantly improved in the warm-up group (p = 0.021; p = 0.04)LapMentor (Simbionix)
      Calatayud et al. (2010)
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      Crossover RCT n:8General Surgery

      Residents
      Participants were randomised to complete a laparoscopic cholecystectomy having completed a generic laparoscopic warm-up VR training program consisting of “lifting and grasping”, “clip applying”, “dissection” or without warm-up.Laparoscopic CholecystectomyGeneric OSATS Global Rating ScaleTrainees acted as own controlSurgical performance was significantly improved following a VR warm-up (p = 0.04)Lapsim
      Kelly et al. (2021)
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      Crossover RCT n:41General Surgery/Urology,/O + GA combination of modules “Ring and Rail 2”, “Match Board 3”, “Endowrist manipulation 2”, “Suture Sponge 3”, and “Running Suture 2” were used across 5 groupsNot specifiedGlobal Evaluative Assessment of Robotic Skills (GEARS) toolSubjects acted as own controlNo significant difference in performance between scores following warm-up and no warm-up in any measured metricdVSS
      Mucksavage et al. (2012)
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      Retrospective review n:1Urology

      Specialist
      Review of outcomes following laparoscopic partial nephrectomies (LPN) and radical nephrectomies (LRN) carried out by a single surgeon were analysed for difference in collected outcomes. Warm-up consisted of pelvic trainer suturing exercises.Laparoscopic partial nephrectomy (LPN) and laparoscopic radical nephrectomy (LRN)Total operative time, surgical time, estimated blood loss, warm ischemia time, complications, positive margins, length of stay, Hb fall, creatinine, analgesic requirementsSubject acted as own controlSurgical time post warm-up was significantly faster (p = 0.03)Pelvic trainer
      da Cruz et al. (2016)
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      Single-blinded RCT n:20General Surgery

      Medical Students
      Participants carried out live porcine laparoscopic cholecystectomy after watching a video explaining the procedure, with half having also undergone a simulated laparoscopic cholecystectomy.Laparoscopic cholecystectomyGlobal Operative Assessment of Laparoscopic Skills (GOALS)No warm-upSubjects who underwent warm-up dissect gallbladder pedicle faster (p = 0.01), pedicle clipping (p = 0.004), blood loss (p = 0.006), depth perception (p = 0.004), bimanual dexterity (p = 0.004), tissue handling (p = 0.012), autonomy (p = 0.02)VRSS LapVR (Immersion Medical)
      Polterauer et al. (2016)
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      Crossover RCT n:10O + G

      Specialist
      Participants performed USO having either undergone warm-up exercises including peg transfer, pattern cutting and fine dissection or performing USO without VR warm-up.Laparoscopic unilateral salpingo-oopherectomy (USO)Objective structured assessment of technical skills (OSATS), operative time, Generic Error Rating Tool (GERT)Subjects acted as own controlNo significant difference in GERT scores (p = 0.5), OSAT scores (p = 0.2), operative time (p = 0.2)LapSim
      Weston et al. (2014)
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      Single-blinded RCT n:75General Surgery

      Specialist
      Participants were randomised to carry out a game console exercise, perform intracorporal suturing, or no warm-up prior to surgery. Videos of LC and LA were taken and assessed.Laparoscopic cholecystectomy, laparoscopic appendicectomyGOALSGame console practice or No warm-upNo significant difference noted across any metricPlayStation 2

      Box trainer
      Deuchler et al. (2016)
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      Single-blinded RCT n:4Surgical Ophthalmology

      Specialist
      Participants were randomised to undergo warmup on simulator comprising of a bimanual task, peeling, and retinal detachment surgery 20 min prior or proceed directly to surgery. Operative performance was videoed and assessed by 2 blinded reviewers.Pars plana vitrectomyGlobal rating assessment of skill in intraocular surgery (GRASIS)No warm-upFinal operative outcome improved post warm-up (p = 0.03)EyeSi
      Desender et al. (2016)
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      Multi-centre RCT n:100Vascular

      Patients with AAA ° +

      Complete operative team
      Vascular surgeons carried out operation on patients having carried out a virtual team-based operation using patient-based metrics within 24 h of the procedure, or proceeding without a virtual run-throughEndovascular Aneurysm RepairIntraoperative errors, 30-day mortality, Imperial College Error Capture (ICECAP), operative time, number of angiogramsPatients randomised to have no virtual run through preoperativelyIntervention group lower error rate (p = 0.004; p = 0.03), number of angiograms lower in the intervention group (p = 0.005; p = 0.004)ANGIO Mentor Express Dual Access Simulation System (Simbionix)
      Legend.
      a Obstetrics + Gynaecology ° Abdominal Aortic Aneurysm.

