Virtual Reality in Robotic Surgery: Training, Skill Transfer, and Preoperative Planning — A Narrative Review

Introduction

Robotic-assisted surgery has become an integral component of modern surgical practice and provides enhanced three-dimensional vision, intricate instrument capability, and superior surgeon ergonomics relative to other laparoscopic techniques. Notwithstanding this, robotic-assisted technique also imposes new technical considerations on the surgeon, including indirect instrument control, loss of tactile feedback, and reliance on visuospatial skills. Taken together, these factors contribute to a steep learning curve and raise concerns regarding patient safety during the early use of this technique by novice trainee surgeons.1,2 

The classical apprentice model of surgical training faces twin challenges related to reduced operative exposure and ethical concerns surrounding trainee involvement in surgery, alongside the growing demand for independent assessment of technical competence. Consequently, simulation-based assessment has been recognised as a cornerstone of competency-based surgical education. Virtual reality (VR) simulation provides a risk-free learning environment in which trainees can practice until proficiency is achieved without exposing patients to harm.1,2 

A high level of evidence from randomised controlled trials, systematic reviews, and meta-analyses has demonstrated that VR-based robotic simulation training improves technical skill performance and facilitates transfer of skills to the operating room. Furthermore, simulation-derived performance metrics have shown predictive value for operative performance in real-world clinical settings.1-4 

Beyond training, VR technologies have expanded into preoperative planning and intraoperative navigation.

Patient-specific VR models reconstructed from cross- sectional imaging enable immersive anatomical visualisation and procedural simulation, particularly for anatomically complex procedures such as robotic prostatectomy, nephrectomy, thoracic surgery, and neurosurgery.4-7 In light of the continued expansion of VR applications in robotic surgery, a comprehensive synthesis of the existing evidence is warranted.

Methods

This narrative review follows PRISMA guidance where applicable. A structured literature search was carried out across peer-reviewed journals to identify studies that evaluated VR and augmented reality (AR) technologies in robotic surgery training, planning, and navigation. 

The included studies had to involve assessment of VR- based simulation for robotic surgical training, skill transfer to the operating room, or use of VR/AR in preoperative planning or intraoperative navigation. Data were synthesised narratively due to heterogeneity in study designs and outcomes as well as VR platforms. Conference proceedings and technical reports were included only if they provided relevant clinical or educational insights. 

Results

VR for robotic surgical training 
Several randomised controlled trials have established that VR-based robotic simulation significantly enhances technical performance compared with conventional training alone. Trainees exposed to VR simulation demonstrate reduced error rates, improved economy of motion, and faster completion of tasks in live robotic procedures. 1,2 

These findings are further supported by systematic reviews and meta-analyses, which also confirm improvements in fundamental robotic skills such as camera control, bimanual dexterity, and depth perception. Collectively, these studies establish strong construct validity for VR simulators and their role within structured training curricula. 1,2 

Recent developments have focused on enhancing simulator fidelity. Haptic-enhanced VR systems in orthopaedic and trauma-related robotic applications demonstrate improved realism by simulating force feedback during bone manipulation and fracture fixation. Such advances may further bridge the gap between simulation and live surgery. 3 

Skill transfer and predictive validity 
Transferability of skills acquired through VR simulation to the operating room represents a critical determinant of clinical relevance. Meta-analytic evidence confirms that surgeons trained using VR simulation demonstrate superior intraoperative performance compared with those trained using traditional methods alone. 3,8 

Mastery-based VR training platforms require trainees to meet predefined proficiency benchmarks before progression and have demonstrated improved skill acquisition while reducing inter-trainee variability. Simulator-derived performance metrics have also shown predictive validity for operative competence, further supporting their use within assessment and credentialing frameworks. 5 

Preoperative planning and surgical navigation 
VR-based preoperative planning allows immersive, patient-specific visualisation of complex anatomy. In urology, randomised clinical trials have demonstrated improved surgical decision-making and functional outcomes following VR-assisted planning for robotic prostatectomy. 6 Similarly, VR models developed for robotic partial nephrectomy provide enhanced understanding of tumour location, renal vasculature, and resection strategy. 9 

In thoracic surgery, VR planning systems enhance spatial orientation and appreciation of tumour relationships with adjacent structures, potentially facilitating safer resections. Neurosurgical applications include VR simulation for robotic transsphenoidal tumour resection, enabling procedural rehearsal and evaluation of motion scaling within confined operative corridors. 10,11 

AR and system integration 
Integration of VR and AR into robotic systems has demonstrated technical feasibility in experimental and early clinical settings. Magnetic resonance imaging (MRI)-based VR navigation tools have been developed for robotic-assisted radical prostatectomy, providing enhanced anatomical guidance. 12 Early case series using synchronised VR and AR platforms suggest potential benefits for intraoperative navigation; however, larger studies are required to determine their clinical impact. 13

Discussion

This review combines the latest evidence concerning the use of VR in robotic surgery. The main themes discussed include surgical training, skill transfer, preoperative planning, and intraoperative navigation. Across different surgical specialities, robotic surgery provides enhanced visualisation, dexterity, and ergonomics. However, it is associated with a steep learning curve due to indirect instrument control and the absence of tactile feedback. Consequently, VR-based technologies have been proposed as a means to overcome these challenges, with increasing evidence demonstrating their educational as well as procedural relevance. 1-3 

The strongest evidence identified relates to the application of VR simulation in training robotic surgical skills. Robotic surgery requires advanced psychomotor skills that differ from those used in open or conventional laparoscopic surgery, including three-dimensional spatial awareness, bimanual coordination, and precise camera control. Randomised controlled trials and meta-analyses consistently demonstrate that VR-based training significantly improves these fundamental skills, whereas traditional training alone yields comparatively limited benefits. 1-3 These improvements are clinically relevant, as inadequate technical skills during early robotic experience have been associated with prolonged operative times and increased technical errors. 

