Neurosurgical procedures performed during residency in Europe—preliminary numbers and time trends

Education and Training in Global Neurosurgery: Current State and Path Toward a Uniform Curriculum

Education is a sustainable long-term measure to address the global burden of neurosurgical disease. Neurosurgery residencies in high-income countries are accredited by a regional governing body and incorporate various educational activities. Few opportunities for training may be present in low-income and middle-income countries due to a lack of neurosurgery residency programs, tuition, and health care workforce reductions. Core components of a neurosurgical training curriculum include operative room experience, clinical rounds, managing inpatients, and educational conferences. A gold standard for neurosurgical education is essential for creating comprehensive training experience, though training must be contextually appropriate.

A Step-by-Step Dissection of Cerebral Pathologies for Neurosurgical Trainees: The Middle Cerebral Artery Bifurcation Aneurysm

BACKGROUND

 Aneurysmal subarachnoid hemorrhage remains one of the most prevalent causes of strokes in the young causing a high socioeconomic damage. Both emergent and elective treatments of intracranial aneurysms remain essential challenges for neurovascular centers. We aim to present conceptual education on clip ligation of middle cerebral artery bifurcation aneurysms in an accessible and structured way to maximize the educational takeaway of residents from aneurysm cases.

METHODS

 After 30 years of experience of the senior author in cerebrovascular surgery in three centers, we closely reviewed an exemplary case of elective right middle cerebral artery bifurcation aneurysm clipping and contrasted it to an alternative microneurosurgical approach to illustrate key principles of microneurosurgical clip ligation for neurosurgical trainees.

RESULTS

 Dissection of the sylvian fissure, subfrontal approach to the optic-carotid complex, proximal control, aneurysm dissection, dissection of kissing branches, dissection of aneurysm fundus, temporary and permanent clipping, as well as aneurysm inspection and resection are highlighted as key steps of clip ligation. This proximal-to-distal approach is contrasted to the distal-to-proximal approach. Additionally, general principles of intracranial surgery such as use of retraction, arachnoid dissection, and draining of cerebrospinal fluid are addressed.

CONCLUSION

 Due to a constantly decreasing case load in the era of neurointerventionalism, the paradox of facing increased complexity with decreased experience must be met with a sophisticated practical and theoretical education of neurosurgical trainees early on and with a low threshold.

The "STARS" study: advanced preoperative rehearsal and intraoperative navigation in neurosurgical oncology

BACKGROUND

Neurosurgical 3D visualizers and simulators are innovative devices capable of defining a surgical strategy in advance and possibly making neurosurgery safer by rehearsing the phases of the operation beforehand. The aim of this study is to evaluate Surgical Theater™ (Surgical Theater LLC, Mayfield, OH, USA), a new 3D neurosurgical planning, simulation, and navigation system, and qualitatively assess its use in the operating room.

METHODS

Clinical data were collected from 30 patients harboring various types of brain tumors; Surgical Theater™ was used for the preoperative planning and intraoperative 3D navigation. Preoperative and postoperative questionnaires were completed by first and second operators to get qualitative feedback on the system's functionality. Furthermore, we measured and compared the impact of this technology on surgery duration.

RESULTS

Neurosurgeons were overall satisfied when using this rehearsal and navigation tool and found it efficient and easy to use; interestingly, residents considered this device more useful as compared to their more senior colleagues (with significantly higher scores, P<0.05), possibly because of their limited anatomical experience and spatial/surgical rehearsal ability. The length of the surgical procedure was not affected by this technology (P>0.05).

CONCLUSIONS

Surgical Theater™ system was found to be clinically useful in improving anatomical understanding, surgical planning, and intraoperative navigation, especially for younger and less experienced neurosurgeons.

Strategies to improve surgical technical competency: a systematic review

BACKGROUND

A cornerstone of surgical residency training is an educational program that produces highly skilled and effective surgeons. Training structures are constantly being revised due to evolving program structures, shifting workforces, and variability in the clinical environment. This has resulted in significant heterogeneity in all surgical resident education, training tools utilized, and measures of training efficacy.

METHODS

We systematically reviewed educational interventions for technical skills in neurosurgery published across PubMed, Embase, and Web of Science over four decades. We extracted general characteristics of each surgical training tool while categorizing educational interventions by modality and neurosurgical application.

