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Objective To assess the effect of virtual reality training on an actual laparoscopic operation.Design Prospective randomised controlled and blinded trial.Setting Seven gynaecological departments in the Zeeland region of Denmark.Participants 24 first and second year registrars specialising in gynaecology and obstetrics.Interventions Proficiency based virtual reality simulator training in laparoscopic salpingectomy and standard clinical education (controls).Main outcome measure The main outcome measure was technical performance assessed by two independent observers blinded to trainee and training status using a previously validated general and task specific rating scale. The secondary outcome measure was operation time in minutes.Results The simulator trained group (n=11) reached a median total score of 33 points (interquartile range 32-36 points), equivalent to the experience gained after 20-50 laparoscopic procedures, whereas the control group (n=10) reached a median total score of 23 (22-27) points, equivalent to the experience gained from fewer than five procedures (P<0.001). The median total operation time in the simulator trained group was 12 minutes (interquartile range 10-14 minutes) and in the control group was 24 (20-29) minutes (P<0.001). The observers’ inter-rater agreement was 0.79.Conclusion Skills in laparoscopic surgery can be increased in a clinically relevant manner using proficiency based virtual reality simulator training. The performance level of novices was increased to that of intermediately experienced laparoscopists and operation time was halved. Simulator training should be considered before trainees carry out laparoscopic procedures.Trial registration ClinicalTrials.gov NCT00311792.

Background-We tested prospectively the hypothesis that stroke development can be predicted by echolucency of carotid atherosclerotic plaques in previously symptomatic and asymptomatic patients. Methods and Results-We followed incidence of ipsilateral ischemic strokes for 4.4 years in 111 asymptomatic and 135 symptomatic patients with Ն50% relevant carotid artery stenosis. At inclusion, echogenicity of carotid plaques and degree of stenosis were evaluated with high-resolution B-mode ultrasound with computer-assisted image processing and Doppler ultrasound, respectively. We observed 44 ipsilateral ischemic strokes. In symptomatic patients, relative risk of ipsilateral ischemic stroke for echolucent versus echorich plaques was 3.1 (95% CI, 1.3 to 7.3), whereas for 80% to 99% versus 50% to 79% stenosis, the relative risk was 1.4 (95% CI, 0.7 to 3.0). Relative to symptomatic patients with echorich 50% to 79% stenotic plaques, those with echorich 80% to 99% stenotic plaques, echolucent 50% to 79% stenotic plaques, and echolucent 80% to 99% stenotic plaques had relative risks of ipsilateral ischemic strokes of 3.1 (95%CI, 0.7 to 14), 4.2 (95% CI, 1.2 to 15), and 7.9 (95% CI, 2.1 to 30), equivalent to absolute risk increases of 11%, 18%, and 28%. This was not observed in previously asymptomatic patients. Conclusions-Echolucent