      3.3 Specialty

      General surgery was the specialty most frequently analysing outcomes following surgical priming,
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      ,
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      ,
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      ,
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      followed by Obstetrics + Gynaecology,
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      ,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      Urology,
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      with one study evaluating surgical Ophthalmology,
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      and Vascular surgery
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      procedures included.
      Laparoscopic Cholecystectomies were the most commonly used procedure to assess the impact of preoperative preparation,
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      ,
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      ,
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      ,
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      with Laparoscopic appendicectomies,
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      ,
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      ,
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      Laparoscopic colonic resection,
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      ,
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      tubal surgery,
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      ,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      partial and radical nephrectomies
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      also used. Bariatric surgery procedures, laparoscopic hernia repair,
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      laparoscopic hysterectomy,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      endovascular aortic repair (EVAR),
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      and vitrectomy
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      were each used in a single study.

      3.4 Level of experience

      Medical students were used by da Cruz et al.,
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      surgery naïve surgical trainees by Araujo et al.
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      Residents were used in four studies
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      ,
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      ,
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      ,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      with the majority of studies using a combination of both residents and specialists.
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      ,
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      ,
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      Specialists were used solely in three studies.
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      ,
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      Desender et al.
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      used a preparatory team approach, and one study did not specify the level of experience.
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.

      3.5 Preoperative surgical warm-up methods used

      LapMentor (Simbionix),
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      ,
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      ,
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      and LapSim (SurgicalScience)
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      ,
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      ,
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      were the most commonly used virtual reality simulators. One study each used simulators including “LAPA-PRO”,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      “TASKIT” laparoscopic box trainer (Ethicon Endosurgery),
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      “dVSS”,
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      “LapVR”,
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      “ANGIO Mentor Express Dual Access (Simbionix)”,
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      and “EyeSi”.
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      Four studies
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      ,
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      ,
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      used low fidelity box trainers, with Weston et al.
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      also including a group exposed to video gaming devices in the preoperative period.
      Studies used either a generic or specific warm-up approach. Within studies using a procedure specific warm-up, two main methods were used; the complete procedure was utilised in the virtual environment in four studies,
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      ,
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      ,
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      ,
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      while simulated modules consisting of operative steps specific to the procedure to be performed were included in three studies.
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      ,
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      ,
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      Generic surgical skill modules were used in six studies either in isolation
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      ,
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      ,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      or in conjunction with a simulated module specific to the operation to be carried out.
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      Generic warm-up tasks were predominantly used for laparoscopic skills including: peg/bead transfer/transference,
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      ,
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      ,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      cuts/electrocautery,
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      ,
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      rubber band placement,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      endoloop/intracorporal/extracorporeal suturing,
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      ,
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      knots,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      or dedicated bimanual tasks.
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      Suturing or box tasks were used to warm-up preoperatively in two studies.
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      Video games were used as a mode of surgical warm-up in one of the intervention groups utilised by Weston et al.
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.