A key strength of VR simulation lies in its alignment with competency-based surgical education, representing a departure from traditional apprenticeship-based models that rely heavily on case volume. VR simulators provide objective and reproducible performance metrics, including task completion time, instrument path length, and error frequency, enabling structured feedback, benchmarking, and longitudinal assessment of trainee progression. 1 Meta-analytic evidence further demonstrates a correlation between simulator-derived metrics and intraoperative performance, supporting the construct and predictive validity of VR-based assessment tools. 3 

The transfer of skills acquired through VR simulation to the operating room is central to determining the clinical value of these training modalities. High-level evidence indicates that surgeons trained using VR simulation perform better intraoperatively than those trained exclusively through conventional methods, with greater efficiency and fewer technical errors. 3 These findings counter concerns that simulation-based training may not translate to real-world surgical performance and support the integration of VR into structured robotic surgery curricula. 2 

Mastery-based VR training platforms further enhance the effectiveness of simulation by requiring trainees to achieve predefined proficiency thresholds before progression. Evidence suggests that such platforms promote more consistent skill acquisition and reduce inter-trainee variability, potentially contributing to safer and more reliable operative performance. 5 

Despite these advantages, limitations in simulator fidelity persist. Robotic surgery is inherently challenging due to the absence of tactile sensation, as surgeons cannot directly feel tissue interaction. Traditional VR systems have struggled to replicate haptic feedback accurately. Recent developments in haptic-enabled VR simulators aim to address this limitation by incorporating force-feedback mechanisms that simulate tissue resistance and bone interaction. Early studies in robot-assisted orthopaedic and trauma surgery suggest improved realism and user engagement; however, robust evidence demonstrating improved intraoperative outcomes remains limited. 11 

Beyond training, VR has demonstrated growing clinical utility in preoperative planning for robot- assisted surgery. Patient-specific VR models derived from computed tomography or MRI allow surgeons to immerse themselves in complex anatomy within a three-dimensional environment. Randomised clinical trials in urology have shown that VR-assisted planning for robotic prostatectomy improves surgical decision- making and functional outcomes, including continence and erectile function. 4 

These findings suggest that enhanced anatomical understanding may translate into tangible patient benefits. Similarly, VR-based planning for robotic partial nephrectomy improves visualisation of tumour location, renal vasculature, and resection margins, potentially reducing intraoperative uncertainty and ischaemia time. 6 In robotic thoracic surgery, VR planning tools enhance spatial orientation and comprehension of tumour relationships to vascular and bronchial structures, which is particularly valuable in minimally invasive procedures where tactile cues are absent. 7

The high precision required in neurosurgery underscores the relevance of VR applications in this field. VR simulation of robotic transsphenoidal brain tumour resection enables procedural rehearsal within confined anatomical spaces and facilitates evaluation of motion scaling, potentially improving surgical accuracy.10 Review studies further highlight the value of VR and augmented reality in neurosurgical education, spatial orientation, and operative rehearsal.9,14 

The integration of VR with AR and navigation systems represents an important emerging direction in robotic surgery. MRI-based VR navigation tools have been developed to enhance anatomical guidance during robotic-assisted radical prostatectomy, improving intraoperative orientation relative to critical structures.7 Early clinical experiences with synchronised VR and AR platforms suggest improved alignment between preoperative planning and intraoperative anatomy; however, current evidence remains limited to small case series.15 

Limitations

Several limitations of the existing evidence base regarding virtual reality (VR) in robotic surgery must be acknowledged, despite promising findings. Firstly, considerable heterogeneity exists in terms of VR platforms, training curricula, and outcome measures, thereby hindering direct comparisons across studies. Few studies assess only short-term technical outcomes, while long-term skill retention and patient-centred endpoints remain largely unexplored. Moreover, the cost and technical infrastructure necessary for VR systems may restrict the adoption of such technology in resource- constrained settings.1,2 

Secondly, studies evaluating VR-based robotic training mostly address short-term technical outcomes measured immediately after simulation or early operative exposure. While improvements in task performance, error rates, and efficiency have been consistently reported, data on long- term skill retention and sustained operative competence remain scarce.2,5 How VR-acquired skills persist over time, particularly in low-volume robotic practices, remains an open question. 

Thirdly, although the evidence supporting VR as a training tool is substantial, data regarding its use in preoperative planning and intraoperative navigation remain limited. Most studies in these domains are observational, single-centre investigations, or small case series, particularly in neurosurgical and thoracic applications.7,14,15 

Another challenge that persists while using VR is the difference in simulator quality. It is necessary to evaluate how well surgeons retain their skills over time. Additional research is also required on how VR affects patient outcomes.7,13 VR can be expensive and requires a lot of infrastructure.1,2 This can act as a barrier in certain clinical scenarios.