RESULTS

We identified 626 studies which developed surgical training tools across eight different training modalities: textbooks and literature (11), online resources (53), didactic teaching and one-on-one instruction (7), laboratory courses (50), cadaveric models (63), animal models (47), mixed reality (166), and physical models (229). While publication volume has grown exponentially, a majority of studies were cited with relatively low frequency. Most training programs were published in the development and validation phase with only 2.1% of tools implemented long-term. Each training modality expressed unique strengths and limitations, with limited data reported on the educational impact connected to each training tool.

CONCLUSIONS

Numerous surgical training tools have been developed and implemented across residency training programs. Though many creative and cutting-edge tools have been devised, evidence supporting educational efficacy and long-term application is lacking. Increased utilization of novel surgical training tools will require validation of metrics used to assess the training outcomes and optimized integration with clinical practice.

Neurosurgical training and education - General European certification is supported: Results of an EANS survey

Introduction

Delivering high-quality Neurosurgical care is dependent on excellence in neurosurgical training. Across Europe requirements of these programs vary from state to state. This study aims to determine satisfaction with these programs and views towards a unified certifications process for Neurosurgical training.

Methods

An electronic survey was disseminated to European trainees, Fellows and Consultants from 11/21 to 02/22. For descriptive purposes, categorical variables, i.e. Age, Gender, year of training, country and outcomes were analyzed.

Results

A total of 339 responses were submitted, representing all EANS member states except for Cyprus and Macedonia. Seventy-five were <30 years, 82.3% were male, ∼60% were Specialists, and twenty-four per cent held a fellowship with the European Board of Neurosurgery. 80.2% believed that a joint standardized Neurosurgical certificate in Europe is necessary, with 31.6% believing residency had not prepared them fully as a neurosurgeon.

Conclusion

This survey shows that views towards general European-wide certification is positive and that there is ongoing consensus that there is concern with some aspects of training and high variability in its delivery across Europe.

Structure of Neurosurgical Care in Germany in Comparison to Countries Organized in the European Association of Neurosurgical Societies: A Need to Reorganize Neurosurgical Training and Care in Germany

BACKGROUND

 Although the world is experiencing a deficit in the neurosurgical workforce, the number of neurosurgeons in Germany has increased within the last two decades. The aim of the present study was to assess the neurosurgical workforce in Germany, compare it to European countries, and assess structures in neurosurgical departments in Germany.

METHODS

 Data regarding the number of neurosurgeons in Germany as well as the number of departments, beds, cases, and neurosurgical procedures were gathered. A survey among German neurosurgical departments was performed to assess the structure of neurosurgical care. Furthermore, another survey among European countries was performed to acquire information regarding the number of surgeons and the regulation of training.

RESULTS

 From 2000 to 2019, the number of board-certified neurosurgeons in Germany increased by 151% from 973 to 2,446. During the same period, the German population increased by only 1% from 82.26 million to 83.17 million. Thus, the number of neurosurgeons per 100,000 inhabitants increased from 1.18 to 2.94. The increase of neurosurgeons is not paralleled by an increase in departments or an increase in neurosurgical procedures within the active neurosurgical departments. In comparison to the participating European countries, where the number of neurosurgeons per 100,000 inhabitants ranged from 0.45 to 2.94, with Germany shows the highest number.

CONCLUSIONS

 German institutions of medical administration urgently need to consider regulation of neurosurgical specialist training to prevent a further uncontrolled increase in neurosurgeons in a manner that is not adapted to the needs of neurosurgical care for the German population. Actions might include a regulation of entry to the training and of the number of training sites. Furthermore, an integration of non-physician assistant health care professionals and delegation of non-surgical workload from neurosurgeons is necessary. A further increase in neurosurgeons would be associated with a decrease in the surgical caseload per surgeons during training and after board certification, which might compromise the quality of neurosurgical care.

Motivators of becoming and staying a neurosurgeon in the Netherlands: a survey and focus group

OBJECTIVE

The aim of this study was to gain insight in motivators and demotivators of the Dutch neurosurgical residents and neurosurgeons.

METHODS

A mixed method study was conducted. A survey was sent by the Dutch Neurosurgical Society to all Dutch neurosurgeons and residents in the framework of the yearly national quality conference. The focus groups were held during the Dutch national training days for neurosurgical residents. Baseline statistics were made of all survey data. Focus group recordings were transcribed verbatim and open coded in a constant comparative manner.