      3.6 Assessment used

      Both objective and subjective methods of assessment were used within studies. A variety of subjective laparoscopic global rating scales were used to measure the impact of preoperative warm-up including Objective Structured Assessment of technical skills (OSAT),
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      ,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      modified Global Rating Scale,
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      Global Evaluative Assessment of Robotic Skills (GEARS),
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      Global Operative Assessment of Laparoscopic Skills (GOALS),
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      simulation derived scores from virtual reality based modules,
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      ,
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      generic laparoscopic technical skills,
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      and those specific to the procedure.
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      Deuchler et al.
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      used a Global Rating Assessment of Skill in Intraocular Surgery (GRASIS) as the only non-laparoscopic-based procedure in this review. Lee et al.
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      used a modified global rating scale not yet validated in the literature.
      Polterauer et al.
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      additionally used a Generic Error Rating Tool (GERT) to evaluate number of mistakes in conjunction with overall performance, with Desender et al.
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      similarly using a measure of intraoperative errors via the Imperial College Error Capture (ICECAP).
      Objective assessments used to evaluate preparatory warm-up included participant specific endpoints including electroencephalogram (EEG) monitoring,
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      posture,
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      and pupillary eye trackers.
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      Patient based outcomes were more commonly used, including operative time
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      ; blood loss
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      ; postoperative laboratory markers including renal function and haemoglobin drop
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ; complications
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      ; 30-day mortality
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      ; pain/analgesic requirements,
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      and length of stay.
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      Desender et al.
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      also used number of intraoperative images taken to evaluate efficacy of patient-specific preoperative virtual run-throughs.

      3.7 Time dedicated to warm-up

      Two main methods were used during the required warm-up time given to participants. Studies included in this review used a predominantly task-based approach to the warm-up procedure, with nine studies allotting time dedicated to the warm-up period based on completion of a required task.
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      ,
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      ,
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      ,
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      Seven studies provided an allotted time for the warm-up period, with shorter dedicated warm-ups ranging from 5 to 10 min in three studies,
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      ,
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      and longer dedicated preoperative warm-up of 15–20 min prescribed in four studies.
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      ,
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      ,
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      Aruajo et al.
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      allocated a time of 2 h to complete the set task, although noted all participants completed it within this time frame.

      3.8 Time warm-up implemented prior to surgery

      A degree of heterogeneity was demonstrated in the use of preoperative priming prior to the operative assessment. While four studies noted the warm-up was completed immediately preoperatively,
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      ,
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      ,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      ,
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      two reported completion of the tasks within 1518-30 min,
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      one study within 1 h.
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      Deuchler et al.
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      reported the longest degradation time with completion of the simulated operation done within 24 h. Six studies did not specify the use of warm-up in relation to the operative list to be completed.
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      ,
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      ,
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      ,
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      ,
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      ,
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.

      3.9 Outcomes

      Improved surgical performance was found in 12 of the 15 studies included for analysis. In three studies
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      ,
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      ,
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      no significant changes were reported in outcomes between the intervention and control groups (Table 2.).
      Table 2Outcomes from studies included for analysis.
      Improvement post-warm-upYesNo
      Objective-based outcomes
      Radiological outcomesLower number of angiograms (p = 0.004)
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      Participant based outcomesGreater posture stability (p < 0.05),
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • et al.
      The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.


      Greater EEG recorded attention scores (p < 0.02)
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • et al.
      The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.


      Lower Mental workload scores (p < 0.001)
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • et al.
      The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
      Patient based outcomesDecreased blood loss (p = 0.006)
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      (p = 0.01)
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      TimeGallbladder pedicle dissection faster (p = 0.01)
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.


      Operative time (p = 0.03)
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      (p = 0.019)
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      Operative time (p = 0.2)25
      Simulation derived metricsOverall performance improvement (p = 0.03)
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      Subjective-based outcomes
      Error rateLower error rate (p = 0.004)
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      No difference in GERT scores (p = 0.5)25
      Kinemetric outcomes
      OSATOverall improvement (p = 0.04)
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      (p 0.001)
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      No improvement noted overall (p = 0.2)25
      GOALSDepth perception (p = 0.004)
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.


      Bimanual dexterity (p = 0.004)
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.


      Tissue handling (p = 0.012)
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.


      Autonomy (p = 0.02)
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      No improvement in any measured metric
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      GEARSNo improvement in any metric
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      Modified GRSImproved respect for tissue (p = 0.021; p = 0.04)
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      GRASISImproved overall performance (p = 0.03)
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      Generic laparoscopic skillsOverall improvement (p = 0.002)
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      Specific procedural skillsOverall improvement (p = 0.001)
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      Psychomotor testingGreater hand smoothness of movement (p < 0.03)
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • et al.
      The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.


      Smoothness of instruments (p < 0.05)
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • et al.
      The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.

