ORIGINAL ARTICLES Warm-up in a Virtual Reality Environment Improves Performance in the Operating Room Dan Calatayud, MD,* Sonal Arora, MBBS,† Rajesh Aggarwal, PhD,† Irina Kruglikova, MD,‡ Svend Schulze, DSc,* Peter Funch-Jensen, DSc,‡ and Teodor Grantcharov, PhD§ Objective: To assess the impact of warm-up on laparoscopic performance in the operating room (OR). Background: Implementation of simulation-based training into clinical practice remains limited despite evidence to show that the improvement in skills is transferred to the OR. The aim of this study was to evaluate the impact of a short virtual reality warm-up training program on laparoscopic performance in the OP. Methods: Sixteen Laparoscopic Cholecystectomies were performed by 8 surgeons in the OR. Participants were randomized to a group which received a preprocedure warm-up using a virtual reality simulator and no warm-up group. After the initial laparoscopic cholecystectomy all surgeons served as their own controls by performing another procedure with or without preop- erative warm-up. All OR procedures were videotaped and assessed by 2 independent observers using the generic OSATS global rating scale (from 7 to 35). Results: There was significantly better surgical performance on the laparo- scopic Cholecystectomy following preoperative warm-up, median 28.5 (range  18.5–32.0) versus median 19.25 (range  15–31.5), P  0.042. The results demonstrated excellent reliability of the assessment tool used (Cronbach’s   0.92). Conclusion: This study showed a significant beneficial impact of warm-up on laparoscopic performance in the OP. The suggested program is short, easy to perform, and therefore realistic to implement in the daily life in a busy surgical department. This will potentially improve the procedural outcome and contribute to improved patient safety and better utilization of OR resources. (Ann Surg 2010;251: 1181–1185) C hanging work practices, 1 models of training, 2 and patient safety issues 3 have rendered the need for alternative training strategies outside the operating room (OR). Simulation-based training allows surgeons to practice and hone their skills in a safe, realistic setting. 4 In addition, with ever expanding new technologies such as mini- mally invasive surgery and its 2 dimensional viewing systems and counter-intuitive instruments, simulation allows surgeons to develop the complex psychomotor skills required in a manner valued by the profession and public alike. Furthermore, the use of simulation to reduce the learning curve means that surgeons have the opportunity to reach a predefined level of proficiency before they practice upon patients. Following such simulation-based training, several studies have demonstrated improved performance on the simulator itself with significant learning curves delineated. 5–7 Other studies have shown that the improved performance effects are reproducible on real laparoscopic tasks 8 with a recent systematic review concluding that skills acquired through simulation- based training can be trans- ferred to the OR. 9 In particular, simulation training improves operative performance in terms of time, 10 confidence and procedural comple- tion 11 with fewer errors 12,13 and reduced patient discomfort. 14 Although simulation-based training may require substantial investment in terms of resources and faculty, costs must be balanced against that of traditional training, with one study estimating the cost of 4 years of OR training being $50,000. 15 With this in mind, virtual reality (VR) trainers are becoming an increasingly attractive option as they require little running cost, once bought are always available for use and allow for repeatable skills training. Despite these benefits, the implementation of simulation- based training into surgical practice remains minimal. “Contextual- isation” of simulation training through appropriate integration into an authentic clinical environment may help overcome this. 16 A potential application may be to use simulation as a form of warm-up, performed just before undertaking the real procedure. This may allow for the benefits of simulation-based training to lead to im- provements at the point of delivery of care. There is, however, a dearth of literature examining the potential of simulation for “warm up” in the real clinical environment before carrying out an operative procedure. This is not surprising because, in comparison to other high performance industries such as sport and music, surgery is not practiced before the actual performance itself. Such warm-up has been shown to be effective as a strategy in rowing, 17 tennis, 18 cycling, 19 and ballet 20 where it can enhance performance, 17 reduce energy requirements, 20 muscle soreness, and musculo-tendinous injuries 21 as well as the time required to complete the task. 22 Surgeons also need to perform highly coordinated motor tasks under time pressure and in often unsuitable ergonomic environments, 23 making them suited to these benefits of warm-up. A review by Bishop 24 as to why warm-up is effective in terms of exercise performance highlighted increased baseline oxygen consumption, improved anaerobic energy provision, less stiffness, and better nerve-conduction rate as potential mechanisms. From a psychologic perspective, warm-up may provide the opportunity to practice potential problems and strategies for over- coming them thus increasing the individual’s perceived control of the situation. 25 Studies have demonstrated the effect of warm-up to reduce anxiety 26 and increase preparedness. If these positive psy- chologic and physical effects of warm-up can be replicated in surgery, it may significantly enhance outcomes not only short-term from the patient perspective but also long-term in terms of the surgeon’s own health. Direct warm-up would not be possible on the actual patient itself but the increased availability of simulators make this a realistic opportunity in the surgical domain. Furthermore, as patient-specific simulation technologies continue to gain speed and momentum, this From the *Department of Surgery D, Glostrup University Hospital, Glostrup, Denmark; †Department of Biosurgery and Surgical Technology, Imperial College, London, United Kingdom; ‡Department of Surgery L, Aarhus University Hospital, Aarhus, Denmark; and §Division of General Surgery, St. Michael’s Hospital, Toronto, Canada. Reprints: Sonal Arora, MBBS, Department of Biosurgery and Surgical Technol- ogy, Imperial College, 10th Floor, QEQM Building, St. Mary’s Hospital, Praed St, London, W2 1NY, United Kingdom. E-mail: Sonal.Arora06@imperial.ac.uk. Copyright © 2010 by Lippincott Williams & Wilkins ISSN: 0003-4932/10/25106-1181 DOI: 10.1097/SLA.0b013e3181deb630 Annals of Surgery • Volume 251, Number 6, June 2010 www.annalsofsurgery.com | 1181