RESULTS

The survey yielded a response rate of 47.3% of neurosurgeons and 72.5% of residents. 42.5% of residents participated in the focus groups. Overall, motivators according to residents and neurosurgeons were divided between autonomous and controlled motivation. For residents, the motivators to become a neurosurgeon were mostly patient-centered. Neurosurgeons had the same general motivators as residents. Around one-third of neurosurgeons considered ending their career as a neurosurgeon. Among residents, 9.5% considered quitting residency. Neurosurgeons and residents indicated that no time for their family life, increased administrative burden and non-patient-related tasks were reasons to consider leaving the profession. Also, less perceived respect from patients and society was a reason to consider ending their career as a neurosurgeon.

CONCLUSION

Neurosurgeons and residents in neurosurgery are mostly motivated by intrinsic motivators. Factors such as administrative burden, less perceived respect from patients and society, and increase in non-patient-related tasks are large demotivators for both neurosurgeons and residents.

360° 3D virtual reality operative video for the training of residents in neurosurgery

OBJECTIVE

Training of residents is an essential but time-consuming and costly task in the surgical disciplines. During the coronavirus disease 2019 pandemic, surgical education became even more challenging because of the reduced caseload due to the increased shift to corona care. In this context, augmented 360° 3D virtual reality (VR) videos of surgical procedures enable effective off-site training through virtual participation in the surgery. The goal of this study was to establish and evaluate 360° 3D VR operative videos for neurosurgical training.

METHODS

Using a 360° camera, the authors recorded three standard neurosurgical procedures: a lumbar discectomy, brain metastasis resection, and clipping of an aneurysm. Combined with the stereoscopic view of the surgical microscope, 7- to 10-minute 360° 3D VR videos augmented with annotations, overlays, and commentary were created. These videos were then presented to the neurosurgical residents at the authors’ institution using a head-mounted display. Before viewing the videos, the residents were asked to fill out a questionnaire indicating their VR experience and self-assessment of surgical skills regarding the specific procedure. After watching the videos, the residents completed another questionnaire to evaluate their quality and usefulness. The parameters were scaled with a 5-point Likert scale.

RESULTS

Twenty-two residents participated in this study. The mean years of experience of the participants in neurosurgery was 3.2 years, ranging from the 1st through the 7th year of training. Most participants (86.4%) had no or less than 15 minutes of VR experience. The overall quality of the videos was rated good to very good. Immersion, the feeling of being in the operating room, was high, and almost all participants (91%) stated that 360° VR videos provide a useful addition to the neurosurgical training. VR sickness was negligible in the cohort.

CONCLUSIONS

In this study, the authors demonstrated the feasibility and high acceptance of augmented 360° 3D VR videos in neurosurgical training. Augmentation of 360° videos with complementary and interactive content has the potential to effectively support trainees in acquiring conceptual knowledge. Further studies are necessary to investigate the effectiveness of their use in improving surgical skills.

Three-Dimensional Modeling in Training, Simulation, and Surgical Planning in Open Vascular and Endovascular Neurosurgery: A Systematic Review of the Literature

BACKGROUND

The expanding use of three-dimensional (3D) printing in open vascular and endovascular neurosurgery presents a promising new tool in resident learning as well as operative planning. Recent studies have investigated the accuracy, efficacy, and practicality of 3D-printed models of patient-specific disease.

OBJECTIVE

To review the literature exploring 3D modeling in neurovascular and endovascular surgery for training, simulation, and surgical preparation.

METHODS

A systematic search of the PubMed database was conducted using keywords relating to 3D printing and neurovascular or endovascular surgery. Articles were manually screened to include those that focused on resident training, surgical simulation, or preoperative planning. Information on fabrication method, materials, cost, and validation measures was collected.

RESULTS

A total of 27 articles were identified that met inclusion criteria. Twenty-one studies used 3D printing to produce aneurysm models, 5 produced arteriovenous malformation models, and 1 produced aneurysm and arteriovenous malformation models. Stereolithography was the most common fabrication method used, with acrylonitrile butadiene styrene and VeroClearTangoPlus (Stratasys) being the most frequently used materials. The mean manufacturing cost per model was U.S. $624.83. Outcomes included model measurement accuracy, concordance of intraoperative devices with those selected preoperatively, and qualitative feedback.

CONCLUSIONS

Models generated by 3D printing are anatomically accurate and aid in resident learning as well as operative planning in open vascular and endovascular neurosurgery. As advancements in printing methods are made and manufacturing costs decrease, this tool may supplement training on a wider scale in a field in which direct exposure to cases is limited.