      3.9.1 Objective outcomes

      Studies evaluating objective metrics demonstrated a significant improvement in radiological, patient, and participant-based endpoints with the exception of one study.
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      Polterauer et al.
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      found no difference in operative time from procedures carried out by specialists having completed a generic preoperative warm-up was found (p = 0.2)21. This is in contrast with two studies who demonstrated a significantly faster time to completion by trainees (p = 0.01)
      • Pietersen P.I.
      • Bjerrum F.
      • Tolsgaard M.G.
      • Konge L.
      • Andersen S.A.W.
      Standard setting in simulation-based training of surgical procedures: a systematic review.
      , and specialists (p = 0.03)
      • Kahol K.
      • Satava R.M.
      • Ferrara J.
      • Smith M.L.
      Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect.
      who were preoperatively primed using generic exercises. Similarly, da Cruz et al.
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      found intraoperative steps were completed in a shorter duration by novices who had practiced procedure specific manoeuvres as a preoperative warm-up (p = 0.01).
      Both studies evaluating patient-based outcomes demonstrated a significant improvement in estimated blood loss in those who had completed a preoperative warm-up, with both generic (p = 0.01)
      • Troncoso-Bacelis A.
      • Soto-Amaro J.
      • Ramirez-Velazquez C.
      [Warming up with endotrainer prior to laparoscopic cholecystectomy].
      and specific procedure (p = 0.006)
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      approaches proving efficacious.
      Paschold et al.
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      reported a significant difference in outcomes using simulator based metrics following completion of simulator modules, demonstrated using a simulator following completion of an intraoperative procedure (p = 0.03).

      3.9.2 Kinemetric-based outcomes

      Two studies noted a significant improvement in unexperienced participants' operative performances following completion of a procedure specific warm-up.
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      ,
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      Araujo et al.
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      noted a significant improvement in novices having completed a virtual laparoscopic sigmoid colectomy (p = 0.001), and da Cruz et al.
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      found medical students having completed a virtual cholecystectomy performed better than their unprimed counterparts across several metrics including depth perception (p = 0.004), bimanual dexterity (p = 0.004), tissue handling (p = 0.01), and autonomy (p = 0.02).
      In studies using an operative component specific to the procedure in their warm-up, a significant improvement was noted kinemetric assessments made intraoperatively. Calatayud et al.
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      noted a significant improvement in overall performance using validated assessment tools within the surgically primed groups (p = 0.04). Similarly, Moldovanu et al.
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      found a similar outcome with the preoperatively prepared demonstrating a greater degree of respect for tissue (p = 0.04) than those who had not undergone a surgical warm-up using procedure specific components.
      Generic warm-ups using basic laparoscopic or other skills resulted in heterogenous outcomes. Three studies found an improvement in kinemetric outcomes in participants having completed a generic warm up.
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      ,
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      ,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      Simulation based warm up resulted in an improved overall performance (p, 0.001),
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      box training warm up resulting in improved depth perception (p = 0.02), bimanual dexterity (p = 0.01), and efficient movement (p = 0.03),
      • Moran-Atkin E.
      • Abdalla G.
      • Chen G.
      • et al.
      Preoperative warm-up the key to improved resident technique: a randomized study.
      and a combination of both resulting in greater hand smoothness (<0.03)
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      and use of instruments (<0.05).
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      In contrast, two studies found despite the intervention, no significant difference in observed performance was noted.
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      ,
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      Suturing to improve dexterity in the preoperative period demonstrated similar heterogenous results. While Mucksavage et al.
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      noted speed was improved intraoperatively (p = 0.03), Weston et al.
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      found no significant difference across any kinemetric assessment was noted. Similarly, no significant difference was noted in the group carrying out video games in the preoperative period.
      • Weston M.K.
      • Stephens J.H.
      • Schafer A.
      • Hewett P.J.
      Warm-up before laparoscopic surgery is not essential.
      A lower number of recorded errors were noted in the intervention group by Desender et al.
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      reaching a statistically significant degree (p = 0.004). In contrast, Polterauer et al.
      • Polterauer S.
      • Husslein H.
      • Kranawetter M.
      • et al.
      Effect of preoperative warm-up exercise before laparoscopic gynecological surgery: a randomized trial.
      noted no significant change in the rate of errors made by participants following preoperative priming (p = 0.5). Desender et al.
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      used patient specific anatomy in the preoperative simulated simulation, which may account for the stark contrast in the findings between these studies.

