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Cognitive load and performance in immersive virtual reality versus conventional virtual reality simulation training of laparoscopic surgery: a randomized trial



Virtual reality simulators combined with head-mounted displays enable highly immersive virtual reality (VR) for surgical skills training, potentially bridging the gap between the simulation environment and real-life operating room conditions. However, the increased complexity of the learning situation in immersive VR could potentially induce high cognitive load thereby inhibiting performance and learning. This study aims to compare cognitive load and performance in immersive VR and conventional VR simulation training.


A randomized controlled trial of residents (n = 31) performing laparoscopic salpingectomies with an ectopic pregnancy in either immersive VR or conventional VR simulation. Cognitive load was estimated by secondary-task reaction time at baseline, and during nonstressor and stressor phases of the procedure. Simulator metrics were used to evaluate performance.


Cognitive load was increased by 66% and 58% during immersive VR and conventional VR simulation, respectively (p < 0.001), compared to baseline. A light stressor induced a further increase in cognitive load by 15.2% and a severe stressor by 43.1% in the immersive VR group compared to 23% (severe stressor) in the conventional VR group. Immersive VR also caused a significantly worse performance on most simulator metrics.


Immersive VR simulation training induces a higher cognitive load and results in a poorer performance than conventional VR simulation training in laparoscopy. High extraneous load and element interactivity in the immersive VR are suggested as mechanisms explaining this finding. However, immersive VR offers some potential advantages over conventional VR such as more real-life conditions but we only recommend introducing immersive VR in surgical skills training after initial training in conventional VR.

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    Videos as online content: https://youtu.be/-PJKZJz6cc0 (calm phase), https://youtu.be/COtp3x0MWoI (light stressor), https://youtu.be/LqNV8euKTxM (severe stressor), https://youtu.be/TEAdtLBbixE (full procedure).


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The authors would like to thank the following for their help in producing the 360o videos: Fanny Klara Karolina Kullberg, Mai Homburg, and Christoffer Skov Olesen for their portrayal of the staff in the operating room; Helle Skovgaard and Lars Bo Svendsen for their help in precuring a location for the recording of the videos; and Absolute Zero© for their help in recording and processing the videos.

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Correspondence to Joakim Grant Frederiksen.

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Joakim Grant Frederiksen, Stine Maya Dreier Sørensen, Lars Konge, Morten Bo Søndergaard Svendsen, Morten Nobel-Jørgensen, Flemming Bjerrum, and Steven Arild Wuyts Andersen have no conflicts of interest or financial ties to disclose

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Frederiksen, J.G., Sørensen, S.M.D., Konge, L. et al. Cognitive load and performance in immersive virtual reality versus conventional virtual reality simulation training of laparoscopic surgery: a randomized trial. Surg Endosc 34, 1244–1252 (2020). https://doi.org/10.1007/s00464-019-06887-8

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  • Laparoscopic surgical skills training
  • Immersive virtual reality
  • Cognitive load
  • Head-mounted device
  • Simulation