Evaluation of the precision of operative augmented reality compared to standard neuronavigation using a 3D-printed skull

OBJECTIVE

Augmented reality (AR) in cranial surgery allows direct projection of preregistered overlaid images in real time on the microscope surgical field. In this study, the authors aimed to compare the precision of AR-assisted navigation and standard pointer-based neuronavigation (NV) by using a 3D-printed skull in surgical conditions.

METHODS

A commercial standardized 3D-printed skull was scanned, fused, and referenced with an MR image and a CT scan of a patient with a 2 × 2-mm right frontal sinus defect. The defect was identified, registered, and integrated into NV. The target was physically marked on the 3D-printed skull replicating the right frontal sinus defect. Twenty-six subjects participated, 25 of whom had no prior NV or AR experience and 1 with little AR experience. The subjects were briefly trained in how to use NV, AR, and AR recalibration tools. Participants were asked to do the following: 1) "target the center of the defect in the 3D-printed skull with a navigation pointer, assisted only by NV orientation," and 2) "use the surgical microscope and AR to focus on the center of the projected object" under conventional surgical conditions. For the AR task, the number of recalibrations was recorded. Confidence regarding NV and AR precision were assessed prior to and after the experiment by using a 9-level Likert scale.

RESULTS

The median distance to target was statistically lower for AR than for NV (1 mm [Q1: 1 mm, Q3: 2 mm] vs 3 mm [Q1: 2 mm, Q3: 4 mm] [p < 0.001]). In the AR task, the median number of recalibrations was 4 (Q1: 4, Q3: 4.75). The number of recalibrations was significantly correlated with the precision (Spearman rho: -0.71, p < 0.05). The trust assessment after performing the experiment scored a median of 8 for AR and 5.5 for NV (p < 0.01).

CONCLUSIONS

This study shows for the first time the superiority of AR over NV in terms of precision. AR is easy to use. The number of recalibrations performed using reference structures increases the precision of the navigation. The confidence regarding precision increases with experience.

Single- versus dual-attending strategy for spinal deformity surgery: 2-year experience and systematic review of the literature

OBJECTIVE

Adult spinal deformity (ASD) surgery is complex and associated with high morbidity and complication rates. There is growing evidence in the literature for the beneficial effects of an approach to surgery in which two attending physicians rather than a single attending physician perform surgery for and oversee the surgical care of a single patient in a dual-attending care model. The authors developed a dual-attending care collaboration in August 2017 in which a neurosurgeon and an orthopedic surgeon mutually operated on patients with ASD.

METHODS

The authors recorded data for 2 years of experience with ASD patients operated on by dual attending surgeons. Analyses included estimated blood loss (EBL), transfusions, length of stay (LOS), discharge disposition, complication rates, emergency room visits and readmissions, subjective health status improvement, and disability (Oswestry Disability Index [ODI] score) and pain (visual analog scale [VAS] score) at last follow-up. In addition, the pertinent literature for dual-attending spinal deformity correction was systematically reviewed.

RESULTS

The study group comprised 19 of 254 (7.5%) consecutively operated patients who underwent thoracolumbar fusion during the period from January 2017 to June 2019 (68.4% female; mean patient age 65.1 years, ODI score 44.5, VAS pain score 6.8). The study patients were matched by age, sex, anesthesia risk, BMI, smoking status, ODI score, VAS pain score, prior spine surgeries, and basic operative characteristics (type of interbody implants, instrumented segments, pelvic fixation) to 19 control patients (all p > 0.05). There was a trend toward less EBL (mean 763 vs 1524 ml, p = 0.059), fewer intraoperative red blood cell transfusions (mean 0.5 vs 2.3, p = 0.079), and fewer 90-day readmissions (0% vs 15.8%, p = 0.071) in the dual-attending group. LOS and discharge disposition were similar, as were the rates of any < 30-day postsurgery complications, < 90-day postsurgery emergency room visits, and reoperations, and ODI and VAS pain scores at last follow-up (all p > 0.05). At last follow-up, 94.7% vs 68.4% of patients in the dual- versus single-attending group stated their health status had improved (p = 0.036). In the authors' literature search of prior articles on spinal deformity correction, 5 of 8 (62.5%) articles reported lower EBL and 6 of 8 (75%) articles reported significantly lower operation duration in dual-attending cases. The literature contained differing results with regard to complication- or reoperation-sparing effects associated with dual-attending cases. Similar clinical outcomes of dual- versus single-attending cases were reported.