      4. Discussion

      The use of virtual reality-based simulation has been discussed in its potential uses to accelerate surgical skill acquisition,
      • Fried M.P.
      • Sadoughi B.
      • Gibber M.J.
      • et al.
      From virtual reality to the operating room: the endoscopic sinus surgery simulator experiment.
      and shorten learning curves,
      • Atesok K.
      • Satava R.M.
      • Van Heest A.
      • et al.
      Retention of skills after simulation-based training in orthopaedic surgery.
      through providing a safe learning environment for surgical trainees.
      • Huffman E.M.
      • Choi J.N.
      • Martin J.R.
      • et al.
      A competency-based laparoscopic cholecystectomy curriculum significantly improves general surgery residents' operative performance and decreases skill variability: cohort study.
      This review highlights its potential use in helping promote patient safety through surgically priming primary operators prior to the first case of the day. In studies whereby the preoperative warm-up carried out was specific to the operative case to be completed, a significant improvement across both objective and subjective metrics was demonstrated consistently.
      Subjective assessment in surgical performance remains the standard method of evaluation in surgical and simulated surgical performances.
      • van Empel P.J.
      • van Rijssen L.B.
      • Commandeur J.P.
      • et al.
      Objective versus Subjective Assessment of Laparoscopic Skill. ISRN Minimally Invasive Surgery.
      Numerous subjective assessment tools exist, with several attempts in recent years to develop a standardised instrument to subjectively assess surgical performance, with functional components within each tool consistent across the studies in which they are applied.
      • Seagull F.J.
      • Rooney D.M.
      Filling a void: developing a standard subjective assessment tool for surgical simulation through focused review of current practices.
      Several subjective assessment tools were used in the studies included in this review, with an improved overall performance score noted in four studies.
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      ,
      • Chen C.C.
      • Green I.C.
      • Colbert-Getz J.M.
      • et al.
      Warm-up on a simulator improves residents' performance in laparoscopic surgery: a randomized trial.
      ,
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      ,
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      Specific technical skills noted to demonstrate improvement following priming included tissue handling,
      • Moldovanu R.
      • Târcoveanu E.
      • Dimofte G.
      • Lupaşcu C.
      • Bradea C.
      Preoperative warm-up using a virtual reality simulator.
      ,
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      instrument dexterity,
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      ,
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      and depth perception.
      • da Cruz J.A.S.
      • Dos Reis S.T.
      • Cunha Frati R.M.
      • et al.
      Does warm-up training in a virtual reality simulator improve surgical performance? A prospective randomized analysis.
      Three studies however found no significant difference overall performance or measures metrics following priming; this highlights the potential future benefit to be yielded from introduction of a standardised template of subjective assessment of surgical performance,
      • Seagull F.J.
      • Rooney D.M.
      Filling a void: developing a standard subjective assessment tool for surgical simulation through focused review of current practices.
      or addition of objective assessment tools in evaluation of surgical skills.
      • van Empel P.J.
      • van Rijssen L.B.
      • Commandeur J.P.
      • et al.
      Objective versus Subjective Assessment of Laparoscopic Skill. ISRN Minimally Invasive Surgery.
      The use of objective assessment tools in surgical skill acquisition are increasing in recognition of an evolving Halstedian surgical training model to a structured training method.
      • Oropesa I.
      • Sanchez-Gonzalez P.
      • Lamata P.
      • et al.
      Methods and tools for objective assessment of psychomotor skills in laparoscopic surgery.
      A plethora of objective assessment methods were used across in studies included in this review, which consistently demonstrated an improved performance following priming compared to unprimed surgical performance. Simulation derived performance was found to improve globally following preoperative priming by Paschold et al.
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      Similarly, improved performance through participant-based outcomes were identified. Lower mental workload was reported in participants by Lee et al.,
      • Lee J.Y.
      • Mucksavage P.
      • Kerbl D.C.
      • et al.
      Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery.
      also finding participants had greater attention recorded on EEG.
      Time as an objective measurement in performance assessment has demonstrated limitations in the literature.
      • Araujo S.E.