CONCLUSIONS

Establishing a dual-attending care management platform for ASD correction was feasible at the authors' institution. Results of the use of a dual-attending strategy at the authors' institution were favorable. Positive safety and outcome profiles were found in articles on this topic identified by a systematic literature review.

Perioperative Practice Patterns of Craniotomies-Results of a National Neurosurgical Survey in Poland

BACKGROUND

Perioperative craniotomy practices depend mainly on neurosurgeon preferences. To investigate the variations in these preferences, we surveyed neurosurgeons in Poland regarding different aspects of their practices.

METHODS

Anonymous questionnaires were circulated in 2019 at the neurosurgery conferences in Poland. We then analyzed the responses, categorized in subgroups by sex, affiliation, and stage of training.

RESULTS

A total of 114 responses to the questionnaire were obtained. For surgical site exposure, regional hair shaving was the most common pattern (64.9%), followed by whole-scalp (19.3%) and strip line shaving (12.3%). Most respondents (65.8%) used clamp-based devices for bone flap fixation, and approximately one third (30.7%) reported using bone suturing. During cranioplasty, respondents most often used artificial bone implants (69.3%), followed by a preserved bone flap from the patient (24.5%). More than three quarters reported that they (77.2%) performed routine radiologic evaluation after uncomplicated brain tumor surgery. Most patients (64.0%) were discharged between the third and sixth postoperative days. Almost half of emergent surgeries (48.2%) and most elective surgeries (89.5%) were performed with the help of an assistant surgeon. No significant differences were found in practice between the sexes or by affiliation or training stage. We inferred an influence of regional economic status on some of the reported choices.

CONCLUSIONS

Perioperative craniotomy practices among Polish neurosurgeons show a significant heterogeneity. Economic factors can explain some choices, but others trace to a conservative mindset. Further studies are needed to identify which factors are most relevant and to identify approaches to a standardized method of care.

Changing Hands: A Rising Role of the Tumor Surgeon in Teaching Sylvian Fissure Dissection

OBJECTIVE

The landscape of microneurosurgery has changed considerably over the past 2 decades, with a decline in indications for open surgery on cerebrovascular pathology and ever-increasing indications for open resection of brain tumors. This study investigated how these trends in case volume affected residents' training experiences in microsurgery and, specifically, Sylvian fissure dissection.

METHODS

Resident case logs were reviewed, identifying open cerebrovascular operations and craniotomies for tumor. Operations involving Sylvian fissure dissection were identified through operative reports. Changes in case number by resident were plotted over time, and linear regression was applied.

RESULTS

Among 23 chief residents, 3045 operations were identified, 1071 of which were for cerebrovascular pathology and 1974 for tumor. Open cerebrovascular experience decreased (P < 0.0001) while tumor volume remained unchanged (P = 0.221). The number of Sylvian fissure dissections per resident did not change over time overall (P = 0.583) or within cerebrovascular operations (P = 0.071). The number of Sylvian fissure dissections in tumor operations increased (P = 0.004). This effect was predominated by an increase in intraaxial tumors approached via Sylvian fissure dissection (P = 0.003). The proportion of Sylvian fissure dissections in tumor surgery increased from 15% in 2009 to 34% by 2019 (P = 0.003).

CONCLUSIONS

Residents are seeing an increasing proportion of their Sylvian fissure dissection experience during tumor operations. The distribution of this experience will continue to evolve as surgical indications change but suggests a growing role for tumor surgeons in resident training in microsurgery.

Procedures performed during neurosurgery residency in Europe

Background

In a previous article (10.1007/s00701-019-03888-3), preliminary results of a survey, aiming to shed light on the number of surgical procedures performed and assisted during neurosurgery residency in Europe were reported. We here present the final results and extend the analyses.

Methods

Board-certified neurosurgeons of European Association of Neurosurgical Societies (EANS) member countries were asked to review their residency case logs and participate in a 31-question electronic survey (SurveyMonkey Inc., San Mateo, CA). The responses received between April 25, 2018, and April 25, 2020, were considered. We excluded responses that were incomplete, from non-EANS member countries, or from respondents that have not yet completed their residency.

Results

Of 430 responses, 168 were considered for analysis after checking in- and exclusion criteria. Survey responders had a mean age of 42.7 ± 8.8 years, and 88.8% were male. Responses mainly came from surgeons employed at university/teaching hospitals (85.1%) in Germany (22.0%), France (12.5%), the United Kingdom (UK; 8.3%), Switzerland (7.7%), and Greece (7.1%). Most responders graduated in the years between 2011 and 2019 (57.7%). Thirty-eight responders (22.6%) graduated before and 130 responders (77.4%) after the European WTD 2003/88/EC came into effect. The mean number of surgical procedures performed independently, supervised or assisted throughout residency was 540 (95% CI 424–657), 482 (95% CI 398–568), and 579 (95% CI 441–717), respectively. Detailed numbers for cranial, spinal, adult, and pediatric subgroups are presented in the article. There was an annual decrease of about 33 cases in total caseload between 1976 and 2019 (coeff. − 33, 95% CI − 62 to − 4, p = 0.025). Variables associated with lesser total caseload during residency were training abroad (1210 vs. 1747, p = 0.083) and female sex by trend (947 vs. 1671, p = 0.111), whereas case numbers were comparable across the EANS countries (p = 0.443).

Conclusion

The final results of this survey largely confirm the previously reported numbers. They provide an opportunity for current trainees to compare their own case logs with. Again, we confirm a significant decline in surgical exposure during training between 1976 and 2019. In addition, the current analysis reveals that female sex and training abroad may be variables associated with lesser case numbers during residency.

Electronic supplementary material

The online version of this article (10.1007/s00701-020-04513-4) contains supplementary material, which is available to authorized users.

The World Federation of Neurosurgical Societies Young Neurosurgeons Survey (Part I): Demographics, Resources, and Education

BACKGROUND

Providing a comprehensive and effective neurosurgical service requires adequate numbers of well-trained, resourced, and motivated neurosurgeons. The survey aims to better understand 1) the demographics of young neurosurgeons worldwide; 2) the challenges in training and resources that they face; 3) perceived barriers; and 4) needs for development.

METHODS

This was a cross-sectional study in which a widely disseminated online survey (April 2018-November 2019) was used to procure a nonprobabilistic sample from current neurosurgical trainees and those within 10 years of training. Data were grouped by World Bank income classifications and analyzed using χ2 tests because of its categorical nature.

RESULTS

There were 1294 respondents, with 953 completed responses included in the analysis. Of respondents, 45.2% were from high-income countries (HICs), 23.2% from upper-middle-income countries, 26.8% lower-middle-income countries, and 4.1% from low-income countries. Most respondents (79.8%) were male, a figure more pronounced in lower-income groups. Neuro-oncology was the most popular in HICs and spinal surgery in all other groups. Although access to computed tomography scanning was near universal (98.64%), magnetic resonance imaging access decreased to 66.67% in low-income countries, compared with 98.61% in HICs. Similar patterns were noted with access to operating microscopes, image guidance systems, and high-speed drills. Of respondents, 71.4% had dedicated time for neurosurgical education.

CONCLUSIONS

These data confirm and quantify disparities in the equipment and training opportunities among young neurosurgeons practicing in different income groups. We hope that this study will act as a guide to further understand these differences and target resources to remedy them.

The impact of surgical simulation on patient outcomes: a systematic review and meta-analysis

The use of simulation in surgical training is ever growing. Evidence suggests such training may have beneficial clinically relevant effects. The objective of this research is to investigate the effects of surgical simulation training on clinically relevant patient outcomes by evaluating randomized controlled trials (RCT). PubMed was searched using PRISMA guidelines: "surgery" [All Fields] AND "simulation" [All Fields] AND "patient outcome" [All Fields]. Of 119 papers identified, 100 were excluded for various reasons. Meta-analyses were conducted using the inverse-variance random-effects method. Nineteen papers were reviewed using the CASP RCT Checklist. Sixteen studies looked at surgical training, two studies assessed patient-specific simulator practice, and one paper focused on warming-up on a simulator before performing surgery. Median study population size was 22 (range 3-73). Most articles reported outcome measures such as post-intervention Global Rating Scale (GRS) score and/or operative time. On average, the intervention group scored 0.42 (95% confidence interval 0.12 to 0.71, P = 0.005) points higher on a standardized GRS scale of 1-10. On average, the intervention group was 44% (1% to 87%, P = 0.04) faster than the control group. Four papers assessed the impact of simulation training on patient outcomes, with only one finding a significant effect. We found a significant effect of simulation training on operative performance as assessed by GRS, albeit a small one, as well as a significant reduction to operative time. However, there is to date scant evidence from RCTs to suggest a significant effect of surgical simulation training on patient outcomes.