      • Delaney C.P.
      • Seid V.E.
      • et al.
      Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.
      While shorter operative times has beneficial downstream effects on patient outcomes,
      • Zettervall S.L.
      • Haskins I.N.
      • Deery S.E.
      • Amdur R.L.
      • Lin P.P.
      • Vaziri K.
      Open colectomies of shorter operative time do not result in improved outcomes compared with prolonged laparoscopic operations.
      and help reduce inefficiency commonly experienced on the operative list,
      • Travis E.
      • Woodhouse S.
      • Tan R.
      • Patel S.
      • Donovan J.
      • Brogan K.
      Operating theatre time, where does it all go? A prospective observational study.
      its use as a method to evaluate proficiency should be used with caution. In this review, three of the four studies looking at operative times saw preoperative warm-up resulted in shorter surgical times recorded. Mucksavage et al.
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      found a significant decrease in operative time following introduction of a warm-up, however as a retrospective review using a single surgeon with a sequential rather than parallel method used, the impact of a greater degree of surgical experience during the period with which warm-up procedures were used on subsequent clinical and patient outcomes should be considered.
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      Similarly, while the use of radiological imaging has not demonstrated construct validity in the literature,
      • Feeley A.
      • Feeley I.
      • Merghani K.
      • Sheehan E.
      A pilot study to evaluate the face & construct validity of an orthopaedic virtual reality simulator.
      and its use is not reflective of superior operative performance; reduction in radiation exposure for both patient and practitioner should be encouraged to reduce sequelae associated with prolonged or repeat exposure
      • Narain A.S.
      • Hijji F.Y.
      • Yom K.H.
      • Kudaravalli K.T.
      • Haws B.E.
      • Singh K.
      Radiation exposure and reduction in the operating room: perspectives and future directions in spine surgery.
      as found by Desender et al.
      • Desender L.M.
      • Van Herzeele I.
      • Lachat M.L.
      • et al.
      Patient-specific rehearsal before EVAR: influence on technical and nontechnical operative performance. A randomized controlled trial.
      Studies have previously sought to evaluate the impact of surgical order on operative lists has an effect on surgical outcomes,
      • Thomas A.A.
      • Kim B.
      • Derboghossians A.
      • et al.
      Impact of surgical case order on perioperative outcomes for robotic-assisted radical prostatectomy.
      operative times,
      • Pike T.W.
      • Mushtaq F.
      • Mann R.P.
      • et al.
      Operating list composition and surgical performance.
      and infection risk.
      • Li X.
      • Zhang Q.
      • Dong J.
      • Zhang G.
      • Chai W.
      • Chen J.
      Impact of surgical case order on peri-operative outcomes for total joint arthroplasty.
      To date no significant impact on rates of complications arising from operative list composition has been demonstrated, with rates of orthopaedic postoperative infections thought to be associated with case order, potentially secondary to inadequate cleaning interoperatively.
      • Li X.
      • Zhang Q.
      • Dong J.
      • Zhang G.
      • Chai W.
      • Chen J.
      Impact of surgical case order on peri-operative outcomes for total joint arthroplasty.
      While most studies have found second and subsequent cases have shorter operative times, in comparison to the primary case of the day,
      • Thomas A.A.
      • Kim B.
      • Derboghossians A.
      • et al.
      Impact of surgical case order on perioperative outcomes for robotic-assisted radical prostatectomy.
      ,
      • Lavelle E.S.
      • Turner L.C.
      • Shepherd J.P.
      Impact of case order on laparoscopic sacrocolpopexy: do surgeons need a warm-up?.
      Makhdom et al.
      • Makhdom A.M.
      • Almaawi A.
      • Tanzer D.
      • Tanzer M.
      Does warming up improve surgical outcome in total hip arthroplasty?.
      found that second and subsequent cases were significantly slower than the first case of the day. Lavelle et al.
      • Lavelle E.S.
      • Turner L.C.
      • Shepherd J.P.
      Impact of case order on laparoscopic sacrocolpopexy: do surgeons need a warm-up?.
      found that patient on second and subsequent cases on the operating list had shorter operative times, and hospital lengths of stay. This was reflected in findings from studies included in this review, with significantly lower recorded blood loss following preoperative priming found in two studies.
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      This has potential implications on long-term downstream effects on patient outcomes and hospital costs, with additional benefits of a preoperative warm-up to promote work flow in operating lists, with three studies finding preoperative priming yielded significantly shorter operative times.
      • Mucksavage P.
      • Lee J.
      • Kerbl D.C.
      • Clayman R.V.
      • McDougall E.M.
      Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon.
      ,
      • Paschold M.
      • Huber T.
      • Kauff D.W.
      • Buchheim K.
      • Lang H.
      • Kneist W.
      Preconditioning in laparoscopic surgery--results of a virtual reality pilot study.
      ,
      • Calatayud D.
      • Arora S.
      • Aggarwal R.
      • et al.
      Warm-up in a virtual reality environment improves performance in the operating room.
      Laparoscopic procedures have been reported to transfer well to the virtual platform due to the nature of the 2D feedback received.
      • Feeley A.
      • Feeley I.
      • Merghani K.
      • Sheehan E.
      Use of virtual reality simulation in surgical training: a systematic review on predictive validity and current use in surgical curricula.
      Similarly, conventional box training provides ample opportunities to obtain adequate exposure to the laparoscopic operative setup to derive significant benefit from its use.
      • Hoopes S.
      • Pham T.
      • Lindo F.M.
      • Antosh D.D.
      Home surgical skill training resources for Obstetrics and gynecology trainees during a pandemic.
      In this review the use of operative aids including high-fidelity simulation, box trainers, and simple suturing techniques appear to have an impact on subsequent operative performance. The use of simulation for surgical training in open procedures is sparse in the literature.
      • Feeley A.
      • Feeley I.
      • Merghani K.
      • Sheehan E.
      A pilot study to evaluate the face & construct validity of an orthopaedic virtual reality simulator.
      Only one study in this review used a non-laparoscopic or endovascular surgery to evaluate the impact of preoperative preparation, with positive results.
      • Deuchler S.
      • Wagner C.
      • Singh P.
      • et al.
      Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
      The merits of preoperative surgical priming appear not to be limited by surgical approach, highlighting the generalisability of this practice to all surgical specialities.
      Use of virtual reality simulation has been reported to have variable impact on reported efficacy, and improvement in operative performance based on level of experience.
      • Lohre R.
      • Bois A.J.
      • Athwal G.S.
      • Goel D.P.
      (CSES) CSaES
      Improved complex skill acquisition by immersive virtual reality training: a randomized controlled trial.
      While residents and surgeons in training are felt to benefit from simulation to accelerate skill acquisition,
      • Huffman E.M.
      • Choi J.N.
      • Martin J.R.
      • et al.
      A competency-based laparoscopic cholecystectomy curriculum significantly improves general surgery residents' operative performance and decreases skill variability: cohort study.
      this review highlights the potential use of simulation in experienced specialists, with improvement in outcomes demonstrated in both novices and qualified surgeons. While practical limitations of preoperative preparation using surgical simulators were not discussed at length in studies included for review; barriers to the introduction of preoperative priming should be considered, including additional constraints of time on surgical trainees, potential costs of equipment, and the potential limited availability of space near theatre to facilitate surgeon access to preoperative tools.

      4.1 Limitations

      Significant heterogeneity in study design was noted in this review. While a cross-over RCT method was used in three studies, most studies included used a parallel RCT design, and the impact of inter-surgeon performance variability
      • Kelly J.D.
      • Kowalewski T.M.
      • Brand T.
      • et al.
      Virtual reality warm-up before robot-assisted surgery: a randomized controlled trial.
      should be considered in the context of the findings.

      5. Conclusion

      Procedure specific warm-up methods consistently demonstrated significantly better outcomes in endpoints measured, including operative metrics and surgical performance, and in reported rates of intraoperative errors recorded. Heterogeneity in the benefit of generic warm-up procedures is apparent, however their use yielded mixed-positive results on both low and high-fidelity simulation-based equipment across all levels of experience. The use of procedure specific warm-ups should be considered to improve intraoperative performance and operative metrics including operative time and patient blood loss.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Financial disclosure

      No grants or financial support was received for this work.

      Conflict of interest

      This is a letter pertaining to the submission of the manuscript “Use of procedure specific preoperative warm-up during surgical priming improves operative outcomes: a systematic review”.
      We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.
      We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property.

      Acknowledgements

      None.

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